What is the most effective treatment for premenstrual syndrome (PMS) symptoms, including mood changes, breast tenderness, and abdominal bloating?

Treatment of Premenstrual Syndrome

For this 38-year-old woman with moderate-to-severe PMS symptoms including mood changes, physical symptoms, and sleep disturbance, SSRIs (selective serotonin reuptake inhibitors) are the most effective first-line pharmacologic treatment, with fluoxetine, sertraline, or paroxetine being FDA-approved options that can be administered either continuously or during the luteal phase only.

Evidence-Based Treatment Approach

First-Line Pharmacologic Treatment: SSRIs

SSRIs are the drugs of choice for PMS/PMDD, effectively treating both physical and mood symptoms 1, 2. The evidence demonstrates that SSRIs reduce overall premenstrual symptoms with moderate-to-high certainty (SMD -0.57) 3.

Administration Strategy

• Continuous administration is more effective than luteal-phase-only dosing (SMD -0.69 vs -0.39, P = 0.03) 3
• However, luteal-phase administration (starting 14 days before expected menses) remains a valid option with fewer side effects and may be preferred by some patients 3
• Both regimens are effective, but continuous dosing shows superior symptom reduction 3

FDA-Approved Options

The following SSRIs have proven efficacy for PMS/PMDD 2:

• Fluoxetine (FDA-approved for PMDD)
• Sertraline (FDA-approved for PMDD)
• Controlled-release paroxetine (FDA-approved for PMDD)

Second-Line Options

If SSRIs are ineffective, contraindicated, or not tolerated 2:

Combined Oral Contraceptives

• Oral contraceptives containing drospirenone have demonstrated efficacy in randomized placebo-controlled trials 4
• These primarily improve physical symptoms rather than mood symptoms 1
• Consider this option particularly if contraception is also desired 2

Targeted Symptom Management

For specific symptoms as adjunctive therapy 2:

• Spironolactone for bloating and breast tenderness
• NSAIDs for physical pain symptoms
• Anxiolytics for severe anxiety symptoms (though not first-line)

Non-Pharmacologic Interventions

Lifestyle modifications should be recommended for all women with PMS as first-line management, particularly for mild-to-moderate symptoms 2:

• Exercise and physical activity 5, 2
• Cognitive behavioral therapy may reduce the perceived burden of symptoms 5
• Weight loss if overweight, smoking cessation, and limiting alcohol if it triggers symptoms 5

Expected Adverse Effects of SSRIs

Patients should be counseled about common side effects (all moderate-certainty evidence) 3:

Most Common:

• Nausea (OR 3.30) - most frequent side effect
• Asthenia/decreased energy (OR 3.28)
• Somnolence and decreased concentration (OR 3.26)

Other Notable Effects:

• Sexual dysfunction or decreased libido (OR 2.32) 3
• Insomnia (OR 1.99) 3
• Dry mouth (OR 2.70) 3
• Dizziness (OR 1.96) 3

Clinical Decision Algorithm

1. Confirm diagnosis: Prospective daily symptom monitoring over at least 2 menstrual cycles is required for accurate diagnosis 4

2. Assess severity:

   • Mild-to-moderate symptoms → Start with lifestyle modifications and exercise 2
   • Moderate-to-severe symptoms (as in this case) → Initiate SSRI therapy 1, 2

3. SSRI selection and dosing:

   • Start with fluoxetine, sertraline, or controlled-release paroxetine 2
   • Choose between continuous or luteal-phase administration based on patient preference and symptom severity 3
   • Continuous dosing preferred for more severe symptoms 3

4. If inadequate response after 2-3 cycles:

   • Switch to alternative SSRI 2
   • Consider adding or switching to drospirenone-containing oral contraceptive 4
   • Add targeted symptom management (spironolactone for bloating, NSAIDs for pain) 2

Important Caveats

• Serotonergic antidepressants improve both physical and mood symptoms, while oral contraceptives primarily improve physical symptoms 1
• The evidence base has moderate risk of publication bias, with 68% of studies funded by pharmaceutical companies 3
• Despite this limitation, the consistency of findings across multiple trials supports SSRI efficacy 3
• Treatment selection should consider the patient's need for contraception, symptom profile (mood vs. physical predominance), and tolerance for potential side effects 2