Patient Presentation
A 15-year-old female came to clinic for her sports physical examination. She was overall well and had no complaints. During her menstrual history she stated that she had some increased fatigue starting at ~1 day before her period, and pain during the first 24-36 hours. She denied cramping, hypermenorrhagia, mood changes or breast tenderness. She had consistent cycles of about 30-31 days that she kept track of. The past medical history showed menarche at age 11.5 years.

The pertinent physical exam showed normal growth parameters around the 50-75% and normal vital signs. Her examination was normal and she was Tanner V for breast and public hair.

The diagnosis of a healthy female with menstrual symptoms was made. With further questioning she said that she felt that the pain was manageable with no treatment or with some over-the-counter ibuprofen. The pediatrician recommended that if the pain increased she could try to start using the ibuprofen ahead of her period for its anti-inflammatory properties and not just its pain-relieving properties. She also reviewed general healthy life-style changes. “Some people find eating a little more carbohydrate just before and first couple of days their periods also helps,” she offered. The teenager laughed, “I thought I was being crazy because sometimes I get the munchies and just want to eat bread and pasta for those couple of days. Now I know that is normal.

Discussion
Menstruation is a normal function of human females. It begins generally between 9 – 16 years of age. There are three levels of menstrual problems:

• Menstrual symptoms (MS)
  • Symptoms: acne, abdominal bloating, breast tenderness, food crazing, fatigue, irritability, depression, mood swings, heavy menstrual bleeding, dysmenorrhea, dissatisfaction with appearance, feeling stressed and other mood changes. Up to 200 symptoms have been ascribed as MS.
  • Prevalence – overall 80-90% of women have some symptoms
• Premenstrual syndrome (PMS)
  • Symptoms: same as MS but has impaired functioning
  • Prevalence – 15 – 40%
• Premenstrual dysphoric disorder (PMDD)
  • Symptoms: same as MS but has severe functional impairment especially psychosocial
  • Prevalence – 1.2 – 8.0%

Premenstrual disorders ((PMDs) includes PMS and PMDD) symptoms occur during the luteal phase (i.e. from ovulation until menses or ~ Day 13-14 until Day 0), subsides with menses, and women are symptom free during the follicular phase (from menses until ovulation or ~ Day 0 – Day 13-14). The cause is not fully understood, but felt to be due to some individuals being more sensitive to the hormonal fluctuations, not necessarily a steady state of the same hormone. Abnormal serotonin activity which through different mechanisms decreases serotonin could be another reason. Gamma aminobutyric acid (GABA) activity regulates progesterone and also anxiety, and may be lower during the luteal phase thereby causing MS.

For these reasons, treatment is often targets menstrual regulation or suppression, and neurotransmitter regulation. Examples are contraceptive hormones, gonadotropin agonists, and selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors. Other symptomatic treatment is often used such as nonsteroidal anti-inflammatory medications for dysmenorrhea. Spironolactone is used to treat bloating/fluid retention, and breast tenderness and it also can improve patient’s mood. Other non-pharmacological treatments include increased or timed carbohydrate consumption and exercise. Vitamins and herbals have varying quality of evidence to support their use. Benefits have been shown for cognitive behavioral therapy and acupuncture. Regular sleep, decreasing caffeine, smoking and other drugs are also good lifestyle interventions.

Obviously MS have a significant impact on women. In a study of over 42,000 women aged 15-45, dysmenorrhea was the most common symptom (85%), psychological problems (77%) and fatigue (71%). Approximately 40% were unable to perform at least some normal tasks and > 50% did not tell their family the reason for the task omission or transferring the responsibility for the task.

Learning Point
The diagnosis of PMDs is harder as this is a clinical diagnosis. While it may seem obvious, the key to diagnosing PMDs is that they occur in menstruating women (not premenarchal, preovulatory, nor menopausal), and occur during the luteal phase only. Therefore there should be a symptom free period during each menstrual cycle. Generally this symptom-free time is at least 1 week and usually more like 2 weeks. In adults, PMDs diagnoses are “required” to be made prospectively after 2 menstrual cycles. Some people use this for adolescents as well but adolescents have anovulatory cycles which may make the 2 cycle requirement difficult for someone with a very irregular cycle. For PMDs diagnoses, symptoms must be present (but not all symptoms present as there are up to 200 have be ascribed to PMDs) nor does a specific combination of symptoms must be present. For adolescents, ovulatory cycles often begin at the same time as the normal mid-adolescence psychosocial conflict with parents also occurs. The moody teenager could be moody but could also have a PMD.

Note that some people have some of the problems listed below making PMDs diagnosis more difficult.
The differential diagnosis, especially if there is no symptom-free period, includes:

• Anemia
• Autoimmune disorders
  • Diabetes mellitus
  • Hypothyroidism
• Collagen vascular disease
• Seizure disorders
• Endometriosis
• Anxiety and depression disorders
  • Generalized anxiety
  • Major depression
  • Bipolar disorder
  • Panic disorder
• Eating disorders
• Substance use

Questions for Further Discussion
1. What advice do you generally offer for teenagers with mild menstrual symptoms?
2. What criteria do you use to refer to adolescent medicine or gynecology for a possible PMD?
3. How do you treat dysmenorrhea?

Related Cases

Disease: Menstruation | Premenstrual Syndrome

Symptom/Presentation: Fatigue | Health Maintenance and Disease Prevention | Pain

Specialty: Adolescent Medicine | Obstetrics / Gynecology

Age: Teenager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Premenstrual Syndrome and Period Pain.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Akgul S, Kanbur N. Premenstrual disorder and the adolescent: clinical case report, literature review, and diagnostic and therapeutic challenges. International Journal of Adolescent Medicine and Health. 2015;27(4):363-368. doi:10.1515/ijamh-2014-0051

Schoep ME, Nieboer TE, van der Zanden M, Braat DDM, Nap AW. The impact of menstrual symptoms on everyday life: a survey among 42,879 women. Am J Obstet Gynecol. 2019;220(6):569.e1-569.e7. doi:10.1016/j.ajog.2019.02.048

Itriyeva K. Premenstrual syndrome and premenstrual dysphoric disorder in adolescents. Curr Probl Pediatr Adolesc Health Care. 2022;52(5):101187. doi:10.1016/j.cppeds.2022.101187

Liu X, Li R, Wang S, Zhang J. Global, regional, and national burden of premenstrual syndrome, 1990-2019: an analysis based on the Global Burden of Disease Study 2019. Hum Reprod. 2024;39(6):1303-1315. doi:10.1093/humrep/deae081

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa