premenstrual syndrome (PMS); premenstrual dysphoric disorder (PMDD)
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Introduction
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
Clinical manifestations
- bloating
- headache
- bowel changes
- breast pain & tenderness (mastodynia)
- backache
- anxiety
- irritability
- mood swings
- 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
Management
- symptom-oriented
- pre-treatment daily diary of symptoms & menses for at least 2 months
- avoidance of caffeine
- spironolactone 100 mg/day for bloating (take for 2 weeks before menses
- NSAIDs for severe cramps
- NSAIDs (topical diclofenac) first line[1], bromocryptine or danazol for mastodynia
- oral contraceptives to suppress ovulation
- may increase risk of stroke in patients with migraine[1]
- danazol to induce endometrial atrophy & attenuate migraine
- gonadotropin-releasing hormone agonists
- severe cases
- complete suppression of gonadal function
- gonadorelin
- leuprolide
- estrogen replacement to avoid bone loss if > 6 months of therapy
- mood disorders (premenstrual dysphoric disorder)
- benzodiazepines for anxiety disorder
- selective serotonin re-uptake inhibitors (SSRI) 1st line[1]
- fluoxetine (Prozac)[4]
- sertraline (Zoloft)[1][4]
- SSRIs improve overall premenstrual symptoms but increase adverse effects most commonly nausea, asthenia & somnolence[11]
- calcium 1200 mg/day may help with pain, cramping & mood changes; may take a few months for benefit[7]
- magnesium 200-400 mg/day may help with headache, fluid retention & mood changes
- vitamin E 400 IU/day
- vitamin B6 100 mg QD[7]
- complex carbohydrates improve mood & reduce food cravings
- aerobic exercise can help with fluid retention
- 'natural' or pharmaceutical progesterone of NO benefit
* 20 mg of fluoxetine improves both physical & mood symptoms[5]
More general terms
References
- ↑ Jump up to: 1.0 1.1 1.2 1.3 1.4 1.5 Medical Knowledge Self Assessment Program (MKSAP) 11, 19. American College of Physicians, Philadelphia 1998, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025 - ↑ Prescriber's Letter 7(8):46 2000
- ↑ Journal Watch 21(22):179, 2001 Wyatt et al BMJ 323:776, 2001
- ↑ Jump up to: 4.0 4.1 4.2 Prescriber's Letter 9(6):35 2002
- ↑ Jump up to: 5.0 5.1 5.2 Journal Watch 22(20):147-48, 2002 Cohen LS, Obstet Gynecol 100:435, 2002
- ↑ Jump up to: 6.0 6.1 6.2 Journal Watch 24(7):60, 2004 Freeman EW et al, Am J Psychiatry 161:343, 2004 PMID: https://www.ncbi.nlm.nih.gov/pubmed/14754784
- ↑ Jump up to: 7.0 7.1 7.2 Prescriber's Letter 12(8): 2005 Calcium and Other Supplements for PMS Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=210813&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ Jump up to: 8.0 8.1 Chocano-Bedoya PO et al. Dietary B vitamin intake and incident premenstrual syndrome. Am J Clin Nutr 2011 May; 93:1080 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21346091
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/23744611
- ↑ Lanza di Scalea T, Pearlstein T. Premenstrual dysphoric disorder. Med Clin North Am. 2019;103:613-628. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31078196
- ↑ Jump up to: 11.0 11.1 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: https://www.ncbi.nlm.nih.gov/pubmed/39140320 PMCID: PMC11323276 (available on 2025-08-14)