Nearly one-fourth (27.7%) of the Indian female population falls in the 15 to 29 years age group.1 This reproductively important transition phase of life associated with growth spurts in several physical and mental dimensions. It is estimated in epidemiological surveys that as many as 80% of reproductive age women experience some symptoms in the premenstrual phase.2

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome (PMS) which significantly impairs quality of life.3 The disability-adjusted life years lost to this is comparable with other major psychiatric disorders, such as depression and anxiety.4 Recently, PMDD has been incorporated in the main body of Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V), from Appendix B as in DSM-IV.5

The psychological symptoms associated with PMDD are depressed mood, anxiety, affective labiality, anger or irritability, decreased interest in usual activities, difficulty in concentrating, easy fatigability, change in appetite, overeating, hypersomnia or insomnia, feeling overwhelmed, and other physical symptoms, such as breast tenderness, pain, bloating, and weight gain. These symptoms are present for most of the time during the last week of the luteal phase, begin to remit within a few days of the onset of menstrual flow, and are absent in the week after menses.6 Women with PMS report significant impairment in personal relationships, compromised work levels, and increased absence from work, school, or college.7

Serotonin neurotransmitter abnormalities is the commonly implicated etiology,8 as suggested by preclinical studies and proven therapeutic efficacy of serotonergic drugs, in managing PMDD.9,10 Lifestyle factors like caffeine, salt, chocolate, refined sugars, sedentary habits aggravate symptoms of PMS/PMDD. But lifestyle modifications lack definitive therapeutic evidence.3 Premenstrual syndrome is relatively underinvestigated in Indian context owing to various sociocultural factors. We aimed to study PMS/PMDD its associated symptomatology, sociodemographic, menstrual factors, and functional impairment.


In an observational cross-sectional study, randomly selected 150 females (18–30 years) presenting to Department of Psychiatry, Mahatma Gandhi Medical College & Hospital, Jaipur, Rajasthan, India, were evaluated.

All females 18 to 30 years old, with regular menstrual cycles (21–35 days) and willing to give written informed consent were included in the study. Subjects with medical and gynecological illnesses, such as anemia, diabetes, hypothyroidism, asthma, migraine, epilepsy, pelvic inflammatory disease, endometriosis, and amenorrhea were excluded. Also subjects with history of substance abuse or psychotropic drugs were excluded from the study. After sociodemographic data, detailed menstrual history, premenstrual symptoms, hormonal pills use, family history in first-degree relatives were collected. Premenstrual symptoms screening tool (PSST) was applied.2 The questions and meaning of related terms were explained to the participants up to their satisfaction. Confidentiality was assured to all the participants ensuring cooperation and participation.

Premenstrual Symptoms Screening Tool

Steiner et al2 developed this screening tool for premenstrual symptoms. This “translates” categorical DSM-IV-TR criteria12 into a rating scale with degrees of severity. It consists of 14 items assessing premenstrual symptoms of mood, anxiety, sleep, appetite, and physical symptoms. It also includes functional impairment items of five different domains.

Participants rate their experience of each symptom and functional impairment in last 12 months duration during most of the cycles on 4-point Likert scale as “not at all,” “mild,” “moderate,” or “severe.” Using PSST scoring criteria, PMDD, moderate to severe PMS, and no/mild PMS subjects were identified.1

Structured Clinical Interview for DSM-IV-TR (SCID-DSM-IV)

The SCID-PMDD is a clinician-administered structured interview developed and validated by Accortt et al.11 It includes 11 psychological and physical symptoms of criterion A12 phrased in a detailed layperson format similar to items on the SCID13 to facilitate the assessment of the specific DSM-IV-TR criteria for PMDD.

Statistical Analysis

Descriptive and analytical statistical analysis was done using Statistical Package for the Social Sciences version 4.0


Out of total studied 150 subjects, 18 participants (7.33%) on screening by PSST met DSM-IV-TR criteria for the diagnosis of PMDD. Twenty-one participants (14.7%) marginally missed the DSM-IV-TR criteria for the diagnosis of PMDD (moderate to severe PMS).

Remaining 118 subjects (78.67%) had “no/mild PMS.”

On analyzing the sociodemographic characteristics of studied subjects, there was no statistically significant difference among three groups with respect to residence, religion, and marital status. Postgraduate students had higher rates of PMS and PMDD compared with illiterates and graduates (Table 1).

The most common reported symptom was “fatigue/lack of energy” in the study group (102, 68%), followed by “decrease interest at work” (94, 62.67%) and “anger/irritability” (90, 60%). Almost all participants (95.24%) of “moderate to severe PMS” group and majority of PMDD group (90.91%) reported “fatigue/lack of energy”. Decrease interest in work was reported by all participants of PMDD group, also majority of “moderate to severe PMS” group (95.24%), and near two-thirds of all (60.1%) participants, and thus, it remained the second most common reported symptom (Table 2).

Table 1: Sociodemographic characteristics of subjects

CharacteristicNo/mild PMS n = 118 (%)Moderate to severe PMS n = 21 (%)PMDD n = 11 (%)Total (%)p-value
Mean age23.1 ± 1.222.9 ± 1.121.6 ± 1.90.04
 Rural52 (78.8)10 (15.15)4 (6.06)660.8
 Urban67 (79.8)12 (14.3)5 (5.95)84      
 Hindu118 (78.7)23 (15.33)9 (6.0)1380.6
 Muslim9 (75)2 (16.67)1 (8.3)12      
Marital status                              
 Single104 (80.62)22 (17.05)3 (2.33)1290.8
 Married16 (76.2)4 (19.05)1 (4.76)21      
 Illiterate74 (77.08)14 (14.58)8 (8.3)960.009
 Graduate16 (8.88)2 (11.11)18
 Postgraduate23 (63.89)8 (22.22)5 (13.89)36      

Chi-square test; p < 0.05 is considered statistically significant

Table 2: Symptoms associated with PMS/PMDD

Symptom(s)No/mild PMS n = 118 (%)Moderate to severe PMS n = 21 (%)PMDD n = 11 (%)
Affective lability33 (27.97)17 (80.95)10 (90.91)
Depressed mood52 (44.07)20 (95.24)11 (100)
Decreased interest in social activities49 (41.53)19 (90.48)8 (72.73)
Decreased interest in usual activity at work63 (53.39)20 (95.24)11 (100)
Decreased interest in usual activity at home52 (44.07)18 (85.71)9 (81.82)
Anger/irritability63 (53.39)17 (80.95)10 (90.91)
Anxiety/tension56 (41.46)18 (85.71)11 (100)
Fatigue/lack of energy72 (61.02)20 (95.24)10 (90.91)
Overeating/food craving10 (8.47)9 (42.86)4 (36.36)
Insomnia22 (18.64)16 (76.19)7 (63.64)
Feeling overwhelmed20 (16.95)15 (71.43)7 (63.64)
Hypersomnia29 (24.58)14 (66.67)8 (72.73)
Physical symptoms43 (36.44)16 (76.19)8 (72.73)

Table 3: Functional impairment associated with PMS/PMDD

Functional impairmentNo/mild PMS n = 88 (%)Moderate to severe PMS n = 21 (%)PMDD n = 11 (%)p-value
Relationships with friends, classmates/coworkers35 (39.77)16 (76.19)10 (90.91)<0.004
Relationship with your family23 (26.14)14 (66.67)9 (81.82)<0.003
School/work efficiency or productivity61 (69.32)19 (90.48)10 (90.91)0.0016
Social life activities36 (40.91)17 (80.95)10 (90.91)<0.001
Home responsibilities35 (39.77)18 (85.71)9 (81.82)<0.005

Chi-square test; p < 0.05 is considered statistically significant

A total of 120 participants reported at least one area of impaired functioning. Most frequent functional impairment reported was “school/work efficiency and productivity” seen among 92.5% of the total respondents, 90.48% of “moderate to severe PMS,” and 10 of 11 among “PMDD” group (Table 3).

The mean menstrual cycle length was 23.1 ± 1.2 days in no/mild PMS group and 22.9 ± 1.1 and 21.6 ± 1.9 in moderate to severe PMDD groups respectively. There was no statistically significant difference among groups with respect to age of menarche, length of the menstrual cycle, and days of the menstrual bleeding. Premenstrual dysphoric disorder group and “moderate to severe PMS” group experienced more number of days and years with premenstrual symptoms as compared with “no/mild PMS” group.

All study groups were comparable with respect to regularity of cycles at the time of menarche (p = 0.76), although there was statistically significant difference among groups with respect to positive family history, in first-degree relatives, menstrual cramps, and symptoms onset since menarche.

More number of participants in “moderate to severe PMS” and “PMDD” groups reported that they had symptoms since menarche as compared with “no/mild PMS” group (p <#x00A0;0.003). There was no statistically significant difference among groups with respect to regular exercise (p = 0.24) or regular games (p = 0.82).


Several previous studies were comparable to our study owing to similar sample characteristics like similar age group and preponderance of urban unmarried.14-19

The prevalence of PMS according to DSM-IV-TR criteria was 21.33% (14% for moderate to severe PMS and 7.33% for PMDD) among studied 150 subjects. Rapkin and Mikacich20 and several other Asian studies show similar results.12,13,15,18 In an Indian study, Banerjee et al21 reported 6.4% prevalence of PMDD in Indian women.22 Our results were also concordant with Steiner et al14 who reported the prevalence of severe PMS and PMDD as 21.3 and 8.3% respectively, although few studies like Chayachinda et al23 report a higher prevalence of PMDD (25.1%) of PMDD among Thai nurses. The slightly lower prevalence in our study can be attributed to sociocultural factors, stress, and beliefs in Indian society that affect reporting of the premenstrual symptoms.

Fatigue/lack of energy (68%) was the most common reported symptom in our study sample.

Similar results were suggested by Nourjah18 and Bakhshani et al,15 whereas Pearlstein et al,24 Tabassum et al,16 and Nisar et al25 reported it as the third most common symptom.

Second and third most common symptoms reported by our study subjects were decreased interest in work (62.67%) and anger/irritability (60%) respectively. Several studies in past have reported anger/irritability as the most common symptom.2,14,16,24-26 Stout et al27 in a community-based nonpatient sample reported “decreased energy” and “being irritable” as the most common reported premenstrual symptoms. Singh et al19 while studying Indian college students reported that the most common symptom in subjects “not having any impairment” was “irritability” and those “with impairment” was “tiredness and lack of energy.” In DSM-V the order of symptoms have been revised for diagnostic criteria of PMDD.28 “Mood swings and irritability” are now at the top of the list as compared with “markedly depressed mood” in the DSM-IV-TR. Our findings are consistent with this change in DSM-V.28

Table 4: Correlation of PMS/PMDD

CharacteristicNo/mild PMSn = 118 (%)Moderate to severe PMS n = 21 (%)PMDD n = 11 (%)p-value
Age at menarche (years)14.8 ± 1.614.5 ± 1.213.9 ± 0.20.06
BMI18.1 ± 3.719.8 ± 3.819.2 ± 3.50.005
Length of cycle (days)29.3 ± 2.428.5 ± 2.328.4 ± 1.80.4
Days bleeding lasts4.8 ± 1.84.9 ± 1.34.9 ± 1.10.6
Premenstrual symptom duration (days)1.6 ± 1.22.8 ± 1.63.9 ± 1.1<0.001
Years with premenstrual symptom2.5 ± 2.13.8 ± 1.73.8 ± 1.10.005

Chi-square test; p < 0.05 is considered statistically significant

Table 5: Demographic correlations

CharacteristicNo/mild PMS n = 118 (%)Moderate to severe PMS n = 21 (%)PMDD n = 11 (%)p-value
Regularity of cycle at menarche88 (74.58)16 (76.19)8 (72.73)0.76
Onset of symptoms since menarche26 (22.03)14 (66.67)5 (45.45)<0.003
Menstrual cramps67 (56.78)18 (85.71)9 (81.82)0.008
Family history of PMS24 (20.34)10 (47.62)4 (36.36)0.006
Regular exercise30 (25.42)4 (19.05)1 (9.09)0.24
Regular games33 (27.97)7 (33.33)3 (27.27)0.82

Chi-square test; p < 0.05 is considered statistically significant

Steiner et al14 suggested nearly three-quarters PMDD and almost half of the severe PMS cases reported that symptoms interfered with their relationships and/or school/work efficiency/productivity. Similarly, in our study, “school/work efficiency and productivity” was the most common (60%) reported functional impairment (Table 4).

Our study suggests association of higher body mass index (BMI) with “moderate to severe PMS” and “PMDD” groups than “no/mild PMS” group (p = 0.005). Another Indian study by Bansal et al26 and literature supports our findings.22

Similar to Steiner et al2 and Issa et al,17 our study found no significant difference in length of the menstrual cycle (p = 0.4) and days of the menstrual bleeding (p = 0.6) in all the groups.

Our study suggests statistically significant higher duration of premenstrual symptoms in “PMDD” group and “moderate to severe PMS” group. This is probably because of the chronic, relapsing, and remitting nature of illness. Study by Steiner et al2 supports our results. Positive family history and menstrual cramps were more common in “moderate to severe” PMDD study groups, as also suggested in several other studies.2,14,17,18,22,23,25,29,30 Also, Deuster et al,31 Nourjah,18 and Nisar et al25 found a family history of PMS in more than half of the study participants (57%). A genetic preponderance is suggested in several studies (Table 5).32-34

The “onset of symptoms since menarche” was significantly more in “moderate to severe PMS” and PMDD groups, which is supported by existing literature.14 Physical exercise in the form of regular exercise and games failed to show any association with study groups. Benefits of aerobic exercise have been suggested for PMS sufferers, and high-intensity aerobic exercise was found to be superior to low-intensity one for PMS treatment.22

The study has certain limitations. The study sample represented only a group at a single tertiary care center. Recall bias cannot be ruled out as subjects reporting premenstrual symptoms was based on retrospective recall of symptoms. Larger prospective population-based studies are recommended using gold standard prospective daily diaries of symptoms for future trials.


Premenstrual syndrome is a common underrecognized entity presenting at a tertiary care center. The most common presenting symptoms include fatigue and decreased interest in work. It significantly causes functional impairment commonly in the form of decreased work efficiency and productivity. Higher BMI, early onset of symptoms since menarche, longer duration of premenstrual symptoms, menstrual cramps, and family history are significant correlates. Early diagnosis may pave the way for effective management and significant improvement in quality of life.

Conflicts of interest

Source of support: Nil

Conflict of interest: None