Premenstrual Syndrome (Premenstrual Tension)

A condition characterized by nervousness, irritability, emotional instability, anxiety, depression, and possibly headaches, edema, and mastalgia, occurring during the 7 to 10 days before and usually disappearing a few hours after onset of menses.

Etiology

Premenstrual syndrome (PMS) appears to be related to fluctuations in estrogen and progesterone. Estrogen and progesterone may cause transitory fluid retention, which seems to explain some PMS symptoms. Recent data suggest that women with PMS metabolize progesterone differently, producing less allopregnanolone (a neurosteroid that enhances GABAA receptor function in the brain and that has anxiolytic effects). Production of pregnenolone, which has an opposite effect in the brain, may be increased.

Pathogenesis

The etiology of the symptom complex of PMS is not known, although several theories have been proposed, including estrogen-progesterone imbalance, excess aldosterone, hypoglycemia, hyperprolactinemia, and psychogenic factors. A hormonal imbalance previously was thought to be related to the clinical manifestations of PMS/PMDD, but in the most recent consensus, physiologic ovarian function is believed to be the trigger. This is supported by the efficacy of ovarian cyclicity suppression, either medically or surgically, in eliminating premenstrual complaints.

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Further research has shown that serotonin (5-hydroxytryptamine [5-HT]), a neurotransmitter, is important in the pathogenesis of PMS/PMDD. Both estrogen and progesterone have been shown to influence the activity of serotonin centrally. Many of the symptoms of other mood disorders resembling the features of PMS/PMDD have been associated with serotonergic dysfunction.

Diagnosis

No objective screening or diagnostic tests for PMS and PMDD are available; thus special attention must be paid to the patient's medical history. Certain medical conditions (eg, thyroid disease and anemia) with symptoms that can mimic those of PMS/PMDD must be ruled out.

The patient is instructed to chart her symptoms for at least 2 symptomatic cycles. The classic criteria for PMS require that the patient have symptoms in the luteal phase and a symptom-free period of at least 7 days in the first half of the cycle for a minimum of 2 consecutive symptomatic cycles. To meet the criteria for PMDD, in addition to the criteria for PMS, she must have a chief complaint of at least 1 of the following: irritability, tension, dysphoria, or mood lability; and 5 of 11 of the following: depressed mood, anxiety, affective lability, irritability, decreased interest in daily activities, concentration difficulties, lack of energy, change in appetite or food cravings, sleep disturbances, feeling overwhelmed, or physical symptoms (eg, breast tenderness, bloating).