Definition Classification and Prevalence

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Premenstrual syndrome, or premenstrual dysphoric disorder (PMDD), is an association of distressing physical, psychological, and/or behavioral symptoms which occur in the luteal phase (second half) of the menstrual cycle of sufficient severity to interfere with the normal activities and personal relationships of many women. Although the late luteal phase is the most common time for symptoms of PMS to be experienced, occasionally symptoms may occur as early as ovulation. To be classified as PMS, symptoms must be relieved by the onset of or during menstruation. Indeed, a symptom-free week after menstruation is necessary for differential diagnosis from other gynecological or psychiatric disorders.

Despite the plethora of research studies on the subject, there exists no commonly agreed definition of PMS among gynecologists and researchers. The lack of consensus is probably due to the large number of symptoms described. PMS was previously associated only with nervous tension and termed premenstrual tension (PMT). However, this term is no longer used as it only describes a limited range of the numerous symptoms experienced by many women. The most commonly mentioned symptoms of PMS are now grouped into psychological and somatic categories (Table 1).

Classification

The variable symptoms of PMS have been classified into four main categories by the American clinician and researcher Abraham in an attempt to facilitate research and elucidate the etiology of PMS and its links with lifestyle, including diet (Table 2). Abraham contended that each PMS category may exist alone or in combination with other categories. For example, PMS-D normally manifests itself in association with PMS-A, which is usually exhibited first.

Although other classification systems for PMS symptoms have been suggested, there is little evidence to suggest any greater merit of them over Abraham's system. In 1992 an attempt was made to systematize criteria and procedures for diagnosing PMS as LLPDD (late luteal phase dysphoric disorder) in the Diagnostic and Statistical Manual of Mental Disorders. Despite this, there remains much confusion surrounding the classification of PMS symptomatology, which has led to difficulties of data interpretation and diagnosis.

In the absence of quantifiable signs of PMS, most studies have relied upon the self-reporting of symptoms. The methods have largely fallen into two categories: the use of a retrospective Menstrual Health Questionnaire (MHQ) or use of a

Table 1 Summary of the most common premenstrual symptoms

Psychological

Somatic

Aggression Agitation Anorexia Anxiety

Craving for sweets

Argumentative

Confusion

Crying/easy upset

Decreased alertness

Decreased libido

Depression

Emotional liability

Forgetfulness

Hopelessness

Hunger

Impulsive behavior Increased appetite Lethargy Insomnia Irritability

Lack of inspiration Loss of attention Loss of concentration Loss of confidence Loss of self-esteem Pessimism Loss of self-control Nervous tension Mood swings Sadness Violent feelings Social isolation Suicidal tendency Tiredness

Abdominal bloating Acne/spots Breast swelling Breast tenderness Change in bowel habit Clumsiness Constipation Cramps

Diminished activity Diminished efficiency Diminished performance Dizziness Heart pounding Hot/cold flushes Headache General pain/aches Infections (e.g., cold) Passing water frequently Migraine Nausea/sickness Oedema

Poor concentration Swelling of extremities Weight gain prospective Menstrual Diary (MD). While the MHQ may be helpful in screening prospective volunteers for studies of PMS, the requirements for a useful instrument for assessing PMS must include the use of prospective recording and the

Table 2 Abraham's classification of premenstrual symptoms

PMS categorya

Symptoms

PMS-A (Anxiety) PMS-H (Hydration)

PMS-C (Craving)

PMS-D (Depression)

Anxiety, irritability, mood swings, nervous tension Weight gain, abdominal bloating and tenderness, breast tenderness, swelling of the extremities Premenstrual increased appetite, craving for sweets, fatigue, palpitations, headache Depression, withdrawal, lethargy, forgetfulness, confusion, insomnia, difficulty verbalizing aPMS (premenstrual syndrome) is used in place of Abraham's PMT (premenstrual tension).

quantification of symptoms which identify and exclude psychiatric occurrences.

Prevalence

PMS can first appear at any stage in the reproductive life of a woman. However, the most prevalent age of onset is usually from 28 to 34 years and symptoms may be first noticed following pregnancy or oral contraceptive use. The reported prevalence of PMS differs greatly from 21 to 90% of specific female populations studied. Some of this variability relates to the difficulty of a precise definition of PMS, its classification, and the reporting method used. In addition, other factors, such as age, parity, race, culture, psychopathology, menstrual characteristics, occupation, social activities, family life, lifestyle, and stress, may play a part. Indeed, reaction to stress has been advocated by a number of gynecologists as an underlying cause of PMS.

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