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section of gynecological disorders, as a disorder of the female genital organs. The significance of the ICD-10 diagnosis is that it focuses on the two main aspects of PMS: ● the association with the menstrual cycle ● cyclicity and timing. It requires that symptoms occur exclusively during the premenstrual period and remit following menses. It de-emphasizes the nature of specific symptoms or phenomena. It only gives examples such as tension or migraine or any other molimen – any menstrually related symptoms. It does not specify any level of required severity or impairment, no degree of change from the non-symptomatic phase of the menstrual cycle, and no differential diagnosis or exclusion criteria (Table 2.3). The ICD-9 code for PMS is 625.4. ACOG diagnostic criteria Conceptually similar, but a step forward from the ICD- 10 criteria are the American College of Obstetricians and Gynecologists (ACOG) diagnostic criteria for premenstrual syndrome (PMS) 27 (Table 2.3). The ACOG diagnostic criteria require the reporting of at least any one of six affective or one of four somatic symptoms that should exist during the 5 days before the menses at each of three prior menstrual cycles and be DIAGNOSIS OF PMS/PMDD 11 Table 2.2 The burden of PMDD/PMS in the USA and the EU according to most conservative-strict definition: disability adjusted life years (DALY) a lost ● Severity weight of severe PMS 0.50 (Class 5) ● Age of onset of PMS 14–17 years b ● Prevalence in teenagers 5.3–7.8% ● Duration of disease 14–51 years 37 years ● Cycles affected 481–22 (2 pregnancies and postpartum) 459 cycles ● Average days of severe PMS per cycle 6.1 days c ● Total days/years of disorders 2800 days/7.671 years ● DALY (7.671 � 0.5) 3.835 per woman relieved within 4 days of onset of menses. They should not exist until the periovulatory phase of the menstrual cycle, be present in the absence of any pharmacological therapy, be associated with impairment or dysfunction in social or economic performance, and be prospectively confirmed during two menstrual cycles. The significance of the ACOG criteria is that they acknowledge the importance of dysfunction and impairment, specify the symptomatic and the asymptomatic periods, and require prospective confirmation of retrospective reports. In my opinion, the emphasis on timing, with vagueness of nature of symptoms and requirement for at least one symptom without a threshold of minimal number of symptoms, is a conceptual and practical strength of the ACOG criteria. APA DSM-IV criteria USA EU ● Women ages 14–51 (USA); 15–49 (EU) 2000 census 75,580,000 91,445,000 ● Women who would meet criteria for PMDD (��5%) ��3,779,000 ��4,572,250 Total DALYs, lost years of healthy life ��14,492,465 ��17,534,579 The number would be even higher if all women suffering from PMS with impairment are counted Data from a Murray and Lopez, 19 b Wittchen et al, 15 and c Hylan et al. 20 The most elaborate diagnostic criteria of a subtype of PMS are the APA DSM-IV criteria for premenstrual dysphoric disorder – PMDD. 1,2 This set of criteria requires an initial retrospective report that symptoms, their luteal–follicular cyclicity, luteal occurrences, and follicular absence have been presented for the majority of cycles during the previous year. At least five out of 11 listed symptoms must be present; at least one of them should be a major mood symptom – depression, anxiety, irritability, or affective lability. Symptoms should cause impairment and interfere with work, social activities,
12 THE PREMENSTRUAL SYNDROMES Table 2.3 Current diagnostic criteria for PMS/PMDD ICD-10 ACOG DSM-IV Diagnostic entity (and ICD-9 code) PMTS (625.4) PMS (625.4) PMDD (311) Category Gynecology Gynecology Psychiatry Temporal pattern Occur premenstrually Remit following menses Occur 5 days before menses Occur during the last week Remit within 4 days of onset of before menses menses Remit within few days after No recurrence at least until day 13 of cycle onset of follicular phase At least five symptoms, with at least one of: depression, anxiety, or tension, anger or irritability, and monthly swings Other qualifying symptoms are: decreased interest, difficulty concentrating, lack of energy, changed sleep, overwhelmed, out of control, change in appetite Other physical symptoms such as breast tenderness, bloating headaches, pain Markedly interferes with work, social activities, relationships Most menstrual cycles during past year At least two consecutive cycles Not merely an exacerbation of another disorder Not associated with pharmacological, hormone, alcohol or drug use or abuse and/or relationships, not be an exacerbation of another chronic disorder and be prospectively confirmed by daily ratings during at least two consecutive cycles. Because of differing opinions during the APA’s DSM-IV process, PMDD is listed in the DSM-IV and DSM-IV-TR as one of the criteria sets and axes provided for further study, and is designated as ‘Depressive Disorder not otherwise specified’ – ICD-9 code 311. The three main diagnostic criteria are summarized in Table 2.3. UNSOLVED ISSUES WITH CURRENT DIAGNOSTIC CRITERIA The main shortcomings of the current diagnostic criteria are lack of universal agreement on the nature of the PMS as well as lack of universal acceptance of the criteria per se. The closest to universal acceptance is the ICD-10 entity. However, the PMTS description is vague and does not provide specific diagnostic process and criteria: actually, it just acknowledges the existence of the entity.
Page 2: The Premenstrual Syndromes
Page 5 and 6: © 2007 Informa UK Ltd First publis
Page 7 and 8: vi CONTENTS 10. Pathophysiology I:
Page 9 and 10: viii LIST OF CONTRIBUTORS Uriel Hal
Page 12 and 13: Preface Somatic, affective, and beh
Page 14 and 15: 1 History of the premenstrual disor
Page 16 and 17: and estrogen/progesterone imbalance
Page 18 and 19: Dalton’s PMS, new, more precise t
Page 20 and 21: Many other therapeutic areas have b
Page 22 and 23: 2 The diagnosis of PMS/PMDD - the c
Page 26 and 27: Universal acceptance of a diagnosti
Page 28 and 29: Extremely severe Severe None Severi
Page 30 and 31: Table 2.5 Differential diagnosis of
Page 32: 17. Halbreich U, Borenstein J, Pear
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Page 37 and 38: 24 THE PREMENSTRUAL SYNDROMES IS PM
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Page 43 and 44: 30 THE PREMENSTRUAL SYNDROMES Table
Page 45 and 46: 32 THE PREMENSTRUAL SYNDROMES DAILY
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40. WHO. International Classificati
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64 THE PREMENSTRUAL SYNDROMES ∆ 4
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66 THE PREMENSTRUAL SYNDROMES Anter
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68 THE PREMENSTRUAL SYNDROMES REFER
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70 THE PREMENSTRUAL SYNDROMES store
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72 THE PREMENSTRUAL SYNDROMES contr
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74 THE PREMENSTRUAL SYNDROMES Serot
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78 THE PREMENSTRUAL SYNDROMES level
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80 THE PREMENSTRUAL SYNDROMES 110.
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10 Pathophysiology I: role of ovari
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different neuromodulatory profile f
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studied, reflecting in part interes
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disturbed in these patients. Compar
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mid-luteal phases of the menstrual
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hyposensitivity or altered circadia
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52. Osterlund MK, Halldin C, Hurd Y
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135. Facchinetti F, Genazzani AD, M
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11 Pathophysiology II: neuroimaging
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orbitofrontal cortex (OFC), and ant
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EVIDENCE OF ALTERED GABAERGIC FUNCT
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the preclinical data indicating tha
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19. Nordstrom AL, Olsson H, Halldin
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110 THE PREMENSTRUAL SYNDROMES ster
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112 THE PREMENSTRUAL SYNDROMES ESTR
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114 THE PREMENSTRUAL SYNDROMES tria
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118 THE PREMENSTRUAL SYNDROMES GABA
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122 THE PREMENSTRUAL SYNDROMES PERC
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124 THE PREMENSTRUAL SYNDROMES (10
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126 THE PREMENSTRUAL SYNDROMES depr
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128 THE PREMENSTRUAL SYNDROMES and
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15 Psychotropic therapies Meir Stei
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Table 15.2 Intermittent dosing (lut
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Table 15.3 Intermittent vs continuo
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clinical evidence that concomitant
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46. Yamada K, Kanba S. Effectivenes
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142 THE PREMENSTRUAL SYNDROMES Tabl
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144 THE PREMENSTRUAL SYNDROMES redu
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146 THE PREMENSTRUAL SYNDROMES PMDD
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17 Clinical evaluation and manageme
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prior to menses) compared with the
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anxiety, or bipolar disorders, post
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premenstrual cognitive disturbance,
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PMS, and bilateral oophorectomy alo
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69. Studd J, Leather AT. The need f
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162 THE PREMENSTRUAL SYNDROMES GABA
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164 THE PREMENSTRUAL SYNDROMES the
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166 THE PREMENSTRUAL SYNDROMES psyc
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172 THE PREMENSTRUAL SYNDROMES In t
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176 THE PREMENSTRUAL SYNDROMES by g
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178 THE PREMENSTRUAL SYNDROMES REFE
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Index Note to index: PMS is used fo
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levonorgestrol, with estradiol 156
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