How can premenstrual symptoms be managed without hormone therapy?

Managing Premenstrual Symptoms Without Hormones

For women seeking non-hormonal management of premenstrual symptoms, selective serotonin reuptake inhibitors (SSRIs) like sertraline are the evidence-based first-line treatment for moderate-to-severe symptoms, while calcium carbonate supplementation and NSAIDs provide effective options for milder symptoms.

Diagnostic Approach

Before initiating treatment, confirm the diagnosis through prospective symptom tracking:

• Require daily symptom calendars for at least 2 consecutive menstrual cycles to document the timing and severity of symptoms relative to menses 1
• Symptoms must occur during the luteal phase (after ovulation) and resolve within a few days of menstruation onset 2
• Rule out underlying mood disorders (depression, anxiety) that may worsen premenstrually but persist throughout the cycle 1
• Exclude other cyclic conditions: menstrual migraine, mastalgia, or gynecologic pathology 1

Treatment Algorithm by Severity

Mild-to-Moderate Symptoms

First-line: Calcium carbonate 1200 mg daily 3

• Level I evidence supports efficacy for PMS symptoms
• Safe, well-tolerated, with additional bone health benefits
• Should be continued throughout the menstrual cycle

NSAIDs for targeted symptom relief 4

• Mefenamic acid 500 mg three times daily for 5 days during symptomatic periods 4
• Celecoxib 200 mg daily for 5-7 days during bleeding 4
• Particularly effective for physical symptoms (cramping, headache, body aches)

Moderate-to-Severe Symptoms (Including PMDD)

First-line: SSRIs 2, 1, 5, 3

Sertraline is FDA-approved specifically for PMDD and can be dosed in two ways:

• Continuous dosing: 50-150 mg daily throughout the entire menstrual cycle 2
• Intermittent (luteal phase) dosing: Start 14 days before expected menses and continue through the first few days of bleeding 1, 5
  • Most women with PMS/PMDD respond to intermittent therapy 1
  • This approach minimizes medication exposure and side effects
  • Equally effective as continuous dosing for many patients 5

Other SSRIs with evidence include paroxetine, fluoxetine, citalopram, and sertraline 4, 1, 5

Duration of treatment:

• Effectiveness beyond 3 menstrual cycles has not been systematically studied 2
• However, continuation is reasonable as symptoms typically worsen with age until menopause 2
• Periodically reassess need for continued treatment 2

Refractory Cases

If SSRIs and calcium fail to provide adequate relief:

• Consider spironolactone for bloating and fluid retention symptoms 6
• Evaluate for comorbid conditions that may require separate management 1
• At this point, hormonal interventions (ovulation suppression) may be necessary, though this falls outside non-hormonal management 1, 5

Lifestyle Modifications

While evidence is inconclusive, recommend these interventions given their overall health benefits and low risk 3:

• Aerobic exercise - may improve mood and physical symptoms 3
• Stress reduction techniques and cognitive behavioral therapy 3
• Complex carbohydrate-rich diet during symptomatic periods 3

Treatments to Avoid

Do not use progesterone or bromocriptine - these have been proven ineffective despite historical widespread use 3

Common Pitfalls

• Failing to obtain prospective symptom calendars: Retrospective recall is unreliable; always require at least 2 cycles of daily tracking before diagnosis 1
• Missing underlying psychiatric disorders: Depression and anxiety can worsen premenstrually but persist throughout the cycle and require different management 1
• Prescribing vitamin B6 or evening primrose oil: Despite popularity, evidence for these is inconclusive 3
• Delaying SSRI therapy in severe cases: Women with significant functional impairment should receive SSRIs as first-line treatment rather than trying multiple ineffective interventions 1, 3

Monitoring Response

• Reassess at 2-3 months after initiating treatment using continued symptom calendars 2
• Adjust dosing or switch therapies if inadequate response
• For SSRI responders, consider switching from continuous to luteal-phase dosing to minimize exposure 1