Treatment of premenstrual syndrome and premenstrual dysphoric disorder
- Robert F Casper, MD
Robert F Casper, MD
- Professor, Division of Reproductive Sciences
- University of Toronto, Canada
- Senior Investigator
- Lunenfeld-Tanenbaum Research Institute
- Kimberly A Yonkers, MD
Kimberly A Yonkers, MD
- Professor of Psychiatry and Obstetrics and Gynecology
- Yale University
- Section Editors
- Robert L Barbieri, MD
Robert L Barbieri, MD
- Editor-in-Chief — Obstetrics, Gynecology and Women's Health
- Section Editor — General Gynecology and Female Reproductive Endocrinology
- Kate Macy Ladd Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
- William F Crowley, Jr, MD
William F Crowley, Jr, MD
- Section Editor — Female Reproductive Endocrinology
- Daniel K Podolsky Professor of Medicine
- Harvard Medical School
The premenstrual syndrome (PMS) is characterized by the presence of both physical and behavioral symptoms that occur repetitively in the second half of the menstrual cycle and interfere with some aspects of the woman's life. The American Psychiatric Association defines premenstrual dysphoric disorder (PMDD) as a severe form of PMS in which symptoms of anger, irritability, and internal tension are prominent.
The management of PMS and PMDD will be reviewed here. The epidemiology, pathogenesis, clinical manifestations, and diagnosis/differential diagnosis of PMS and PMDD are discussed separately. (See "Clinical manifestations and diagnosis of premenstrual syndrome and premenstrual dysphoric disorder" and "Epidemiology and pathogenesis of premenstrual syndrome and premenstrual dysphoric disorder".)
The core symptoms of premenstrual syndrome (PMS) include affective symptoms such as depression, irritability, and anxiety, and somatic symptoms such as breast pain, bloating and swelling, and headache. The symptom(s) must impair functioning in some way and the symptom must remit at menses or shortly thereafter. Premenstrual dysphoric disorder (PMDD) is a more severe form. The diagnostic criteria for PMS and PMDD are reviewed separately. (See "Clinical manifestations and diagnosis of premenstrual syndrome and premenstrual dysphoric disorder".)
The treatment goals for patients with premenstrual disorders are to relieve symptoms and improve functional impairment. A number of lifestyle measures (exercise and relaxation techniques) and medications (selective serotonin reuptake inhibitors [SSRIs]) are effective for women with either PMS or PMDD (table 1). These therapies have largely supplanted earlier approaches that had little or no scientific evidence to support their efficacy.
A clear diagnosis of PMS or PMDD should be established before treatment is considered. In particular, women must be symptom-free during the follicular phase. This can be best discerned by having a patient chart her mood and physical symptoms daily over the course of at least one, but ideally two menstrual cycles. (figure 1 and table 2). (See "Clinical manifestations and diagnosis of premenstrual syndrome and premenstrual dysphoric disorder".)
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- GENERAL PRINCIPLES
- MILD SYMPTOMS
- Exercise and relaxation techniques
- Ineffective therapies
- MODERATE TO SEVERE SYMPTOMS
- Selective serotonin reuptake inhibitors
- - Dosing
- - Regimens
- Luteal phase therapy
- Symptom-onset therapy
- Choosing a regimen
- - Adverse effects
- Response to therapy
- - Symptomatic improvement
- Duration of therapy
- - No improvement
- Second-line therapies
- - Oral contraceptives
- - GnRH agonists
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS