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Health Protocols

Premenstrual Syndrome (PMS)


PMS and PMDD are diagnosed on the basis of a woman’s symptoms and medical history (Pinkerton 2013; Nillni 2011; Rees 2014). It is important that other gynecological conditions that may cause similar symptoms be distinguished from PMS and PMDD. Menopausal symptoms, endometriosis, dysmenorrhea (painful cramping during the menstrual period), and several other conditions may be mistaken for PMS or PMDD (Yonkers 2008; Rapkin 2014).

PMS and PMDD symptoms must be cyclical, in that a symptom-free interval occurs during the follicular phase. Patients with symptoms that do not remit during the follicular phase may have another disorder or condition with similar symptoms (Rees 2014; Alvero 2014). Practice guidelines recommend that women record their symptoms in a daily diary for at least two consecutive menstrual cycles to help establish a diagnosis (Nevatte 2013; Endicott 2006).

Tests may be performed to rule out other diseases or conditions that cause symptoms similar to those caused by PMS. For instance, thyroid function tests can rule out the possibility of thyroid disease (Rees 2014). Questionnaires may be used to screen for depression and generalized anxiety disorder (Alvero 2014). Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels can help determine if symptoms may be related to menopause ( 2013).

Physicians can diagnose PMS on the basis of standardized criteria from sources such as the International Statistical Classification of Diseases and Related Health Problems 10th edition (ICD-10), which uses the term “premenstrual tension syndrome,” or the American Congress of Obstetricians and Gynecologists (ACOG) guidelines. PMDD is diagnosed based on the guidelines from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) (Rees 2014). The requirements and possible symptoms for each diagnostic tool are listed in Table 2.

Table 2: Symptoms and Symptom Requirements for the ICD-10, ACOG, and DSM-5 Diagnostic Tools for PMS and PMDD*

Diagnostic Tool



ICD-10 — PMS

  • One distressing physical or behavioral symptom
  • feeling sad, hopeless, or self-deprecating
  • tension, anxiety, tearfulness, persistent irritability, or easily changing moods
  • anger
  • decreased interest in usual activities
  • difficulty concentrating
  • fatigue
  • changes in appetite
  • hypersomnia or insomnia
  • feeling overwhelmed or out of control
  • physical symptoms such as headaches, breast tenderness or swelling, joint or muscle pain, bloating or weight gain


  • At least one of the affective and physical symptoms
  • Symptoms occur during five days before menses in each of three previous cycles, and occur in two cycles of recording symptoms
  • Symptoms relieved within four days of menstruation
  • Symptoms do not recur until day 13 or later of cycle
  • Patient suffers from social and economic performance dysfunction
  • Symptoms present in the absence of pharmacologic or hormonal therapy, drugs or alcohol

  Affective symptoms:

  • anxiety
  • confusion
  • depression
  • irritability
  • angry outbursts
  • social withdrawal

 Physical symptoms:

  • headaches
  • breast tenderness
  • abdominal bloating
  • lower-extremity swelling

DSM-5 for PMDD

  • At least 5 of 11 symptoms during the luteal phase
  • Symptoms must resolve soon after menstruation begins
  • Symptoms must include at least 1 of the first 4 listed symptoms
  • Symptoms must be present in the absence of medical drug or hormone use, and not be associated with another psychiatric disorder
  • Symptoms must interfere with usual activities and relationships
  • Symptoms must have occurred during most of the previous 12 months
  • Symptoms must occur during two months of recording symptoms
  • depressed mood
  • significant anxiety
  • easily changing moods
  • persistent anger/irritability
  • decreased interest in usual activities
  • difficulty concentrating
  • lethargy
  • change in eating habits
  • insomnia or hypersomnia
  • feeling of being overwhelmed
  • physical symptoms such as breast tenderness, headaches, bloating, or weight gain

*Derived from (Rees 2014; ACOG 2001)