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# Premenstrual syndrome and premenstrual dysphoric disorder

Premenstrual syndrome is a set of physical and emotional symptoms before periods. Its severe form, PMDD, disrupts work, study and relationships.

Updated 2026-11-01

## Structures involved

Tap one to see what it is and open it in 3D.

- [Ovaries](https://durgical.com/en/anatomy/ovary/)
- [Hypothalamus](https://durgical.com/en/anatomy/hypothalamus/)
- [Endometrium](https://durgical.com/en/anatomy/endometrium/)
- [Pituitary gland](https://durgical.com/en/anatomy/pituitary-gland/)
- [Amygdala](https://durgical.com/en/anatomy/amygdaloid-body/)

## Why it happens

- [The menstrual cycle: ovary and endometrium](https://durgical.com/en/physiology/the-menstrual-cycle-ovary-and-endometrium/)
- [Actions of estrogen and progesterone](https://durgical.com/en/physiology/actions-of-estrogen-and-progesterone/)
- [The main neurotransmitters](https://durgical.com/en/physiology/the-main-neurotransmitters/)

## What it is

Premenstrual syndrome (PMS) is a pattern of physical and emotional symptoms that appear in the luteal phase and resolve within a few days of menstruation. Premenstrual dysphoric disorder (PMDD) is its severe form, with predominant mood symptoms that impair functioning, and is classified as a depressive disorder.

## Who gets it

Mild premenstrual symptoms are very common in women of reproductive age; clinically significant PMS affects a smaller group, and PMDD a few percent. Symptoms usually begin in the teens or twenties and stop with menopause, pregnancy or suppression of ovulation.

## Causes

- Abnormal brain sensitivity to the normal cyclic changes of oestrogen and progesterone
- Altered response to allopregnanolone, a progesterone metabolite that acts on GABA receptors
- Serotonin dysregulation
- Genetic predisposition

## Risk factors

- Family history of PMS or PMDD
- Personal history of depression, anxiety or postpartum depression
- Trauma and chronic stress
- Smoking

## Pathophysiology

Hormone levels are usually normal; the problem is how the brain reacts to them. After ovulation, rising and falling progesterone and its neuroactive metabolites change GABA and serotonin signalling in mood-regulating areas such as the [amygdala](https://durgical.com/en/anatomy/amygdaloid-body/) and prefrontal cortex. In susceptible women this produces irritability, low mood and anxiety, which disappear when ovulation stops.

## Classification

- Premenstrual syndrome (PMS)
- Premenstrual dysphoric disorder (PMDD, DSM-5 depressive disorder)
- Premenstrual exacerbation of another disorder

## Symptoms and signs

- Irritability, anger and interpersonal conflict
- Mood swings, sadness or tearfulness
- Anxiety or tension
- Fatigue, poor concentration, sleep changes
- Food cravings or appetite changes
- Breast tenderness, bloating, headache, joint or muscle pain

## Red flags

- Suicidal thoughts or self-harm
- Symptoms that do not resolve after menstruation (suggests another disorder)
- Severe impairment of work, study or relationships

## Diagnosis

**Clinical**
Symptoms confined to the luteal phase, improving within a few days of menstruation and minimal in the week after, confirmed by prospective daily symptom ratings over at least two cycles. PMDD (DSM-5) requires at least five symptoms, at least one of them affective (marked mood swings, irritability, depressed mood or anxiety), with significant distress or dysfunction.

**Tests**
No laboratory test confirms it; TSH and haemoglobin can exclude thyroid disease and anaemia when suggested by the history.

**Imaging**
Not required.

## Differential diagnosis

- Major depressive disorder or persistent depressive disorder
- Generalised anxiety disorder
- Bipolar disorder
- Premenstrual exacerbation of another psychiatric or medical condition
- Thyroid disease
- Perimenopause

## Goal of treatment

Reduce symptoms and restore daily functioning, starting with education and lifestyle measures and escalating according to severity.

## Treatment

**Lifestyle**
Regular aerobic exercise, sleep regularity, stress management, and reducing caffeine, alcohol and salt; symptom diary to track cycles.

**Conservative**
Cognitive behavioural therapy, especially for emotional symptoms.

**Medical**
SSRIs are first-line drug treatment for PMDD and severe PMS, taken continuously or only in the luteal phase; their effect appears faster than in depression.

**Medical**
Ovulation suppression with combined oral contraceptives (for example drospirenone-containing regimens); GnRH agonists with add-back hormones for refractory cases.

**Follow-up**
Screening for suicidal ideation and coexisting mood disorders, and follow-up of response with daily ratings.

## Complications

- Impaired work, school and relationships
- Depression and suicide risk in PMDD
- Reduced quality of life

## Prognosis

Symptoms tend to recur each cycle until menopause but respond well to treatment; most women with PMDD improve with SSRIs or ovulation suppression.

## Test yourself

Think of the answer, then tap the question to see it.

## What timing pattern is required to diagnose PMS or PMDD?

Symptoms in the luteal phase that resolve within a few days of menstruation, with a symptom-free interval after menses.

## How is the diagnosis confirmed?

With prospective daily symptom ratings over at least two menstrual cycles.

## What is first-line drug treatment for PMDD?

SSRIs, given continuously or only during the luteal phase.

## Are hormone levels abnormal in PMDD?

No; levels are usually normal, and the disorder reflects abnormal brain sensitivity to normal hormonal changes.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/conditions/premenstrual-syndrome-and-premenstrual-dysphoric-disorder/)

## Related conditions

- [Major depressive disorder](https://durgical.com/en/conditions/major-depressive-disorder/)
- [Generalized anxiety disorder](https://durgical.com/en/conditions/generalized-anxiety-disorder/)
- [Bipolar disorder](https://durgical.com/en/conditions/bipolar-disorder/)
- [Persistent depressive disorder (dysthymia)](https://durgical.com/en/conditions/persistent-depressive-disorder/)
- [Hypothyroidism](https://durgical.com/en/conditions/hypothyroidism/)
- [Menopause and climacteric syndrome](https://durgical.com/en/conditions/menopause-and-climacteric-syndrome/)
- [Endometriosis](https://durgical.com/en/conditions/endometriosis/)
- [Suicidal behaviour and suicide risk](https://durgical.com/en/conditions/suicidal-behaviour-and-suicide-risk/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Premenstrual Syndrome](https://medlineplus.gov/premenstrualsyndrome.html) (MedlinePlus (U.S. National Library of Medicine), 2024); [Premenstrual dysphoric disorder](https://medlineplus.gov/ency/article/007193.htm) (MedlinePlus (U.S. National Library of Medicine), 2024).

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Source: https://durgical.com/en/conditions/premenstrual-syndrome-and-premenstrual-dysphoric-disorder/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/premenstrual-syndrome-and-premenstrual-dysphoric-disorder/