Premenstrual Syndrome and Premenstrual Dysphoric Disorder
Evidence-Based Clinical Guidelines
Professor Mykhailo Medvediev
Evidence-Based Medicine
Clinical Guidelines
Overview of Premenstrual Disorders
PMS Definition
Physical and behavioral symptoms occurring in the second half of the menstrual cycle that interfere with daily life
PMDD Definition
Severe form of PMS with prominent anger, irritability, and internal tension symptoms
Key Distinction
PMDD requires ≥5 symptoms including at least one affective symptom with significant functional impairment
Source: American Psychiatric Association DSM-5; ACOG Clinical Practice Guideline No. 7, 2023
Epidemiology: Prevalence Rates
PMS Prevalence
When strict diagnostic criteria are applied, clinically significant PMS affects 20-30% of women with regular menstrual cycles.
Higher estimates (up to 80%) result from including any premenstrual symptoms without functional impairment.
PMDD Prevalence
True PMDD affects approximately 2% of women when prospective diagnostic criteria are used.
Point prevalence of retrospectively reported symptoms ranges from 2.8-6.4%.
Source: Yonkers KA, et al. Lancet 2008; Community studies using prospective ratings
Global Distribution of PMS
PMS is described across diverse cultural settings worldwide, with similar prevalence rates reported internationally.
Mediterranean & Europe
Similar rates across Mediterranean countries, Iceland, and broader European regions
Middle East & Asia
Comparable symptom frequency in Pakistan, Asia, and Middle Eastern countries
Africa & Oceania
Consistent prevalence in Kenya, New Zealand, and other regions
Source: International survey of 7,226 women across Europe, South America, and Asia; Dennerstein L, et al. Menopause Int 2011
Most Common Symptoms
Affective/Behavioral
  • Mood swings (most common)
  • Irritability
  • Anxiety/tension
  • Depressed mood
  • Increased appetite/food cravings
  • Sensitivity to rejection
  • Diminished interest in activities
Physical
  • Abdominal bloating (most common)
  • Extreme fatigue
  • Breast tenderness
  • Headaches
  • Hot flashes
  • Dizziness
Source: Hartlage SA, et al. Arch Gen Psychiatry 2012; Analysis of prospective symptom surveys
Symptom Timing and Pattern
1
Follicular Phase
Symptom-free period following menses onset
2
Ovulation
Mid-cycle, typically day 14
3
Luteal Phase
Symptoms begin, typically lasting 6 days on average
4
Menses
Symptoms resolve with or shortly after onset
Symptoms are most severe in the 4 days before through the first 2-3 days of menses. The core feature is recurrent onset during late luteal phase with symptom-free periods in the follicular phase.
Source: Hartlage SA, et al. Arch Gen Psychiatry 2012; ACOG Clinical Practice Guideline 2023
Impact on Quality of Life
36%
Work Productivity
Decrease in work productivity and increase in absenteeism
40%
Healthcare Visits
Increase in ambulatory healthcare provider visits
25%
QoL Reduction
Significant reduction in health-related quality of life measures
Moderate to severe PMS symptoms are associated with substantial reductions in quality of life, work performance, and increased healthcare utilization.
Source: Borenstein JE, et al. J Womens Health 2007; Heinemann LA, et al. Womens Health Issues 2010
Suicide Risk in PMDD

Clinical Alert: Women with PMDD, especially those with severe symptoms, have elevated risk of suicidal ideation and attempts.
Clinicians should ask patients: "Do your mood symptoms ever become so severe that you think you would be better off if you were not around or not alive?"
Any positive response requires immediate referral to a mental health professional.
Source: Yan H, et al. J Affect Disord 2021; Pilver CE, et al. Soc Psychiatry Psychiatr Epidemiol 2013
Risk Factors for PMDD
Genetic Factors
Association with estrogen receptor alpha (ESR1) gene variations. Different cellular response patterns to ESC/E(Z) complex components.
Educational Level
Lower education associated with increased risk
Smoking
Cigarette smoking identified as risk factor
Trauma History
History of traumatic events or anxiety disorder increases risk
Source: Huo L, et al. Biol Psychiatry 2007; Cohen LS, et al. J Affect Disord 2002; Perkonigg A, et al. J Clin Psychiatry 2004
Pathogenesis: Ovarian Steroids
Key Findings
GnRH agonist-induced "medical ovariectomy" leads to dramatic resolution of PMS symptoms, supporting central role of ovarian steroids.
However, daily serum estradiol and progesterone concentrations are similar in women with and without PMS/PMDD.
Critical Discovery
Women with PMDD have an abnormal response to physiologic hormonal changes, not abnormal hormone levels.
Source: Schmidt PJ, et al. N Engl J Med 1998; Wei SM, et al. Am J Psychiatry 2025
Landmark Study: Differential Hormone Response
A 2025 double-blind crossover trial demonstrated the biological basis of PMDD:
1
Leuprolide Alone
Affective symptoms improved in PMDD patients
2
Hormone Addback
Symptoms worsened with progesterone or estradiol
3
Progesterone Effect
Greater severity of irritability and mood swings
4
Control Group
No mood symptoms with hormone addback
This study (34 PMDD patients vs 76 controls) confirms that dysregulated response to physiologic hormone changes contributes to PMDD pathophysiology, particularly implicating progesterone.
Source: Wei SM, et al. Am J Psychiatry 2025; 182:922
Neurotransmitter Systems
Serotonin
Most implicated neurotransmitter. Lower whole blood serotonin and platelet uptake during luteal phase.
GABA
Allopregnanolone (progesterone metabolite) enhances GABA-A receptor function with anxiolytic effects.
Beta-Endorphin
Differences in peripheral beta-endorphin levels observed in periovulatory and premenstrual phases.
Autonomic System
Evidence implicates autonomic nervous system involvement.
Source: Eriksson E, et al. Neuropsychopharmacology 1994; Rapkin AJ, et al. Obstet Gynecol 1997
Serotonin: The Primary Neurotransmitter
Multiple lines of evidence support serotonin's central role in PMS/PMDD:
1
Biochemical Evidence
Lower whole blood serotonin, reduced platelet serotonin uptake and imipramine binding during luteal phase in PMS patients vs controls
2
Pharmacological Response
Symptoms ameliorated by serotonin agonist fenfluramine and aggravated by acute tryptophan depletion
3
SSRI Efficacy
Selective serotonin reuptake inhibitors are among the most effective treatments for PMS/PMDD
4
Antagonist Challenge
Metergoline (serotonin antagonist) causes return of mood symptoms in fluoxetine-treated PMDD patients
Source: Rapkin AJ, et al. Obstet Gynecol 1987; Roca CA, et al. Am J Psychiatry 2002
Diagnostic Criteria: PMS vs PMDD
PMS Criteria (ACOG)
  • 1-4 symptoms (physical, behavioral, or affective)
  • Symptoms interfere with functioning
  • Present during 5 days before menses
  • Present in ≥3 consecutive cycles
  • Symptom-free interval after menses
PMDD Criteria (DSM-5)
  • ≥5 symptoms total
  • ≥1 must be affective symptom
  • Present most of preceding year
  • Significant distress or interference
  • Symptoms resolve within days after menses
Source: American Psychiatric Association DSM-5; ACOG Clinical Practice Guideline No. 7, 2023
DSM-5 Core Affective Symptoms
At least ONE of the following must be present:
Mood Lability
Mood swings, sudden sadness, increased sensitivity to rejection
Irritability/Anger
Marked irritability, anger, or increased interpersonal conflicts
Depressed Mood
Depressed mood, hopelessness, self-critical thoughts
Anxiety/Tension
Marked anxiety, tension, feeling on edge
Among these, premenstrual irritability is the most common symptom reported by patients.
Source: American Psychiatric Association DSM-5, 2013
DSM-5 Additional Symptoms
At least ONE additional symptom to reach total of 5 symptoms:
Cognitive
Difficulty concentrating
Appetite
Change in appetite, food cravings, overeating
Interest
Diminished interest in usual activities
Energy
Easy fatigability, decreased energy
Control
Feeling overwhelmed or out of control
Physical
Breast tenderness, bloating, weight gain, joint/muscle aches
Sleep
Hypersomnia or insomnia
Source: American Psychiatric Association DSM-5, 2013
Diagnostic Evaluation Process
01
Menstrual History
Detailed cycle history (24-38 day intervals). Confirm relationship between symptoms and cycle phase.
02
Medication Review
Evaluate all medications including hormonal treatments. Determine if symptoms preceded medication use.
03
Rule Out Endocrine
Screen for thyroid disorders (TSH), consider cortisol excess if refractory
04
Prospective Monitoring
Daily symptom recording for 2 months using validated tools (DRSP form)
05
Exclude Mood Disorders
Rule out chronic depression, dysthymia, anxiety disorders through prospective charting
Source: ACOG Clinical Practice Guideline No. 7, 2023; Yonkers KA, et al. Lancet 2008
Daily Record of Severity of Problems (DRSP)
The DRSP is a validated prospectively self-administered questionnaire consisting of:
  • 17 common PMS symptoms
  • 11 symptoms from DSM-5 PMDD diagnostic criteria
  • 6-point rating scale (1=none at all to 6=extreme)
  • Daily completion over at least 2 menstrual cycles
This tool is essential for confirming diagnosis and distinguishing PMS/PMDD from other mood disorders.
Source: Endicott J, et al. Arch Womens Ment Health 2006; ACOG Clinical Practice Guideline 2023
Differential Diagnosis
Mood Disorders
Major depression, dysthymia, anxiety disorders. Key: symptoms present throughout cycle, not just luteal phase.
Menopausal Transition
New mood symptoms in 40s-50s more likely perimenopause. Risk for depression 30-60% during transition.
Thyroid Disorders
Hyper- and hypothyroidism can present with mood symptoms. Screen with TSH.
Substance Use
Alcohol and substance use disorders may present with cyclic symptoms.
Prospective symptom recording is essential to distinguish true premenstrual disorders from conditions with premenstrual exacerbation.
Source: ACOG Clinical Practice Guideline 2023; Gallant SJ, et al. Psychosom Med 1992
Treatment Algorithm Overview
1
2
3
4
5
1
Mild Symptoms
Lifestyle measures: exercise, stress reduction, vitex agnus castus
2
Moderate-Severe
SSRIs (first-line) or COCs (if contraception desired)
3
Partial Response
Optimize dosing, try different SSRI, add CBT
4
Refractory
GnRH agonist with hormone addback
5
Last Resort
Bilateral oophorectomy (strict criteria)
Source: ACOG Clinical Practice Guideline No. 7, 2023
Lifestyle Interventions for Mild Symptoms
Exercise
Regular aerobic exercise beneficial for physical symptoms. Positive health strategy with potential symptom relief.
Stress Reduction
Relaxation techniques and stress management may help alleviate symptoms.
Vitex Agnus Castus
Herbal remedy more effective than placebo for PMS symptoms in systematic reviews.
Source: Steege JF, et al. J Psychosom Res 1993; van Die MD, et al. Planta Med 2013
SSRIs: First-Line Pharmacotherapy
Selective serotonin reuptake inhibitors are the most effective treatment for moderate to severe PMDD with the best evidence base.
Sertraline
Extensively studied, well-tolerated. Starting dose 25-50 mg.
Citalopram
Effective for continuous and luteal phase dosing. Starting dose 10 mg.
Escitalopram
Proven efficacy in luteal phase administration. Starting dose 5-10 mg.
Fluoxetine
Multiple RCTs demonstrate effectiveness. Starting dose 10 mg.
Response rate: 60-70% of women. Beneficial effect expected in first cycle.
Source: Marjoribanks J, et al. Cochrane Database Syst Rev 2013; Shah NR, et al. Obstet Gynecol 2008
SSRI Dosing Regimens
Continuous Daily
Daily administration throughout menstrual cycle. Best for women with low-level symptoms during follicular phase or severe physical symptoms.
Luteal Phase
Start cycle day 14, continue until menses. Less expensive, fewer side effects. Requires predictable symptoms.
Symptom-Onset
Begin at symptom onset until first days of menses. Requires ability to recognize symptom onset.
All three regimens are equally effective. Choice depends on symptom pattern, predictability, and patient preference.
Source: Freeman EW, et al. Arch Gen Psychiatry 1999; Wikander I, et al. J Clin Psychopharmacol 1998
SSRI Dosing Example: Citalopram
Dose adjustments made over first month, with further increases in subsequent cycles as needed. Similar dosing principles apply to other SSRIs.
Source: Wikander I, et al. J Clin Psychopharmacol 1998; ACOG Clinical Practice Guideline 2023
SSRI Side Effects and Management
Common Side Effects (15%)
Nausea (most common, resolves in 4-5 days), headache, insomnia, decreased libido. Dose-dependent and most common reason for discontinuation.
Sexual Dysfunction
Diminished interest, delayed orgasm, anorgasmia. May not improve with dose reduction. Recovers after discontinuation. Consider intermittent dosing.
Discontinuation Symptoms
With continuous daily use: dizziness, tinnitus, "body shocks." Most severe with venlafaxine. Taper when discontinuing.
Management Strategy: Start with low dose, increase gradually. Inform patients about potential side effects. Intermittent regimens reduce side effects.
Source: Marjoribanks J, et al. Cochrane Database Syst Rev 2013; Yonkers KA, et al. Am J Obstet Gynecol 2018
SSRI Response and Duration
Expected Response
60-70%
Response Rate
Women who respond to SSRI therapy
30-40%
Non-Responders
May respond to different SSRI
Beneficial effect expected in first cycle. If suboptimal, increase dose in subsequent cycle.
Treatment Duration
Optimal duration unknown. Typical approach:
  • Continue for 1 year
  • Discuss taper/discontinuation or trial of intermittent therapy
  • Recurrence indicates need to resume treatment
  • May need treatment until pregnancy or menopause
Source: Shah NR, et al. Obstet Gynecol 2008; ACOG Clinical Practice Guideline 2023
Combined Oral Contraceptives for PMDD
For women desiring contraception with moderate-severe non-depressive symptoms:
Drospirenone-Containing COCs
FDA-approved for PMDD. Prefer shortened pill-free interval (4 days vs 7 days). Start with 3mg DRSP/20mcg EE.
Efficacy Evidence
More effective than placebo for PMDD symptoms. Large placebo effect noted (36% vs 48% symptom reduction).
Continuous Administration
May use continuous COC if cyclic regimen ineffective. Limited data but reasonable option for refractory cases.
Important Limitation
COCs improve overall symptoms but may NOT be effective for depressive symptoms. Monitor for mood worsening.
Source: Pearlstein TB, et al. Contraception 2005; de Wit AE, et al. Am J Obstet Gynecol 2021
COC Safety Considerations

FDA Warning (2012): Drospirenone-containing COCs may be associated with higher risk of venous thromboembolism (VTE) compared to levonorgestrel and some other progestins.
Clinical recommendations:
  • Assess individual VTE risk before starting drospirenone COC
  • VTE risk with drospirenone remains lower than pregnancy risk
  • FDA does not advise discontinuation in current users
  • Consider alternative progestins in high-risk patients
Source: FDA Safety Communication 2012; ACOG Clinical Practice Guideline 2023
Cognitive Behavioral Therapy
Evidence Base
Meta-analysis of 5 RCTs shows reduction in anxiety and depression symptoms with CBT vs other interventions.
Benefits
  • Reduces symptom intensity and distress
  • Improves coping skills
  • Can be combined with pharmacotherapy
Recommendation
Consider for women with moderate-severe symptoms and suboptimal response to medication alone.
Source: Busse JW, et al. Psychother Psychosom 2009; Weise C, et al. Psychother Psychosom 2019
GnRH Agonists: Mechanism and Use
Reserved for severe symptoms unresponsive to SSRIs and COCs.
1
Medical Ovariectomy
GnRH agonist suppresses ovarian function, eliminating cyclic hormone changes
2
Symptom Resolution
Dramatic improvement in PMDD symptoms with ovarian suppression
3
Hormone Addback
Continuous estrogen-progestin prevents hypoestrogenic side effects and bone loss
4
Maintained Efficacy
Addback does not diminish PMDD symptom relief
Typical regimen: Leuprolide acetate 3.75mg depot monthly + continuous oral estradiol 1mg + micronized progesterone 100mg daily
Source: Muse KN, et al. N Engl J Med 1984; Wyatt KM, et al. BJOG 2004
GnRH Agonist: Long-Term Management
Month 1-3
Initiate leuprolide + hormone addback. Monitor symptom response and side effects.
Month 4-6
Confirm sustained symptom relief. Assess tolerance of hormone addback regimen.
Month 7-12
Continue if effective. Monitor bone density if long-term use anticipated.
Beyond 1 Year
Long-term use possible with addback. No BMD loss with continuous estrogen-progestin.
Critical: Must use continuous (not cyclic) hormone addback to avoid reproducing PMS symptoms.
Source: Mitwally MF, et al. Menopause 2002; Bedaiwy MA, et al. Fertil Steril 2006
GnRH Antagonist: Emerging Option

New Treatment Option: Combined oral GnRH antagonist with hormone addback in single tablet
Relugolix 40mg + Estradiol 1mg + Norethindrone Acetate 0.5mg
Convenience
Once-daily oral tablet vs injection + two oral tablets for GnRH agonist regimen
Bone Safety
No bone density loss over 2 years in fibroids and endometriosis studies
Current Status
FDA-approved for fibroids and endometriosis. Not yet studied specifically for PMS/PMDD but theoretically equivalent
Source: Syed YY. Drugs 2022; Blair HA. Drugs 2024
Surgical Management: Last Resort
Bilateral oophorectomy considered only when all criteria met:
Confirmed Diagnosis
PMDD confirmed with prospective symptom recording (daily calendar)
GnRH Agonist Success
Only medical approach effective, continuously effective for minimum 6 months
Hormone Tolerance
Tolerance of estrogen (or estrogen-progestin) replacement tested during GnRH therapy
Childbearing Complete
Patient has completed childbearing
Long-Term Need
Several more years of therapy anticipated based on patient's age
Observational studies show bilateral oophorectomy effective for severe, disabling, refractory PMDD.
Source: Casper RF, et al. Am J Obstet Gynecol 1990; Johnson SR. Obstet Gynecol 2004
Treatments NOT Recommended
Alprazolam
Not recommended despite some benefit vs placebo. Risks of potential misuse outweigh benefits. International Society for Premenstrual Disorders advises against use.
Vitamin B6
Inconsistent evidence. Risk of peripheral neuropathy with high doses. Not routinely suggested.
High-Dose Calcium
Low-quality evidence. Potential risks: renal calculi, possible cardiovascular concerns. Not routinely suggested.
Other Vitamins
Vitamin E, primrose oil, magnesium: inconsistent evidence, not more effective than placebo (30% response rate).
Source: Ismaili E, et al. Arch Womens Ment Health 2016; Nevatte T, et al. Arch Womens Ment Health 2013
Treatment Algorithm: Mild Symptoms
01
Lifestyle Modifications
Regular aerobic exercise, stress reduction techniques, adequate sleep
02
Herbal Therapy
Consider vitex agnus castus (chasteberry) - more effective than placebo
03
Monitor Response
Continue prospective symptom tracking. Reassess after 2-3 cycles.
04
Escalate if Needed
If symptoms worsen or functional impairment increases, consider pharmacotherapy
Source: ACOG Clinical Practice Guideline No. 7, 2023
Treatment Algorithm: Moderate-Severe Symptoms
Step 1: First-Line
No contraception need: SSRI (continuous, luteal, or symptom-onset)
Contraception desired: Drospirenone COC with shortened pill-free interval
Step 2: Optimize
Adjust SSRI dose, try different SSRI, switch dosing regimen, or add CBT
Step 3: Combination
SSRI + COC if monotherapy insufficient. Consider continuous COC.
Step 4: GnRH Agonist
With continuous hormone addback for refractory cases
Source: ACOG Clinical Practice Guideline No. 7, 2023
Monitoring Treatment Response
Short-Term (1-3 Cycles)
  • Continue prospective symptom tracking
  • Assess symptom reduction
  • Monitor side effects
  • Evaluate functional improvement
  • Adjust dose if needed
Long-Term (>3 Cycles)
  • Sustained symptom control
  • Quality of life assessment
  • Side effect tolerance
  • Consider dose reduction or intermittent therapy
  • Plan for duration of treatment
Source: ACOG Clinical Practice Guideline No. 7, 2023; Yonkers KA, et al. Am J Obstet Gynecol 2018
Special Populations: Women Without Menstruation
Diagnosis more challenging but possible in women with normal ovulation but no menses:
Post-Hysterectomy
Ovarian conservation with hysterectomy. Cyclic symptoms persist without menstrual reference point.
Endometrial Ablation
35-40% develop amenorrhea. Ovulation persists in most cases.
LNG-IUD Users
Amenorrhea after 6 months, but ~75% continue ovulating. Cyclic symptoms may persist.
Diagnostic approach: Prospective charting essential to document cyclic pattern recurring every 28-35 days (normal intermenstrual interval range).
Source: ACOG Clinical Practice Guideline 2023; Yonkers KA, et al. Lancet 2008
Natural History and Prognosis
1
Menarche to 20s
Symptoms can begin any time after menarche, typically by early 20s
2
Reproductive Years
Symptoms continue throughout reproductive life if untreated. Some experience worsening in late reproductive years.
3
Pregnancy
Transient resolution during pregnancy due to disruption of ovulatory cycles
4
Perimenopause
Women with premenstrual disorders at higher risk for mood disorders during menopausal transition
5
Menopause
Complete resolution after menopause
Source: Rapkin AJ, et al. Expert Rev Pharmacoecon Outcomes Res 2009; Freeman EW, et al. Obstet Gynecol 2004
Key Clinical Pearls
Diagnosis Requires Prospective Tracking
Never diagnose based on retrospective recall alone. Use DRSP form for 2 cycles minimum.
Symptom-Free Follicular Phase Essential
If symptoms present throughout cycle, consider mood disorder rather than PMS/PMDD.
SSRIs Work Quickly
Expect response in first cycle - unlike depression treatment which takes weeks.
Intermittent Dosing Effective
Luteal-phase or symptom-onset SSRI dosing as effective as continuous for many women.
COCs May Not Help Depression
While COCs improve overall symptoms, they may not be effective for depressive symptoms.
Source: ACOG Clinical Practice Guideline No. 7, 2023
Evidence Quality Summary
Evidence quality based on number and quality of RCTs, systematic reviews, and meta-analyses.
Source: Cochrane systematic reviews; ACOG Clinical Practice Guideline 2023
Patient Education Points
1
PMS/PMDD is a Real Medical Condition
Not "just hormones" or psychological weakness. Biological basis with effective treatments available.
2
Accurate Diagnosis Requires Tracking
Keep daily symptom diary for 2 months. Must show symptom-free week after menses.
3
Multiple Effective Treatments
SSRIs, hormonal contraceptives, lifestyle changes. May need to try several approaches.
4
Treatment Works Quickly
Unlike depression treatment, expect improvement in first menstrual cycle with SSRIs.
5
Long-Term Management
May need treatment until pregnancy or menopause. Symptoms resolve completely after menopause.
Source: ACOG Patient Education Materials; UpToDate Patient Information
Future Directions in Research
Genetic Markers
Further research on ESR1 gene and other genetic factors to identify at-risk women and personalize treatment
Neuroimaging Studies
Understanding brain changes during menstrual cycle in PMDD patients vs controls
Novel Therapeutics
GABA modulators, allopregnanolone antagonists, and other targeted treatments under investigation
Precision Medicine
Biomarkers to predict treatment response and guide individualized therapy selection
Source: Dubey N, et al. Mol Psychiatry 2017; Bäckström T, et al. Psychoneuroendocrinology 2021
Clinical Practice Recommendations
Always Use Prospective Diagnosis
DRSP form for minimum 2 cycles before initiating treatment
SSRIs First-Line for PMDD
Start with sertraline, citalopram, escitalopram, or fluoxetine
COCs for Dual Purpose
When contraception needed, use drospirenone COC with shortened pill-free interval
Monitor and Adjust
Expect response in first cycle. Optimize dose or try different agent if needed
Know When to Refer
Refractory cases, suicidal ideation, or diagnostic uncertainty warrant specialist consultation
Source: ACOG Clinical Practice Guideline No. 7, 2023; ISPMD Consensus Guidelines
Summary and Conclusions
Premenstrual syndrome and premenstrual dysphoric disorder are common, biologically-based conditions affecting 20-30% and 2% of reproductive-age women respectively.
Key Diagnostic Points
  • Requires prospective symptom tracking
  • Must have symptom-free follicular phase
  • PMDD: ≥5 symptoms including ≥1 affective
  • Functional impairment essential
Evidence-Based Treatment
  • SSRIs: first-line, 60-70% response
  • Drospirenone COCs: if contraception desired
  • GnRH agonists: refractory cases
  • CBT: adjunctive therapy
Professor Mykhailo Medvediev
Primary Sources: ACOG Clinical Practice Guideline No. 7 (2023); American Psychiatric Association DSM-5 (2013); Cochrane Systematic Reviews; International Society for Premenstrual Disorders Consensus Guidelines