Rationale

Premenstrual syndrome involves physical and

emotional discomfort and may affect
interpersonal relationships.
Effective management of this condition requires an
understanding of symptoms and diagnostic
methods.

Definitions
PMS = Recurrent psychological or physical

symptoms during the luteal phase of

menstrual cycle, resolves by the end of
menstruation, and interferes with some
aspect of function.
Premenstrual Dysphoric Disorder (PMDD) =

more severe form of PMS meeting DSM-IV

criteria.

Incidence
Moderate to severe - 20-40%
Debilitating disease/symptoms - 2.5-5%
Generally age 30-40 yr.
Milder symptoms are believed to occur in about 30%

to 80% of reproductive-age women, while severe

symptoms are estimated to occur in 3% to 5% of
menstruating women.

Aetiology

Symptoms of PMS
Behavioral

Psychological

Mood lability (81)

Food cravings (78)
Increased appetite

(70)
Oversensitivity (69)
Anger (67)
Crying easily (65)
Feeling isolated
(65)

Irritability (91)
Fatigue (92)
Anxiety/tension
(89)
Depression (80)
Forgetfulness (56)
Poor concentration
(47)

Physical

Fatigue (92)
Bloating (90)
Breast
tenderness (85)
Acne (71)
Swelling (67)
Headache (60)
GI symptoms
(48)
Hot flashes (18)
Heart palpitations
(14)
Dizziness (14)

PMDD
DSM-IV criteria:
> 5 symptoms of PMS 1 week prior to and resolve

during menses
>1 psychological symptom x 1 year during most cycles
Depressed mood, increased sensitivity, anxiety, irritability

Interferes with social, occupation, sexual or school

functioning
Symptoms discretely related to menstrual cycle and
not a worsening of a psychiatric or medication condition
Documented symptoms meeting criteria for at least 3
cycles

Diagnosis
Rule out other diseases
Depression
Bipolar disorders
Substance abuse
Personality disorder
Chronic fatigue syndrome
Thyroid disease
Irritable bowel syndrome
True hypoglycemia

Functional
impairment

Not required

Interference with
social or role
functioning
required

Prospective
charting of
symptoms

Not required

Prospective
daily charting of
symptoms
required for two
cycles

Differential Diagnosis
Psychiatric disorders
Medical disorders
Major depression
Anemia
Dysthymia
Autoimmune disorders
Hypothyroidism
Generalized anxiety
Diabetes
Panic disorder
Seizure disorders
Bipolar illness (mood irritability)
Endometriosis
Other
Chronic fatigue
syndrome
Collagen vascular
disease

Differential Diagnosis
(Continued)
Premenstrual exacerbation
Psychosocial
Of psychiatric disorders
spectrum
Of seizure disorders
Past history of sexual
Of endocrine disorders
abuse
Of cancer
Past, present, or
current domestic
Of systemic lupus erythematosus
violence
Of anemia
Of endometriosis

Treatment
Aimed at relieving symptoms, as cause unknown

Conservative
Self help strategies
Nutritional changes
Frequent, small meals
Avoid sweets, caffeine
Magnesium sulfate 360 mg/d
Evening primrose oil
High-protein diet, B6

Exercise - milder symptoms

Treatment
Aimed at relieving symptoms, as cause unknown

Medical
Mood/other symptom relief
Naproxyn (prostaglandin inhibitor)
Mefenamic Salt restriction for water retention
Spironolactone for water retention
Transdermal estrogen
Bromocriptine for breast symptoms
Anti-anxiety drugs
Fluoxetine (Prozac) appears most promising as first-line
medication
Alprazolam (Xanax)

Treatment
Aimed at relieving symptoms, as cause unknown

Medical
Ovulation suppression
Oral contraceptives
Depomedroxyprogesterone acetate (DMPA)
Gonadotropin-releasing hormone (GnRH) agonists

SSRIs
Fluoxetine
(Sarafem)

Sertraline
(Zoloft)

Paroxetine
(Paxil)

Dosage Recemmendations Side effects

for use
to 20 10
mg per
day

First-choice agents for

the treatment of PMDD;
at present, only
fluoxetine is labeled for
this indication.
to 150 50 Clearly effective in
mg per alleviating behavioral
and physical symptoms
day
of PMS and PMDD
For intermittent therapy,
to 30 10 administer during luteal
mg per phase (days before
menses).
day

Insomnia,
drowsiness,
fatigue,
nausea,
nervousness,
headache,
mild tremor,
sexual
dysfunction

Treatment
Aimed at relieving symptoms, as cause unknown

Surgical
Oophorectomy not generally recommended
Possibly indicated if symptoms respond to

GnRH agonists or danazol

Summary of Management
Guidelines
All
women with PMS or PMDD
Nonpharmacologic treatment: education, supportive therapy, rest, exercise,

dietary modifications
Symptom diary to identify times to implement treatment and to monitor
improvement of symptoms
Treatment of specific physical symptoms
Bloating: spironolactone (Aldactone)
Headaches: nonprescription analgesic such as acetaminophen, ibuprofen, or
naproxen sodium (Anaprox; also, nonprescription Aleve)
Fatigue and insomnia: instruction on good sleep hygiene and caffeine
restriction
Breast tenderness: vitamin E, evening primrose oil, luteal-phase
spironolactone, or danazol (Danocrine)
Treatment of psychologic symptoms
For symptoms of PMDD, continuous or intermittent therapy with an SSRI
Treatment failure
Hormonal therapy to manipulate menstrual cycle