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• Menstrual Abnormalities
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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.

Etiology

PMS appears to be caused by 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, excessive aldosterone or ADH). Estrogen and progesterone can cause transitory fluid retention, as can excess aldosterone or ADH.

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. 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. Symptoms are severe enough to interfere with routine daily activities or overall functioning,

Diagnosis

• For PMS, patient's reporting 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.

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 at least one symptom must be from the first 4:

• Feelings of sadness, hopelessness, or self-depreciation
• A tense (on edge) feeling or anxiety
• Emotional lability with frequent tearfulness
• Irritability or anger that persists, leading to increased interpersonal conflicts
• Loss of interest in daily activities, possibly causing withdrawal
• Decreased concentration
• Fatigue, lethargy, or lack of energy
• Changes in eating habits, including bingeing
• Insomnia or hyperinsomnia
• Feelings of being overwhelmed or out of control
• Physical symptoms associated with PMS

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.

Treatment

• General measures
• Sometimes SSRIs or hormonal manipulation

Treatment is symptomatic, beginning with adequate rest and sleep and regular exercise. Regular exercise may help alleviate bloating as well as irritability, anxiety, and insomnia. Dietary changes—increasing protein, decreasing sugar, and taking vitamin B complex (especially pyridoxine, a form of vitamin B₆) or Mg supplements—may help, as may counseling and avoiding stressful activities. Consuming foods high in Ca and vitamin D and, if needed, Ca and vitamin D supplements may help prevent PMS. Fluid retention may be relieved by reducing Na intake and taking a diuretic (eg, hydrochlorothiazideSome Trade Names
ESIDRIX
HYDRODIURIL
Click for Drug Monograph
25 to 50 mg po once/day in the morning) just before symptoms are expected. However, minimizing fluid retention does not relieve all symptoms and may have no effect.

SSRIs (eg, fluoxetineSome Trade Names
PROZAC
SARAFEM
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20 mg po once/day) may be used to reduce anxiety, irritability, and other emotional symptoms, particularly if stress cannot be avoided. SSRIs are effective in relieving symptoms of PMDD.

For some women, hormonal manipulation is effective. Options include

• Oral contraceptives (eg, norethindroneSome Trade Names
  AYGESTIN
  CAMILA
  JOLIVETTE
  ORTHO MICRONOR
  Click for Drug Monograph
  5 mg once/day)
• Progesterone by vaginal suppository (200 to 400 mg once/day)
• An oral progestin (eg, micronized progesterone 100 mg at bedtime) for 10 to 12 days before menses
• A long-acting progestin (eg, medroxyprogesteroneSome Trade Names
  PROVERA
  Click for Drug Monograph
  200 mg IM q 2 to 3 mo)

Rarely, for very severe or refractory symptoms, a gonadotropin-releasing hormone agonist (eg, leuprolideSome Trade Names
LUPRON
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3.75 mg IM, goserelinSome Trade Names
ZOLADEX
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3.6 mg sc q mo) with low-dose estrogen/progestin (eg, estradiolSome Trade Names
ESTRADERM
ESTROGEL
VIVELLE
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0.5 mg once/day plus micronized progesterone 100 mg at bedtime) is given to minimize cyclic fluctuations.

SpironolactoneSome Trade Names
ALDACTONE
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, bromocriptineSome Trade Names
PARLODEL
Click for Drug Monograph
, and monoamine oxidase inhibitors are not useful.

Last full review/revision January 2010 by JoAnn V. Pinkerton, MD

Content last modified January 2010