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 one-third of all premenopausal women, primarily those 25-40 years of age. In about 10% 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. Suppression of ovarian function with a GnRH agonist has been shown to diminish all symptoms during therapy. “Add-back therapy” to provide the hormones suppressed by the GnRH agonist with low-dose estrogen and progestin may allow extended use of a GnRH agonist. Suppression of ovulation with an oral contraceptive is sometimes helpful, but the patient often complains that she still has premenstrual syndrome.

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

Careful evaluation of the patient, with understanding, explanation, and reassurance, is of first importance.
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.
A program of regular conditioning exercise, such as jogging, has been found to decrease depression, anxiety, and fluid retention premenstrually in several studies.
Serotonin reuptake inhibitors such as fluoxetine, 20 mg/d, are effective in relieving tension, irritability, and dysphoria with few side effects.
Luteal phase administration of danazol, 200 mg/d on cycle days 14-28, is effective in reducing symptoms of mastalgia. Other symptoms are not affected by this low-dose therapy.
Spironolactone, 100 mg daily during the luteal phase, is effective for reduction of bloating and breast tenderness.
NSAIDs - eg, mefenamic acid, 500 mg three times a day - have been shown to reduce a number of symptoms, though not breast pain.

Preferences:
Bhatia SC et al: Diagnosis and treatment of premenstrual dysphoric disorder. Am Fam Physician 2002;66:1239.

Kessel B: Premenstrual syndrome: advances in diagnosis and treatment. Obstet Gynecol Clin North Am 2000;27:625.

Wyatt K: Premenstrual syndrome. Clin Evid 2002;7:1739.