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Epidemiology and pathogenesis of premenstrual syndrome and premenstrual dysphoric disorder

Kimberly A Yonkers, MD
Robert F Casper, MD
Section Editors
Robert L Barbieri, MD
William F Crowley, Jr, MD
Deputy Editor
Kathryn A Martin, MD


The premenstrual syndrome (PMS) and the more severe variant of premenstrual dysphoric disorder (PMDD), also called late luteal phase dysphoric disorder in previous versions of the Diagnostic and Statistical Manual (DSM), are characterized by the presence of physical and/or behavioral symptoms that occur repetitively in the second half of the menstrual cycle and often the first few days of menses. The symptoms of PMS or PMDD are severe enough that they interfere with some aspects of the woman's life (eg, family or other social relations, work in or outside the home, etc). The most common physical manifestation is abdominal bloating [1,2]. Breast tenderness and headaches are also common (table 1). (See "Clinical manifestations and diagnosis of premenstrual syndrome and premenstrual dysphoric disorder".)

The diagnosis of PMDD is discussed in greater detail elsewhere. The clinical manifestations, diagnosis, and treatment of PMS/PMDD are discussed separately. (See "Clinical manifestations and diagnosis of premenstrual syndrome and premenstrual dysphoric disorder" and "Treatment of premenstrual syndrome and premenstrual dysphoric disorder".)


Premenstrual dysphoric disorder (PMDD), as defined by the American Psychiatric Association (APA) Diagnostic and Statistical Manual, Fifth Edition (DSM-5), can be differentiated from premenstrual syndrome (PMS) by the presence of at least one affective symptom, such as mood swings, irritability, and/or depression [3]. Premenstrual symptoms are common, affecting up to 75 percent of women with regular menstrual cycles. Clinically significant PMS occurs in 3 to 8 percent of women [1,4], while PMDD affects about 2 percent of women.

The prevalence of PMS in the population has been overestimated because of the failure to apply strict inclusion criteria. Estimates as high as 80 percent have been reported, based upon the inclusion of women who have some form of premenstrual mood or physical symptoms [5]. The problem with these estimates is that they do not consider whether symptoms are moderate to severe or if they interfere with functioning. When one applies strict inclusion criteria for PMDD, estimates are around 2 percent, as illustrated by three community studies that used prospective ratings to determine the diagnosis [6-8]. (See "Clinical manifestations and diagnosis of premenstrual syndrome and premenstrual dysphoric disorder", section on 'Evaluation'.)

PMS has been described in diverse cultural settings, even among women who are not generally aware of the disorder. As an example, similar rates of the disorder have been reported in Mediterranean countries, the Middle East, Iceland, Kenya, and New Zealand [9-12]. In an international survey of 7226 women in Europe, South America, and Asia, the frequency of PMS symptoms was similar across countries and regions, but women in some countries, such as Pakistan, were less familiar with the term PMS when compared with European women [13].


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Literature review current through: Sep 2016. | This topic last updated: Jan 4, 2016.
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  1. Deuster PA, Adera T, South-Paul J. Biological, social, and behavioral factors associated with premenstrual syndrome. Arch Fam Med 1999; 8:122.
  2. Hartlage SA, Freels S, Gotman N, Yonkers K. Criteria for premenstrual dysphoric disorder: secondary analyses of relevant data sets. Arch Gen Psychiatry 2012; 69:300.
  3. Epperson CN, Steiner M, Hartlage SA, et al. Premenstrual dysphoric disorder: evidence for a new category for DSM-5. Am J Psychiatry 2012; 169:465.
  4. Borenstein J, Chiou CF, Dean B, et al. Estimating direct and indirect costs of premenstrual syndrome. J Occup Environ Med 2005; 47:26.
  5. Budeiri DJ, Li Wan Po A, Dornan JC. Clinical trials of treatments of premenstrual syndrome: entry criteria and scales for measuring treatment outcomes. Br J Obstet Gynaecol 1994; 101:689.
  6. Rivera-Tovar AD, Frank E. Late luteal phase dysphoric disorder in young women. Am J Psychiatry 1990; 147:1634.
  7. Soares CN, Cohen LS, Otto MW, Harlow BL. Characteristics of women with premenstrual dysphoric disorder (PMDD) who did or did not report history of depression: a preliminary report from the Harvard Study of Moods and Cycles. J Womens Health Gend Based Med 2001; 10:873.
  8. Gehlert S, Song IH, Chang CH, Hartlage SA. The prevalence of premenstrual dysphoric disorder in a randomly selected group of urban and rural women. Psychol Med 2009; 39:129.
  9. Raja SN, Feehan M, Stanton WR, McGee R. Prevalence and correlates of the premenstrual syndrome in adolescence. J Am Acad Child Adolesc Psychiatry 1992; 31:783.
  10. Monagle L, Dan A, Krogh V, et al. Perimenstrual symptom prevalence rates: an Italian-American comparison. Am J Epidemiol 1993; 138:1070.
  11. Rupani NP, Lema VM. Premenstrual tension among nurses in Nairobi, Kenya. East Afr Med J 1993; 70:310.
  12. Sveinsdóttir H, Marteinsdóttir G. Retrospective assessment of premenstrual changes in Icelandic women. Health Care Women Int 1991; 12:303.
  13. Dennerstein L, Lehert P, Heinemann K. Global study of women's experiences of premenstrual symptoms and their effects on daily life. Menopause Int 2011; 17:88.
  14. Pilver CE, Kasl S, Desai R, Levy BR. Health advantage for black women: patterns in pre-menstrual dysphoric disorder. Psychol Med 2011; 41:1741.
  15. Kendler KS, Karkowski LM, Corey LA, Neale MC. Longitudinal population-based twin study of retrospectively reported premenstrual symptoms and lifetime major depression. Am J Psychiatry 1998; 155:1234.
  16. Treloar SA, Heath AC, Martin NG. Genetic and environmental influences on premenstrual symptoms in an Australian twin sample. Psychol Med 2002; 32:25.
  17. Miller A, Vo H, Huo L, et al. Estrogen receptor alpha (ESR-1) associations with psychological traits in women with PMDD and controls. J Psychiatr Res 2010; 44:788.
  18. Huo L, Straub RE, Roca C, et al. Risk for premenstrual dysphoric disorder is associated with genetic variation in ESR1, the estrogen receptor alpha gene. Biol Psychiatry 2007; 62:925.
  19. Cohen LS, Soares CN, Otto MW, et al. Prevalence and predictors of premenstrual dysphoric disorder (PMDD) in older premenopausal women. The Harvard Study of Moods and Cycles. J Affect Disord 2002; 70:125.
  20. Perkonigg A, Yonkers KA, Pfister H, et al. Risk factors for premenstrual dysphoric disorder in a community sample of young women: the role of traumatic events and posttraumatic stress disorder. J Clin Psychiatry 2004; 65:1314.
  21. Schmidt PJ, Nieman LK, Danaceau MA, et al. Differential behavioral effects of gonadal steroids in women with and in those without premenstrual syndrome. N Engl J Med 1998; 338:209.
  22. Andersch B, Abrahamsson L, Wendestam C, et al. Hormone profile in premenstrual tension: effects of bromocriptine and diuretics. Clin Endocrinol (Oxf) 1979; 11:657.
  23. Taylor JW. Plasma progesterone, oestradiol 17 beta and premenstrual symptoms. Acta Psychiatr Scand 1979; 60:76.
  24. Schmidt PJ, Purdy RH, Moore PH Jr, et al. Circulating levels of anxiolytic steroids in the luteal phase in women with premenstrual syndrome and in control subjects. J Clin Endocrinol Metab 1994; 79:1256.
  25. Chan AF, Mortola JF, Wood SH, Yen SS. Persistence of premenstrual syndrome during low-dose administration of the progesterone antagonist RU 486. Obstet Gynecol 1994; 84:1001.
  26. Wardlaw SL, Thoron L, Frantz AG. Effects of sex steroids on brain beta-endorphin. Brain Res 1982; 245:327.
  27. Majewska MD, Harrison NL, Schwartz RD, et al. Steroid hormone metabolites are barbiturate-like modulators of the GABA receptor. Science 1986; 232:1004.
  28. Bethea CL. Regulation of progestin receptors in raphe neurons of steroid-treated monkeys. Neuroendocrinology 1994; 60:50.
  29. Chuong CJ, Coulam CB, Kao PC, et al. Neuropeptide levels in premenstrual syndrome. Fertil Steril 1985; 44:760.
  30. Chuong CJ, Hsi BP, Gibbons WE. Periovulatory beta-endorphin levels in premenstrual syndrome. Obstet Gynecol 1994; 83:755.
  31. Giannini AJ, Martin DM, Turner CE. Beta-endorphin decline in late luteal phase dysphoric disorder. Int J Psychiatry Med 1990; 20:279.
  32. Chuong CJ, Hsi BP. Effect of naloxone on luteinizing hormone secretion in premenstrual syndrome. Fertil Steril 1994; 61:1039.
  33. Smith S, Rinehart JS, Ruddock VE, Schiff I. Treatment of premenstrual syndrome with alprazolam: results of a double-blind, placebo-controlled, randomized crossover clinical trial. Obstet Gynecol 1987; 70:37.
  34. Rapkin AJ, Morgan M, Goldman L, et al. Progesterone metabolite allopregnanolone in women with premenstrual syndrome. Obstet Gynecol 1997; 90:709.
  35. Rapkin AJ, Edelmuth E, Chang LC, et al. Whole-blood serotonin in premenstrual syndrome. Obstet Gynecol 1987; 70:533.
  36. Taylor DL, Mathew RJ, Ho BT, Weinman ML. Serotonin levels and platelet uptake during premenstrual tension. Neuropsychobiology 1984; 12:16.
  37. Ashby CR Jr, Carr LA, Cook CL, et al. Alteration of platelet serotonergic mechanisms and monoamine oxidase activity in premenstrual syndrome. Biol Psychiatry 1988; 24:225.
  38. Steege JF, Stout AL, Knight DL, Nemeroff CB. Reduced platelet tritium-labeled imipramine binding sites in women with premenstrual syndrome. Am J Obstet Gynecol 1992; 167:168.
  39. Rojansky N, Halbreich U, Zander K, et al. Imipramine receptor binding and serotonin uptake in platelets of women with premenstrual changes. Gynecol Obstet Invest 1991; 31:146.
  40. Eriksson E, Alling C, Andersch B, et al. Cerebrospinal fluid levels of monoamine metabolites. A preliminary study of their relation to menstrual cycle phase, sex steroids, and pituitary hormones in healthy women and in women with premenstrual syndrome. Neuropsychopharmacology 1994; 11:201.
  41. Brzezinski AA, Wurtman JJ, Wurtman RJ, et al. d-Fenfluramine suppresses the increased calorie and carbohydrate intakes and improves the mood of women with premenstrual depression. Obstet Gynecol 1990; 76:296.
  42. Menkes DB, Coates DC, Fawcett JP. Acute tryptophan depletion aggravates premenstrual syndrome. J Affect Disord 1994; 32:37.
  43. Roca CA, Schmidt PJ, Smith MJ, et al. Effects of metergoline on symptoms in women with premenstrual dysphoric disorder. Am J Psychiatry 2002; 159:1876.
  44. Chuong CJ, Dawson EB, Smith ER. Vitamin A levels in premenstrual syndrome. Fertil Steril 1990; 54:643.
  45. Chuong CJ, Dawson EB, Smith ER. Vitamin E levels in premenstrual syndrome. Am J Obstet Gynecol 1990; 163:1591.
  46. Chocano-Bedoya PO, Manson JE, Hankinson SE, et al. Dietary B vitamin intake and incident premenstrual syndrome. Am J Clin Nutr 2011; 93:1080.
  47. Wyatt KM, Dimmock PW, Jones PW, Shaughn O'Brien PM. Efficacy of vitamin B-6 in the treatment of premenstrual syndrome: systematic review. BMJ 1999; 318:1375.
  48. Whelan AM, Jurgens TM, Naylor H. Herbs, vitamins and minerals in the treatment of premenstrual syndrome: a systematic review. Can J Clin Pharmacol 2009; 16:e407.
  49. Sherwood RA, Rocks BF, Stewart A, Saxton RS. Magnesium and the premenstrual syndrome. Ann Clin Biochem 1986; 23 ( Pt 6):667.
  50. Facchinetti, F, Borella, P, Fioroni, L, et al. Reduction of monocyte's magnesium in patients affected by premenstrual syndrome. J Psychosom Obstet Gynaecol 1990; 11:221.
  51. Rosenstein DL, Elin RJ, Hosseini JM, et al. Magnesium measures across the menstrual cycle in premenstrual syndrome. Biol Psychiatry 1994; 35:557.
  52. Cerin A, Collins A, Landgren BM, Eneroth P. Hormonal and biochemical profiles of premenstrual syndrome. Treatment with essential fatty acids. Acta Obstet Gynecol Scand 1993; 72:337.
  53. Posaci C, Erten O, Uren A, Acar B. Plasma copper, zinc and magnesium levels in patients with premenstrual tension syndrome. Acta Obstet Gynecol Scand 1994; 73:452.
  54. Facchinetti F, Borella P, Sances G, et al. Oral magnesium successfully relieves premenstrual mood changes. Obstet Gynecol 1991; 78:177.