gynecology and obstetrics
Premenstrual Syndrome (PMS)
Treatment of PMS
Sleep hygiene, exercise, and healthy diet Sometimes selective serotonin reuptake inhibitors (SSRIs) or hormonal medications PMS can be difficult to treat. No single treatment has proven efficacy for all women, and few woman have complete relief with any single type of treatment. Treatment can thus require trial and error, as well as patience. Treatment of PMS is symptomatic, beginning with adequate rest and sleep, regular exercise, and activities that are relaxing. Regular exercise may help alleviate bloating as well as irritability, anxiety, and insomnia. Yoga helps some women. Dietary changes—increasing protein, decreasing sugar, consuming complex carbohydrates, and eating smaller meals more frequently—may help, as may counseling, avoiding stressful activities, relaxation training, light therapy, sleep adjustments, and cognitive-behavioral therapy. Other possible strategies include avoiding certain foods and drinks (eg, cola, coffee, hot dogs, potato chips, canned goods) and eating more of others (eg, fruits, vegetables, milk, high-fiber foods, low-fat meats, foods high in calcium andvitamin D). Calcium supplements (600 mg twice a day) may lessen negative mood and somatic symptoms. Some dietary supplements are mildly efficacious for reducing symptoms; they include chasteberry extract from the agnus castus fruit (which appears to lessen physical symptoms), vitamin B6 (no more than 100 mg a day), andvitamin E. Cognitive-behavioral therapy may help if mood issues are a major concern, including in women with PMDD. Biofeedback and guided imagery may also help. Psychotherapy can help a woman learn to better cope with the symptoms; stress reduction and Relaxation Techniques and Nonsteroidal anti-inflammatory drugs (NSAIDs) can help relieve aches, pains, and Dysmenorrhea . Selective serotonin release inhibitors (SSRIs) have been shown in randomized trials to improve mood and lessen physical symptoms such as breast tenderness and changes in appetite. SSRIs are the medications of choice for relief of anxiety, irritability, and other emotional symptoms, particularly if stress cannot be avoided. SSRIs (eg,fluoxetine20 mg orally once a day) effectively relieve symptoms of PMS and PMDD. Continuous dosing is more effective than intermittent dosing. No SSRI appears to be more effective than another. Clinical trials have shown SSRIs to be effective for treatment of PMDD; those approved for PMDD includefluoxetine,sertralineandparoxetine. Additional SSRIs shown effective in clinical trials includeparoxetine,citalopram, andescitalopram. These medications can be prescribed continuously or only during the 14-day luteal phase (second half) of the menstrual cycle or with a dose increase during the latter 14-day luteal phase. Clomipramine, given for the full cycle or a half-cycle, effectively relieves emotional symptoms, as doesnefazodoneandvenlafaxine, a serotonin-norepinephrinereuptake inhibitor (SNRI). Anxiolytics may help but are usually less desirable because dependence or addiction is possible.Buspirone, which may be given throughout the cycle or during the late luteal phase, helps relieve symptoms of PMS and PMDD. Adverse effects include nausea, headache, anxiety, and dizziness. For some women, hormonal manipulation is effective. Options include Oral contraceptives Progesteroneby vaginal suppository (200 to 400 mg once a day) An oral progestogen (eg, micronizedprogesterone100 mg at bedtime) for 10 to 12 days before menses A long-acting progestin (eg,medroxyprogesterone200 mg IM every 2 to 3 months) Women who choose to use an oral contraceptive for contraception can takedrospirenoneplus ethinylestradiol. However, risk of venous thromboembolism may be increased. Rarely, for very severe or refractory symptoms, a gonadotropin-releasing hormone (GnRH) agonist (eg,leuprolide3.75 mg IM,goserelin3.6 mg subcutaneously every month) with low-dose estrogen/progestin (eg, oralestradiol0.5 mg once a day plus micronizedprogesterone100 mg at bedtime) is given to minimize cyclic fluctuations. Fluid retention may be relieved by reducing sodium intake and taking a diuretic (eg,spironolactone100 mg orally once a day) just before symptoms are expected. However, minimizing fluid retention and taking a diuretic do not relieve all symptoms and may have no effect. Bromocriptineand monoamine oxidase inhibitors are not useful.Danazolhas significant adverse effects. In women with severe symptoms, bilateral oophorectomy may alleviate symptoms because it eliminates menstrual cycles; hormone replacement therapy is then indicated until about age 51 (the average for menopause). 