What are the treatment options for a teenage girl experiencing premenstrual syndrome (PMS)?

Treatment of Premenstrual Syndrome in Adolescents

Start with lifestyle modifications and calcium supplementation as first-line therapy, then escalate to SSRIs (fluoxetine or escitalopram) for moderate-to-severe symptoms, while avoiding combined oral contraceptives as first-line treatment since they primarily address physical symptoms rather than mood disturbances. 1, 2, 3

Initial Assessment and Diagnosis

Confirm the diagnosis through prospective daily symptom charting for two menstrual cycles to verify that symptoms occur during the luteal phase and resolve within the first few days of menstruation. 4, 3 This timing is more critical than the number or type of symptoms.

• Screen for alternative medical causes including thyroid dysfunction and diabetes before initiating treatment, as hypothyroidism can mimic premenstrual symptoms with mood changes and fatigue. 1
• Rule out underlying psychiatric disorders that may be exacerbated premenstrually rather than true PMS/PMDD. 3

Treatment Algorithm

First-Line: Lifestyle Modifications and Non-Pharmacologic Interventions

Begin with education about the nature of PMS and implement conservative measures before considering pharmacotherapy. 4, 3

• Calcium supplementation (1200 mg daily) has demonstrated excellent efficacy in reducing premenstrual symptoms. 5
• Weight loss of ≥10% body weight if overweight can eliminate symptoms in adolescents with mild-to-moderate PMS. 1
• Regular physical activity (150 minutes per week of moderate intensity) provides overall health benefits and symptom reduction. 1
• Smoking cessation improves frequency and severity of symptoms. 1
• Cognitive behavioral therapy (CBT) reduces the perceived burden of premenstrual symptoms with benefits maintained at 3-month follow-up. 1, 2
• Dietary modifications including reducing caffeine, salt, and simple sugars may provide symptomatic relief. 4

Second-Line: Pharmacologic Treatment for Moderate-to-Severe Symptoms

SSRIs are the first-line pharmacologic therapy for adolescents with severe PMS or PMDD, as they improve both physical and mood symptoms. 2, 3

Selective Serotonin Reuptake Inhibitors (Preferred)

• Fluoxetine can be administered safely to teens and is effective for severe PMS/PMDD. 3
• Escitalopram is another safe option for adolescents with severe symptoms. 3
• SSRIs can be dosed continuously or only during the luteal phase (intermittent dosing), though clinical experience in adults suggests both approaches are effective. 3
• Avoid paroxetine in adolescent females who may later require tamoxifen, as it inhibits CYP2D6 and reduces tamoxifen efficacy. 1

SNRIs (Alternative First-Line)

• Venlafaxine reduces symptom intensity by 40-65% and is particularly useful when SSRIs are not tolerated. 1

Third-Line: Hormonal Suppression

Hormonal contraceptives should not be used as first-line treatment for mood symptoms, as they primarily address physical symptoms and do not restore spontaneous menses. 1

• Certain hormonal contraceptive formulations that eliminate ovulation may be considered for severe cases unresponsive to SSRIs. 3
• Screen for contraindications including history of hormone-dependent cancers, thromboembolic events, active liver disease, and abnormal vaginal bleeding before prescribing hormonal therapy. 1
• GnRH agonists can eliminate ovulation but are typically reserved for the most severe, refractory cases due to side effects and need for add-back therapy. 3

Monitoring and Follow-Up

• Reassess treatment response after 6-8 weeks of pharmacologic therapy. 6
• If no improvement occurs, explore poor adherence, comorbid psychiatric disorders (particularly depression and anxiety), or ongoing stressors. 6
• Consider mental health consultation for partial or no response to initial treatment. 6

Critical Pitfalls to Avoid

• Do not prescribe combined oral contraceptives as first-line for mood-predominant PMS/PMDD, as serotonergic antidepressants are superior for affective symptoms. 1, 2
• Avoid custom-compounded bioidentical hormones, as no data support claims of superior safety or efficacy compared to standard therapies. 1
• Do not rely solely on patient recall for diagnosis—prospective daily charting for two cycles is essential to confirm the luteal phase timing of symptoms. 4, 3
• Never overlook screening for depression and anxiety, as these commonly co-occur and require simultaneous treatment rather than sequential management. 6
• Ensure reproductive counseling if prescribing medications with teratogenic potential, as adolescents may not consistently use contraception. 6