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

Treatment Options for Premenstrual Syndrome (PMS)

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

First-Line Treatments

Non-Pharmacological Approaches

• Lifestyle modifications (should be recommended for all women with PMS):
  • Diet low in salt, fat, caffeine, and sugar 2
  • Regular aerobic exercise 2
  • Stress reduction techniques 2
  • Heat application to lower abdomen or back for cramping 3
  • Acupressure at specific points (LI4 and SP6) for cramping 3

Pharmacological Options

1. SSRIs (first-line for moderate-severe symptoms):

   • Fluoxetine, paroxetine, sertraline, escitalopram, citalopram 1
   • Continuous administration is more effective than luteal phase dosing (SMD -0.69 vs -0.39) 1
   • Common side effects: nausea, insomnia, sexual dysfunction, fatigue, dizziness 1

2. NSAIDs for physical symptoms:

   • Ibuprofen 600-800mg every 6-8 hours with food for the first 24-48 hours 3
   • Particularly effective for dysmenorrhea and menorrhagia

3. Calcium supplementation:

   • Shown to reduce emotional, behavioral, and physical premenstrual symptoms 4

Second-Line Treatments

1. Hormonal Contraceptives:

   • Combined oral contraceptives (COCs) with ≤35 μg ethinyl estradiol 3
   • Benefits include decreased menstrual cramping, blood loss, regulation of cycles 3
   • Monophasic COCs with 30-35 μg ethinyl estradiol and levonorgestrel or norgestimate recommended 3
   • LNG-IUD may be considered (50% of users experience amenorrhea or oligomenorrhea by 2 years) 3

2. Other medications:

   • Anxiolytics for anxiety symptoms 5
   • Spironolactone for bloating and fluid retention 5
   • Diuretics for fluid retention 4

Treatment Algorithm

1. For mild symptoms:

   • Start with lifestyle modifications (diet, exercise, stress reduction)
   • Add calcium supplementation
   • Consider NSAIDs for physical symptoms

2. For moderate symptoms:

   • Continue lifestyle modifications
   • Add SSRIs (continuous dosing preferred)
   • Consider hormonal contraception if SSRIs are ineffective or contraindicated

3. For severe symptoms (PMDD):

   • SSRIs as primary treatment (continuous dosing)
   • Consider combination therapy with hormonal contraception
   • Cognitive behavioral therapy as adjunct 6

Special Considerations

• Iron supplementation should be considered if bleeding is heavy to prevent anemia 3
• Herbal supplements like chasteberry may provide benefit for some women 6, though evidence is limited
• Ovulation suppression therapies (e.g., GnRH agonists) may be effective but carry risks of low estrogen effects including cardiac and osteoporotic concerns 4

Monitoring and Follow-up

• Regular follow-up after 3 months to assess treatment response 3
• Monitor for adverse effects, particularly with SSRIs
• Consider changing treatment strategy if inadequate response after 3 cycles

Common Pitfalls to Avoid

1. Failing to distinguish between PMS and PMDD (PMDD affects 3-8% of reproductive-age women and requires more aggressive treatment) 6
2. Not addressing both physical and psychological symptoms
3. Overlooking the importance of lifestyle modifications as foundation of treatment
4. Using luteal phase SSRI dosing when continuous dosing is more effective 1
5. Not providing adequate counseling about expected side effects of medications

Remember that PMS affects 30-40% of reproductive-age women 6, and treatment should address both the physical and psychological symptoms to improve quality of life.