Premenstrual Syndromes : PMS and PMDD - Rutuja :: The site ...

14 THE PREMENSTRUAL SYNDROMES
been reported, only 11 are listed. There is no latitude for
accounting for other symptoms, even though for a
specific individual they may be no less severe than the
listed ones. The requirement of impairment of functioning
does not consider the possibility of women who
manage to continue reasonable day-to-day functioning
despite having severe symptoms, but they do have severe
distress.
As is the case with most DSM-IV clinical entities, the
putatively quantitative measures are actually descriptive
and are vaguely defined (e.g. ‘most menstrual cycles’,
‘most of the time’, ‘within few days’, ‘markedly’ interfere,
‘marked’ anxiety) and therefore are subject to additional
subjective interpretations.
The contribution of inclusion of PMDD in the
DSM-IV to recognition of the entity and to improving
treatment of women suffering from PMS should not be
underestimated. The media coverage of that disorder as
well as industry promotion of FDA-approved medications
certainly increased alertness of patients and clinicians
as well as acceptance of the concept, but this does
not negate the need to further improve and refine the
diagnostic entity.
The ACOG criteria of PMS consider the individual
diversity of symptoms and avoid the trap of a specific
numerical symptom’s threshold. They follow previous
suggestions 33 (and Mortola, unpublished work) for the
logic of PMS diagnosis but do not carry it to specificity
and well-rounded inclusiveness.
THE DURATION OF THE PREMENSTRUAL
PERIOD
The DSM-IV criteria require qualified symptoms to occur
during the week before menses, and the ACOG criteria
require them to occur within 5 days before menses. Both
do not specify for how many days should the symptoms
exist, nor does the DSM-IV specify how soon should
symptoms remit (‘within few days after the onset of
follicular phase’).
For clinical trials, inclusion criteria usually specify
‘severe symptoms for at least 4 days’ or ‘average severity
during 7 days’. When duration of premenstrual symptoms
is reported 20 it is apparent that there is a large
individual variability in the number of premenstrual
symptomatic days. The mean has been reported to be
6.1 days. However, in the USA, UK, and France, 44%,
36%, and 19% of women, respectively, reported in
retrospective telephone interviews that their PMS lasts
no longer than 3 days. Up to 10% of women with PMS
report duration of symptoms for the entire luteal phase
and 1–2% report that their symptoms actually included
the periovulatory period; 12–18% report only 1–2 symptomatic
days. My clinical experience is that some women
may have extremely severe PMS symptoms for only 1–2
days, especially those with premenstrual manic or psychotic
episodes. 36 The possibility that different lengths of
the premenstrual phase of symptoms may be associated
with different phenotypes and underlying mechanisms has
not been fully elucidated yet, partially because women
with a very short premenstrual period (PMP) do not meet
criteria for current clinical trials, as is often the case for
women with a very long symptomatic phase.
The time-related different patterns of PMP and
their differentiation from chronic non-PMS pattern is
demonstrated in Figure 2.1.
PROPOSED DEFINITION AND DIAGNOSTIC
CRITERIA FOR PMS
If the diagnosis of PMS/PMDD is to be widely accepted,
two complementary conceptual procedural operational
steps should be taken. First, an international authoritative
organization should take the lead in formulating
and establishing the diagnosis and its criteria. Indeed
the WHO should perform that task and update the ICD-
10 definition and criteria of PMTS, as a component of the
future ICD-11. The groundwork for such an update
has recently been performed. An interdisciplinary panel
of 16 experts from 13 countries in four continents recommended
diagnostic criteria for PMS and their quantification
for research. 37 The panel was convened by
the World Psychiatric Association (WPA) Section on
Interdisciplinary Collaboration, and its recommendations
still need to be endorsed by diversified major professional
organizations of the related disciplines. Secondly, it should
be recognized that PMS is an interdisciplinary domain: it
involves many aspects of endocrinology, gynecology,
mental health, and clinical neurosciences, and several subdisciplines
of internal medicine, as well as social and
developmental sciences. It is the domain of all of these
disciplines and none of them can claim it exclusively.
The main aspects of a proposed widely accepted definition
of PMS have already been widely accepted:
● The entity is distinguished from other similar entities
mostly by its timing: symptoms appear mostly
cyclically during the luteal phase of the menstrual
cycle and disappear shortly following the beginning
of menses, and are temporally entrained to the menstrual
cycle.
● To be considered a disorder, symptoms should cause
impairment and/or dysfunction. I suggest to add
‘and/or distress’.