Premenstrual disorders are one of the most important disorders that fall in the overlapping territory of psychiatry and gynecology. These disorders are commonly characterized by multiple somatic and psychiatric symptoms. Usually, the symptoms are so prominent that they can cause significant disturbance in the ability of the person to carry out day-to-day activities efficiently. These symptoms have a close temporal relationship with menstrual cycle. The symptoms become prominent during the luteal phase of the cycle and remit following the initiation of menstrual bleeding. There are two major disorders that are referred to in the context of premenstrual disorders. One is the premenstrual syndrome (PMS), which is considered to be of more use to the gynecologist, whereas the other is premenstrual dysphoric disorder (PMDD) which is considered to be the brainchild of psychiatrists. However, there is no doubt about the fact that both these disorders adversely affect socio-occupational functioning and interpersonal relationships.
The etiological basis of both these disorders has a fair deal of overlap. It is considered that both these disorders arise from the overt hypersensitivity of the central nervous system to the hormonal changes occurring during the menstrual cycle leading to decrease in the serotonin levels. It is also speculated that the etiological basis could also lie in the rise in the levels of progesterone or estradiol during the luteal phase, and the remission coincides with the rise of gonadotropin-releasing hormone. As can be appreciated from the introduction, the prevalence of PMS is higher than that of PMDD. Various studies worldwide estimate its prevalence at 20%–50%,[2,3,4] with a gradual increase in its prevalence noted over the recent years. However, the prevalence of PMDD is considerably lower at around 3%–8% across various studies.[2,5] Thus, it is clear that both these disorders have significant prevalence.
There has been some confusion in the medical fraternity about the simultaneous existence of these two diagnostic entities. However, a close study of both these conditions will make it evident that the necessity of their co-existence till now. PMS has a lower threshold and can be very useful for screening patients with premenstrual symptoms, whereas PMDD usually involves more severe and debilitating affective symptoms, mandating more intensive therapy. In the current paper, we have not attempted to do a comprehensive review, but rather we have attempted a scoping review to trace the history of both these disorders in the published literature and relive the incredible story of their evolution. Our attempt in this paper has been to provide a chronological account of how the premenstrual symptoms were conceptualized over the years and how the disorders were born out of necessity.
The current manuscript was an attempt to do a scoping review on the history and evolution of PMS and PMDD. For this purpose, a search was done on PubMed and Google Scholar. The search term used included "premenstrual symptoms," "premenstrual dysphoric disorder," "'premenstrual syndrome," late luteal phase dysphoric disorder," "history," "ICD 9," "ICD 10," "ICD 11," "DSM III," "DSM IV," and "DSM 5." Appropriate Medical Subject Headings terms and Boolean operators were used. Articles were selected if they were in English or English translation was available. Chapters of books that could be obtained from Google books were also available. The references of the identified studies were also searched to identify any appropriate studies on this theme. There were no restrictions placed regarding the date and the type of studies.
Our attempt to unearth the history of the premenstrual disorders traced back to the ancient times. Thus, for the sake of better clarity, the history is being classified as follows:
Pre-twentieth century era
The earliest mention of the premenstrual symptoms can be found on the manuscripts of the Greek physicians of the era of Hippocrates (400 BC-300 BC). Their writings reveal of a condition characterized by dizziness, heaviness, leukorrhea, and melancholia, which was thought to be caused by the accumulation of black bile in the uterus. However, further developments on this happened in the 16th century, when da Monte hypothesized that there can be a relationship between menstrual cycles and depression. However, one of the most comprehensive descriptions of this condition was provided by Prichard under the heading of "dysmenorrheal affections," where he highlighted features such as low mood, irritability, nervousness, proneness to quarrel, and moroseness which occur in relation to "Catamenia."
It is important for us to appreciate a few things about the pre-twentieth century hypotheses of development of this disorder. The theories that were put forward obviously led to the interests of further researchers in this field. However, it was much later that the researchers could identify the luteal phase to be the most important phase in the scheme of things. Additionally, the theories proposed that these symptoms involved a small minority of menstruating females.
Twentieth-century era (1901–1986)
It is believed that the first modern account of the premenstrual symptoms was given by Frank R. T. (1931). He provided description of a condition which he termed as "premenstrual tension," where there is cyclical appearance of emotional tension in the second half of the menstrual cycle. However, later on, Greene and Dalton (1953) countered that emotional tension is only one of multiple symptoms that tend to afflict patients in this disorder and probably "PMS" is a better term to effectively portray the illness. Almost concurrently in 1931, one of the most appreciated seminal works on this topic was done by Karen Horney. It was in her work that she established the relationship of the symptoms such as irritability, tension, depression, and anxiousness to ovulation. She also drew attention to the fact that these symptoms are rather frequent. In a rather recent development, researchers in this area had started to include various somatic symptoms such as pain, breast swelling and tenderness, headache, craving for food, and thirst to the symptom cluster.
As the phenomenological issues of PMS were evolving, researchers started to focus on the etiopathological basis of this disorder. However, the theories put forward were largely heterogeneous. Horney on her theory was reliant on the psychosexual theory proposed by Sigmund Freud and proposed that these symptoms arise from sexual frustrations and unfulfilled wishes of a female to successfully bear a child in her uterus. However, Greene and Dalton proposed that water retention was the reason behind the symptoms, which were in turn caused by abrupt rise in the estrogen–progesterone ratio. Derivatives of this theory is still considered to be one of the most hopeful theories on PMS, though there are many loose ends to tie. Many other etiological factors were also postulated in this regard implicating Vitamin B6, endogenous opioids, or the monoamine oxidase enzymes, but none could provide a comprehensive explanation. Various subsequent researchers even went on the extent to speculate that such symptoms can also occur in nonmenstruating females and neither uterus nor menstruation is a mandatory factor to suffer from this disorder, again to the disagreement of others.
With the apparent failure of the studies to find a good biological basis of the disease, studies also started to explore the psychosocial aspects of the disorder. The initial population-based studies showed that these symptoms are ubiquitous across all cultures and all age groups in menstruating females.[13,14] However, the cultural differences in the interpretation of the symptoms were evident. It was found that a comprehensive presentation comprising of somatic and affective symptoms was more common in the Western culture. This was to the extent that some researchers even speculated that PMS is a Western culture-bound syndrome. On the other hand, various nonwestern cultures often presented with predominant somatic presentation.
As has already been mentioned that it was in 1953 that Greene and Dalton coined the term PMS. However, the popularity of this entity got embroiled in a few limitations of the construct. One of the major controversies that arose was that the classification of the symptoms cluster was arbitrary and thus labeling the condition under the single umbrella of a "syndrome" was not appropriate. Another issue that was raised is the high prevalence of PMS in various samples. It has been argued that if a condition has a prevalence of up to 95%, does the condition still remain statistically abnormal so as to deserve a nomenclature of syndrome? To add to that, the diagnosis of this condition was excessively reliant on self-report and retrospective accounts. Finally, the last issue that has been raised is regarding the poor diagnostic stability of the condition, a criticism that many other psychiatric conditions are also accused of. It was thus realized that there is a need for a stricter diagnostic criterion with better stability which will effectively be able to define this as a pathological process with certainty. Almost as a fall-out of this, the American Psychiatric Association started formalizing the construct of disorder which would address these issues.
The post-Diagnostic and Statistical Manual-III-R era (1987-present)
Diagnostic and Statistical Manual III
The Diagnostic and Statistical Manual 3rd Edition Revised Version (DSM-III-R) was published in 1987. It was for the first time that the criteria for "Late Luteal Phase Dysphoric Disorder (LLPDD)" were included in the appendix section as a "proposed diagnostic category needing later study." This happened only after a workshop conducted under the banner of the National Institute of Mental Health was held in 1983 that looked into the issues raised. Some of the important recommendations proposed in this committee included (a) requirement of at least 30% increase in the symptom severity in the late luteal phase as compared to the mid-follicular phase and (b) establishing an asymptomatic mid-follicular phase. After the publication of the criteria of LLPDD in DSM-III-R, a large volume of data was generated by research. Although the name LLPDD could gather popularity, the criteria were widely used in research. The DSM review process usually consisted of a central task force and work groups for specific disorders. LLPDD was assigned a separate work group because it was considered to be important. The review processes, this time, included revision of the published literature and also interview of members of the work group and other member experts.
If we review these evidences, it can be arranged into three clusters. Firstly, there were a few evidences that supported LLPDD to be included in the main text. They included that there was now a consensus among the experts that this disorder has a prevalence between 3% and 6%, which is statistically significant enough to warrant a separate diagnosis and not merely an extension of physiological process. Furthermore, various treatment modalities had developed that could successfully ameliorate the symptoms and improve the quality of life of the patients such as anxiolytics, antidepressants, and agents suppressing ovulation. Experts who favored inclusion of this entity in the main text also believed that this concept was a good fit of the much-accepted biopsychosocial model of disorder. Secondly, there was another group that had lobbied for deleting this entity as a disorder from the DSM-IV text. They believed that these criteria had high false positives and poor diagnostic validity and can be used as a weapon against females with negative social consequences. The third viewpoint in this regard was of the experts who recommended to retain LLPDD as an entity in the appendix. They believed that the evidence regarding LLPDD is better than the evidence for many other disorders that are already included in the DSM. However, the evidence still requires further study. In addition to this, the DSM-IV task force followed a "consensus model," which meant that the experts believed that if data of substantial nature are displayed to a group of experts, the best decision can be reached from consensus of the experts. However, controversy arose about this model in the case of LLPDD, where many of the outsider experts felt that the work group was too afraid to include it in the main text fearing a controversy.
Diagnostic and Statistical Manual IV and International Classification of Diseases, Tenth Edition
Based on the recommendations of the task force, DSM-IV changed the name of LLPDD and the name PMDD made its debut. The criteria for PMDD were almost similar to that of LLPDD and only one item was added, which was "a subjective sense of being overwhelmed or out of control." However, the criteria were again included in the appendix section and not the main text. Significantly, it is important to mention here that the 10th edition of the International Classification of Disease (ICD-10) which was almost published contemporarily in 1992, included the criteria for PMS with the code of N94.3 under the section of "Noninflammatory disorders of female genital tract" and not under the "F" code of "Mental, behavioral, and neurodevelopmental disorders."
Before the publication of DSM-5 in 2013, a similar review process was conducted. There were a few important developments in this time that had influenced the decision-making. One important event happened was the approval of fluoxetine for the management of PMDD by the United States Food and Drug Administration based on the data presented by the pharmaceutical company Eli Lilly. It was also believed that this approval significantly attenuated the fear of negative social consequences. In actuality, it was noted that this development was looked upon in a very positive way with even lay-press encouraging females to discuss premenstrual issues, change lifestyle, and seek doctors' help if symptoms exacerbate. The location of the chapter in the DSM-5 book was a matter of intense speculation.
Diagnostic and Statistical Manual 5 and International Classification of Diseases 11th Revision
To seek clarification on this, the Mood Disorder's Work Group of DSM-5 created a panel to evaluate the DSM-IV criteria of PMDD, suggest changes, and comment whether the entity should be retained in the appendix section or be moved to the main text. Based on the derivatives of this process, PMDD was finally included in the main text under the section of "depressive disorders."
The International Statistical Classification of Diseases and Related Health Problems, Eleventh Revision (ICD-11), in 2019 has followed the footstep of DSM-5 and has added PMDD in its roster (Code GA34.41). It has been primarily added under the section of genitourinary diseases and has also been cross-listed in the section on depressive disorders due to the preponderance of affective symptoms. The criteria of PMDD as mentioned in ICD-11 are consistent with the DSM-5 criteria. It is believed that this inclusion will go a long way in validating the stature of PMDD as a disorder. A summary of the journey of this evolution is depicted in Figure 1.
As authors of this topic, the first thing that came to our mind was that this was a story worth telling. The reason behind this is that this has been a complex topic which efficiently exposes the caveats in our diagnostic framework while dealing with entities which are not "ready-made science." However, the sincere efforts that have been put in over the years to formalize this issue are also complement worthy. We believe that PMS as a diagnostic entity was more popular among the gynecologists and by its low diagnostic threshold effectively helped in screening at-risk patients. Whereas, PMDD is more popular in the psychiatry fraternity and its stricter criteria help in better identifying the candidates requiring pharmacological and nonpharmacological interventions.
With the advent of ICD-11 and DSM-5, PMDD appears to be a well-accepted diagnostic entity among the medical fraternity. It is now beyond doubt that premenstrual symptoms can debilitate condition and its existence transcends culture, religion, and even methodological issues adapted in research. Although the popularity of PMDD is soaring nowadays, that too for all the right reasons, we feel PMS as a diagnostic entity still remains a very important candidate. It will be interesting to see whether in future its utility is appreciated or it slowly goes out of existence.
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