Definitions PMS/PMDD

NAPS Statement on the definition of PMS

Current situation

Premenstrual Syndromes refers to a spectrum of mood and physical symptoms that occur during the luteal phase of the menstrual cycle (i.e. the phase that begins after ovulation and ends with the start of menstruation). The fields of Psychiatry and Gynaecology have developed separate, but overlapping, diagnostic criteria for premenstrual syndromes.

The American Psychiatric Association (APA) criteria focus predominantly on psychiatric symptoms. These are defined, under the term premenstrual dysphoric disorder (PMDD), within the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). PMDD requires that 5 out of 11 stipulated symptoms (one of which must be from a list of 4 specific mood symptoms), are present during the luteal phase of the menstrual cycle. The diagnosis excludes the exacerbation of another disorder (e.g. depression or panic disorder) and must be severe enough to disrupt daily functioning.

The American Congress of Obstetricians and Gynecologists (ACOG) focuses more equally on psychiatric and physical symptoms in its definition of premenstrual syndrome (PMS). It only requires that 1 out of 6 stipulated mood symptoms, and 1 of 4 stipulated physical symptoms, are present. Further, it does not exclude the exacerbation of another disorder (e.g. depression or panic disorder). However, it stipulates that there must be associated subjective reports of dysfunction.

The World Health Organisation (WHO) focuses predominantly on psychiatric symptoms. These are defined, under the term Premenstrual Tension Syndrome (PMTS) within the International Statistical Classification of Diseases and Related Health Problems (ICD-10). It requires that only 1 out of 9 stipulated mood, or 1 out of a list of other physical symptoms are present. Further, it does not exclude symptoms caused by the exacerbation of another disorder (e.g. depression or panic disorder) or require subjective reports of dysfunction.

Diagnostic criteria for Premenstrual Syndromes:

American Psychiatric Association (APA)

  • Criteria: Diagnostic and Statistical Manual of Mental Disorders (DSM-V)
  • Diagnostic Term: Premenstrual Dysphoric Disorder (PMDD)
  • 5/11 symptoms required (one of which must be from a list of four specific mood symptoms)
  • Can include the exacerbation of another psychiatric disorder
  • Requires significant functional dysfunction
  • 5% prevalence in women of reproductive age

American Congress of Obstetricians and Gynecologists (ACOG)

  • Criteria: N/A
  • Diagnostic Term: Premenstrual Syndrome (PMS)
  • 1/6 mood symptoms required, and 1/4 physical symptoms required
  • Can include the exacerbation of another psychiatric disorder
  • Requires significant functional dysfunction?
  • 30% prevalence in women of reproductive age

The World Health Organisation (WHO)

  • Criteria: International Statistical Classification of Diseases and Related Health Problems (ICD-10)
  • Diagnostic Term: Premenstrual Tension Syndrome (PMTS)
  • 1/9 mood symptoms or one physical symptom required
  • Can include the exacerbation of another psychiatric disorder?
  • Does not require significant functional dysfunction
  • 80% Prevalence in women of reproductive age


With permission of Dr. Michael Craig PhD FRCOG FRCPsych

Critique

There is considerable concern, particularly amongst severely affected sufferers, that the ICD-10 terminology for PMTS is over-inclusive, and consequently results in the condition not being taken seriously by the public, media and health professionals.

Conversely, there is a concern by other sufferers, that premenstrual symptoms required for a diagnosis of PMDD based on the DSM-V criteria are too strict and leave many women with significant dysfunction without a clinical diagnosis and effective management.

The way forward

Taking all this into account, NAPS trustees have reached the following consensus which is in line with the information in the recently published Royal College of Obstetricians and Gynaecologists’ Green Top Guidelines on PMS.2

1) NAPS will change its name to the National Association for Premenstrual Syndromes from “Syndrome”  to reflect the variation in definitions and severities of this disorder.

2) Current PMS terminology should however, be maintained because

  • PMDD refers to only one type of severe form of PMS
  • PMDD excludes some women with severe PMS due to the strict criteria

3) Education of public and healthcare professionals is the key issue going forward.

4) It is vital that there is universal recognition of the severe impact that PMS can have, whatever terminology is used to define this.

In summary

If PMS symptoms affect physical, psychological, social and economic wellbeing, then this should be regarded as being clinically significant PMS, warranting prompt diagnosis, appropriate recognition and evidence based medical care.

Some cases of PMS will qualify for a PMDD diagnosis, but in non-PMDD cases of severe PMS, symptoms may have an equally or even more serious impact on the sufferer.

References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-V), 5th edn. Washington DC: APA; 2013.
  2. Green L J, O’Brien PMS, Panay N, Craig M on behalf of the Royal College of Obstetricians and Gynaecologists. Management of premenstrual syndrome. BJOG 2017 ;124:e73–e105. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg48/