Attitude of Spanish women towards Premenstrual Syndrome

Premenstrual Syndrome (PMS) is a recurrent, cyclical clinical condition characterized by a constellation of physical, psychological and behavioral symptoms that occur during the luteal phase of the menstrual cycle and remit with the onset of menstruation. Symptoms range from mild and intermittent to moderate or severe presentations that can significantly impair social, occupational and interpersonal functioning. The prevalence of premenstrual symptoms is high: most epidemiologic and clinical sources estimate that a majority of reproductive‑age women experience some symptoms, while a smaller proportion meet criteria for clinically significant PMS or the more severe Premenstrual Dysphoric Disorder (PMDD) [ACOG; Mayo Clinic; NIH].

This article reviews the clinical features, diagnostic approach and evidence‑based management of PMS, and discusses findings from the first census‑based population survey conducted in Spain examining the prevalence, impact and attitudes of women and clinicians toward PMS. Sources consulted include professional guidelines and patient information from the American College of Obstetricians and Gynecologists (ACOG), the National Institutes of Health (NIH), the Mayo Clinic and the Cleveland Clinic.

Epidemiology and the Spanish population survey

Epidemiologic estimates for premenstrual symptoms vary depending on case definitions and screening methods. Many women report at least one premenstrual symptom during their reproductive years; ACOG and major clinical resources place lifetime symptom prevalence in the majority of women (often cited as up to about 75–80%). Approximately 20–40% of women experience symptoms of moderate severity that interfere with daily activities, and 3–8% may meet criteria for PMDD, a formally defined psychiatric disorder with marked affective symptoms [ACOG; NIH].

In Spain, the Daphne team reported the first census‑based population survey of PMS conducted at a national level and described as among the first population surveys of its type in Europe. The survey sampled 2,018 women of reproductive age to estimate symptom frequency, severity and attitudes toward the condition. According to the survey results as reported by the investigators, approximately 80% of women report premenstrual symptoms during their lives. The authors focused analysis on the subgroup with moderate to severe symptoms, estimating that a substantive proportion of Spanish women experience symptom clusters that have a measurable impact on daily functioning. The investigators extrapolated survey findings to the general female population in Spain to quantify the number of women potentially affected by moderate or severe PMS [Daphne survey report].

It is important to interpret single‑country estimates in the context of methodology: telephone or self‑report surveys often yield higher symptom prevalence than clinic‑based samples, and population weighting and case definitions (self‑reported symptoms vs. prospectively recorded cyclical symptoms) influence estimates. Nonetheless, the Spanish survey highlights the high population burden of premenstrual symptomatology and underscores the need for clinician awareness and public health strategies.

Clinical features and timing

PMS is defined by symptoms that reliably emerge in the luteal phase (typically in the week or two before menses) and remit within a few days after the onset of menstruation. Symptoms may include:

Physical: breast tenderness or mastalgia, bloating and fluid retention, headaches, musculoskeletal pain, weight gain, acne flares, gastrointestinal changes and fatigue.
Psychological/emotional: irritability, anger, mood lability, depressed mood, anxiety, tension, tearfulness.
Behavioral and cognitive: decreased concentration, sleep disturbances (insomnia or hypersomnia), changes in appetite or food cravings, social withdrawal, decreased interest in usual activities.

ACOG notes that there are many possible symptoms and that individual women may experience unique symptom clusters. The intensity and pattern of symptoms—particularly their consistent temporal relationship to the menstrual cycle—are key to diagnosis [ACOG; Mayo Clinic].

Distinction between PMS and PMDD

Premenstrual Dysphoric Disorder is a distinct, more severe condition defined in psychiatric classification systems (DSM‑5). PMDD is characterized by predominately affective symptoms (marked mood lability, severe irritability or anger, depressive symptoms, and anxiety) with substantial functional impairment and a clear cyclical pattern. By definition, PMDD requires prospective daily ratings across at least two symptomatic cycles for confirmation. PMDD affects a smaller proportion of women than PMS but has disproportionate effects on quality of life and may warrant psychiatric consultation and specific pharmacotherapy [NIH; ACOG].

Pathophysiology: what is known and what remains uncertain

The precise etiology of PMS and PMDD is not fully elucidated, but several interacting biological and psychosocial mechanisms are implicated:

Cyclical hormonal fluctuations: Symptoms occur in relation to the luteal rise and fall of ovarian steroids—primarily progesterone and estrogen—rather than to absolute hormone levels. The change in neuroactive steroid metabolites of progesterone (allopregnanolone) and their effects on GABAergic neurotransmission has been postulated to contribute to mood and anxiety symptoms.
Neurotransmitter dysregulation: Serotonergic system alterations likely contribute to affective and behavioral symptoms. This mechanism underlies the efficacy of serotonergic antidepressants (SSRIs) for PMS/PMDD.
Hypothalamic‑pituitary‑adrenal (HPA) axis variation and stress reactivity: Some evidence suggests altered stress responsivity in affected women.
Genetic vulnerability and environmental factors: Family aggregation studies and twin studies indicate a heritable component for PMDD/PMS; psychosocial stressors and coexistent psychiatric disorders modify symptom expression.
Prostaglandins and inflammatory mediators: These may mediate somatic symptoms such as pain and headaches.

Overall, contemporary models favor an interaction between normal hormonal cyclical changes and neurobiological sensitivity in susceptible individuals, rather than a simple excess or deficiency of a single hormone [ACOG; NIH].

Diagnostic approach

Accurate diagnosis of PMS and PMDD relies on careful history, documentation of symptom cyclicity and exclusion of other causes. Recommended diagnostic steps include:

Clinical history: Document the temporal pattern of symptoms, severity, functional impact, and relationship to the menstrual cycle. Ask specifically about timing (luteal onset, remission with menses), symptom type and effects on work, school and relationships.
Prospective symptom charting: Clinical guidelines recommend prospective daily ratings using a validated tool for at least two consecutive menstrual cycles. The Daily Record of Severity of Problems (DRSP) and other symptom calendars are commonly used; these instruments allow confirmation that symptoms are reliably present during the luteal phase and absent or markedly reduced in the follicular phase.
Screening for psychiatric and medical comorbidities: Assess for major depressive disorder, anxiety disorders, bipolar disorder, thyroid disease, anemia, and other conditions that may cause cyclical or non‑cyclical mood and somatic symptoms. Substance use and medication effects (e.g., withdrawal from benzodiazepines) should be evaluated.
Physical examination and targeted testing: A focused examination is appropriate when indicated. Routine laboratory testing is not necessary for routine PMS diagnosis but thyroid function tests, pregnancy testing and other indicated investigations may be obtained based on clinical judgment.

DSM‑5 criteria require prospective daily ratings for PMDD; ACOG similarly emphasizes prospective documentation for clinical confirmation of significant PMS or PMDD [ACOG; NIH].

Differential diagnosis

Conditions to consider and exclude include:

Major depressive disorder or dysthymia: Mood symptoms that are persistent and not strictly cyclical suggest a primary mood disorder.
Bipolar disorder: Cyclical mood symptoms with hypomania/mania require careful assessment because SSRIs used for PMS/PMDD may trigger mania.
Thyroid disease: Hypothyroidism and hyperthyroidism can produce mood and somatic symptoms.
Chronic pelvic pain conditions (e.g., endometriosis): These may cause cyclical pain but typically have a different symptom pattern.
Medications and substance use: Steroid withdrawal, recreational drugs or alcohol use can cause mood and somatic changes.
Perimenopause: In older reproductive‑age women, perimenopausal hormone fluctuations may produce irregular symptoms.

A thorough clinical evaluation is essential to identify alternative or comorbid diagnoses and to inform treatment selection [Mayo Clinic; Cleveland Clinic].

Impact on quality of life, work and relationships

Moderate to severe PMS and PMDD can have measurable adverse effects on work productivity, social functioning and interpersonal relationships. Symptoms such as marked irritability, mood swings and decreased concentration can impair job performance and strain family and partner relationships. The economic and social burden includes absenteeism, presenteeism (reduced productivity while at work) and increased healthcare utilization.

Findings from the Spanish census-based survey underscore that a substantial proportion of women report symptoms that interfere with daily life. The survey also explored attitudes toward symptoms and care‑seeking behavior. Key themes commonly reported in population surveys and qualitative investigations include:

Normalization of symptoms: Many women perceive premenstrual symptoms as a normal and expected part of the menstrual cycle and therefore may not seek medical care.
Underreporting: Cultural factors, stigma or lack of awareness about effective treatments contribute to underreporting of symptoms to healthcare providers.
Variable clinician response: Some women perceive that clinicians minimize or normalize symptoms, while others receive active management.
Impact on reproductive planning and decision making: In some cases, symptom severity influences contraceptive choices or decisions about pregnancy.

Understanding patient attitudes and barriers to care is important to improve recognition, reduce stigma and facilitate appropriate treatment or referral [Spanish survey; ACOG].

Attitudes of Spanish women and clinicians: implications of the Daphne survey

The Daphne survey reported that approximately 80% of women in Spain experience some premenstrual symptoms during their lifetime. The investigators emphasized the subgroup with moderate to severe symptoms because of the functional implications. While the survey reported high prevalence, it also highlighted attitudinal aspects that are clinically relevant:

Many women view premenstrual symptoms as an expected part of femininity and may not present to healthcare providers unless symptoms are severe.
Self‑management strategies (over‑the‑counter analgesics, dietary adjustments, rest) are commonly used before professional consultation.
There is a need for improved clinician awareness, standardized screening in primary care and gynecology settings, and accessible education about effective treatments.

These findings support the need for population-level outreach and clinician education to facilitate earlier identification and treatment of women whose symptoms cause significant impairment. The survey also suggests that public health initiatives in Spain and comparable settings should address both symptom recognition and destigmatization to reduce barriers to care [Daphne survey report].

Evidence‑based management

Management of PMS is individualized based on symptom severity, symptom type (somatic vs. affective), comorbidities and patient preferences. Treatment options include lifestyle measures, psychosocial interventions, nutraceuticals and pharmacologic therapies. Shared decision making and documentation of response during prospective symptom tracking are recommended.

First‑line and nonpharmacologic interventions

Education and self‑management: Patients should receive information about the cyclical nature of PMS and strategies to monitor symptoms. Prospective tracking with a symptom diary can aid self‑management and treatment decisions.
Lifestyle modification: Regular aerobic exercise (e.g., brisk walking, cycling) has evidence for reducing some premenstrual symptoms. Sleep hygiene, stress management and avoidance of excessive caffeine, nicotine and alcohol may reduce symptom severity.
Dietary measures and supplements:
Calcium supplementation (1,000–1,200 mg/day) has demonstrated modest benefit for some women with PMS in randomized trials and is recommended as a reasonable adjunctive measure by several guideline summaries.
Limited evidence exists for vitamin B6 (pyridoxine) at low doses; high doses should be avoided due to the risk of neuropathy.
Other supplements (magnesium, vitamin E) have been studied with mixed results; clinicians should counsel patients regarding evidence and potential interactions.
Nonpharmacologic therapies: Cognitive behavioral therapy (CBT) has demonstrated benefit for emotional and behavioral symptoms, particularly in PMDD, and may be helpful when preferred by the patient or when pharmacotherapy is contraindicated.

Pharmacologic therapies

Selective serotonin reuptake inhibitors (SSRIs): SSRIs (e.g., sertraline, fluoxetine, paroxetine, escitalopram) are first‑line pharmacologic treatment for moderate–severe PMS and PMDD, particularly when affective symptoms predominate. SSRIs can be administered continuously (daily) or intermittently (during the luteal phase only) depending on symptom pattern and patient preference; luteal‑phase dosing has been shown to be effective for many women with PMDD and offers a lower pill burden and fewer side effects for some patients. Response to SSRIs can be rapid (within days to weeks) for PMDD symptoms. Dosing strategies should follow standard antidepressant titration and monitoring for side effects [ACOG; NIH].
Combined hormonal contraceptives (CHCs): Some combined oral contraceptives, especially those containing drospirenone in a 24/4 regimen, have shown benefit for PMDD symptoms in clinical trials. CHCs may be particularly useful for women who also desire contraception. Not all formulations are equally effective for mood symptoms; counseling should address risks and benefits and consider individual medical contraindications to estrogen use [ACOG; Mayo Clinic].
Nonsteroidal anti‑inflammatory drugs (NSAIDs): NSAIDs such as ibuprofen are effective for somatic symptoms (dysmenorrhea, headaches, musculoskeletal pain) but do not substantially alter affective symptoms. NSAIDs can be used as needed during the symptomatic luteal phase for pain control.
Second‑line and specialty therapies: For refractory severe cases not responding to SSRIs or CHCs, consultation with a gynecologist and psychiatrist is appropriate. Options include gonadotropin‑releasing hormone (GnRH) agonists to induce medical ovarian suppression, often combined with “add‑back” hormone therapy to reduce hypoestrogenic side effects. GnRH agonists are reserved for severe, treatment‑resistant cases due to risks and the need for specialist monitoring [ACOG; Cleveland Clinic].

Monitoring and follow‑up

Reassessment with prospective symptom charts allows objective evaluation of treatment response.
Monitor for medication side effects, emergence of suicidal ideation (particularly with initiation of antidepressants), and potential interactions with other prescribed agents.
Consider stepwise escalation: begin with lifestyle measures and education for mild symptoms; use SSRIs or CHCs for moderate to severe symptoms; refer for specialty care for refractory or complex cases.

Role of clinicians and systems-level recommendations

Primary care providers, gynecologists and mental health clinicians play complementary roles in screening, diagnosis and management of PMS and PMDD. Practical steps to improve care include:

Routine inquiry: Incorporate questions about cyclical mood or somatic symptoms into reproductive health and primary care assessments, especially when women present with mood lability, irritability, sleep disturbances or recurrent somatic complaints.
Use of validated tools: Encourage prospective symptom recording (e.g., DRSP) as part of initial evaluation and follow‑up.
Shared decision making: Discuss evidence, benefits, risks and preferences regarding SSRIs, CHCs, lifestyle interventions and psychotherapy.
Education and referral: Provide patient education materials and facilitate referrals to mental health professionals when indicated, particularly for PMDD or comorbid psychiatric disorders.
Workplace and social support: Advocate for reasonable accommodations when symptoms substantially impair occupational functioning and support workplace policies that recognize menstrual health as a component of employee wellbeing.

The findings of the Spanish population survey highlight the need for clinician training and public education to reduce normalization that prevents women from seeking effective care.

When to seek medical care

Women should seek professional evaluation when premenstrual symptoms:

Interfere with work, school, or relationships.
Are severe, recurrent and predictable in relation to the menstrual cycle.
Include suicidal ideation or behaviors, severe depressive symptoms, or possible bipolar features.
Fail to respond to reasonable self‑care measures.

Prompt recognition and appropriate treatment can substantially reduce symptom burden and improve quality of life.

Public health and educational implications

Population surveys such as the Spanish Daphne study support the following public health priorities:

Increase awareness among women and clinicians that effective treatments are available and that severe symptoms are not simply an inevitable part of menstruation.
Implement educational campaigns targeting primary care, school and workplace settings to reduce stigma and encourage symptom reporting.
Expand access to validated screening tools and evidence‑based treatments in primary care and gynecology clinics.
Support research on pathophysiology, personalized treatment strategies and long‑term outcomes across diverse populations.

Addressing structural and cultural barriers to care will be important to close the gap between symptom prevalence and treatment uptake.

Practical advice for patients

Keep a daily symptom diary for at least two cycles to document timing and severity of symptoms—this will help you and your clinician make an accurate diagnosis.
Try lifestyle modifications: regular aerobic exercise, balanced diet, limiting caffeine and alcohol, and prioritizing sleep and stress reduction.
Discuss calcium supplementation with your clinician as an adjunct therapy.
If mood symptoms are prominent or daily functioning is impaired, ask about SSRIs and the options for continuous vs. luteal‑phase dosing.
If contraception is also desired, ask about CHC formulations with demonstrated benefit for cyclical mood symptoms.
Seek referral for CBT or psychiatric consultation if symptoms are severe, if there is limited response to first‑line therapies, or if there are comorbid psychiatric conditions.

Conclusion

Premenstrual Syndrome is a common, clinically significant condition for many women that spans physical, emotional and behavioral domains. The first census‑based population survey in Spain confirms that premenstrual symptoms are widely experienced and that a considerable subgroup endures moderate to severe symptoms that interfere with daily life. Clinical recognition requires attention to the cyclical pattern of symptoms, prospective symptom recording and exclusion of alternative causes. Evidence‑based interventions—including lifestyle measures, calcium supplementation, cognitive behavioral therapy and pharmacologic treatments such as SSRIs and selected combined hormonal contraceptives—can substantially reduce symptom burden. Improved clinician awareness, patient education and system‑level support are essential to ensure that women with disabling premenstrual symptoms receive timely and effective care.

References and selected resources

American College of Obstetricians and Gynecologists (ACOG). Patient information and practice guidance on Premenstrual Syndrome and Premenstrual Dysphoric Disorder. Available at: https://www.acog.org
National Institutes of Health / National Institute of Mental Health (NIH/NIMH). Information on Premenstrual Dysphoric Disorder. Available at: https://www.nimh.nih.gov
Mayo Clinic. Premenstrual Syndrome (PMS) Overview. Available at: https://www.mayoclinic.org
Cleveland Clinic. Premenstrual Syndrome (PMS): Symptoms and Treatment. Available at: https://my.clevelandclinic.org

(Spanish Daphne survey: population survey on PMS—data as reported by the Daphne research team and national press releases; clinicians should consult the original survey report for detailed methodology and full results.)