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premenstrual syndrome (PMS); premenstrual dysphoric disorder (PMDD)

Variable constellation of physical & emotional symptoms that are most severe during the week prior to the menstrual period & occasionally 1-2 days after. Epidemiology: - high dietary intake of thiamine & riboflavin reduces incidence of new-onset PMS [8] Pathology: - involvement of GABA &/or serotonin Clinical manifestations: 1) bloating 2) headache 3) bowel changes 4) breast pain & tenderness (mastodynia) 5) backache 6) anxiety 7) irritability 8) mood swings 9) depression Diagnostic criteria: - at least 1 primary symptom - mood swings - irritability or anger - feelings of hopelessness or depressed mood - anxiety - at least 5 symptoms in total, including - appetite changes - decreased interest in usual activities - fatigue - difficulty concentrating - feelings of loss of control - sleep disturbance - physical symptoms presumptively collectively counts as 1 symptom - breast tenderness, weight gain, bloating, myalgia). Management: 1) symptom-oriented 2) pre-treatment daily diary of symptoms & menses for at least 2 months 3) avoidance of caffeine 4) spironolactone 100 mg/day for bloating (take for 2 weeks before menses 5) NSAIDs for severe cramps 6) bromocryptine for mastodynia 7) oral contraceptives to suppress ovulation - may increase risk of stroke in patients with migraine [1] 8) danazol to induce endometrial atrophy & attenuate migraine 9) gonadotropin-releasing hormone agonists a) severe cases b) complete suppression of gonadal function c) gonadorelin d) leuprolide e) estrogen replacement to avoid bone loss if > 6 months of therapy 10) mood disorders (premenstrual dysphoric disorder) a) benzodiazepines for anxiety disorder - alprazolam (Xanax) b) selective serotonin re-uptake inhibitors (SSRI) 1st line [1] 1] fluoxetine (Prozac) [4] a] 10-20* mg PO QD starting 14 days prior to expected menses, continuing through 1st full days of bleeding [5], or b] Prozac weekly 7 & 14 days prior to menses 2] sertraline (Zoloft) [1,4] a] 50-150 mg QD b] intermittent dosing 7 & 14 days prior to menses c] start 50 mg; increase to 100 mg after 3 doses d] intermittent dosing starting 14 days prior to menses & continuing until day 2 of next cycle [6] e] large placebo effect [6] (still 1st line [1]) 3] SSRIs improve overall premenstrual symptoms but increase adverse effects most commonly nausea, asthenia & somnolence [11] 11) calcium 1200 mg/day may help with pain, cramping & mood changes; may take a few months for benefit [7] 12) magnesium 200-400 mg/day may help with headache, fluid retention & mood changes 13) vitamin E 400 IU/day 14) vitamin B6 100 mg QD [7] 14) complex carbohydrates improve mood & reduce food cravings 15) aerobic exercise can help with fluid retention 16) 'natural' or pharmaceutical progesterone of NO benefit * 20 mg of fluoxetine improves both physical & mood symptoms [5]

General

gynecologic disease syndrome mood disorder

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 19. American College of Physicians, Philadelphia 1998, 2021.
  2. Prescriber's Letter 7(8):46 2000
  3. Journal Watch 21(22):179, 2001 Wyatt et al BMJ 323:776, 2001
  4. Prescriber's Letter 9(6):35 2002
  5. Journal Watch 22(20):147-48, 2002 Cohen LS, Obstet Gynecol 100:435, 2002
  6. Journal Watch 24(7):60, 2004 Freeman EW et al, Am J Psychiatry 161:343, 2004 PMID: 14754784
  7. Prescriber's Letter 12(8): 2005 Calcium and Other Supplements for PMS Detail-Document#: 210813 (subscription needed) http://www.prescribersletter.com
  8. Chocano-Bedoya PO et al. Dietary B vitamin intake and incident premenstrual syndrome. Am J Clin Nutr 2011 May; 93:1080 PMID: 21346091
  9. Marjoribanks J, Brown J, O'Brien PM, Wyatt K. Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database Syst Rev. 2013 Jun 7;6:CD001396. Review. PMID: 23744611
  10. Lanza di Scalea T, Pearlstein T. Premenstrual dysphoric disorder. Med Clin North Am. 2019;103:613-628. PMID: 31078196
  11. Jespersen C, Lauritsen MP, Frokjaer VG, et al. Selective serotonin reuptake inhibitors for premenstrual syndrome and premenstrual dysphoric disorder. Cochrane Database Syst Rev. 2024 Aug 14;8(8):CD001396. PMID: 39140320 PMCID: PMC11323276 (available on 2025-08-14)