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* This is the Professional Version. *

Premenstrual Syndrome (PMS)

(Premenstrual Tension)

By JoAnn V. Pinkerton, MD

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Patient Education

Premenstrual syndrome (PMS) is characterized by irritability, anxiety, emotional lability, depression, edema, breast pain, and headaches, occurring during the 7 to 10 days before and usually ending a few hours after onset of menses. Diagnosis is clinical, often based on the patient’s daily recording of symptoms. Treatment is symptomatic and includes diet, drugs, and counseling.

About 20 to 50% of women of reproductive age have PMS; about 5% have a severe form of PMS called premenstrual dysphoric disorder.

Etiology

The cause is unclear.

Possible causes or contributing factors include

  • Multiple endocrine factors (eg, hypoglycemia, other changes in carbohydrate metabolism, hyperprolactinemia, fluctuations in levels of circulating estrogen and progesterone, abnormal responses to estrogen and progesterone, excess aldosterone or ADH)

  • A genetic predisposition

  • Serotonin deficiency

  • Possibly magnesium and calcium deficiencies

Estrogen and progesterone can cause transitory fluid retention, as can excess aldosterone or ADH.

Serotonin deficiency is thought to contribute because women who are most affected by PMS have lower serotonin levels and because SSRIs (which increase serotonin) sometimes relieve symptoms of PMS.

Magnesium and calcium deficiencies may contribute.

Symptoms and Signs

Type and intensity of symptoms vary from woman to woman and from cycle to cycle. Symptoms last a few hours to 10 days, usually ending when menses begins. Symptoms may become more severe during stress or perimenopause. In perimenopausal women, symptoms may persist until after menses.

The most common symptoms are irritability, anxiety, agitation, anger, insomnia, difficulty concentrating, lethargy, depression, and severe fatigue. Fluid retention causes edema, transient weight gain, and breast fullness and pain. Pelvic heaviness or pressure and backache may occur. Some women, particularly younger ones, have dysmenorrhea when menses begins.

Other nonspecific symptoms may include headache, vertigo, paresthesias of the extremities, syncope, palpitations, constipation, nausea, vomiting, and changes in appetite. Acne and neurodermatitis may also occur. Existing skin disorders may worsen, as may respiratory problems (eg, allergies, infection) and eye problems (eg, visual disturbances, conjunctivitis).

Premenstrual dysphoric disorder (PMDD)

Some women have severe PMS symptoms that occur regularly and only during the 2nd half of the menstrual cycle; symptoms end with menses or shortly after. Mood is markedly depressed, and anxiety, irritability, and emotional lability are pronounced. Suicidal thoughts may be present. Interest in daily activities is greatly decreased.

In contrast to PMS, PMDDcauses symptoms that are severe enough to interfere with routine daily activities or overall functioning. PMDD is a severely distressing, disabling, and often underdiagnosed.

Pearls & Pitfalls

  • Consider premenstrual dysphoric disorder if women have nonspecific but severe symptoms just before menses.

Diagnosis

  • For PMS, patient’s report of symptoms

  • For PMDD, clinical criteria

PMS is diagnosed based on physical symptoms (eg, bloating, weight gain, breast tenderness, swelling of hands and feet). Women may be asked to record their symptoms daily. Physical examination and laboratory testing are not helpful.

If PMDD is suspected, women are asked to rate their symptoms daily for 2 cycles to determine whether severe symptoms occur regularly.

For PMDD to be diagnosed, women must have 5 of the following symptoms for most of the week before menses, and symptoms must become minimal or absent during the week after menstruation. Symptoms must include at least one of the following:

  • Marked mood swings (eg, sudden sadness)

  • Marked irritability or anger or increased interpersonal conflicts

  • Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts

  • Marked anxiety, tension, or an on-edge feeling

In addition, ≥ 1 of the following must be present:

  • Decreased interest in usual activities, possibly causing withdrawal

  • Difficulty concentrating

  • Low energy or fatigue

  • Marked changes in appetite, overeating, or specific food cravings

  • Insomnia or hyperinsomnia

  • Feelings of being overwhelmed or out of control

  • Physical symptoms associated with PMS (eg, breast tenderness, edema)

Also, the symptom pattern must have occurred for most of the previous 12 mo, and symptoms must be severe enough to interfere with daily activities and function.

Patients with symptoms of depression are evaluated using a depression inventory or are referred to a mental health care practitioner for formal evaluation.

Treatment

  • General measures

  • Sometimes SSRIs or hormonal manipulation

PMS can be difficult to treat. No single treatment has proven efficacy for all women, and few woman have complete relief with any single type of treatment. Treatment can thus require trial and error, as well as patience.

General measures

Treatment is symptomatic, beginning with adequate rest and sleep, regular exercise, and activities that are relaxing. Regular exercise may help alleviate bloating as well as irritability, anxiety, and insomnia. Yoga helps some women.

Dietary changes—increasing protein, decreasing sugar, consuming complex carbohydrates, and eating smaller meals more frequently—may help, as may counseling, avoiding stressful activities, relaxation training, light therapy, sleep adjustments, and cognitive-behavioral therapy. Other possible strategies include avoiding certain foods and drinks (eg, cola, coffee, hot dogs, potato chips, canned goods) and eating more of others (eg, fruits, vegetables, milk, high-fiber foods, low-fat meats, foods high in calcium and vitamin D). The beneficial effects of dietary supplements have not been substantiated.

Drugs

NSAIDs can help relieve aches, pains, and dysmenorrhea.

SSRIs (eg, fluoxetine 20 mg po once/day) are the drugs of choice for relief of anxiety, irritability, and other emotional symptoms, particularly if stress cannot be avoided. SSRIs effectively relieve symptoms of PMS and PMDD. Continuous dosing is more effective than intermittent dosing. No SSRI appears to be more effective than another.

Clomipramine, given for the full cycle or a half-cycle, effectively relieves emotional symptoms, as does nefazodone, a serotonin-norepinephrine reuptake inhibitor (SNRI).

Anxiolytics may help but are usually less desirable because dependence or addiction is possible. Buspirone, which may be given throughout the cycle or during the late luteal phase, helps relieve symptoms of PMS and PMDD. Adverse effects include nausea, headache, anxiety, and dizziness.

For some women, hormonal manipulation is effective. Options include

  • Oral contraceptives

  • Progesterone by vaginal suppository (200 to 400 mg once/day)

  • An oral progestogen (eg, micronized progesterone 100 mg at bedtime) for 10 to 12 days before menses

  • A long-acting progestin (eg, medroxyprogesterone 200 mg IM q 2 to 3 mo)

Women who choose to use an oral contraceptive for contraception can take drospirenone plus ethinyl estradiol. However, risk of venous thromboembolism may be increased.

Rarely, for very severe or refractory symptoms, a gonadotropin-releasing hormone agonist (eg, leuprolide 3.75 mg IM, goserelin 3.6 mg sc q mo) with low-dose estrogen/progestin (eg, oral estradiol 0.5 mg once/day plus micronized progesterone 100 mg at bedtime) is given to minimize cyclic fluctuations.

Fluid retention may be relieved by reducing sodium intake and taking a diuretic (eg, spironolactone 100 mg po once/day) just before symptoms are expected. However, minimizing fluid retention and taking a diuretic do not relieve all symptoms and may have no effect.

Bromocriptine and monoamine oxidase inhibitors are not useful.

Surgery

In women with severe symptoms, bilateral oophorectomy may alleviate symptoms because it eliminates menstrual cycles; hormone replacement therapy is then indicated until about age 51 (when menopause usually occurs).

Key Points

  • Symptoms of PMS can be nonspecific and vary from woman to woman.

  • PMS is diagnosed based on symptoms alone.

  • If symptoms seem severe and disabling, consider PMDD (which is often underdiagnosed), and ask patients to record symptoms for ≥ 2 cycles; for a diagnosis of PMDD, clinical criteria must be met.

  • Usually, treatment is a matter of trying various strategies to identify what helps a particular patient.

Resources In This Article

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • CRINONE
  • ZOLADEX
  • ALDACTONE
  • ANAFRANIL
  • PROZAC, SARAFEM
  • PROVERA
  • LEVOPHED
  • No US brand name
  • ESTRADERM, ESTROGEL, VIVELLE
  • LUPRON
  • PARLODEL

* This is the Professional Version. *