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Key Features

Essentials of Diagnosis

  • Recurrent, variable cluster of troublesome physical and emotional symptoms that develops during the 5 days before the onset of menses

  • Symptoms subside within 4 days after menstruation occurs

  • In about 10% of affected women, the syndrome may be severe

General Considerations

  • The pathogenesis is still uncertain. Psychosocial factors may play a role

  • Suppression of ovulation with an oral contraceptive is sometimes helpful, but the patient often complains that she still has premenstrual syndrome

Demographics

  • Intermittently affects about one-third of all premenopausal women, primarily those 25–40 years of age

Clinical Findings

Symptoms and Signs

  • Women may not experience all the symptoms or signs at one time

  • Bloating

  • Breast pain

  • Ankle swelling

  • A sense of increased weight

  • Skin disorders

  • Irritability, aggressiveness, depression, inability to concentrate, libido change, lethargy, and food cravings

Differential Diagnosis

  • Depression

  • Premenstrual dysphoric disorder

  • Endometriosis

  • Uterine leiomyomas (fibroids)

  • Pregnancy

  • Anxiety disorder

  • Hypothyroidism

Diagnosis

Diagnostic Procedures

  • Careful evaluation of the patient

  • History of symptoms

Treatment

General Measures

  • Current treatment methods are mainly empiric

  • Provide support for the emotional and physical distress

  • Advise the patient to keep a daily diary of all symptoms for 2–3 months to help in evaluating the timing and characteristics of the syndrome

  • If her symptoms occur throughout the month rather than in the 2 weeks before menses, she may have depression or other mental health problems in addition to premenstrual syndrome

Specific Measures

FOR MILD TO MODERATE SYMPTOMS

  • Aerobic exercise

  • Reduction of caffeine, salt, and alcohol intake

  • Alternative therapies, eg, an increase in dietary calcium (to 1200 mg/day), vitamin D, or magnesium, and complex carbohydrates in the diet, acupuncture, and herbal treatments, may be helpful but remain unproven

FOR PHYSICAL SYMPTOMS

  • Drugs that prevent ovulation, such as hormonal contraceptives

    • Continuous combined oral contraceptive pill or vaginal ring use

    • Depot medroxyprogesterone acetate [DMPA] 150 mg intramuscularly (every 3 months)

    • Etonogestrel subdermal (Nexplanon) progestin implant (every 3 years)

    • High-dose progestin (medroxyprogesterone acetate 20–30 mg orally daily, or GnRH agonist with “add-back” therapy, such as conjugated equine estrogen, 0.625 mg orally daily with medroxyprogesterone acetate, 2.5–5 mg orally daily)

WHEN MOOD DISORDERS PREDOMINATE

  • First-line drug therapy includes serotonergic antidepressants (citalopram, escitalopram, fluoxetine, sertraline, venlafaxine)

  • Several serotonin reuptake inhibitors (such as fluoxetine, 20 mg orally, either daily or only on symptom days) have been shown to ...

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