What is the first-line treatment for Premenstrual Syndrome (PMS)?

First-Line Treatment for Premenstrual Syndrome (PMS)

For women with PMS, lifestyle modifications including regular aerobic exercise (at least 150 minutes/week of moderate-intensity activity), healthy diet, and behavioral strategies should be initiated first, with selective serotonin reuptake inhibitors (SSRIs) as the established first-line pharmacological treatment when lifestyle changes are insufficient. 1, 2, 3

Initial Management Approach: Lifestyle Modifications

• Begin with at least 150 minutes per week of moderate-intensity physical activity or 75 minutes per week of vigorous-intensity activity, performed in bouts of at least 10 minutes, aiming for 30 minutes daily on most days 4
• Include muscle-strengthening activities on 2 non-consecutive days per week 4
• Implement stress management techniques and cognitive-behavioral therapy to address psychological symptoms 1, 2
• Adopt a balanced, healthy diet without specific restrictive requirements, focusing on individual preferences while maintaining nutritional adequacy 4
• Use SMART goal setting (specific, measurable, achievable, realistic, timely) and self-monitoring to track progress 4

These lifestyle interventions may be sufficient for mild-to-moderate PMS symptoms and should be recommended for all women regardless of symptom severity 2

First-Line Pharmacological Treatment: SSRIs

When lifestyle modifications alone are inadequate, SSRIs are the established first-line pharmacological treatment for PMS and PMDD, with proven efficacy in reducing both physical and mood symptoms 5, 6, 2, 3

SSRI Efficacy and Administration

• SSRIs reduce overall self-rated premenstrual symptoms with moderate certainty (SMD -0.57,95% CI -0.72 to -0.42) 3
• Continuous administration is more effective than luteal-phase-only dosing (continuous: SMD -0.69 vs luteal phase: SMD -0.39; P = 0.03 for subgroup difference) 3
• Three FDA-approved SSRIs for PMDD include fluoxetine, controlled-release paroxetine, and sertraline 2
• Both continuous daily dosing and luteal phase dosing (starting 14 days before expected menses) are effective options 5, 3

Common SSRI Adverse Effects to Counsel Patients About

Patients should be informed of the following adverse effects, which occur more frequently than with placebo:

• Nausea (OR 3.30; most common side effect) 3
• Asthenia or decreased energy (OR 3.28) 3
• Somnolence and decreased concentration (OR 3.26) 3
• Insomnia (OR 1.99) 3
• Sexual dysfunction or decreased libido (OR 2.32) 3
• Dizziness (OR 1.96) 3

Second-Line and Alternative Pharmacological Options

If SSRIs are ineffective or not tolerated, consider the following alternatives:

• Combined oral contraceptives (particularly drospirenone-containing formulations) primarily improve physical symptoms and may be preferred when contraception is also desired 7, 6, 2
• Anxiolytics (alprazolam, buspirone) for predominantly anxiety symptoms 5, 2
• Spironolactone for bloating and fluid retention 2
• NSAIDs for pain-related symptoms 2

Important Contraindication for Drospirenone-Containing OCPs

Women should not use drospirenone-containing oral contraceptives if they have kidney, liver, or adrenal disease, or are taking medications that increase potassium (NSAIDs for chronic conditions, potassium-sparing diuretics, ACE inhibitors, ARBs) 7

Supplement Considerations

• Calcium supplementation has demonstrated consistent therapeutic benefit and may be recommended 5, 2
• Other supplements (chasteberry, vitamins, minerals) have unclear or conflicting evidence and should not replace proven first-line treatments 6, 2

Critical Diagnostic Requirement

Before initiating treatment, confirm the diagnosis using prospective daily symptom charting (such as the Daily Record of Severity of Problems) for at least two menstrual cycles to document that symptoms occur specifically during the luteal phase and resolve within a few days of menstruation 1, 6

Common Pitfalls to Avoid

• Do not delay evidence-based SSRI treatment while pursuing unproven herbal or complementary therapies 4
• Do not confuse mild PMS (which affects 30-40% of reproductive-age women) with PMDD (affecting 3-8%), as PMDD requires more aggressive pharmacological intervention 6
• Avoid sudden cessation of SSRIs, which can precipitate withdrawal syndrome; taper gradually if discontinuation is needed 5
• Do not prescribe drospirenone-containing OCPs without screening for contraindications related to potassium elevation 7