Treatment Options for Premenstrual Syndrome (PMS)
For most women with PMS, a combination of lifestyle modifications and non-hormonal pharmacologic treatments should be the first-line approach, with selective serotonin reuptake inhibitors (SSRIs) being the most effective medication for moderate to severe symptoms. 1
Understanding PMS
Premenstrual syndrome (PMS) is characterized by recurrent physical, psychological, and behavioral symptoms that occur during the luteal phase of the menstrual cycle (typically 1-2 weeks before menstruation) and resolve within a few days of menstruation. PMS affects approximately 30-40% of reproductive-age women, with 3-8% experiencing a severe form called Premenstrual Dysphoric Disorder (PMDD) 2.
First-Line Treatment Options
Lifestyle Modifications
- Diet changes: Reduce salt, fat, caffeine, and sugar intake 3
- Regular aerobic exercise: Helps reduce symptom severity 3
- Stress reduction techniques: Meditation, yoga, or other relaxation methods 3
Non-Hormonal Pharmacologic Treatments
NSAIDs
- Ibuprofen: 400-800 mg every 6-8 hours during symptomatic days 4
- Particularly effective for physical symptoms like cramping, headaches, and breast tenderness
- Can be used for short-term treatment (5-7 days) during bleeding episodes 5
SSRIs (First-line medication for moderate to severe symptoms)
- Fluoxetine: 20 mg daily 6, 1
- Sertraline: 50-150 mg daily 1
- Paroxetine: 10-30 mg daily 1
- Escitalopram: 10-20 mg daily 1
SSRIs can be administered in two ways:
- Continuous administration: Daily throughout the menstrual cycle (more effective)
- Luteal phase administration: Only during the 2 weeks before menstruation 1
The Cochrane review found that continuous administration is probably more effective than luteal phase administration (P = 0.03 for subgroup difference) 1.
Second-Line Treatment Options
Hormonal Treatments
- Combined oral contraceptives (COCs): May help with physical symptoms but less effective for mood symptoms 7
- Continuous use of COCs: Some women with pure menstrual symptoms benefit from continuous use without a break 8
- Note: COCs are contraindicated in women with migraine with aura due to increased stroke risk 8
Other Medications
Treatment Algorithm Based on Symptom Severity
Mild PMS
- Start with lifestyle modifications (diet, exercise, stress management)
- Add NSAIDs during symptomatic days if needed
Moderate PMS
- Lifestyle modifications
- NSAIDs for physical symptoms
- Consider SSRIs if symptoms impact quality of life
Severe PMS/PMDD
- SSRIs (continuous administration preferred)
- Lifestyle modifications as adjunctive therapy
- Consider hormonal treatments if SSRIs are ineffective
Common Side Effects of SSRIs
SSRIs are associated with several side effects, including:
- Nausea (most common)
- Insomnia
- Sexual dysfunction
- Fatigue
- Dizziness
- Dry mouth 1
Special Considerations
- Women with migraine: Combined hormonal contraceptives are contraindicated in women with migraine with aura 8
- Women approaching menopause: Higher risk of endometrial pathology; consider endometrial sampling 5
- Women with depression: SSRIs may provide dual benefit for both PMS and depression 1
Monitoring and Follow-up
Evaluate treatment response within 2-3 months after initiation or change in treatment. Key outcome measures include symptom frequency, severity, and impact on daily functioning. Consider using a daily symptom diary to track effectiveness 8.
Cautions and Pitfalls
- SSRIs may interact with other medications through CYP2D6 inhibition 6
- Pure SSRIs (particularly paroxetine) should be used with caution in women taking tamoxifen due to potential drug interactions 8
- When discontinuing SSRIs, gradually taper to minimize withdrawal symptoms 8
- Recognize that PMS symptoms can overlap with other conditions like thyroid dysfunction, diabetes, and mood disorders 3
The evidence strongly supports that SSRIs are the most effective treatment for moderate to severe PMS/PMDD symptoms, particularly when administered continuously rather than only during the luteal phase 1.