The premenstrual syndrome is a recurrent, variable cluster of troublesome physical and emotional symptoms that develop during the 7-14 days before the onset of menses and subside when menstruation occurs. The syndrome intermittently affects about 40% of all premenopausal women, primarily those 25-40 years of age. In about 10-15% of affected women, the syndrome may be severe. Although not every woman experiences all the symptoms or signs at one time, many describe bloating, breast pain, ankle swelling, a sense of increased weight, skin disorders, irritability, aggressiveness, depression, inability to concentrate, libido change, lethargy, and food cravings. The pathogenesis of premenstrual syndrome is still uncertain. Psychosocial factors may play a role.

Current treatment methods are mainly empiric. The clinician should provide the best support possible for the patient’s emotional and physical distress. This includes the following:

1. Careful evaluation of the patient, with understanding, explanation, and reassurance, is of first importance.

2. Advise the patient to keep a daily diary of all symptoms for 2-3 months, to help in evaluating the timing and characteristics of the syndrome. If her symptoms occur throughout the month rather than in the 2 weeks before menses, she may be depressed or may have other emotional problems in addition to premenstrual syndrome.

3. For mild to moderate symptoms, a program of aerobic exercise; reduction of caffeine, salt, and alcohol intake; and an increase in complex carbohydrates in the diet may be helpful.

4. When physical symptoms predominate, spironolactone, 100 mg daily during the luteal phase, is effective for reduction of bloating and breast tenderness. Oral contraceptives or injectable progestin medroxyprogesterone acetate (DMPA) will decrease breast pain and cramping. NSAIDs, such as 500 mg of mefenamic acid three times a day, will reduce a number of symptoms but not breast pain.

5. When mood disorders predominate, serotonin reuptake inhibitors such as 20 mg/d of fluoxetine, either daily or only on symptom days, are effective in relieving tension, irritability, and dysphoria with few side effects.

6. When the above regimens are not effective, ovarian function can be suppressed with continuous high-dose progestin (20-30 mg/d of oral medroxyprogesterone acetate [MPA] or 150 mg of DMPA every 3 months or GnRH agonist with add-back therapy if continued for more than 6 months).

Johnson SR: Premenstrual syndrome, premenstrual dysphoric disorder, and beyond: a clinical primer for practitioners. Obstet Gynecol 2004;104:845. [PMID: 15458909]