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Premenstrual syndrome

Definition
PMS is a collection of physical and emotional symptoms occurring in the luteal phase of the menstrual cycle and disappearing within a few days of menstruation. PMDD is a more severe form of PMS characterized by intense mood symptoms.
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Pathophysiology
The pathophysiology of PMS and PMDD is not fully understood, but hormonal changes that occur with the natural menstrual cycle, specifically the progesterone produced following ovulation, and serotonin deficits have been implicated. An aberrant response to these hormonal fluctuations is thought to underlie the symptoms of these conditions.
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Epidemiology
The prevalence of PMS and premenopausal dysphoric disorder in women of reproductive age is estimated at 12.2% and 5.8%, respectively.
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Disease course
The clinical course of PMS and PMDD is characterized by a cyclical pattern of symptoms that recur in the luteal phase of the menstrual cycle. Symptoms include mood swings, irritability, depression, anxiety, bloating, breast tenderness, and fatigue. Symptoms of PMDD can be debilitating and significantly impair daily life activities.
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Prognosis and risk of recurrence
PMS and PMDD are chronic conditions, but their symptoms can be managed with appropriate treatment.
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Key sources
The following summarized guidelines for the evaluation and management of premenstrual syndrome are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2016) and the Royal College of Obstetricians and Gynaecologists (RCOG 2016).
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Guidelines

1.Diagnostic investigations

History and physical examination: as per AAFP 2016 guidelines, use the Daily Record of Severity of Problems to help diagnose PMS and PMDD.
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  • GnRH analog trial

2.Medical management

General principles: consider managing patients with severe PMS by a multidisciplinary team comprising a general practitioner, a general gynecologist or a gynecologist with a special interest in PMS, a mental health professional (psychiatrist, clinical psychologist, or counselor), and a dietitian.
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  • SSRIs

  • Combined oral contraceptives

  • Estrogen patches and implants

  • Progesterone and progestins

  • GnRH analogs

  • Danazol

  • Spironolactone

3.Nonpharmacologic interventions

Cognitive behavioral therapy: as per AAFP 2016 guidelines, consider offering CBT to improve symptoms of PMS and PMDD.
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  • Alternative and complementary therapies

4.Therapeutic procedures

Endometrial ablation: do not offer endometrial ablation in patients with severe PMS.
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5.Surgical interventions

Hysterectomy and bilateral oophorectomy: consider offering hysterectomy and bilateral oophorectomy in patients with PMS when medical treatment has failed, long-term GnRH analog therapy is required, or other gynecological conditions indicate surgery.
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6.Specific circumstances

Pregnant patients: provide pregnancy counseling at every opportunity and inform that PMS symptoms will abate during pregnancy. Discontinue SSRIs before and during pregnancy.
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