GPAtlas🧭 When to suspect
Suspect premenstrual syndrome (PMS) when a woman of reproductive age describes recurrent psychological, physical and/or behavioural symptoms that appear in the luteal phase of the menstrual cycle, are severe enough to interfere with daily functioning, and then resolve with the onset of menstruation – leaving a symptom-free week in the follicular phase. Around 40% of women experience some PMS, and 5–8% have severe PMS.
The most severe form is premenstrual dysphoric disorder (PMDD) – a recognised diagnosis in DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) and ICD-11 (International Classification of Diseases, 11th revision), dominated by mood symptoms with marked functional impairment.
The two skills that matter in primary care are: establish a clear cyclical pattern prospectively (recall is unreliable), and separate core PMS from a premenstrual exacerbation of another condition, which is managed quite differently. The International Society for Premenstrual Disorders (ISPMD) classification is the framework GPs are expected to recognise:
| Type of premenstrual disorder | Defining feature |
|---|---|
| Core PMS | Ovulatory cycles; luteal-phase symptoms that fully resolve with menstruation. PMDD is the severe, mood-predominant variant. |
| Premenstrual exacerbation of an underlying disorder | Symptoms of a chronic condition (e.g. depression, anxiety, epilepsy, asthma, migraine) are present throughout the cycle but worsen premenstrually – there is no symptom-free week. |
| Progestogen-induced premenstrual disorder | Symptoms provoked by exogenous progestogen (cyclical hormone replacement therapy or the combined pill) in a progestogen-sensitive woman. |
| Premenstrual disorder with absent menstruation | Cyclical ovarian activity continues to drive symptoms despite no bleeding (e.g. after endometrial ablation, hysterectomy with ovarian conservation, or a levonorgestrel-releasing intrauterine system). |
Raise suspicion particularly where there is a family history of PMS, a personal or family history of mood disorder, or a history of perinatal depression. Smoking, high stress and obesity are associated.
Source: RCOG Green-top Guideline No. 48 · ISPMD consensus
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