Understanding Your Premenstrual Experience
If your symptoms worsen in the week or two before your period, naming what you are experiencing is the first step towards effective self-advocacy. While premenstrual syndromes are widespread, the underlying mechanisms, severity and clinical approaches differ significantly across Premenstrual Syndrome (PMS), Premenstrual Dysphoric Disorder (PMDD) and Premenstrual Exacerbation (PME) (1).
Key Differences at a Glance
| Feature | Premenstrual Syndrome (PMS) | Premenstrual Dysphoric Disorder (PMDD) | Premenstrual Exacerbation (PME) |
|---|---|---|---|
| Core Nature | Cyclical physical, emotional and behavioural symptoms occurring before menstruation | Severe cyclical mood disorder associated with sensitivity to normal hormonal fluctuations | Premenstrual worsening of symptoms from an existing physical or psychiatric condition |
| Primary Symptoms | Variable physical and emotional symptoms like bloating, fatigue, breast tenderness, irritability and mood changes | Marked affective lability, irritability or anger, depressed mood, severe anxiety, suicidal ideation | Symptoms of the underlying condition (e.g., depression, ADHD, asthma) become more severe premenstrually |
| Functional Impact | Variable; symptoms may interfere with wellbeing, relationships and daily activities | Clinically significant functional impairment in work, social life or relationships | Variable; depends on the underlying condition with noticeable premenstrual worsening |
| Pattern Outside Premenstrual Phase | Symptoms usually improve once menstruation begins and often resolve by the end of the period | Symptoms improve within a few days of bleeding and become minimal or absent in the postmenopausal week | Baseline symptoms remain outside the premenstrual phase but are less severe |
Premenstrual Syndrome (PMS)
Premenstrual symptoms are common, although only a proportion of menstruating individuals experience symptoms severe enough to meet criteria for PMS (1). It is characterised by mild-to-moderate physical discomfort (such as bloating, cramping or headaches) and subtle emotional changes in the days leading up to menstruation (1).
PMS can still affect wellbeing, relationships and daily activities with the degree of disruption varying considerably between individuals (2).
Premenstrual Dysphoric Disorder (PMDD)
PMDD is a distinct, severe neurobiological condition recognised in the DSM-5-TR. PMDD is not thought to result simply from abnormal hormone levels. Current evidence suggests that altered sensitivity to normal cyclical changes in ovarian steroids and neurosteroids, including allopregnanolone, may play an important role (3).
Timing: Symptoms follow a clear cyclical pattern, appearing or worsening during the luteal phase and resolving shortly after bleeding begins (2).
Key Marker: PMDD symptoms become minimal or absent during the postmenstrual follicular phase, creating a clear contrast with the symptomatic premenstrual phase (2, 4).
Premenstrual Exacerbation (PME)
PME refers to premenstrual amplification of an existing chronic condition. Common examples include baseline major depressive disorder, anxiety disorders or physical conditions like migraines and asthma worsening during the luteal phase (5, 6).
Key Marker: Unlike PMDD, symptoms are present throughout the entire cycle but experience a distinct “luteal drop” or flare-up before menstruation.
How to Track for Diagnosis
Because laboratory tests cannot diagnose PMDD or PME, clinical guidelines require prospective symptom tracking:
Log daily: Record physical and emotional symptoms daily using an app or paper tracker alongside your cycle phase (7).
Track for at least 2 cycles: This reveals whether your symptoms disappear post-bleeding (pointing towards PMDD) or persist at a lower baseline (pointing towards PME) (4).
Bring your data: Share your multi-cycle tracking logs with a healthcare provider to guide an accurate and tailored management plan (8).
References & Clinical Reading
Yonkers KA, O’Brien PS, Eriksson E. Premenstrual syndrome. The Lancet [Internet]. 2008 Apr;371(9619):1200–10. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3118460/
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) [Internet]. 2022;5(5). Available from: https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787
Bäckström T, Bixo M, Johansson M, Nyberg S, Ossewaarde L, Ragagnin G, et al. Allopregnanolone and mood disorders. Progress in Neurobiology [Internet]. 2014 Feb;113:88–94. Available from: https://doi.org/10.1016/j.pneurobio.2013.07.005
Eisenlohr-Moul TA, Girdler SS, Schmalenberger KM, Dawson DN, Surana P, Johnson JL, et al. Toward the reliable diagnosis of DSM-5 premenstrual dysphoric disorder: The carolina premenstrual assessment scoring system (C-PASS). American Journal of Psychiatry [Internet]. 2017 Jan;174(1):51–9. Available from: https://psychiatryonline.org/doi/10.1176/appi.ajp.2016.15121510
Nolan LN, Hughes L. Premenstrual exacerbation of mental health disorders: A systematic review of prospective studies. Archives of Women’s Mental Health [Internet]. 2022 July 22;. Available from: https://pubmed.ncbi.nlm.nih.gov/35867164/
Gibbs CJ, Coutts II, Lock R, Finnegan OC, White RJ. Premenstrual exacerbation of asthma. Thorax [Internet]. 1984 Nov 1;39(11):833–6. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC459933/
Green L, O’Brien P, Panay N, Craig M. Management of Premenstrual Syndrome. BJOG: an International Journal of Obstetrics & Gynaecology [Internet]. 2016 Nov 30;124(3):e73–105. Available from: https://www.rcog.org.uk/globalassets/documents/guidelines/gt48managementpremensturalsyndrome.pdf
Royal College of Obstetricians & Gynaecologists. Managing premenstrual syndrome (PMS) [Internet]. RCOG. 2018. Available from: https://www.rcog.org.uk/for-the-public/browse-our-patient-information/managing-premenstrual-syndrome-pms/
