Differential Diagnosis

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A comprehensive history and physical examination are indicated to rule out other possible causes of the emotional and physical symptoms of PMS. The differential diagnosis includes premenstrual molimina, hypothyroidism, perimenopause and major mood or anxiety disorders. Most ovulatory women experience some physical changes (e.g., breast tenderness, bloating, and food cravings) during the luteal phase. If these physical symptoms do not interfere with normal life functions, the term molimina can be applied. Hypothyroidism can share many of the same symptoms as PMS; however there should be no cyclic variation. A thyroid stimulating hormone level is a sufficient screen, if warranted by clinical suspicion. There is also considerable overlap between the symptoms of perimenopause and those of PMS. Many women experience symptoms of emotional irritability, cyclic mastalgia, bloating and hot flashes as part of the perimenopause. It is likely that similar pathophysiologic factors mediate symptoms in both disorders. In a practical sense, to document PMS, women should maintain a calendar of symptoms that can be correlated with the reproductive cycle. For PMDD, women must meet the DSM-IV-TR diagnostic criteria (Table 10.1).

Distinguishing the emotional symptoms observed in PMS from those present in other major mood or anxiety disorders (e.g., major depressive disorder, dys-thymia, panic disorder) is important because of the different treatment strategies. Women with PMS respond to unique therapeutic interventions, such as calcium carbonate, gonadotropin releasing hormone agonists and intermittent dosing with serotonin reuptake inhibitors (SRIs). If patients present with continuous mood or anxiety symptoms across the menstrual cycle, the diagnosis of PMS cannot be made. If patients exhibit mood and/or anxiety symptoms across the menstrual cycle with an increase in severity during the luteal phase, the appropriate diagnosis is premenstrual exacerbation (PME) of the underlying condition, not PMS. Therefore, diagnostic verification of premenstrual syndrome is best accomplished through prospective daily symptom recording (or "charting"). This prospective rating is required to make a diagnosis of PMDD.

A number of valid and reliable diagnostic instruments, e.g., Calendar of Premenstrual Experiences (COPE), Premenstrual Symptoms Screening Tool (PSST), Visual Analogue Scale (VAS), Daily Record of Severity of Problems (DRSP), are available to document emotional and physical symptoms across the menstrual cycle. These forms include emotional, physical and functional symptoms that patients rate or "chart" daily using a Likert-type scale to assess the presence, timing, and severity of symptoms. The diagnosis of PMS/PMDD is verified if there is: (1) demonstrated evidence of a relative absence of symptoms during the follicular phase of the menstrual cycle; (2) significant increase in emotional and/or physical symptoms during the luteal phase of the menstrual cycle; and (3) functional impairment during the luteal phase of the menstrual cycle (for PMDD).

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