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

ecause ovulation is less frequent as women enter the
menopausal transition. 35 These findings were supported
in a population-based cohort study of women who
reported that their PMS symptoms significantly decreased
after age 40 years old. 37 New symptoms that occur in the
transition to menopause may be difficult to distinguish
from those of PMS/PMDD. Another study found that a
higher-than-expected percentage of perimenopausal
women with an onset of depression also had premenstrual
dysphoria. 38 Several studies have shown that
women with a history of PMS were more likely to experience
symptoms in the transition to menopause that
were not limited to the luteal phase of the menstrual
cycle, particularly hot flashes, depressed mood, poor
sleep, and decreased libido. 37–39
PMS AND DIAGNOSTIC CRITERIA
The diagnosis of PMS continues to lack widely
accepted criteria and remains controversial, in spite of
the many women who seek medical treatment for the
disorder. 31,32 At this time, three proffered diagnoses
differ considerably in their criteria and utility for assessment
in clinical practice.
The WHO International Classification of Diseases, 10th
edition (ICD-10) lists premenstrual tension syndrome
(PMTS) as a gynecological disorder. 40 This diagnosis
requires no specific symptoms or number of symptoms,
and provides no requirement for level of severity, differential
diagnosis, or exclusion criteria, resulting in no
systematic criteria for PMS. The non-specificity of this
diagnosis is consistent with the view that there are over
300 premenstrual complaints associated with PMS but
fails to differentiate severe PMS either from normal
premenstrual changes or from other psychiatric or
physical disorders with similar presenting complaints.
In contrast to the non-specificity of the ICD-10
diagnosis of PMTS, criteria for a severe, dysphoric
form of PMS, termed premenstrual dysphoric disorder,
were included for further research in the Diagnostic
and Statistical Manual of Mental Disorders, 4th edition
(DSM-IV). 41 The PMDD criteria require five of 11 specified
symptoms at a severe level in the premenstrual
phase of the cycle, symptom remission in the follicular
phase of the cycle, marked functional impairment,
absence of other diagnoses that would account for the
symptoms, and prospective confirmation of the symptoms
for at least two consecutive menstrual cycles.
The symptoms included in the PMDD diagnosis are
depressed mood, anxiety/tension, mood swings, anger/
irritability, decreased interest, difficulty concentrating,
fatigue, appetite changes, sleep difficulties, feeling out of
control, and physical symptoms. Of the five symptoms
CLINICAL PRESENTATION AND COURSE OF PMS 57
required to meet the PMDD criteria, at least one must
be among the first four emotional symptoms listed above,
and all physical symptoms, regardless of the number, are
considered a single symptom for meeting the diagnostic
criteria.
The PMDD criteria have been used by many
researchers in recent years. These criteria mark a major
step in providing specific parameters for a diagnosis of
premenstrual symptoms, and the use of PMDD criteria
has contributed to identifying effective treatments and
increasing scientific information about the disorder.
However, the clinical application of the PMDD criteria
is limited by its psychiatric focus and complexity and
only a small minority of women who seek treatment
for premenstrual symptoms meet the PMDD criteria.
Moreover, there is no data-based evidence for the
assumptions of the diagnosis, and responses to treatment
do not differ between women diagnosed with
PMDD and women who do not meet the PMDD criteria
but have severe PMS. 20,21
In contrast to the psychiatric emphasis of PMDD, a
third diagnostic approach was recently offered by the
American College of Obstetricians and Gynecologists
(ACOG). 42 The ACOG criteria for PMS require only
one of 10 specified symptoms during the 5 days before
menses, remission during the menstrual flow without
recurrence of the symptoms until at least cycle day 13,
identifiable impairment or distress, absence of other
diagnoses that would account for the symptom(s), and
prospective confirmation of the symptom(s) for three
menstrual cycles.
The symptoms included in the ACOG criteria are
depression, angry outbursts, irritability, anxiety, confusion,
social withdrawal, breast tenderness, abdominal
bloating, headache, and swelling of extremities.
The ACOG criteria avoid the symptom count required
for the PMDD diagnosis and instead emphasize overall
severity as demonstrated by distress or impaired functioning.
As with the PMDD and ICD-10 criteria, the
extent to which these criteria appropriately diagnose
women who seek treatment for PMS has not been
demonstrated.
Each of these three diagnoses attempts to provide
parameters for a diagnosis of PMS. Importantly, all
lack a standard approach to operationalizing their proposed
criteria. The severity of the symptoms, the degree
of distress or interference with functioning, and the
predominant symptoms of the patient’s complaint can
vary widely depending on the methods applied to operationalize
the diagnostic criteria. This was demonstrated
in a recent study, which showed that the method
selected to determine severity thresholds for PMDD
resulted in widely divergent samples. 43 The study also
showed that the interference criterion contributes little