Premenstrual syndrome was included in the ICD-9 and ICD-10 of the WHO. The diagnosis requires that symptoms such as tension, migraine or any other molimen must occur during the premenstrual phase of between 1 to 7 days before menstruation and remit following menses. However, the ICD-10 does not specify any other criteria such as severity, degree of symptom change or
impairment, differential diagnosis or exclusion criteria. The ICD-10 diagnosis focuses only on the two main aspects of PMS, i.e. the timing and cyclic relationship with menstruation. It does not require a minimum number of symptoms nor degree of functional impairment. According to Halbreich (2004), it is the closest set of criteria yet to emerge that may attract universal
acceptance.
According to the ACOG (2000), a diagnosis of PMS should include: at least one affective or somatic symptom; other symptoms consistent with the classification of defined PMS; restriction of these symptoms to the 5 days before menses at each of three prior menstrual cycles, with relief occurring within 4 days of the onset of menses; impairment at mild to moderate or severe levels in some facets of the woman’s usual life; and the exclusion of other disorders (e.g. psychiatric illness). The information should be based on prospectively recorded diaries kept by the women, preferably every day for approximately eight to ten consecutive days for two to three consecutive months. These ACOG criteria acknowledge the timing and the nature of symptoms and the level of impairment, and require prospective confirmation of retrospective reports. It considers the individual
diversity of symptoms and the requirement of at least one symptom, which avoids the constraint of a threshold of a specific number of symptoms.
In 1983, the National Institute of Mental Health (NIMH) proposed that the diagnosis of PMS was dependent on the occurrence of an increase in symptom severity of at least 30% in the six days before menstruation as compared with the days after menses. Documentation of these changes is required to be recorded in a daily symptom diary for at least two consecutive cycles (Parker 1994). The quantitative suggestion of at least a 30% change in perceived severity of the symptoms between premenstrual and post-menstrual phases, together with the charting of daily symptoms across two consecutive months led to the completion of diagnosis of PMS that differentiates it from the
diagnostic criteria of other conditions, such as mood disorders, anxiety disorder, dysthymic disorder or personality disorder.
The most detailed diagnostic criteria of a subtype of PMS include the criteria for PMDD according to the DSM-IV-TR of the American Psychiatric
Association (APA 2000). This diagnosis requires women sufferers (or someone with whom they live) to chart their symptoms daily for two complete cycles by prospective daily charting, and their chief complaints must include one of the four core symptoms (irritability, tension, dysphoria, and lability of mood) and at least five of eleven total symptoms. The symptoms should be present during most menstrual cycles in the past year; should demonstrate clear worsening during the last week of the luteal phase and should remit within a few days after the onset of the menstrual phase; should have interfered with social or
occupational roles; and should not be an exacerbation of another chronic disorder. Despite being the most detailed diagnostic criteria of a subtype of PMS, there are no guidelines in the criteria for quantifying the measures on either the frequency of the symptoms, or the degree of the symptom severity or functional impairment.
There are variations between the current diagnostic categories of PMS. The current DSM-IV-TR requires at least five specified symptoms for a diagnosis of PMDD to be made, while the ICD-10 requires only one distressing symptom for a diagnosis of PMS to be made. The DSM-IV-TR criteria require a temporal criterion where symptoms must occur only or mainly during the week before menses, whilst the ACOG criteria require them to occur within 5 days before menses. However, both do not specify for how many days the symptoms should exist.
2.6.2 Summary
A universally accepted diagnostic entity is critically important for distinguishing between PMS and other disorders, for determining the prevalence of the
disorder, for unifying disease coding, for further research, for regulatory purposes and most importantly, for determining suitable treatment. Diagnostic criteria for PMS must recognize the broad range of symptoms, the temporal pattern of the symptoms and the critical issue of symptom severity. A diagnosis of PMS should consist of the determination of the timing of the symptoms in
relation to various phases of the menstrual cycle, the stipulation of significant changes between post-menstrual and premenstrual symptom severity, careful reports of impairment of functioning, and diagnostic differentiation to
distinguish PMS from other medical and psychiatric conditions. To date, there has been no hormone or laboratory test which can provide an unequivocal PMS diagnosis and the current diagnostic standard requires confirmation of subjective symptom reports by prospective daily diaries.
2.7 Subtypes of PMS
Since the classification of diseases may contribute to specific treatments for each subtype, some researchers have attempted to identify subtypes of PMS by grouping women’s experiences according to different clusters of symptoms or symptom severity.
The pioneer investigator of premenstrual problems, Frank (1931), observed that there were three types of women who presented to him complaining of
premenstrual tension. The first type of women was those handicapped by premenstrual disturbances of a multiplex nature. The second group was those whose complaints were of sufficient gravity to require rest in bed for one or two days, and the last type consisted of those in whom severe systemic
disorders manifested themselves, predominantly during the premenstrual period. Dalton (1964, 1984) described three categories of premenstrual disorder:
premenstrual syndrome (so called ‘true’ PMS) which refers to a combination of physical and psychological symptoms; and menstrual distress syndrome (MDS) which applies to patterns with similar symptoms present at a moderate level throughout the cycle, which worsen premenstrually.
In 1983, Abraham attempted to assign nutritional aetiological factors for each of four symptom subgroups, based on hypothesized nutritional deficits, in order to guide decisions about different nutritional supplement for the syndrome. The four subgroups are:-
PMT-A, which includes affective symptoms of anxiety, irritability, nervous
tension and behaviour patterns detrimental to self, family and society. The proposed cause is deficiency of vitamin B and magnesium.
PMT-H, where water retention is the major problem. It is associated with
water and salt retention, abdominal bloating, mastalgia and weight gain. The proposed cause is deficiency of vitamin B6 and E, and magnesium.
PMT-C, is characterised by craving for sweets, increased appetite and
indulgence in eating refined sugar followed by palpitation, fatigue, fainting spells, headache and ‘shakes’. The proposed cause is deficiency of vitamin B and E, magnesium and zinc.
PMT-D, the symptoms are depression, withdrawal, insomnia, forgetfulness
and confusion, and the proposed cause is also deficiency of vitamin B and magnesium.
However, it is common for women to experience more than one of the subtypes in any month. Also, some of the nutritional deficiency factors, e.g. magnesium,
vitamin B, appear in all or more than one subtype thus rendering the
classification somewhat confusing. Therefore, most recent treatment guidelines of PMS such as the ACOG Practice Bulletin (2000) recommend magnesium, calcium, and vitamin E to all PMS sufferers.
In the last 20 years, Late Luteal Phase Dysphoric Disorder (LLPDD) and Premenstrual Dysphoric disorder (PMDD) have appeared in the appendix of the Diagnostic and Statistical Manual of Mental Disorders (APA 1987, 1994). Both refer to women with premenstrual complaints who suffer primarily from
serious affective symptoms which may be considered as the most severe forms of PMS (Taylor 1994). This subtype of severe form PMS i.e. PMDD, which is classified under the domain of psychiatric disorders allows the prescription of antidepressant drugs (SSRIs) for the treatment of the disorder.
In summary, the grouping of the above subtypes occurred in two stages. In the early stage, pioneer researchers of premenstrual problems grouped the PMS sufferers into subtypes according to symptom severity in order to confirm/grade the disorder. The more recently proposed subtypes were determined according to different clusters of symptoms. In each case, different subtypes call for differential treatment modalities.