What are the criteria for diagnosing and treating Premenstrual Syndrome (PMS) in patients with varying symptom severity?

Diagnosing and Treating Premenstrual Syndrome (PMS)

Diagnostic Criteria for PMS

PMS is diagnosed clinically when characteristic symptoms occur consistently during the luteal phase of the menstrual cycle and resolve with menstruation or within the week following it, with at least one symptom-free week during the follicular phase. 1, 2

Essential Diagnostic Requirements:

• Prospective symptom tracking for at least 2 menstrual cycles is mandatory - symptoms can vary cycle to cycle, making retrospective diagnosis unreliable 2, 3
• Use the Daily Record of Severity of Problems (DRSP), a validated prospective survey tool that mirrors diagnostic criteria 4, 2, 3
• Symptoms must occur only from near ovulation through the luteal phase and remit with or shortly after menses onset 1, 5
• There must be at least 1 symptom-free week during the follicular phase - this is critical to distinguish PMS from other psychiatric disorders 1
• Laboratory tests are not helpful in diagnosis and should not be routinely ordered 1

Critical Pitfall to Avoid:

• Up to 50% of patients who believe they have PMS actually suffer from another mental illness, usually a depressive disorder 1
• If symptoms persist throughout the entire month without a symptom-free follicular phase, reassess for underlying psychiatric conditions rather than PMS 2

When to Treat: Severity Thresholds

Treatment is indicated when symptoms are severe enough to significantly interfere with the patient's ability to function within her normal lifestyle. 1

Treatment Algorithm Based on Symptom Severity:

• Mild symptoms or moderate-to-severe symptoms that are not bothersome: Watchful waiting is appropriate - the risks of medical therapy outweigh benefits when symptoms don't significantly impact quality of life 1
• Bothersome moderate-to-severe symptoms: Active treatment is warranted when symptoms interfere with daily activities, work, school, social activities, or relationships 2, 3

Distinguishing PMS from PMDD

Premenstrual Dysphoric Disorder (PMDD) requires that symptoms substantially interfere with work, school, social activities, or relationships OR cause significant distress - this represents a more severe form requiring more aggressive treatment. 2, 3

PMDD-Specific Criteria:

• PMDD affects 3-8% of premenopausal women, while PMS affects 20-32% (or up to 75% by some estimates) 5, 3
• PMDD causes severe dysfunction in social or occupational realms, not just discomfort 3
• The same diagnostic approach applies (prospective tracking with DRSP for ≥2 cycles), but the functional impairment threshold is higher 2, 3

First-Line Treatment Recommendations

Selective serotonin reuptake inhibitors (SSRIs) are first-line pharmacologic therapy for both PMS and PMDD, with rapid onset of improvement. 2, 6, 3

SSRI Dosing for PMS/PMDD:

• Sertraline 50-150 mg/day 6, 3
• Fluoxetine 10-20 mg/day 6, 3
• Escitalopram 10-20 mg/day 6, 3
• Paroxetine 12.5-25 mg/day 6
• Citalopram (dose range not specified but validated) 3

SSRI Administration Strategies:

• Continuous daily dosing throughout the menstrual cycle is one validated approach - sertraline 50-150 mg/day showed significant improvement in DRSP scores, HAMD-17 scores, and CGI scores 4
• Luteal phase-only dosing (last 2 weeks of cycle, discontinued at menses onset) is equally effective - sertraline 50-100 mg/day during luteal phase significantly improved DRSP and CGI scores 4
• SSRIs demonstrate rapid onset of action in PMS/PMDD, unlike their delayed effect in depression 2

Important Caveat:

• Adverse effects can limit SSRI use - counsel patients about potential side effects and monitor tolerability 2

Alternative and Adjunctive Treatments

Evidence-Based Non-Pharmacologic Options:

• Cognitive Behavioral Therapy (CBT) reduces functional impairment, depressed mood, anxiety, mood swings, irritability, insomnia, and conflict with others 6, 3
• Exercise may ameliorate symptoms 2
• Acupuncture or acupressure may provide benefit 2
• Vitex agnus castus (herbal supplement) may reduce symptoms 2

Nutritional Supplementation:

• Calcium carbonate has demonstrated excellent efficacy 5
• Vitamin D and Vitamin B6 have limited but supportive evidence 3

Second-Line Pharmacologic Treatment

Oral contraceptives containing drospirenone (3 mg) with ethinyl estradiol (0.02 mg) are FDA-approved for PMDD treatment in women who choose oral contraceptives for contraception. 7, 6

Drospirenone Regimen:

• 24 days of active hormonal pills (drospirenone 3 mg + ethinyl estradiol 0.02 mg), followed by 4 days of inactive tablets 7
• Drospirenone appears to be a first or second-line treatment depending on patient preference for contraception 6
• Do not use in patients with renal impairment, adrenal insufficiency, or predisposition to hyperkalemia - drospirenone has anti-mineralocorticoid activity 7
• Check serum potassium during the first treatment cycle in women on long-term medications that may increase potassium 7

Important Contraindications:

• Women over 35 who smoke should not use this combination due to cardiovascular risk 7
• Contraindicated in patients with high risk of arterial/venous thrombotic diseases, liver disease, or breast cancer 7

Treatment Failure and Reassessment

If symptoms are not controlled with medications or other interventions, or if symptoms persist throughout the month, reassess for another underlying cause. 2

Reassessment Algorithm:

• Verify that prospective symptom tracking confirms luteal-phase-only symptoms with follicular phase remission
• Screen for major depressive disorder, generalized anxiety disorder, or other psychiatric conditions that may present similarly
• Consider that 50% of self-diagnosed PMS cases are actually other mental illnesses 1
• If SSRIs fail, consider switching agents or adding CBT before abandoning the PMS/PMDD diagnosis