Treatment Options for Premenstrual Syndrome (PMS)
The first-line treatment for premenstrual syndrome should include lifestyle modifications, followed by nonhormonal pharmacologic options such as SSRIs for moderate to severe symptoms, with hormonal therapies reserved for cases unresponsive to initial interventions. 1
Initial Assessment
- Diagnosis requires documentation of symptoms using the Daily Record of Severity of Problems during at least two consecutive menstrual cycles
- Key symptoms include affective (irritability, mood swings, anxiety), physical (breast tenderness, bloating, headaches), and behavioral changes that occur during luteal phase and resolve within days of menstruation
- Distinguish between PMS (affecting 30-40% of reproductive-age women) and Premenstrual Dysphoric Disorder (PMDD - affecting 3-8%), which represents more severe symptoms 1
Treatment Algorithm
Step 1: Lifestyle Modifications (First-Line)
- Exercise: Regular aerobic exercise (at least 30 minutes, 3-5 times weekly)
- Dietary changes:
- Reduce caffeine, alcohol, salt, and refined sugar intake
- Increase complex carbohydrates, fruits, vegetables
- Small, frequent meals to prevent hypoglycemia
- Stress management: Cognitive behavioral therapy, mindfulness, relaxation techniques
- Sleep hygiene: Regular sleep schedule with 7-8 hours nightly 2
Step 2: Nutritional Supplements
- Calcium: 1200 mg daily (shown effective in reducing emotional, behavioral, and physical symptoms) 3
- Vitamin B6: 50-100 mg daily (may help with mood symptoms)
- Magnesium: 200-400 mg daily (may reduce water retention and mood symptoms)
- Chasteberry extract: 20-40 mg daily (may help regulate hormonal fluctuations) 1
Step 3: Nonhormonal Pharmacologic Options (for moderate-severe symptoms)
SSRIs (first-line pharmacologic therapy):
- Continuous administration: More effective than luteal phase dosing 4
- Options include fluoxetine (20 mg daily), sertraline (50-150 mg daily), paroxetine (20 mg daily), or escitalopram (10-20 mg daily)
- Common side effects: nausea (NNTH: 7), insomnia, sexual dysfunction, fatigue 4
- Caution with paroxetine in women taking tamoxifen due to CYP2D6 inhibition 5
NSAIDs: For physical symptoms, particularly menstrual pain and headaches
- Ibuprofen 400-600 mg every 6 hours or naproxen 500 mg twice daily during symptomatic days
Step 4: Hormonal Therapies (for cases unresponsive to above treatments)
Combined oral contraceptives (COCs):
Cyclic progestins:
Step 5: For Severe, Refractory PMDD
- GnRH agonists: Consider for short-term use (≤6 months) with add-back hormone therapy
- Danazol: Limited by androgenic side effects
- Light therapy: 10,000 lux for 30 minutes daily during luteal phase
Special Considerations
For Menstrual Migraines
- Perimenstrual preventive treatment with long-acting NSAIDs or triptans
- Start 2 days before expected menstruation and continue for 5 days 5
For Severe Mood Symptoms
- Consider psychiatric evaluation if symptoms significantly impact functioning
- Cognitive behavioral therapy shows efficacy for psychological symptoms 3
Monitoring and Follow-up
- Reassess symptoms after 2-3 menstrual cycles of treatment
- If initial treatment fails, move to next step in algorithm
- Consider combination therapy for mixed physical and psychological symptoms
Pitfalls and Caveats
- Avoid paroxetine in women taking tamoxifen due to drug interactions 5
- COCs are contraindicated in women with migraine with aura 5
- Limit vitamin B6 to ≤100 mg daily to avoid peripheral neuropathy
- GnRH agonists should be used short-term due to bone density concerns
- SSRIs may take 1-2 cycles to show full benefit; counsel patients accordingly
By following this structured approach, most women with PMS can achieve significant symptom relief. Treatment should progress through these steps based on symptom severity and response to previous interventions.