Each woman is unique in terms of her physical experience of menstrual cycle events, her cognitive inter-
Table IV Diagnostic Evaluation of Premenstrual Syndrome
General medical history
• Overall health
• Current medical and psychological issues
• Medications (prescribed and over-the-counter)
• Past medical and psychiatric history
• Habits (e.g., exercise, sleep, and eating patterns, smoking, alcohol, and drugs)
• Developmental and social history
• Family illness history
Focused medical history
• Overall gynecological health
• Menstrual history (e.g., age at menarche, length of menstrual cycle, quantity and pattern of bleeding)
• Nature, timing, and severity of symptoms around menstruation
• Pattern of menstrual and premenstrual symptoms during adolescence and early adulthood
• Pattern of menstrual and premenstrual symptoms in relation to pregnancy, breast-feeding, and hormonal interventions (e.g., oral contraceptives)
• Unrecognized endocrine problems (e.g., thyroid dysfunction, androgen excess)
• Mental status examination
• Screening physical examination, including examination for signs of
• endocrine dysfunction
• gynecologic illness
• overlooked health problems (e.g., anemia, infection)
• Screening laboratory tests (e.g., thyroid function tests) Prospective symptom rating
Patient records the timing and severity of physical and psychological symptoms for at least two menstrual cycles. The pattern is evaluated during a subsequent appointment.
pretation of sensations related to menstruation, her conscious and unconscious emotional responses to her internal rhythms and timing, and her adaptive behaviors toward menstrual cycle events. When a woman expresses concern about her menstrual cycle or offers complaints suggestive of PMS, the health care provider must attend to the whole person and understand, from a developmental perspective, the complex social context in which the woman lives (Table IV). Such an approach is essential for making an accurate diagnosis of PMS and pursuing appropriate treatment interventions.
As there is no absolute independent, verifiable biological marker (such as a blood test) or physio-behavioral measure (such as increased nocturnal temperature or other signs related to individual circadian rhythms) to identify PMS reliably, the diagnosis of PMS is believed to be a clinical judgment. It is thought to be present when three criteria are met: (1) no other condition is present that accounts for the patient's symptoms, (2) prospective daily symptom ratings demonstrate a marked change in severity of symptoms premenstrually for at least two menstrual cycles, and (3) there is a symptom-free week (usually Days 5 to 10) during the menstrual cycles. It is possible for a woman to have a psychiatric disorder or a physical disorder in addition to PMS as long as the symptoms of PMS are distinct from the other disorder and occur during the luteal phase and remit during menses.
Clinical investigation of PMS thus involves two kinds of information. First, it entails prospective documentation by the woman of symptoms and signs she experiences in clear association with phases of her menstrual cycle. Prospective daily ratings of symptoms with respect to quantity, quality, and severity for a minimum of 2 months are required to confirm a woman's retrospective report of premenstrual symptomatology (Table V). A retrospective history of PMS is not sufficient for a diagnosis because it introduces biases, leading to an overdiagnosis of PMS. Second, other medical conditions that may account for the patient's discomfort must be excluded. Clinicians must therefore perform a careful health history. A complete physical examination must also be conducted, including a mental status examination and a pelvic examination. Psychiatric conditions such as depression, anxiety, somatoform disorders, and others must be considered in the evaluation process. Gynecological conditions such as uterine fibroids, endometriosis, and fibrocystic breast disease, and other physical conditions such as anemia and endocrine dysfunction (e.g., diabetes mellitus, thyroid disease, Cushing's disease) must also be considered and appropriate diagnostic tests performed in the evaluation process. Coexistent medical and psychiatric disorders must be distinguished from disorders that might cause the patient's symptoms and signs.
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