Premenstrual Syndrome (PMS)

(Premenstrual Dysphoric Disorder; Premenstrual Tension)

ByJoAnn V. Pinkerton, MD, University of Virginia Health System
Reviewed/Revised Jan 2023
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Premenstrual syndrome (PMS) is a recurrent luteal-phase disorder characterized by irritability, anxiety, emotional lability, depression, edema, breast pain, and headaches, occurring during the 5 days before and usually ending a few hours after onset of menses. Premenstrual dysphoric disorder is a severe form of PMS. Diagnosis is clinical, often based on the patient’s daily recording of symptoms. Treatment is symptomatic and includes diet, medications, and counseling.

About 20 to 50% of women of reproductive age have PMS; about 5% have a severe form of PMS called premenstrual dysphoric disorder (PMDD).

Etiology of PMS

The cause of PMS is unclear.

Possible causes or contributing factors include

  • Multiple endocrine factors (eg, hypoglycemia, other changes in carbohydrate metabolism, hyperprolactinemia, fluctuations in levels of circulating estrogen and progesterone, abnormal responses to estrogen and progesterone, excess aldosterone or antidiuretic hormone [ADH])

  • Genetic predisposition

  • Serotonin deficiency

  • Possibly magnesium and calcium deficiencies

Estrogen and progesterone can cause transitory fluid retention, as can excess aldosterone or ADH.

Serotonin deficiency is thought to contribute because women who are most affected by PMS have lower serotonin levels and because selective serotonin reuptake inhibitors (SSRIs), which increase serotonin, sometimes relieve symptoms of PMS.

Magnesium and calcium deficiencies may contribute.

Symptoms and Signs of PMS

Type and intensity of PMS symptoms vary from woman to woman and from cycle to cycle. Symptoms typically start during the 5 days before menses and ending within a few hours of when menses begins. Symptoms may become more severe during stress or perimenopause. In perimenopausal women, symptoms may persist until after menses.

The most common symptoms are irritability, anxiety, agitation, anger, insomnia, difficulty concentrating, lethargy, depression, and severe fatigue. Fluid retention causes edema, transient weight gain, and breast fullness and pain. Pelvic heaviness or pressure and backache may occur. Some women, particularly younger ones, have dysmenorrhea when menses begins.

Other nonspecific symptoms may include headache, vertigo, paresthesias of the extremities, syncope, palpitations, constipation, nausea, vomiting, and changes in appetite. Acne and neurodermatitis may also occur.

Preexisting disorders may worsen while PMS symptoms are occurring. They include the following:

  • Skin disorders

  • Eye problems (eg, conjunctivitis)

  • Seizure disorders (increased seizures)

  • Connective tissue disorders (eg, systemic lupus erythematosus [SLE, or lupus], rheumatoid arthritis, with flare-ups)

  • Respiratory disorders (eg, allergies, infections)

  • Migraines

  • Mood disorders (eg, depression, anxiety)

  • Sleep disorders (eg, insomnia, hypersomnia)

Premenstrual dysphoric disorder (PMDD)

Some women have premenstrual dysphoric disorder (PMDD—see also Premenstrual dysphoric disorder under Symptoms and Signs of Depressive Disorders), a severe form of PMS. In PMDD, symptoms occur regularly and only during the 2nd half of the menstrual cycle; symptoms end with menses or shortly after. Mood is markedly depressed, and anxiety, irritability, and emotional lability are pronounced. Suicidal thoughts may be present. Interest in daily activities is greatly decreased.

In contrast to PMS, PMDD causes symptoms that are severe enough to interfere with routine daily activities or overall functioning. PMDD is severely distressing, disabling, and often underdiagnosed.

Pearls & Pitfalls

  • Consider premenstrual dysphoric disorder if women have nonspecific but severe symptoms that affect their ability to function just before menses.

Diagnosis of PMS

  • For PMS, patient’s report of symptoms

  • Sometimes a depression inventory

  • For PMDD, clinical criteria

PMS is diagnosed based on physical symptoms (eg, bloating, weight gain, breast tenderness, swelling of hands and feet). Women may be asked to record their symptoms daily. Physical examination and laboratory testing are not helpful.

If PMDD is suspected, women are asked to rate their symptoms daily for 2 cycles to determine whether severe symptoms occur regularly.

For PMDD to be diagnosed, women must have 5 of the following symptoms for most of the week before menses, and symptoms must become minimal or absent during the week after menstruation. Symptoms must include ≥ 1 of the following:

  • Marked mood swings (eg, sudden sadness)

  • Marked irritability or anger or increased interpersonal conflicts

  • Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts

  • Marked anxiety, tension, or an on-edge feeling

In addition, ≥ 1 of the following must be present:

  • Decreased interest in usual activities, possibly causing withdrawal

  • Difficulty concentrating

  • Low energy or fatigue

  • Marked changes in appetite, overeating, or specific food cravings

  • Insomnia or hyperinsomnia

  • Feelings of being overwhelmed or out of control

  • Physical symptoms associated with PMS (eg, breast tenderness, edema)

Also, the symptom pattern must have occurred for most of the previous 12 months, and symptoms must be severe enough to interfere with daily activities and function.

Patients with symptoms of depression are evaluated using a depression inventory or are referred to a mental health care practitioner for formal evaluation.

Treatment of PMS

  • Sleep hygiene, exercise, and healthy diet

  • Sometimes selective serotonin reuptake inhibitors (SSRIs) or hormonal medications

PMS can be difficult to treat. No single treatment has proven efficacy for all women, and few woman have complete relief with any single type of treatment. Treatment can thus require trial and error, as well as patience.

General measures

Treatment of PMS is symptomatic, beginning with adequate rest and sleep, regular exercise, and activities that are relaxing. Regular exercise may help alleviate bloating as well as irritability, anxiety, and insomnia. Yoga helps some women.

Cognitive-behavioral therapy may help if mood issues are a major concern, including in women with PMDD. Biofeedback and guided imagery may also help. Psychotherapy can help a woman learn to better cope with the symptoms; stress reduction and relaxation techniques and meditation can help relieve tension and strain.


Nonsteroidal anti-inflammatory drugs (NSAIDs) can help relieve aches, pains, and dysmenorrhea.

For some women, hormonal manipulation is effective. Options include

  • Oral contraceptives


In women with severe symptoms, bilateral oophorectomy may alleviate symptoms because it eliminates menstrual cycles; hormone replacement therapy is then indicated until about age 51 (the average for menopause).

Key Points

  • Symptoms of premenstrual syndrome (PMS) can be nonspecific and vary from woman to woman.

  • Diagnose PMS based on symptoms alone.

  • If symptoms seem severe and disabling, consider premenstrual dysphoric disorder (PMDD), which is often underdiagnosed, and ask patients to record symptoms for ≥ 2 cycles; for a diagnosis of PMDD, clinical criteria must be met.

  • Usually, treatment is a matter of trying various strategies to identify what helps a particular patient; start with lifestyle modifications, then SSRIs, oral contraceptives, or sometimes cognitive-behavioral therapy.

  • GnRH agonists and oophorectomy are reserved for severe cases.

More Information

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

  1. Lanza di Scalea T, Pearlstein T: Premenstrual dysphoric disorder. Med Clin North Am 103(4):613–628, 2019. doi: 10.1016/j.mcna.2019.02.007: This article discusses the definition, etiology, and treatment of premenstrual dysphoric disorder.

  2. Appleton SM: Premenstrual syndrome: Evidence-based evaluation and treatment. Clin Obstet Gynecol (1):52–61, 2018. doi: 10.1097/GRF.0000000000000339: Evidence for diagnosis and treatment is reviewed.

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