Description

Premenstrual syndrome is a constellation of symptoms that occurs prior to menstruation and is severe enough to interfere significantly with the patient’s life. DSM-IV-R diagnosis is premenstrual dysmorphic disorder when the dominant symptoms are emotional.

System(s) affected: Endocrine/Metabolic, Reproductive, Nervous

Genetics: Unknown, probably familial incidence

Incidence/Prevalence in USA: Almost all women have some symptoms prior to menses (this is not PMS). About 5% have actual PMS.

Predominant age: Childbearing years, increasing with years

Predominant sex: Females only

Sings and symptoms

Symptoms can involve any organ system but the following are more common:

• Depressed mood
• Mood swings
• Irritability
• Difficulty concentrating
• Fatigue
• Edema
• Breast tenderness
• Headaches
• Sleep disturbances

Causes:

Unknown, presumed hormonal; perhaps interacting with neurotransmitters

Risk Factors

• Premenstrual exacerbations can occur with other diseases (i.e., depression)
• Caffeine and high fluid intake exacerbate PMS symptoms
• Stress may precipitate
• PMS increases with age
• History of depression
• Tobacco use

Diagnosis

Diagnosis

The major differentials are psychiatric syndromes, particularly depressive disorders and/or dysthymia. Other entities may be suggested by history or physical.

Laboratory
There are no laboratory tests which confirm or refute PMS. History and physical may disclose a need for specific laboratory tests.

Drugs that may alter lab results: N/A

Disorders that may alter lab results: N/A

Diagnostic Procedures
Patients complete questionnaires over a minimum of two months to confirm premenstrual exacerbation of symptoms and lack of substantial symptoms in the follicular phase

Treatment

APPROPRIATE HEALTH CARE
Outpatient

General Measure

• Increase daily exercise
• Eat regular, balanced meals
• Stop smoking
• Get regular sleep
• Stress reduction techniques
• Cognitive behavioral therapy (may provide better long-term effect than SSRIs)
• Support groups
• Light therapy

Activity

• No restrictions
• Exercise is recommended

Diet
Low-salt; low-caffeine; low-fat; frequent, small meals; high complex carbohydrates

Patient Education
Explain PMS and treatment

Medications

Drugs of choice
No single drug works for all women. Drugs that are used with varying degrees of success are listed.

• Antidepressants [fluoxetine (Prozac, Sarafem), sertraline, clomipramine, citalopram or nortriptyline], particularly for patients with depressive symptoms. Antidepressants can work when used only during the luteal phase of the menstrual cycle.
• Elemental calcium 1000 mg/day
• Diuretics (usually spironolactone) during luteal phase
• Symptomatic treatment of pain (ibuprofen or acetaminophen)
• Vitamin B6 in modest doses (50 mg bid, may be toxic in higher doses)
• Vitamin E: up to 600 IU/day
• Evening primrose oil, high content of fatty acids, 500 mg qd to 1000 mg tid for breast tenderness, believed to decrease prostaglandin synthesis
• Oral contraceptives may help
• Bromocriptine 2.5 mg tid at time of symptoms and danazol 100 mg bid may also work for breast tenderness, but have more side effects
• Danazol for the total PMS symptom complex
• Gonadotropin-releasing hormone agonists with or without concurrent estrogens/progestins
• L-tryptophan 2 g three times a day

Contraindications: Refer to manufacturer’s profile of each drug

Precautions: Refer to manufacturer’s profile of each drug

Significant possible interactions: Refer to manufacturer’s profile of each drug

Patient Monitoring
See patient to provide general support and further patient education

Expected Cource/Prognosis
Many patients can have their symptoms adequately controlled. Disappears at menopause.

Synonyms

• Premenstrual dysphoric disorder
• PMDD

ICD-9-CM
625.4 Premenstrual tension syndromes