established seven criteria (a through g) for the diagnosis of pmdd which is paraphrased below. there is overlap between the criteria for pmdd in the dsm-5 and the criteria found in the daily record of severity of problems (drsp). according to the dsm-5, a diagnosis of pmdd requires the presence of at least five of these symptoms with one of the symptoms being numbers 1–4. these symptoms should occur during the week before menses and remit after initiation of menses. in order to meet criteria for the diagnosis, the symptoms should be charted prospectively for two consecutive ovulation cycles in order to confirm a temporal and cyclical nature of the symptoms. the symptoms should also be severe enough to affect normal work, school, social activities, and/or relationships with others. the symptoms of criteria a-c must have been met for most menstrual cycles that occurred in the preceding year, and have to have cause significant impairment in family, work, school, or social functioning. (criterion d). timing criterion a: during most menstrual cycles throughout the past year, at least 5 of the symptoms outlined in criterion b and criterion c must be present in the final week before the onset of menses, must start to improve within a few days after the onset of menses, and become minimal or absent in the week post-menses. symptoms criterion b: one (or more) of the following symptoms must be present: marked affective lability (e.g., mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection) marked irritability or anger or increased interpersonal conflicts marked depressed mood, feelings of hopelessness, or self-deprecating thoughts marked anxiety, tension, and/or feelings of being keyed up or on edge criterion c: one (or more) of the following symptoms must be present additionally, to reach a total of 5 symptoms when combined with present symptoms from criterion b above: decreased interest in usual activities (e.g., work, school, friends, hobbies). subjective difficulty in concentration. lethargy, easy fatigability, or marked lack of energy. marked change in appetite; overeating; or specific food cravings. hypersomnia or insomnia. a sense of being overwhelmed or out of control. physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of "bloating", or weight gain. severity criterion d: the symptoms observed in criteria a-c are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home). consideration of other psychiatric disorders criterion e: the disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder—although it may co-occur with any of these disorders. confirmation of the disorder criterion f: criterion a should be confirmed by prospective daily ratings during at least two symptomatic cycles. the diagnosis may be made provisionally prior to this confirmation. criterion g: the symptoms are not attributable to the physiological effects of a substance (e.g., drug abuse, a medication, other treatments) or another medical condition (e.g., hyperthyroidism). clinically significant distress is not defined explicitly by the dsm-iv, where it has been critiqued by multiple scholars as being too vague, and potentially detrimental for those who have symptoms of depression, anxiety, or other mood disorders because they do not meet the clinical significance requirement. icd 11 diagnostic criteria for pmdd are also provided by the 2016 world health organization's international classification of diseases (icd-11-cm): ga34.41 premenstrual dysphoric disorder description during a majority of menstrual cycles within the past year, a pattern of mood symptoms (depressed mood, irritability), somatic symptoms (lethargy, joint pain, overeating), or cognitive symptoms (concentration difficulties, forgetfulness) that begin several days before the onset of menses, start to improve within a few days after the onset of menses, and then become minimal or absent within approximately 1 week following the onset of menses. the temporal relationship of the symptoms and luteal and menstrual phases of the cycle may be confirmed by a prospective symptom diary. the symptoms are severe enough to cause significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning and do not represent the exacerbation of a mental disorder. royal college of obstetricians and gynecologists and the international society for the study of premenstrual disorders other organizations that have published diagnostic criteria for pmdd include the royal college of obstetricians and gynecologists and the international society for the study of premenstrual disorders (ispmd). the ispmd was a consensus group established by an international multidisciplinary group of experts. the group's diagnostic criteria for pmdd focuses on the cyclic nature of the symptoms occurring during the luteal phase of the menstrual cycle, as well as the symptoms being absent after menstruation and before ovulation and causing significant impairment. the ispmd diagnostic criteria for pmdd do not specify symptom characteristics or number of symptoms. differential diagnosis a critical part of diagnosing pmdd is ruling out underlying psychiatric disorder or physical illness that can cause similar symptoms. that exhibits premenstrual exacerbation, the menopausal transition, hyperthyroidism, hypothyroidism, as well as other mood disorders. furthermore, many medical disorders are worsened prior to ordering menses, but these typically do not present strictly during the luteal phase. mood disorders – there is potential for patients to have psychiatric disorders with superimposed pmdd or psychiatric disorders. in order to establish the timeline of symptoms required for a diagnosis of pmdd symptoms need to be tracked using scales like the calendar of premenstrual experiences or the daily record of severity of problems. menopausal transition – affective symptoms associated with the menopausal transition most commonly start when menstrual cycle starts to become irregular or anovulatory whereas pmdd symptoms occur during the luteal phase of ovulatory cycles. thyroid disorders—patients with both hyperthyroidism and hypothyroidism may present with affective symptoms. the patient's history is very important to determine whether the provider should suspect thyroid disorders. patients should also have thyroid hormone levels checked to ensure no underlying thyroid disorder is present. treatment medication several medications have been shown to effectively reduce the physical and emotional symptoms of pmdd. antidepressant treatment selective serotonin reuptake inhibitors (ssris) are the first-line medication. women taking ssris to ease pmdd generally report >50% alleviation in symptoms, which was significant improvement compared to placebo. two approaches to dosing have been studied: continuous dosing (daily) and luteal dosing (14 days before menstruation and discontinuing at the onset of menses). both dosing schedules have similar effectiveness with some recent studies demonstrating greater symptom control with continuous dosing. this gives patients control of how they want to dose their medication in alliance with their mental health provider. serotonin norepinephrine reuptake inhibitors (snris) have also been studied in the treatment of pmdd and shown efficacy in reducing symptoms. these are an alternative for patients who do not respond to ssri's. however, they are more likely to be dosed continuously due to snri discontinuation syndrome - a flu-like feeling caused by dropping blood levels of snri. anxiolytics two medications typically given to reduce acute anxiety have been studied in treatment for pmdd: alprazolam (xanax) and buspirone. alprazolam carries a risk of abuse and causes central nervous system depression and results of clinical trials have not shown benefit to treatment. buspirone showed lower efficacy than ssri, but may be used as an adjunctive treatment or alternative if ssri side effects are intolerable to the patient. psychotherapy cognitive behavioral therapy (cbt) has been shown to be effective for reducing premenstrual symptoms in women with (retrospectively-reported) pms. cbt is an evidence-based approach for treating depression and focuses on the link between mood, thoughts, and actions to help women address current issues and symptoms. when cbt was compared to ssri alone or in combination with ssri, groups receiving cbt had significant improvement of pms symptoms. through the practice of cbt, women are better able to recognize and modify recurrent issues as well as thought and behavior patterns that interfere with functioning well or that make depressive symptoms worse. however, a recent meta-analysis suggests that existing psychotherapies may be primarily useful for reducing impairment (rather than symptom severity) in pmdd. hormonal treatment oral contraceptives have been effective in reducing pms symptoms, but only certain formulations have proven to be modestly effective in the treatment of pmdd. transdermal estrogen and intrauterine devices containing levonorgestrel have also had modest efficacy. another fda approved treatment for pmdd is the oral contraceptive with ethinylestradiol and drospirenone (a novel progestin) taken on a 24-4 schedule (24 active pills, 4 inactive pills). it has been shown that hormonal birth control containing drospirenone and low levels of estrogen helps relieve severe pmdd symptoms, for at least the first three months that it is used. the idea behind using oral contraceptives is to suppress ovulation, therefore suppressing sex hormone fluctuations. another treatment, typically used when other options have failed, is injection of a gonadotropin-releasing hormone(gnrh) agonist with adjunctive estrogen and progesterone or tibolone. this is a last resort because gnrh antagonists can cause medical menopause by shutting down the body's pathway for reproductive hormones called the hypothalamic, pituitary, gonadal axis. as a result, gnrh therapy presents increased risk of osteopenia (decreased bone density) and cardiovascular disease. this therapy is often reserved for patients considering surgical menopause to test the outcome of the surgery. surgical menopause in a minority of patient who meet specific criteria and drug-based treatments are ineffective or produce significant side effects, hysterectomy and bilateral oophorectomy followed by estrogen replacement therapy is an option typically, the uterus is removed during the same surgery, and the women is prescribed a low-dose estrogen patch to reduce the symptoms produced by surgically induced menopause. there are five guidelines that should be considered before undergoing a surgical treatment. the vast majority of women with pmdd will not require surgical treatment to experience resolution of symptoms. the diagnosis of pmdd must be confirmed gnrh agonist therapy must be the only medical therapy that has been effective and it must have been effective continuously for a minimum of six months tolerance of estrogen replacement therapy has been tested the woman does not desire further children the woman's age warrants several more years of therapy adjunctive and alternative treatments other proposed treatments include dietary modification, herbal remedies including st john's wort and chasteberry, acupuncture, and exercise. some evidence suggests caffeine, sugar and alcohol intake may increase pms symptoms. a review article claimed significant improvement of pms symptoms with herbal treatments and acupuncture but the studies selected for review did not stratify severity of symptoms. finally, the american college of obstetricians and gynecologists recommends regular aerobic exercise to reduce pms symptoms. history in the 18th century, there were early accounts of weeping and other symptoms recurring almost every month, and in 1822 prichard gave this description: "many women … display a degree of excitement and irritation … at the period of menstruation; these are chiefly females of very irritable habits. in such instances, … an unusual vehemence of feeling and expression is observed … or there is torpor and dejection of mind with a despondent disposition". in 1827 a german mother was acquitted of infanticide on the grounds of menstrual mood disorder. premenstrual tension was also described in the french literature of the early 19th century. nearly one hundred years later, there were american descriptions of a cyclic personality change appearing 10–14 days before, and ending dramatically at the menses. the diagnostic category was discussed in the dsm-iiir (1987), in which the proposed condition was named "late luteal phase dysphoric disorder" and was included in the appendix as a proposed diagnostic category needing further study. preparations for the dsm-iv led to debate about whether to keep the category at all, only keep it in the appendix, or remove it entirely; the reviewers determined that the condition was still too poorly studied and defined, so it was kept in the appendix but elaborated with diagnostic criteria to aid further study. as preparations were underway in 1998 for the dsm-iv-tr, the conversation changed, as eli lilly and company paid for a large clinical trial of fluoxetine as a potential treatment for the condition that was then conducted by canadian academics and published in the new england journal of medicine in 1995. other studies have been conducted