What are the best treatments for premenstrual syndrome (PMS) symptoms that occur before and after a menstrual period?

Treatment Options for Premenstrual Syndrome (PMS) Symptoms

For women experiencing PMS symptoms before and after menstrual periods, first-line treatment should include lifestyle modifications, with selective serotonin reuptake inhibitors (SSRIs) recommended for moderate to severe symptoms that don't respond to non-pharmacological approaches. 1

Understanding PMS and PMDD

PMS is characterized by recurrent physical, psychological, and behavioral symptoms that typically occur 7-14 days before menses and resolve within 1-2 days after menstruation begins 2. Premenstrual Dysphoric Disorder (PMDD) represents a more severe form on the PMS spectrum, affecting 3-8% of reproductive-age women, while PMS affects 30-40% 3.

True PMS symptoms occur during the luteal phase of the menstrual cycle with a symptom-free period during the follicular phase 2. Accurate diagnosis requires tracking symptoms using a Daily Record of Severity of Problems for at least two menstrual cycles 3.

First-Line Treatment: Lifestyle Modifications

For mild to moderate PMS symptoms, start with:

1. Dietary changes:

   • Reduce salt, fat, caffeine, and sugar intake 4
   • Consider weight loss if overweight (≥10% weight loss can help eliminate hot flash symptoms) 1

2. Regular aerobic exercise:

   • Implement a consistent exercise regimen 2, 4
   • While evidence specifically for PMS is limited, exercise has many beneficial effects on overall health 1

3. Stress management:

   • Cognitive-behavioral therapy (CBT) has shown effectiveness for PMS symptoms 2, 3
   • Mind-body interventions and physical training 1

4. Substance modification:

   • Quit smoking (can improve frequency and severity of hot flashes) 1
   • Limit alcohol if it triggers symptoms 1

Pharmacological Options for Moderate to Severe Symptoms

If lifestyle modifications are insufficient:

1. Selective Serotonin Reuptake Inhibitors (SSRIs):

   • First-line pharmacological treatment for moderate to severe symptoms 3, 5
   • Effective for both physical and mood symptoms 3
   • Can be used intermittently during luteal phase only 5
   • Options include paroxetine, sertraline, fluoxetine, and citalopram

2. Other non-hormonal options:

   • Venlafaxine (SNRI) 1
   • Gabapentin 1
   • Clonidine 1
   • Alprazolam (during premenstrual period only) 6

3. Hormonal treatments:

   • Combined oral contraceptives may help primarily with physical symptoms 3
   • For vaginal dryness and dyspareunia:
     • First try hormone-free lubricants and moisturizers (water-based gel, hyaluronic acid gel) 1
     • If ineffective, consider low-dose estrogen-containing vaginal medication 1

4. Complementary approaches:

   • Acupuncture may help with hot flashes 1
   • Chasteberry (Vitex agnus-castus) has shown some benefit 3
   • Calcium and vitamin B6 supplements may help some women 2

Treatment Algorithm

1. Start with accurate diagnosis:

   • Confirm symptoms occur primarily during luteal phase
   • Rule out other conditions (thyroid dysfunction, diabetes, hypoglycemia, dysmenorrhea) 4
   • Use symptom tracking for at least two cycles

2. For mild symptoms:

   • Implement all lifestyle modifications for 2-3 months
   • Dietary changes + exercise + stress management

3. For moderate symptoms or if lifestyle changes insufficient:

   • Continue lifestyle modifications
   • Add non-prescription supplements (calcium, vitamin B6)
   • Consider SSRIs during luteal phase only

4. For severe symptoms (PMDD):

   • SSRIs (continuous or luteal phase)
   • Consider hormonal treatments if SSRIs ineffective
   • Referral to mental health specialist if significant mood symptoms persist

Common Pitfalls to Avoid

1. Misdiagnosis: Ensure symptoms truly follow menstrual pattern and aren't another condition like depression, anxiety, or thyroid disorder 5

2. Inadequate symptom tracking: Accurate diagnosis requires prospective symptom calendars, not just retrospective reporting 5

3. Premature medication use: Try lifestyle modifications first for mild symptoms before moving to pharmacological options

4. Overlooking symptom severity: Match treatment intensity to symptom severity; severe symptoms (PMDD) typically require pharmacological intervention 5

5. Ignoring treatment response: Regular follow-up every 2-3 months is essential to assess effectiveness and adjust treatment as needed 7

By following this structured approach and matching treatment intensity to symptom severity, most women with PMS can experience significant symptom relief and improved quality of life.