What are the treatment options for Premenstrual Syndrome (PMS)?

Treatment Options for Premenstrual Syndrome (PMS)

Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for moderate to severe PMS and PMDD due to their proven efficacy in reducing both physical and psychological symptoms. 1

First-Line Treatments

Pharmacological Options

• SSRIs are most effective when administered continuously rather than only during the luteal phase (SMD -0.69 vs -0.39) 1
• Commonly prescribed SSRIs include fluoxetine, paroxetine, sertraline, escitalopram, and citalopram 1
• Common side effects of SSRIs include nausea, insomnia, sexual dysfunction, fatigue, dizziness, and dry mouth 1

Hormonal Treatments

• Combined oral contraceptives (COCs) are effective for managing physical symptoms of PMS 2
• Continuous or extended-cycle COCs can be used to reduce hormone fluctuations that trigger symptoms 2
• Counsel patients about potential changes in bleeding patterns during extended or continuous COC use 3

Second-Line Treatments

For Specific Symptom Management

• For women with PMS and heavy menstrual bleeding, consider adding tranexamic acid to the current COC regimen 4
• Levonorgestrel intrauterine device (IUD) can be considered as second-line therapy for persistent heavy menstrual bleeding in women with PMS 4
• For women with predominant anxiety symptoms, alprazolam may be beneficial when used during the luteal phase 5, 6

Non-Pharmacological Approaches

• Lifestyle modifications should be implemented alongside pharmacological treatments:
  • Regular physical exercise 3
  • Stress management techniques 7
  • Dietary modifications (reduced caffeine, alcohol, salt, and refined sugar) 7

Treatment Algorithm Based on Symptom Severity

Mild PMS

• Start with lifestyle modifications and dietary changes 7
• Consider calcium supplementation (has demonstrated consistent therapeutic benefit) 5
• Monitor symptoms using a daily symptom diary to track effectiveness 2

Moderate to Severe PMS/PMDD

• First-line: SSRIs (either continuous or luteal phase dosing, with continuous showing greater efficacy) 1
• Second-line options if SSRIs are ineffective or poorly tolerated:
  • Venlafaxine or duloxetine 5
  • Hormonal therapy with COCs 2
  • Combination therapy for specific symptoms (e.g., adding tranexamic acid for heavy bleeding) 4

Special Considerations

• When prescribing SSRIs, warn patients about potential side effects, particularly nausea, insomnia, and sexual dysfunction 1
• For patients with predominant physical symptoms, COCs may be more appropriate as first-line therapy 2
• For patients with both PMS and menstrual migraine, continuous COC regimens may provide dual benefits 3

Common Pitfalls to Avoid

• Avoid progesterone-only treatments as they have been proven ineffective for PMS management 6
• Do not rely solely on symptom-based treatment without proper diagnosis using prospective symptom tracking 2
• Avoid delaying treatment for severe symptoms (especially in PMDD) as this can significantly impact quality of life 5
• Be aware that some treatments that seem intuitive (like progesterone supplementation) lack evidence of efficacy 6