18-07: Premenstrual Syndrome

GENERAL CONSIDERATIONS

The premenstrual syndrome (PMS) is a recurrent, variable cluster of troublesome physical and emotional symptoms that develop during the 5 days before the onset of menses and subside within 4 days after menstruation occurs. PMS intermittently affects about 40% of all premenopausal women, primarily those 25–40 years of age. In about 5–8% of affected women, the syndrome may be severe. Although not every woman experiences all the symptoms or signs at one time, many describe bloating, breast pain, headache, swelling, irritability, aggressiveness, depression, inability to concentrate, libido change, lethargy, and food cravings. When emotional or mood symptoms predominate, along with physical symptoms, and there is a clear functional impairment with work or personal relationships, the term “premenstrual dysphoric disorder” (PMDD) may be applied. The pathogenesis of PMS/PMDD is still uncertain, and current treatment methods are mainly empiric. The clinician should provide support for both the patient’s emotional and physical distress, including the following:

1. Careful evaluation of the patient, with understanding, explanation, and reassurance.

2. Advice to keep a daily diary of all symptoms for 2–3 months, such as the Daily Record of Severity of Problems, to evaluate the timing and characteristics of her symptoms. If her symptoms occur throughout the month rather than in the 2 weeks before menses, she may have depression or other mental health diagnosis instead of or in addition to PMS.

TREATMENT

For mild to moderate symptoms, a program of aerobic exercise; reduction of caffeine, salt, and alcohol intake; and use of alternative therapies, such as acupuncture and herbal treatments may be helpful, although these interventions remain unproven.

Medications that prevent ovulation, such as hormonal contraceptives, may lessen physical symptoms. These include continuous combined hormonal contraceptive methods (pill, patch, or vaginal ring) or GnRH agonist with “add-back” therapy (eg, conjugated equine estrogen, 0.625 mg orally daily, with medroxyprogesterone acetate, 2.5–5 mg orally daily).

When mood disorders predominate, several serotonin reuptake inhibitors have been shown to be effective in relieving tension, irritability, and dysphoria with few side effects. First-line medication therapy includes serotonergic antidepressants (citalopram, escitalopram, fluoxetine, sertraline, venlafaxine) either daily or only on symptom days. There are limited data to support the use of calcium, vitamin D, and vitamin B₆ supplementation. There is insufficient evidence to support cognitive behavioral therapy.