What are the conservative management options for premenstrual syndrome (PMS)?

Conservative Management for Premenstrual Syndrome

Start with lifestyle modifications including dietary changes, regular exercise, and stress management as first-line conservative therapy for all women with PMS before considering pharmacologic interventions. 1, 2

Initial Conservative Approach

Dietary Modifications

• Reduce dietary energy intake by 30% or 500-750 kcal/day if weight management is needed, targeting 1,200-1,500 kcal/day based on individual requirements 3
• Follow general healthy eating principles with balanced macronutrient distribution 3
• Avoid restrictive or nutritionally unbalanced diets; tailor changes to food preferences for sustainability 3
• Consider reducing caffeine, alcohol, and refined sugar intake to minimize symptom exacerbation 1

Physical Activity Recommendations

• Prescribe a minimum of 150 minutes per week of moderate-intensity physical activity or 75 minutes per week of vigorous-intensity exercise 3
• Include muscle-strengthening activities on 2 non-consecutive days per week 3
• Perform activity in at least 10-minute bouts, aiming for 30 minutes daily on most days 3
• For adolescents, recommend at least 60 minutes of moderate-to-vigorous intensity activity daily 3

Behavioral and Lifestyle Strategies

• Implement behavioral strategies including goal-setting, self-monitoring, stimulus control, and problem-solving to optimize adherence 3
• Address psychological factors such as anxiety, depressive symptoms, and body image concerns that may impair engagement 3
• Ensure adequate rest and sleep patterns 1
• Modify stress factors through stress management techniques 4
• Enhance social support systems 1

Patient Education and Counseling

Essential Counseling Points

• Provide education about PMS symptom patterns and expected timing during the menstrual cycle 1, 2
• Use the Daily Record of Severity of Problems for women to self-report symptoms and track severity 2
• Ensure health professional interactions are respectful, patient-centered, and consider cultural, socioeconomic, and ethnic differences 3
• Address potential weight-related stigma sensitively 3

When Conservative Measures Are Insufficient

Progression to Pharmacologic Therapy

• Consider pharmacologic treatment when conservative therapies are ineffective or when PMS symptoms are moderate to severe 1, 5
• Serotonergic antidepressants are the drugs of choice for improving both physical and mood symptoms 2
• Combined oral contraceptives primarily improve physical symptoms 2
• Prostaglandin inhibitors are effective for physical complaints associated with PMS 5

Alternative Considerations

• Cognitive behavioral therapy can be considered as an adjunct to lifestyle modifications 2
• Herbal medicine such as chasteberry may be an option, though evidence quality varies 2
• Nutritional supplementation may provide benefit in some cases 5

Important Clinical Caveats

Healthy lifestyle modifications may contribute to health and quality of life benefits even in the absence of weight loss 3. This is particularly important for women who may not need or desire weight reduction but still experience PMS symptoms.

The effectiveness of conservative management depends heavily on patient adherence, which is optimized through comprehensive behavioral interventions and ongoing support 3. Referral to appropriately trained allied health professionals should be considered when complex issues arise 3.

Avoid progesterone supplementation as it has been proven ineffective in controlled trials 4, despite its historical use. The most effective current conservative management combines accurate diagnosis, stress control, sensible diet and exercise levels 4.