What are the treatment options for Premenstrual Syndrome (PMS)?

Treatment Options for Premenstrual Syndrome (PMS)

The first-line treatment for Premenstrual Syndrome includes selective serotonin reuptake inhibitors (SSRIs) for moderate to severe symptoms, with lifestyle modifications as foundational therapy for all patients. 1, 2

Diagnosis and Assessment

Before initiating treatment, proper diagnosis is essential:

• Confirm PMS through symptom tracking using the Daily Record of Severity of Problems
• Symptoms must occur during luteal phase (7-14 days before menses) and resolve within 1-2 days after menstruation begins
• Distinguish between PMS (affects 30-40% of reproductive-age females) and the more severe Premenstrual Dysphoric Disorder (PMDD, affects 3-8%) 3

Treatment Algorithm

First-Line Approaches:

1. Lifestyle Modifications (for all patients):

   • Regular aerobic exercise
   • Stress management techniques
   • Healthy diet with reduced caffeine, salt, and alcohol
   • Adequate sleep
   • Cognitive-behavioral therapy to improve coping strategies 4

2. Nutritional Supplements:

   • Calcium supplementation (has demonstrated consistent therapeutic benefit) 1, 5

3. Pharmacological Treatment (for moderate to severe symptoms):

   • SSRIs (first-line pharmacological treatment):

     • Fluoxetine: 10-20 mg daily 6
     • Paroxetine: 10-40 mg daily or 20 mg 3-4 hours pre-intercourse
     • Sertraline: 25-200 mg daily or 50 mg 4-8 hours pre-intercourse 2

   • Administration Options:

     • Continuous daily dosing
     • Luteal phase dosing (only during the 2 weeks before menstruation)
     • Both regimens are effective with no clear evidence of difference in effectiveness 2

Second-Line Approaches:

1. Other Psychiatric Medications:

   • Venlafaxine, duloxetine, alprazolam, or buspirone 1

2. Hormonal Interventions:

   • Combined oral contraceptives (primarily improve physical symptoms) 3

Efficacy and Side Effects

• SSRIs demonstrate moderate effect sizes for symptom reduction (SMD -0.65,95% CI -0.46 to -0.84) 2
• Most common SSRI side effects:
  • Nausea (1 in 7 patients)
  • Asthenia/decreased energy (1 in 9 patients)
  • Somnolence (1 in 13 patients)
  • Fatigue (1 in 14 patients)
  • Decreased libido (1 in 14 patients)
  • Sweating (1 in 14 patients) 2

Special Considerations

• Patients with more psychological symptoms may benefit more from SSRIs
• Patients with predominantly physical symptoms may respond better to combined oral contraceptives 3
• Side effects are dose-dependent; start with lower doses and titrate as needed 2
• Treatment should be continued until satisfactory symptom control is achieved

Common Pitfalls to Avoid

1. Failing to distinguish between PMS and other conditions with similar symptoms
2. Not tracking symptoms to confirm the cyclical nature of PMS
3. Relying solely on pharmacological treatments without implementing lifestyle changes
4. Using medications with poor evidence base (many herbal remedies lack sufficient evidence)
5. Not addressing both physical and psychological symptoms

By following this treatment algorithm and selecting therapies based on symptom severity and predominant symptom type, most women with PMS can achieve significant improvement in quality of life and functioning.