Premenstrual Syndrome

What is Premenstrual Syndrome (PMS)?

Premenstrual syndrome is a psychiatric condition characterized by physical and behavioral symptoms in the second half of the menstrual cycle.  These symptoms often include irritability, mood swings, anxiety, depression, increased appetite, and loss of interest.  Individuals may also experience fatigue, abdominal discomfort, breast tenderness, and headache.  Symptoms can be debilitating and interfere with social and occupation function.  Premenstrual dysphoric disorder is similar to premenstrual syndrome but more severe and often accompanied by symptoms of anger.

These disorders are likely related to an altered response of the neurotransmitter serotonin to sex hormone changes.  Genetic and environmental factors are likely responsible for the pathogenesis of the disease.

What Causes Premenstrual Syndrome (PMS)?

Premenstrual syndrome is caused by genetic and environmental factors.  There is an association between premenstrual syndrome and variation in the gene ESR1 (estrogen receptor alpha).  Studies show that the disease may related to abnormal responses of the neurotransmitter serotonin to sex hormones.  Limited evidence suggests that high vitamin B6 supplementation can prevent the condition.

Risk factors associated with the disease include:

• Low educational achievement
• Tobacco use
• History of trauma
• History of anxiety disorder

How Common is Premenstrual Syndrome (PMS)?

Premenstrual syndrome is exceedingly common in the United States and often initially evaluated in the primary care clinic.  The condition may require referral to an obstetrics/gynecology or psychiatry specialist if first-line and conservative measures are unsuccessful.

Premenstrual symptoms occur in up to an estimated 75% of women.  About 3%-8% of women experience clinically significant symptoms.  Approximately 2% of women suffer from premenstrual dysphoric disorder.

Signs and Symptoms

Symptoms of premenstrual syndrome often include:

• Mood swings
• Irritability
• Anxiety
• Depression
• Increased appetite
• Sensitivity to rejection
• Loss of interest in activities (anhedonia)

Patients may also experience fatigue, abdominal discomfort, breast tenderness, headache, and hot flashes.  Symptoms occur during the second half of the menstrual cycle and improve with menses or just after menses.

Diagnosis

Premenstrual syndrome and premenstrual dysphoric disorder are diagnosed based on criteria set by the American Psychiatric Association Diagnostic and Statistical Manual, Fifth Edition.

The key features of premenstrual syndrome include the recurrence of physical and behavioral symptoms in the second half of the menstrual cycle.  These symptoms must interrupt with certain aspects of the individual’s life, resulting in psychosocial and functional impairment.  Premenstrual dysphoric disorder requires the presence of an affective symptom.  This may include mood swings, irritability, or depression.

These symptoms should not be better explained by another underlying medical or psychiatric diagnosis.  They also cannot be due to an adverse effect of a medication.  Patients are typically encouraged to record their symptoms regularly.  Tools such as the Daily Record of Severity of Problems form can be helpful.

Commonly ordered blood tests include a CMP (comprehensive metabolic panel), CBC (complete blood cell count), and thyroid function studies (TSH, free T4).  These tests are obtained rule out common metabolic disorders that can have overlapping symptoms with premenstrual syndrome.

Premenstrual Syndrome Treatment

Mild premenstrual symptoms is usually managed conservatively with lifestyle changes such as exercise and techniques to reduce stress.  Individuals that suffer from severe psychosocial impairment can benefit from medical therapy.  The first-line medical treatment for premenstrual syndrome are selective serotonin reuptake inhibitors (SSRIs).  This frequently includes one of the following agents:

• Prozac (Fluoxetine)
• Zoloft (Sertraline)
• Celexa (Citalopram)
• Lexapro (Escitalopram)

SSRIs can be prescribed continuously or in the luteal phase of the menstrual cycle only.  Individuals receiving luteal phase treatment can discontinue their SSRI once menses begins.  There is also some evidence to suggest that using therapy at the onset of symptoms and stopping in the first several days of menses is also an effective dosing regimen.

Oral contraceptives are preferred over SSRIs in some women.  Occasionally, an SSRI and oral contraceptive are used concomitantly.

Oral contraceptives containing drospirenone are usually first-line agents, such as 3 mg drospirenone/20 mcg ethinyl estradiol.  Occasionally gonadotropin-releasing hormone (GnRH) agonist therapy (eg, Lupron (Leuprolide)) with estrogen-progestin addback is used.  Oophorectomy (surgical removal of the ovaries) is typically a last resort measure if medical therapy fails.