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Epidemiology and Etiology of Premenstrual Syndromes

Authors: Ellen W. Freeman, PhDFaculty and Disclosures



Premenstrual syndrome (PMS) is characterized by significant mood, behavioral, and physical changes that occur several days to 2 weeks before menses and abate during the menstrual flow. Although most menstruating women experience signs and symptoms linked to the menstrual cycle, the majority of these signs and symptoms are mild and reflect normal physiologic changes. However, a minority experience symptoms that impair work, relationships, and social activities. Women experiencing symptoms that decrease their level of functioning may be helped with medical treatment.

The term PMS is used in this column to describe symptoms linked to the menstrual cycle that are distressing or interfere with usual functioning. Other terms for clinically significant premenstrual symptoms include premenstrual tension, premenstrual dysphoria, cycle-related symptoms, menstrually related symptoms, late luteal phase dysphoric disorder, and premenstrual dysphoric disorder (PMDD). Clinical guidelines for PMS management have been developed by the American College of Obstetrics and Gynecology.[1]

PMDD is the most severe form of PMS. The condition has been categorized as a "depressive disorder not otherwise specified" in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)[2]; diagnosis is based on number and type of associated symptoms.

Several hundred symptoms have been attributed to PMS. This is partly due to the absence of clear diagnostic criteria that distinguish PMS from normal menstrual cycle changes or from other clinical problems. Consequently, symptoms associated with a number of physical and psychiatric disorders that are exacerbated premenstrually may be confused with PMS. Common disorders that may co-occur with PMS include migraine headache, panic disorder, and depression. One example of such concomitance was demonstrated by the large STAR-D study of major depressive disorder; 64% of premenopausal women not taking oral contraceptives reported premenstrual worsening of depression.[3] Other conditions can be differentiated from PMS because occurrence of associated symptoms is not limited to the luteal phase of the menstrual cycle.

Women with clinically significant PMS usually experience more than 1 symptom; on average, those seeking treatment report 3 or more troublesome symptoms. The most frequently reported mood symptoms such as irritability, anxiety, nervous tension, mood swings, feeling out of control, and depressed mood. Additional symptoms that often accompany mood symptoms include decreased interest in usual activities, fatigue, poor concentration, poor sleep, and physical changes such as breast tenderness and abdominal swelling.

Dysmenorrhea is not PMS. Dysmenorrhea is characterized by menstrual cramps, abdominal pain, or backache that may occur for several days prior to the onset of menses, but typically peak on the first day of flow.

The specific symptoms appear to have little importance in the diagnosis of PMS. The critical elements are the relationship of symptoms to the menstrual cycle, the severity of the symptoms, and the extent that symptoms limit usual functioning.

In contrast to PMS, the diagnosis of PMDD is based on patient report of at least 5 specific symptoms listed in the DSM-IV criteria, although it is acknowledged that these may vary from month to month. Criteria include physical symptoms, such as breast tenderness and joint pain; and mood symptoms, such as marked anxiety, persistent irritability, or feelings of hopelessness.[2]



Surveys indicate that PMS is among the most common health problems reported by reproductive age women. Current estimates of the prevalence of clinically significant PMS vary from 12.6% to 31% of menstruating women.[4] Epidemiologic studies have identified approximately 20% of reproductive age women as having moderate to severe PMS.[5]The prevalence of PMDD is estimated to affect 5% to 8% of menstruating women. Available data suggest that PMS occurs across cultures at essentially comparable rates.[6]


The morbidity of PMS is due to severity of symptoms, chronicity, and the resulting emotional distress or impairment in work, relationships, and activities. When assessed by standard measures, the level of impairment of PMS is significantly higher than community norms and is similar to that of major depression.[7] Women with PMS report greatest impairments in personal relationships, compromised work levels, and increased absenteeism from work.

Current clinical evidence suggests that PMS tends to be a chronic illness with little spontaneous recovery. Symptoms that improve with medical treatment may worsen quickly after treatment is stopped.[8] Data have indicated that an individual diagnosed with PMDD experiences 3.8 years of disability during her reproductive years.[6]

Risk Factors for Premenstrual Syndrome

Population-based studies have not consistently found strong association between PMS and standard demographic risk factors such as education, income, employment, marital status, or number of children.[9] Racial differences have been reported in several studies, with blacks reporting more physical symptoms and more depressed mood compared to whites. However, other data are conflicting and well-designed studies are needed to definitively identify potential demographic risk factors.[10]

Menstrual cycle characteristics such as cycle length or age at menarche have not been associated with PMS. Oral contraceptive use is also not considered a risk factor for PMS.[11]

Age. PMS appears to be associated with ovulatory menstrual cycles. Therefore, it may begin at any time after menarche and continue until ovulation ends at menopause. The majority of patients initially seeking treatment for PMS are aged from mid-20s to late-30s. However, many report that PMS symptoms started a decade earlier. There is evidence that some adolescents experience the same symptoms and the severity levels as older women,[12] but this age group has not yet been represented in clinical trials and data-based evidence is limited.

Stress. Higher levels of perceived stress and higher "daily hassles" scores have been identified as risk factors for PMS by population-based studies.[13 Traumatic events have been shown to increase the odds of developing PMDD more than 4 times.

Genetics. Studies of twins have significantly contributed to data related to possible genetic factors in PMS.[14] Kendler and colleagues[15] identified substantial heritability of premenstrual depression and anxiety. These researchers concluded that the genetic risk factors for PMS are not closely related to genetic risk factors for lifetime major depression. No genetic marker or polymorphic profile for PMS has been identified.[16]

Obesity. A strong association between PMS and a body mass index ≥30 is reported in a recent population-based study.[17] Because previous studies have not focused on the relationship between obesity and PMS, further investigation is needed to confirm these findings.

Overall Health. Women with other health problems are more likely to have PMS. The presence of just 1 medical or psychological problem has been demonstrated to increase the risk of PMS nearly 2 times.[5]

Depression and Anxiety. Current mood and anxiety disorders or history of mood or anxiety disorders are common in women with PMS.[18] In a population-based study, nearly 50% of those with PMDD were found to have an anxiety disorder currently or in the past year compared with only 22% without PMDD; approximately 30% with PMDD had a depressive disorder compared with 12% without.[5] In another study of women seeking PMS treatment, 31% had a current mood disorder and 15% a current anxiety disorder.[19]

Table of Contents

  1. Overview
  2. Etiology
  • Print