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

Treatment Options for Premenstrual Syndrome (PMS)

Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacological treatment for moderate to severe premenstrual syndrome, with continuous administration being more effective than luteal phase dosing. 1

Understanding PMS and PMDD

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

Treatment Algorithm

First-line Approaches:

1. Lifestyle Modifications

   • Diet low in salt, caffeine, and sugar
   • Regular aerobic exercise
   • Stress reduction techniques

2. Non-prescription Options

   • NSAIDs (e.g., ibuprofen): Recommended for short-term treatment (5-7 days) during bleeding episodes 3
     • Caution: May cause gastric irritation; avoid in patients with history of GI bleeding 4
   • Iron supplementation: For patients with heavy menstrual bleeding (ferrous sulfate 200mg three times daily) 3

3. First-line Pharmacological Treatment

   • SSRIs: Most effective for both physical and mood symptoms 3, 1
     • Options include fluoxetine, paroxetine, sertraline, escitalopram, and citalopram
     • Continuous administration is more effective than luteal phase dosing (SMD -0.69 vs -0.39) 1
     • FDA-approved options: fluoxetine, controlled-release paroxetine, and sertraline 5
     • Common side effects: nausea (OR 3.30), insomnia (OR 1.99), sexual dysfunction (OR 2.32), fatigue (OR 1.52) 1
     • Caution with fluoxetine: Risk of serotonin syndrome when combined with other serotonergic agents 6

Second-line Approaches:

1. Hormonal Treatments

   • Combined oral contraceptives (COCs): Recommended for women with pure menstrual symptoms 3
     • Contraindicated in women with migraine with aura due to increased stroke risk 3
     • Primarily improves physical symptoms rather than mood symptoms 2

2. Other Pharmacological Options

   • Anxiolytics: For supportive care to relieve symptoms 5
   • Spironolactone: For fluid retention symptoms 5

Special Considerations

1. Medication Interactions

   • SSRIs may interact with other medications through CYP2D6 inhibition 3
   • Paroxetine should be used with caution in women taking tamoxifen 3

2. Monitoring and Follow-up

   • Evaluate treatment response within 2-3 months 3
   • Consider using a daily symptom diary to track effectiveness 3
   • For patients on iron supplementation, monitor hemoglobin concentration and continue supplementation for three months after correction of anemia 3

3. Severe Cases (PMDD)

   • Require more intensive treatment, typically with SSRIs 1
   • Consider referral to mental health provider if significant psychological symptoms persist despite treatment 7

Common Pitfalls to Avoid

1. Misdiagnosis: PMS symptoms can overlap with other conditions like thyroid dysfunction, hypoglycemia, and primary dysmenorrhea 8

2. Inadequate Treatment Duration: SSRIs may take several cycles to reach full effectiveness

3. Overlooking Side Effects: Monitor for SSRI-related adverse effects, particularly nausea, insomnia, and sexual dysfunction 1

4. Assuming COCs Will Resolve All Symptoms: COCs primarily improve physical symptoms but may be less effective for mood symptoms 2

5. Neglecting Non-pharmacological Approaches: Lifestyle modifications should be implemented alongside pharmacological treatments for optimal results

By following this treatment algorithm and considering individual patient factors, clinicians can effectively manage PMS symptoms and improve patients' quality of life.