Premenstrual Syndrome

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

Symptoms and Signs

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

• Bloating

• Breast pain

• Headache

• Swelling

• 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

Diagnostic Procedures

• Careful evaluation of the patient

• History of symptoms

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

  • Combined hormonal contraceptive methods (pill, patch, or vaginal ring)

  • 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 be effective in relieving tension, irritability, and dysphoria with few side effects

• There is little data to support the use of calcium, vitamin D, and vitamin B₆ supplementation

• There is insufficient evidence to support cognitive behavior therapy

Prognosis

• Symptom-specific therapy is usually helpful in ameliorating symptoms