What treatment options are available for a 38-year-old woman (G3P3) with premenstrual syndrome (PMS) symptoms, a history of smoking, and prior tubal ligation?

Treatment for PMS in a 38-Year-Old Woman with Prior Tubal Ligation Who Smokes

Start with an SSRI (fluoxetine 20 mg, sertraline 50-150 mg, or paroxetine CR 12.5-25 mg daily) as first-line pharmacotherapy, given continuously rather than luteal-phase only, since this patient is not seeking contraception and SSRIs are the most effective treatment for both physical and mood symptoms of PMS. 1, 2, 3

First-Line Treatment Approach

SSRIs as Primary Pharmacotherapy

• SSRIs reduce overall premenstrual symptoms significantly (standardized mean difference -0.57), with continuous administration being more effective than luteal-phase-only dosing (SMD -0.69 vs -0.39) 3
• Fluoxetine, paroxetine CR, and sertraline are FDA-approved specifically for premenstrual dysphoric disorder 2, 4
• SSRIs improve both physical symptoms and mood symptoms, making them superior to hormonal options that primarily address physical complaints 1, 2

Dosing Strategy

• Initiate at standard antidepressant doses: fluoxetine 20 mg daily, sertraline 50-150 mg daily, or paroxetine CR 12.5-25 mg daily 2, 3
• Continuous daily administration is preferred over luteal-phase dosing for this patient, as she has completed childbearing and contraception is not needed 3
• Follow up within 2-3 weeks to assess efficacy and side effects, then periodically but at least every 12 weeks 5

Critical Consideration: Smoking Cessation

Smoking as a Modifiable Risk Factor

• Smoking increases colorectal cancer risk and may worsen overall health outcomes, making cessation a priority alongside PMS treatment 5
• Every patient who smokes should be asked about readiness to quit at every visit 5

Smoking Cessation Protocol

• Offer combination nicotine replacement therapy (NRT) OR varenicline as first-line pharmacotherapy, paired with behavioral counseling (4+ sessions of 10-30 minutes each during the 12-week treatment course) 5
• Varenicline has the highest efficacy among first-line smoking cessation medications (OR 2.55) 5
• Important drug interaction: If prescribing both an SSRI for PMS and bupropion for smoking cessation, use caution as both affect serotonin pathways, though bupropion is considered second-line for smoking cessation 5, 4

Why Hormonal Contraceptives Are NOT Recommended Here

Contraindications and Limitations

• Combined oral contraceptives are not appropriate for this 38-year-old smoker, as smoking becomes a Category 3-4 contraindication at age ≥35 years due to increased thromboembolic risk 6
• This patient has already had tubal ligation, so contraception is not needed 7
• While combined oral contraceptives can improve physical PMS symptoms, they primarily address physical rather than mood symptoms and are less effective than SSRIs for comprehensive symptom relief 1, 2

Expected Adverse Effects and Management

Common SSRI Side Effects

• Nausea (OR 3.30), insomnia (OR 1.99), sexual dysfunction (OR 2.32), fatigue (OR 1.52), and dizziness (OR 1.96) are the most common adverse effects 3
• Most side effects are mild and often improve after the first 1-2 weeks of treatment 5, 4
• Patients should be counseled to report severe, abrupt behavioral changes, agitation, or suicidal ideation immediately, though these are rare 4

Monitoring Strategy

• Assess within 2-3 weeks for symptom improvement and medication tolerance 5
• Nicotine withdrawal symptoms peak within 1-2 weeks if smoking cessation is initiated concurrently 5
• Continue SSRI treatment for at least 12 weeks before considering it ineffective 2, 3

Adjunctive and Supportive Measures

Lifestyle Modifications

• Recommend regular exercise, healthy diet, and avoidance of obesity as first-line non-pharmacologic interventions for all women with PMS, though evidence is limited 5, 2
• These modifications may be sufficient for mild-to-moderate symptoms and should be implemented regardless of pharmacotherapy 2

Second-Line Options if SSRIs Fail

• Consider spironolactone for fluid retention and bloating symptoms 8, 2
• NSAIDs can be used for dysmenorrhea and physical pain symptoms 2
• Anxiolytics may provide supportive care for anxiety symptoms, though they are not first-line 2

Common Pitfalls to Avoid

• Do not prescribe combined oral contraceptives to this patient due to age >35 years and active smoking status 6
• Do not use luteal-phase-only SSRI dosing when continuous administration is more effective and contraception is not a concern 3
• Do not overlook smoking cessation counseling, as this represents a critical opportunity to reduce long-term morbidity and mortality 5
• Do not discontinue SSRIs prematurely if side effects are mild; most adverse effects diminish within 1-2 weeks 5, 4