Reproductive health is a pivotal determinant of women’s mental health across the lifespan. Menstruation, a key physiological process in women, exhibits cyclical changes closely linked to the risk of adverse psychological and mental states (1). Premenstrual syndrome (PMS) manifests as a constellation of emotional and physical symptoms, including irritability, anxiety, depression, bloating, diarrhea, and breast tenderness. Symptoms characteristically emerge during the luteal phase and resolve within a week after menses onset. When severe emotional lability predominates, it is classified as premenstrual dysphoric disorder (PMDD) (1, 2), formally recognized as a depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (3). PMS/PMDD imposes significant physical and mental health burdens throughout women's reproductive years, with potential long-term impacts on well-being (4). PMS affects 20-30% of reproductive-aged women globally (5), with up to 90% reporting some premenstrual symptoms; mood swings and anxiety are common, persistent symptoms across age groups (6). Worldwide meta-analyses indicate a PMDD prevalence of 3.2% (7). Although the pathogenesis of PMS remains incompletely elucidated, fluctuations in ovarian hormones are considered central (8).

PMS not only reduces quality of life and social functioning but is also identified as a risk factor for perinatal depression (9). PMDD is associated with a high risk of self-injurious thoughts and behaviors (10). The multifaceted negative impact of PMS on physical, mental, and reproductive health, affecting mood, work efficiency, and interpersonal relationships, translates into considerable economic and health burdens for individuals, families, and society. However, cultural and societal influences often lead women to conceal menstrual-related symptoms (11), particularly emotional ones, creating disparities in symptom expression across regions. Coupled with evolving societal roles and increasing stressors experienced by women globally, this suggests a potentially substantial hidden burden of PMS. Furthermore, significant disparities exist in PMS diagnosis and management across countries and regions with varying levels of socioeconomic development. Therefore, a comprehensive understanding of the PMS burden across different regions and populations is crucial for formulating precise and effective public health policies.

Initiated in 1991, the Global Burden of Disease (GBD) study is a comprehensive global health research project that has provided ongoing, empirically based assessments of health status worldwide for over three decades, with increasing detail in each iteration (12). The widespread COVID-19 pandemic has had long-term, severe impacts on population health globally. GBD 2021 introduced, for the first time, estimates of the health loss attributable to the COVID-19 pandemic. Notably, depressive and anxiety disorders dominated the years lived with disability (YLDs) burden in 2020 and 2021, with a greater burden observed in females than males (13).

Although existing GBD studies report a surge in global prevalent PMS cases and YLDs from 1990 to 2019, while age-standardized prevalence rate (ASPR) and age-standardized YLDs rate remained relatively stable (14), due to data constraints in earlier database versions not yet updated through 2021, previous analyses primarily focused on descriptive trends from 1990 to 2019. The COVID-19 pandemic has exerted substantial adverse effects on women’s mental health. The incorporation of 2020 and 2021 data in the GBD 2021 release now enables a more accurate estimation of the PMS burden in the post-pandemic context. Unlike previous studies on this topic, our research examines PMS burden trends from 1990 through 2021 and extends projections of disease burden development through 2050. In summary, this study leverages GBD data spanning 1990–2021 to conduct a comprehensive analysis, which aims to conduct a comprehensive analysis using GBD 2021 data to: 1) Analyze trends in ASPR, age-standardized incidence rate (ASIR), and age-standardized YLDs rate of PMS among females globally, stratified by region, Socio-demographic Index (SDI), and age; 2) Assess cross-national changes in PMS burden inequality, particularly concerning SDI, during 1990–2021 and investigate the correlation between SDI and PMS burden. 3) this study will project future PMS burden trends up to 2050, thereby aiding a comprehensive assessment of the global PMS burden across future time periods and anticipating its developmental trajectory, aiming to provide epidemiological evidence for global PMS prevention and control, and inform the development of targeted intervention strategies and future resource allocation, and ultimately safeguard women’s reproductive mental health.

PMS primarily manifesting as menstruation-related mood disorders, is associated with luteal-phase hormonal fluctuations, aberrant stress perception, and neurotransmitter imbalances (18, 19). The experience and reporting of emotions—particularly menstruation-related emotional symptoms—is strongly influenced by complex sociocultural and regional factors. Furthermore, the symptom-based diagnostic approach for PMS may contribute to underestimation of its true disease burden (14). Despite this, recent studies indicate PMS is a major driver of increased burden among combined gynecological diseases (20). Multiple studies demonstrate that females are disproportionately affected by mood disorders compared to males (21, 22), with depression historically exhibiting higher prevalence in female populations (23). This underscores significant gaps in attention to female menstrual mental health.

The United Nations Sustainable Development Goals explicitly recognized mental health and maternal health as central and intrinsic components of overall health (24). Global mental health has been inevitably impacted by complex healthcare, social, and public policy factors during the COVID-19 pandemic (25). Disparities in the allocation of macro-level societal resources are key determinants of global mental health inequalities. Promoting mental health equity through enhanced social services has thus emerged as a critical priority for transformative change (26, 27). Consequently, this study aims to provide insights for increasing awareness of female menstrual mental health, reducing regional inequalities, and advancing global mental health initiatives.

Utilizing GBD 2021 data, this study systematically analyzed dynamic trends in PMS burden globally, across five SDI regions, and in 204 countries/territories from 1990 to 2021, exploring age distribution patterns. We delved deeper into the correlation between SDI and PMS burden and employed the BAPC model to prospectively project burden trends up to 2050. Our results show that the global burden of PMS, measured by ASPR, ASIR, and age-standardized YLDs rate, increased in 2021 compared to 1990, including a U-shaped trend period (increase, decrease, then increase again) overall. Key risk factors for PMS include hormonal changes, stress, diet, and neurotransmitter imbalances, while medication use (including contraceptives), smoking, alcohol and caffeine consumption, and even education, age, and obstetric history also play roles (28). The rise in ASPR and ASIR is closely tied to population growth over the past three decades. Global socioeconomic progress has fostered greater awareness of mental health issues, including menstrual-related psychological problems, leading to increased recognition of PMS. Furthermore, evolving female societal roles, rising daily stress levels, increased negative emotions, and unhealthy lifestyles may contribute to the rising burden (29). The impact of the COVID-19 pandemic on women’s mental health likely also influenced PMS burden.

Among the five SDI regions, the low-middle SDI region consistently bore the heaviest burden, followed by the middle SDI region. The high SDI region generally had the lightest burden for most of 1990-2021. Notably, the low SDI region had the second-lightest burden after the high SDI region. Further correlation analyses at regional and national levels confirmed that ASPR and age-standardized YLDs rate exhibit an initial increase followed by a decrease with rising SDI. This non-linear relationship underscores a complex interplay between socioeconomic development and PMS burden (30). Initial socioeconomic improvements may coincide with increased stress among women and heightened awareness of menstrual mental health, yet constrained access to mental health services and medical care might increase diagnosis rates without adequate treatment, potentially worsening the burden. However, further socioeconomic advancement—bringing higher incomes, better education (potentially reducing stress), healthier lifestyles, more positive coping mechanisms, and improved healthcare access—likely contributes to burden reduction (14). Conversely, in low SDI settings, factors like inadequate healthcare, gender marginalization, menstrual stigma, limited PMS awareness, and restricted symptom expression likely lead to severe underdiagnosis (1, 14).

The age distribution of PMS prevalence shifted from a peak in the 20–24 age group in 1990 to the 35–39 group in 2021, followed by 40-44. This suggests a concentration of PMS prevalence among women aged 35–44 years over time. Women in this age group often face multiple stressors related to career, childcare, and eldercare, compounded by evolving societal roles, making them potentially more vulnerable to PMS. PMS itself can impair work efficiency, family relationships, and social interactions, potentially exacerbating symptoms and significantly impacting daily life (31). Stress is strongly linked to PMS; studies report higher PMS incidence among nurses under high stress (32). PMDD patients report experiencing acutely elevated daily stress (33), and PMS patients exhibit heightened stress sensitivity premenstrually (34). Stress is also a key factor in symptom exacerbation (35), possibly mediated by hypothalamic-pituitary-adrenal (HPA) and hypothalamic-pituitary-ovarian (HPO) axis interactions, central neurotransmitter imbalances, and neuroinflammation (18). Furthermore, PMS is a predictor of perinatal generalized anxiety (36). Therefore, greater societal attention and resources are needed for the mental health of reproductive-aged women, particularly those aged 35-44. Furthermore, the development of appropriate stress management and intervention measures, along with more comprehensive mental health support strategies, is considered a key focus for future research (37).

Fluctuations in ovarian hormone levels represent a core feature of PMS, which may be closely linked to the fact that ovarian steroids (estrogens, progestogens, and their metabolites) have receptor sites across multiple brain regions, thereby influencing neurotransmitter systems (8).Studies indicate that elevated levels of both estrogens and progestogens are involved in the occurrence of premenstrual depression, with a more pronounced association observed for progestogens (38).The underlying causes of these hormonal fluctuations include, on one hand, the interaction between the HPA and HPO axis triggered by stressors as previously discussed. On the other hand, dietary factors play a significant and non-negligible role. A cross-sectional analysis from China revealed that the traditional south China diet, characterized by high intake of rice and animal protein, was inversely associated with both PMS and PMDD, and this association was not explained by comorbid depression or anxiety symptoms (39). Additionally, dietary patterns high in calories, red and processed meats, fats, excessive caffeine, and sodium have been identified as risk factors for PMS-related symptoms (40, 41), Consistent evidence suggests potential benefits from adequate supplementation of vitamin B6 (≥50 mg/day), calcium (≥1000 mg/day), and zinc (≥30 mg/day) for PMS management (42).It is particularly noteworthy that while red meat and poultry are good sources of B vitamins, iron, and zinc—nutrients associated with reduced PMS risk—their origin from predominant artificial breeding practices increases the likelihood of containing high levels of exogenous hormones. Dietary intake of such products may elevate total and free estradiol levels while reducing sex hormone-binding globulin levels, ultimately exerting adverse effects on PMS (39).These findings highlight the importance of dietary modifications—such as reducing intake of red meat, poultry, high-calorie foods, caffeine, and sodium—along with appropriate nutrient supplementation (e.g., vitamin B6, calcium, zinc) for populations in high-burden regions and high-risk age groups for PMS.

Projections based on the BAPC model indicate declining trends in global age-standardized prevalent cases and YLDs for PMS by 2050, partly attributable to global population aging. However, given rising stress levels among women, PMS remains a significant concern. The substantial physical and mental burden PMS imposes throughout a woman’s life (4), and its association with personality disorders and suicide risk (19), demand attention. Current pharmacological treatments, including Selective Serotonin Reuptake Inhibitors, Combined Oral Contraceptives, and Gonadotropin-Releasing Hormone Agonists, are effective but have limitations due to side effects and potential impacts on fertility (2). The growing recognition of non-pharmacological therapies offers advantages. This suggests that closer collaboration between mental health services and medical systems at the societal level could be a practically significant step towards reducing the PMS burden and promoting global women’s mental health.

PMS is strongly influenced by social, economic, and cultural factors. Effective PMS management requires not only medical attention but also societal, cultural, and economic support. This integrated approach is essential to reduce regional disparities in PMS awareness and healthcare access, enabling early identification and intervention for high-risk and affected individuals through mental health services and medical care. To accurately analyze and reduce the global burden of PMS, equitable allocation of healthcare resources is paramount in resource-limited settings, focus should be prioritized on socioeconomically and medically underdeveloped regions. Enhancing menstrual health literacy and healthcare infrastructure in low SDI regions is critically important. Key measures include expanding basic healthcare infrastructure, implementing widespread community-based psychoeducational initiatives on menstrual health, increasing financial support for healthcare, enhancing the emphasis on women’s physiological and mental health curricula in educational institutions, and utilizing books, journals, websites, and other media to help eliminate stigma and raise public awareness of menstruation-related psychological health in low-development settings. Middle SDI regions require more robust mental health services and broader promotion of lifestyle management strategies, through coordinated efforts between medical institutions and community-based mental health services, scientifically grounded stress management and coping strategies can be implemented, thereby promoting comprehensive PMS improvement and safeguarding women’s menstrual-related mental well-being. Such efforts hold significant promise for mitigating the global burden of PMS and its societal impacts, ultimately enhancing global mental health. However, scientifically sound and efficient policy preference as well as specific resource allocation strategies for healthcare and social support still require in-depth research and exploration. Furthermore, individualized PMS management models, which encompassing medical intervention, mental health support, dietary adjustment, stress management, and physical activity. They need further refinement and broader dissemination.

Although this study offers valuable insights into the global burden of PMS, several limitations should be acknowledged and addressed in future work (1): Due to database constraints, this study relied on GBD 2021 data for the global PMS burden analysis. In addition, the lack of PMS-specific risk factor data limited further analysis of their impact, potentially restricting the depth of discussion on preventive strategies. (2) PMS is significantly influenced by sociocultural factors, including stigma, limited awareness, and low health system coverage—particularly in low-SDI regions—leading to underreporting and nondisclosure, which may introduce bias and result in underestimation of the true PMS burden. (3) Predictive models cannot fully account for future policy adjustments across regions, which may lead to discrepancies between projected estimates and actual future burden.

The global burden of PMS has increased since 1990 and demonstrates an inverse U-shaped relationship with SDI. However, the true burden in low-SDI regions is likely severely underestimated due to substantial underreporting and nondisclosure. Regarding age, compared to 1990, the burden in 2021 shifted towards women aged 35-44. While focusing on women’s mental health across the lifespan, increased attention to the mental health, particular attention should be given to stress management of 35-44 age group. Furthermore, regions with underdeveloped socioeconomic and healthcare conditions require increased attention, including financial support, policy prioritization, emphasis on basic education, and assistance from media channels. In low-SDI regions, efforts should focus on raising public awareness of menstruation-related psychological issues and improving access to medical resources and psychological support. Meanwhile, low-middle and middle SDI regions should prioritize closer collaboration between community-based psychological services and healthcare systems, along with the development of effective stress management strategies. These measures will help enhance the equity of medical and psychological service resources, alleviate the global burden of PMS, and safeguard women’s mental health.