What are the treatment options for premenstrual syndrome (PMS)?

Treatment Options for Premenstrual Syndrome (PMS)

Drospirenone-containing combined oral contraceptives are the first-line pharmacological treatment for PMS due to their proven efficacy in treating both physical and psychological symptoms. 1

Understanding PMS

Premenstrual syndrome (PMS) affects 30-40% of reproductive-age women and is characterized by recurrent physical, psychological, and behavioral symptoms that occur during the luteal phase of the menstrual cycle and resolve shortly after menstruation begins 2. Premenstrual dysphoric disorder (PMDD) is a severe form affecting 3-8% of women, causing significant functional impairment 2.

Treatment Algorithm

First-line treatments:

1. Lifestyle modifications

   • Regular exercise
   • Stress reduction techniques
   • Adequate sleep
   • Dietary changes (reducing caffeine, salt, alcohol)
   • These should be recommended for all women with mild-to-moderate PMS symptoms 3

2. Pharmacological options:

   • Drospirenone-containing combined oral contraceptives (COCs)
     • Particularly effective for both physical and mood symptoms 1
     • FDA-approved for treatment of PMDD in women who desire contraception
     • Contains 24 active pills and 4 placebo pills to minimize hormone fluctuations
     • Drospirenone has anti-mineralocorticoid properties that help reduce bloating and water retention

Second-line treatments:

1. Selective Serotonin Reuptake Inhibitors (SSRIs)

   • Effective for moderate to severe PMS/PMDD, particularly for psychological symptoms 4
   • Can be administered continuously or during luteal phase only
   • Continuous administration is more effective than luteal phase dosing (SMD -0.69 vs -0.39) 4
   • FDA-approved options include fluoxetine, sertraline, and controlled-release paroxetine 3
   • Common side effects include nausea, insomnia, sexual dysfunction, and fatigue 4

2. Other hormonal options:

   • Progestin-only pills (POPs) for women with contraindications to estrogen 5
   • GnRH agonists (with add-back therapy) for severe cases not responding to other treatments 6

3. Symptom-specific treatments:

   • NSAIDs for pain and cramping
   • Spironolactone for bloating and water retention 3
   • Anxiolytics for severe anxiety symptoms 3

Third-line treatments:

1. Supplements and herbal remedies:
   • Calcium supplementation (most evidence-supported supplement) 6
   • Vitamin B6
   • Chasteberry (Vitex agnus-castus) 2
   • Evidence is limited and results are mixed for most supplements

Special Considerations

Perimenopausal women

• PMS symptoms may worsen during perimenopause 7
• Hormonal treatments that provide both symptom relief and endometrial protection may be needed
• Consider continuous combined HRT regimens to avoid cyclical symptoms 7

Women with contraindications to estrogen

• Women over 35 who smoke
• History of thromboembolism
• Uncontrolled hypertension
• Consider progestin-only methods or non-hormonal approaches 5

Treatment-resistant cases

• Consider combination therapy (e.g., hormonal treatment plus SSRI)
• Cognitive behavioral therapy has shown benefit 6
• Surgical options (oophorectomy) should be considered only as a last resort after all other options have failed 7

Monitoring and Follow-up

• Encourage patients to track symptoms using a daily record of severity of problems
• Assess treatment response after 2-3 menstrual cycles
• Monitor for side effects, particularly with hormonal treatments and SSRIs
• Adjust treatment as needed based on symptom control and tolerability

Pitfalls to Avoid

1. Misdiagnosis: Ensure symptoms are cyclical and related to menstrual cycle by having patients track symptoms for 2-3 months
2. Inadequate treatment duration: Allow sufficient time (2-3 cycles) to assess treatment efficacy
3. Overlooking comorbidities: Screen for underlying mood disorders that may be exacerbated premenstrually
4. Using unproven treatments: Focus on evidence-based approaches before trying supplements with limited evidence
5. Ignoring contraceptive needs: Consider contraceptive requirements when selecting hormonal treatments

By following this structured approach and selecting treatments based on symptom severity, patient preferences, and contraceptive needs, most women with PMS can achieve significant symptom improvement and better quality of life.