Premenstrual syndrome is a constellation of symptoms that occurs prior to menstruation and is severe enough to interfere significantly with the patient’s life. DSM-IV-R diagnosis is premenstrual dysmorphic disorder when the dominant symptoms are emotional.
System(s) affected: Endocrine/Metabolic, Reproductive, Nervous
Genetics: Unknown, probably familial incidence
Incidence/Prevalence in USA: Almost all women have some symptoms prior to menses (this is not PMS). About 5% have actual PMS.
Predominant age: Childbearing years, increasing with years
Predominant sex: Females only
Sings and symptoms
Symptoms can involve any organ system but the following are more common:
- Depressed mood
- Mood swings
- Difficulty concentrating
- Breast tenderness
- Sleep disturbances
Unknown, presumed hormonal; perhaps interacting with neurotransmitters
- Premenstrual exacerbations can occur with other diseases (i.e., depression)
- Caffeine and high fluid intake exacerbate PMS symptoms
- Stress may precipitate
- PMS increases with age
- History of depression
- Tobacco use
The major differentials are psychiatric syndromes, particularly depressive disorders and/or dysthymia. Other entities may be suggested by history or physical.
There are no laboratory tests which confirm or refute PMS. History and physical may disclose a need for specific laboratory tests.
Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A
Patients complete questionnaires over a minimum of two months to confirm premenstrual exacerbation of symptoms and lack of substantial symptoms in the follicular phase
APPROPRIATE HEALTH CARE
- Increase daily exercise
- Eat regular, balanced meals
- Stop smoking
- Get regular sleep
- Stress reduction techniques
- Cognitive behavioral therapy (may provide better long-term effect than SSRIs)
- Support groups
- Light therapy
- No restrictions
- Exercise is recommended
Low-salt; low-caffeine; low-fat; frequent, small meals; high complex carbohydrates
Explain PMS and treatment
Drugs of choice
No single drug works for all women. Drugs that are used with varying degrees of success are listed.
- Antidepressants [fluoxetine (Prozac, Sarafem), sertraline, clomipramine, citalopram or nortriptyline], particularly for patients with depressive symptoms. Antidepressants can work when used only during the luteal phase of the menstrual cycle.
- Elemental calcium 1000 mg/day
- Diuretics (usually spironolactone) during luteal phase
- Symptomatic treatment of pain (ibuprofen or acetaminophen)
- Vitamin B6 in modest doses (50 mg bid, may be toxic in higher doses)
- Vitamin E: up to 600 IU/day
- Evening primrose oil, high content of fatty acids, 500 mg qd to 1000 mg tid for breast tenderness, believed to decrease prostaglandin synthesis
- Oral contraceptives may help
- Bromocriptine 2.5 mg tid at time of symptoms and danazol 100 mg bid may also work for breast tenderness, but have more side effects
- Danazol for the total PMS symptom complex
- Gonadotropin-releasing hormone agonists with or without concurrent estrogens/progestins
- L-tryptophan 2 g three times a day
Contraindications: Refer to manufacturer’s profile of each drug
Precautions: Refer to manufacturer’s profile of each drug
Significant possible interactions: Refer to manufacturer’s profile of each drug
See patient to provide general support and further patient education
Many patients can have their symptoms adequately controlled. Disappears at menopause.
- Premenstrual dysphoric disorder
625.4 Premenstrual tension syndromes
Revision date: July 7, 2011
Last revised: by Tatiana Kuznetsova, D.M.D.