(Published June 2008)

• Using This Guide
• Definitions
• Signs and Symptoms
• Diagnostic Approach
• Treatment
• Patient Counseling
• Appendix A: Patient Resources
• Appendix B: Patient Screening Test for Premenstrual Dysphoric Disorder
• Publication Information

Using This Guide

It is estimated that 75–85% of menstruating women experience some uncomfortable symptoms during the premenstrual phase of their cycles.¹ Many women experience premenstrual symptoms that do not require specific treatment. In contrast, the symptoms of premenstrual disorders interfere with normal functioning and have a significant negative effect on a woman’s quality of life.

Despite increasing attention and awareness of premenstrual disorders, they are notoriously underrecognized. Many women delay seeking treatment and thus go undiagnosed for years. Yet the degree and prevalence of disability of premenstrual disorders equal that associated with many widely recognized conditions.² Overall, women with premenstrual disorders represent a largely uncared-for group for whom the evidence for conventional therapy is sparse and controversial.³ Treatment options vary and produce overall response rates of less than 60%.²

The key to effective management of premenstrual disorders is time, patience, and knowledge of various treatments that have proven to be effective. This Quick Reference Guide for Clinicians^® has been designed to help health care providers to recognize premenstrual disorders and apply evidence-based management strategies. Also provided are clinical management alternatives and patient education information and resources.

The practical steps outlined here will equip clinicians with the tools necessary to accurately and appropriately diagnose, treat, and counsel women dealing with premenstrual disorders. The information provided in this guide will help providers to reduce patients’ uncertainty regarding treatment options and to be more effective in offering positive treatment strategies for women presenting with these symptoms.

References

1. Mishell DR Jr. Premenstrual disorders: epidemiology and disease burden. Am J Manag Care. 2005;11(16 Suppl):S473–479.
2. Halbreich U, Borenstein J, Pearlstein T, Kahn LS. The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). Psychoneuroendocrinology. 2003;28(Suppl 3):1–23.
3. Domoney CL, Vashisht A, Studd JW. Premenstrual syndrome and the use of alternative therapies. Ann N Y Acad Sci. 2003;997:330–340.

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Definitions

Despite the familiarity of premenstrual symptoms to many women, there is no clear consensus on the definition of premenstrual disorders. Rather, these conditions make up a continuum of disorders that are defined according to the nature and severity of their symptoms.¹

• Premenstrual molimina are the symptoms, sensations, feelings, and observations, such as bloating, headaches, nausea, ovulatory pain, and breast tenderness, that many women experience during the premenstrual phase of their cycles. These symptoms are minor, do not cause functional impairment, and are minimally distressing. They predict impending ovulation and subsequent menstruation. If they occur within 3 days of the onset of menses and do not represent a patient’s chief presenting complaint, they are considered to be a normal part of a woman’s menstrual cycle.
  
• Premenstrual syndrome (PMS) is a term coined in 1931 to describe a constellation of physical and emotional symptoms unique to women during their childbearing years.² Premenstrual symptoms in general are often described or referred to as PMS.³ Accepted definitions of the disorder require that symptoms must occur only during the luteal phase to be considered PMS.
• Premenstrual dysphoric disorder (PMDD) is defined by diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM).⁴ Both PMS and PMDD produce symptoms that are associated with the ovarian cycle of a woman of reproductive age. These disorders represent abnormal responses to normal endocrine changes associated with ovulation. The symptoms of these disorders may continue to occur during a woman’s menstrual cycle until she reaches menopause. (See “Signs and Symptoms” below for the DSM criteria required for a diagnosis of PMDD.)

In contrast to psychiatrists and other mental health professionals, most obstetrician/gynecologists (ob/gyns) and other women’s health care providers do not distinguish between PMS and PMDD. The approaches to diagnosis and management of these disorders are therefore addressed together in this guide.

References

1. Yonkers KA, Pearlstein T, Rosenheck RA. Premenstrual disorders: bridging research and clinical reality. Arch Womens Ment Health. 2003;6(4):287–92.
2. Moline ML, Zendell SM. Evaluating and managing premenstrual syndrome. Medscape Womens Health 2000;5(2):1. Available at www.medscape.com/viewarticle/408913. Accessed March 25, 2008.
3. Steiner M. Premenstrual syndrome and premenstrual dysphoric disorder: guidelines for management. J Psychiatry Neurosci. 2000;25(5):459–68.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision. Washington, DC: American Psychiatric Association, 2000.
5. Mishell DR Jr. Premenstrual disorders: epidemiology and disease burden. Am J Manag Care. 2005;11(16 Suppl):S473–9.
6. Halbreich U, Borenstein J, Pearlstein T, Kahn LS. The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). Psychoneuroendocrinology. 2003;28(Suppl 3):1–23.
7. U.S. Department of Health and Human Services, National Women’s Health Information Center. womenshealth.gov. Premenstrual Syndrome. Available at www.4woman.gov/faq/pms.htm. Accessed April 7, 2008.
8. Rapkin AJ, Tsao JCI, Turk N, Anderson M, Zeltzer LK. Relationships among self-rated Tanner staging, hormones, and psychosocial factors in health female adolescents. J Pediatr Adolesc Gynecol. 2006;19:181–7.
9. Steiner M. Premenstrual syndrome and premenstrual dysphoric disorder: guidelines for management. J Psychiatry Neurosci. 2000;25(5):459–68.
10. American College of Obstetricians and Gynecologists. Premenstrual Syndrome. ACOG Practice Bulletin No. 15. Washington, DC: American College of Obstetricians and Gynecologists, 2000.
11. Bhatia SC, Bhatia SK. Diagnosis and treatment of premenstrual dysphoric disorder. Am Fam Physician. 2002;66(7):1239–48.
12. Ginsberg KA, Dinsay R. In: Ransom SB, ed. Practical Strategies in Obstetrics and Gynecology. Philadelphia: W.B. Saunders; 2000:684–9.
13. U.S. Census Bureau. Annual estimates of the population by sex and five-year age groups for the United States: April 1, 2000 to July 1, 2004. U.S. Census Bureau, Population Division.
14. Maxson WS, Rosenwaks Z. In: Copeland LJ, Jarrell JF, eds. Textbook of Gynecology, 2nd ed. Philadelphia: W.B. Saunders; 2000:513–4.
15. Speroff L, Glass RH, Kase NG, eds. Menstrual Disorders in Gynecologic Endocrinology and Infertility, 6th Ed. Philadelphia, PA: Lippincott Williams & Wilkins, 1999:557–74.

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Signs and Symptoms

Symptoms of both PMS and PMDD occur during the luteal phase of the menstrual cycle (days 14–28 in a 28-day cycle) and notably subside within 2–3 days after menses begins. Some women experience positive symptoms, such as a sense of well-being, in the luteal phase of their cycles. More often, negative symptoms undermine a woman’s ability to function across multiple settings, including work, school, and home.¹

Premenstrual Syndrome

Although more than 200 symptoms have been associated with PMS, common symptoms include the following:²

The American College of Obstetricians and Gynecologists (ACOG) has developed the following diagnostic criteria for the diagnosis of PMS:³

Premenstrual Dysphoric Disorder

Reproductive health professionals generally view PMDD as a particularly severe form of PMS with pronounced psychological and emotional symptoms.⁴ Unlike mental health professionals, most obstetrician/gynecologists (ob/gyns) do not distinguish between PMS and PMDD. The DSM criteria for the diagnosis of PMDD is listed in the chart below.⁵

References

1. Malone DC. Managing the spectrum of premenstrual symptoms. Am J Manag Care. 2005:11(16):S471–2.
2. Dickerson LM, Mazyck PJ, Hunter MH. Premenstrual syndrome. Am Fam Physician. 2003;67(8):1743–52.
3. American College of Obstetricians and Gynecologists. Premenstrual Syndrome. ACOG Practice Bulletin No. 15. Washington, DC: American College of Obstetricians and Gynecologists, 2000.
4. Rapkin A. A review of treatment of premenstrual syndrome and premenstrual dysphoric disorder. Psychoneuroendocrinology. 2003;28(Suppl 3):39–53.
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision. Washington, DC: American Psychiatric Association, 2000.

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Diagnostic Approach

Changing and inconsistent diagnostic criteria for premenstrual disorders over the past few decades can make the diagnosis of PMS/PMDD a challenge. Patients should be counseled that it may take some time to complete the diagnostic process. They should be assured that various treatments can be tried until an effective and suitable approach is found.¹ Immediate measures should be recommended to the patient to ameliorate symptoms while a definitive diagnosis is being sought. These include lifestyle modifications such as stress reduction, exercise, dietary changes, supplements, and psychosocial support.^2,3

The Multiple-Visit Diagnostic Process

Diagnosis is best approached as a multiple-visit process.⁴ In general, the diagnosis of PMS is one of exclusion, and it is important to differentiate it from other conditions sharing similar characteristics. Almost two-thirds of women with PMS symptoms have a psychiatric disorder as well, thus complicating the evaluation of premenstrual symptoms.

To meet the criteria for PMS or PMDD, symptoms must:

• Occur in the luteal phase of the menstrual cycle and resolve within a few days of the start of menstruation
• Create problems or impairment for the patient
• Not be better explained by another diagnosis

Obtaining prospective charting information for a 2-month period represents the best way to diagnose both PMS and PMDD.⁴ A symptom chart such as that shown in Figure 1 is provided to the patient, who marks the occurrence and severity of symptoms on each day of at least two consecutive months. The clinician can then assess the pattern of symptoms in relation to the entire cycle. A clear pattern of symptoms that occur throughout the entire luteal phase and stop within 3 days of the onset of menses is diagnostic of PMS.

Visit 1

During the first visit, a history of menstrual symptoms and the presenting complaint should be elicited from the patient and a differential diagnosis developed (Table 1).

• A complete medical history should include menstrual history, history of gynecologic conditions (e.g., endometriosis, surgery), and obstetric history.
• Treatment or psychotherapy for mental health problems, particularly mood disorders (anxiety, depression), should also be recorded and a psychiatric or psychotherapeutic referral considered as warranted.
• Laboratory tests should be conducted to aid in the differential diagnosis:⁶
  • Chemistry profile to assess electrolyte disturbances
  • Complete blood cell count to rule out anemia
  • Thyroid-stimulating hormone level to rule out thyroid disorders

The affective symptoms of PMDD in particular may closely resemble those of premenstrual exacerbations of psychiatric disorders, especially depression and anxiety. If the patient reports no symptom-free period, it may be appropriate to refer her to a mental health professional.⁶

At the end of the first visit, the patient should be instructed in the use of a daily symptom rating chart (see “The Charting Interval” and ”Menstrual Symptoms Chart” ) and counseled about lifestyle changes, such as diet, exercise, and sleep habits that may ameliorate some symptoms until the next visit. A follow-up visit should be scheduled for 6–8 weeks.

The Charting Interval

In the interim between the first and second visits, the patient should keep a daily record of her symptoms and try the nonpharmacologic measures decided upon at the first visit.

Prospective charting of symptoms has been found to be an effective and accurate approach to the diagnosis of premenstrual disorders for a variety of reasons:

• DSM-IV criteria require prospective information for a diagnosis of PMDD. More than half of women who present with “severe premenstrual symptoms” are found not to have a luteal-phase pattern according to prospective charting.⁴
• Self-help strategies such as lifestyle changes can be initiated and evaluated during the charting period. Deferring pharmacologic treatment during this interval allows these measures to be objectively evaluated.
• Many women benefit from charting by gaining the ability to see their individual menstrual patterns and plan their activities around the most difficult phases of their cycles.

The Second Visit

At the second visit, the laboratory test results and the patient’s daily charting should be reviewed. A diagnosis of PMS or PMDD requires the symptoms to occur throughout the luteal phase of the menstrual cycle and to abate with the onset of menses.

Most ob/gyns do not distinguish between PMS and PMDD. Patients whose mental and emotional symptoms are not responsive to the treatment approaches described here should be referred for psychiatric evaluation.

References

1. Rapkin AJ. New treatment approaches for premenstrual disorders. Am J Manag Care. 2005;11(16 Suppl):S480–91.
2. American College of Obstetricians and Gynecologists. Premenstrual Syndrome. ACOG Practice Bulletin No. 15. Washington, DC: American College of Obstetricians and Gynecologists, 2000.
3. Dickerson LM, Mazyck PJ, Hunter MH. Premenstrual syndrome. Am Fam Physician. 2003;67(8):1743–52.
4. Johnson SR. Premenstrual syndrome, premenstrual dysphoric disorder, and beyond: a clinical primer for practitioners. Obstet Gynecol. 2004;104(4):845–59.
5. Guille C, Spencer S, Cavus I, Epperson CN. The role of sex steroids in catamenial epilepsy and premenstrual dysphoric disorder: implications for diagnosis and treatment. Epilepsy Behav. 2008; Mar 16.
6. Kaur G, Gonsalves L, Thaker HL. Premenstrual dysphoric disorder: a review for the treating practitioner. Cleve Clin Med. 2004;71(4):303–21 passim.

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Treatment

More than 80 different therapies have been suggested for the treatment of PMS/PMDD, resulting in much conflicting information and many unwarranted claims of effectiveness. No single intervention is effective for all women, and there is a substantial placebo response with many therapies.¹ It may take time and several attempts to determine the safest and most effective treatment for an individual patient.

Treatment of PMS/PMDD is best approached in a stepwise fashion, beginning with lifestyle modifications and progressing to nutritional supplementation, nonpharmacologic therapy, and nonprescription and prescription medications. Conservative treatment has proved beneficial in many women and should be considered first-line therapy in women with mild symptoms and adjunctive therapy in all others.

Table 2 shows a hierarchical approach to the treatment of PMS/PMDD that matches the aggressiveness of the approach to the severity of symptoms. Selection of therapy can also be matched to the nature of the symptoms. For instance, women with a PMS diagnosis presenting with bloating and breast tenderness as her key symptoms (Level 2) may be prescribed spironolactone, if there are no contraindications, to minimize this specific symptom.

Treatment must be individualized and often requires a combination of approaches. Long-term treatment of PMS/PMDD is typically required, as evidence indicates that symptoms return when treatment is discontinued.³

Lifestyle Changes

Treatment of mild premenstrual disorders begins with 2–3 months of lifestyle changes during the same time the woman is charting her symptoms. Based on medical history, the modifications listed in Table 3 can be suggested. 

Pharmacologic Treatment

Selective Serotonin Reuptake Inhibitors

Selective serotonin reuptake inhibitors (SSRIs) should be considered first-line therapy for the pharmacologic treatment of severe premenstrual symptoms.²² An estimated 60% of women respond to this class of drugs.¹⁵ SSRIs have been shown to be effective for both PMS and PMDD⁹ and to be equally efficacious for the treatment of physical, behavioral, and psychological symptoms.²³

Safety and Side Effects

The long-term safety of SSRIs has been demonstrated based on their widespread use in treating depression.¹ More recently, this class of drugs has had labeling changes to reflect the increased risk of suicidal thinking and behavior in young adults.^22,23

Side effects of SSRIs include the following:

• Anxiety
• Sedation
• Insomnia
• Decreased libido
• Gastrointestinal disturbances (including nausea and indigestion)
• Fatigue
• Headache
• Dry mouth
• Dizziness
• Tremor
• Sweating
• Weight gain

These side effects are generally manageable and may be reduced or eliminated by dose modification and use during the luteal phase only. There is no addictive potential and no tolerance with extended use of SSRIs. SSRIs are classified as Pregnancy Category C.

Orgasmic dysfunction (normal libido and arousal with delayed or absent orgasm) is the most problematic side effect of this class of drugs, reported in up to 80% of patients taking SSRIs continuously and for long duration.24

Sexual dysfunction can be managed by the following:³

• Taking a watch and wait approach, as it may resolve on its own
• Reducing the dose
• Taking drug holidays
• Substituting another SSRI agent
• Augmenting treatment with various agents (such as bupropion)

Women who have been counseled to anticipate that it may be more difficult to achieve orgasm when using SSRIs and other serotonergic agents may be best equipped to manage this common side effect, often through communication with their partner. Many women experiencing relief of their PMS/PMDD symptoms may be so pleased with their improvement on SSRIs that they are willing to tolerate or adapt to the sexual dysfunction associated with use of this class of medications.

Dosing

Unlike the use of SSRIs to treat depression, which may take 4–8 weeks to show efficacy, SSRIs used to treat PMS may reduce symptoms in a matter of days, and usually within 4 weeks after the start of treatment.²³ For this reason, intermittent dosing with these medications can be used in some patients, thereby reducing prescription costs and side effects and increasing compliance. Other women prefer the simplicity of continuous daily dosing.

The doses of SSRIs needed to treat PMS are typically lower than those used to treat depression and anxiety.²³ Table 4 shows the recommended doses of various SSRIs for the treatment of premenstrual disorders. Intermittent treatment is recommended, either during the luteal phase or on symptom days only.²

Other Serotonergic Agents

Agents such as venlafaxine and clomipramine are also often used to treat PMDD.²⁵ These agents inhibit the serotonin transporter as well as the uptake of norepinephrine and may be beneficial for some women who do not respond to or tolerate the “pure” SSRIs.^2,15 Adding bupropion (a nonserotonergic agent) to a serotonergic antidepressant can boost antidepressant efficacy without increasing side effects such as orgasmic dysfunction. Nonserotonergic antidepressants, however, have not specifically been found to be effective in treating PMS.²

Oral Contraceptives

The use of oral contraceptives (OCs) reduces dysmenorrhea, intensity and duration of menstrual flow. Because premenstrual symptoms occur almost exclusively in ovulatory cycles, inhibiting ovulation could be expected to reduce or eliminate these symptoms.²⁶ Hormonal contraceptives that suppress ovulation, including the pill, patch, vaginal ring, and depot-medroxyprogesterone acetate (DMPA) injections, offer effective relief from premenstrual symptoms for many women.

Because women using OCs for PMS often experience symptoms during the hormone-free interval, the selected treatment strategy should minimize or eliminate the hormone-free interval. Women may use monophasic OCs continuously, omitting the 7-day inert pills and starting a second pack immediately after the last active pill of their current pack. This regimen is safe and can be used indefinitely. Extended-regimen OCs, which are packaged with 84 days of active treatment with a 7-day pill-free interval (e.g., Seasonale^®, Seasonique^®), or continuous OC regimens (Lybrel^®) may decrease hormone withdrawal symptoms, which include menstrually related headaches, cyclic mood swings, pelvic pain, and dysmenorrhea. Unscheduled bleeding is common during extended or continuous use of OCs. Provided that the patient has used OC tablets for a minimum of the last 21 days, taking a 3-day break from OC use and then resuming their use can reduce future episodes of unscheduled bleeding.²⁷ Monthly OCs with a reduced hormone-free interval (Mircette^®, LoEstrin 24^®,YAZ^®) may also have advantages over traditional 21/7 OC formulations in treating premenstrual symptoms.

Until recently, only limited data have assessed the efficacy of OCs in the treatment of PMS, and the few randomized trials have published conflicting results. However, two recently published multicenter randomized trials found that women’s PMDD symptoms were significantly reduced with a combination OC formulation (24 tablets containing drospirenone and ethinyl estradiol followed by 4 hormonally inert tablets).^27,28 Drospirenone is a spironolactone antagonist that binds to the androgen receptor. This OC formulation had a greater impact on physical symptoms than placebo but also significantly improved mood symptoms. On the basis of these landmark trials, this 24/4 OC formulation with drospirenone (YAZ^®), has received FDA approval for the treatment of PMDD, and also represents an OC formulation that clinicians and women may choose when PMS or other premenstrual symptoms are present.

If PMS or PMDD is diagnosed in a patient who is already using OCs, premenstrual symptoms may be reduced by switching to a formulation with a reduced hormone-free interval, to an extended continuous OC formulation, or to one that contains the progestin drospirenone.

Other Pharmacologic Agents

Other medications have been used to treat the symptoms of PMS/PMDD with various levels of success (Table 5). 

Patients should be advised not to take herbal preparations randomly or without consultation.

A few studies have examined the use of other forms of alternative therapies for the treatment of PMS/PMDD. Other alternative therapies women may want to explore include the following:^15,30

• Acupressure and acupuncture
• Chiropractic and massage therapy
• Homeopathic remedies
• Hypnosis
• Light therapy
• Reflexology³¹
• Vaginal biofeedback³⁴
  
  

References

1. Dimmock PW, Wyatt KM, Jones PW, O’Brien PM. Efficacy of selective serotonin-reuptake inhibitors in premenstrual syndrome: a systematic review. Lancet. 2000;356:1131–6.
2. Johnson SR. Premenstrual syndrome, premenstrual dysphoric disorder, and beyond: a clinical primer for practitioners. Obstet Gynecol. 2004;104(4):845–59.
3. Steiner M. Premenstrual syndrome and premenstrual dysphoric disorder: guidelines for managment. J Psychiatry Neurosci. 2000;25(5):464-5.
4. Bhatia SC, Bhatia SK. Diagnosis and treatment of premenstrual dysphoric disorder. Am Fam Physician. 2002;66(7):1239–48.
5. Bowman MA. Premenstrual syndrome. In: Dambro MR, Griffith JA, eds. Griffith’s 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams & Wilkins; 2000:862–3.
6. Freeman EW, Sondheimer SJ. Premenstrual dysphoric disorder: recognition and treatment. Primary Care Companion J Clin Psychiatry. 2003;5:30–9.
7. Endicott J, Freeman EW, Kielich AM, Sondheimer SJ. PMS: new treatments that really work. Patient Care. 1996;30:88–123.
8. Johnson WG, Carr-Nangle RE, Bergeron KC. Macronutrient intake, eating habits and exercise as moderators of menstrual distress in healthy women. Psychosom Med. 1995;57:324–30.
9. Rapkin AJ. New treatment approaches for premenstrual disorders. Am J Manag Care. 2005;11(16 Suppl):S480–91.
10. Bertone-Johnson ER, Hankinson SE, Bendich A, Johnson SR, Willett WC, Manson JE. Calcium and vitamin D intake and risk of incident premenstrual syndrome. Arch Intern Med. 2005;165(11):1246–52.
11. Hardy ML. Herbs of special interest to women. J Am Pharm Assoc. 2000;40:234–42.
12. Rapkin A. A review of treatment of premenstrual syndrome and premenstrual dysphoric disorder. Psychoneuroendocrinology. 2003;28(Suppl 3):39–53.
13. Thys-Jacobs S, Ceccarelli S, Bierman A, Weisman H, Cohen MA, Alvir J. Calcium supplementation in premenstrual syndrome: a randomized crossover trial. J Gen Intern Med. 1989;4(3):183–9.
14. Thys-Jacobs S, Starkey P, Bernstein D, Tian J. Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Premenstrual Syndrome Study Group. Am J Obstet Gynecol. 1998;179(2):444–52.
15. Kaur G, Gonsalves L, Thaker HL. Premenstrual dysphoric disorder: a review for the treating practitioner. Cleve Clin Med. 2004;71(4):303–21 passim.
16. Maxson WS, Rosenwaks Z. In: Copeland LJ, Jarrell JF, eds. Textbook of Gynecology, 2nd ed. Philadelphia: W. B. Saunders, 2000:513–4.
17. Ward MW, Holimon TD. Calcium treatment for premenstrual syndrome. Ann Pharmacother. 1999;33:1356–8.
18. Parry BL, Rausch JL. Premenstrual dysphoric disorder. In: Kaplan HI, Sadock BJ, Cancro R, eds. Comprehensive Textbook of Psychiatry, 6th ed. Baltimore, MD: Williams & Wilkins, 1995:1707–13.
19. Christensen AP, Oei TP. The efficacy of cognitive-behavioral therapy in treating premenstrual dysphoric changes. J Affect Disord. 1995;33:57–63.
20. Krasnik C, Montori VM, Guyatt GH, Heels-Ansdell D, Busse JW, Medically Unexplained Syndromes Study Group. The effect of bright light therapy on depression associated with premenstrual dysphoric disorder. Am J Obstet Gynecol. 2005;193(3 Pt 1):658–61.
21. Lam RW, Carter D, Misri S, Kuan AJ, Yatham LN, Zis AP. A controlled study of light therapy in women with late luteal phase dysphoric disorder. Psychiatry Res. 1999;86(3):185–92.
22. American College of Obstetricians and Gynecologists. Premenstrual Syndrome. ACOG Practice Bulletin No. 15. Washington, DC: American College of Obstetricians and Gynecologists, 2000.
23. Wyatt KM, Dimmock PW, O’Brien PM. Selective serotonin reuptake inhibitors for premenstrual syndrome (Review). Cochrane Library 2007(4):1–26.
24. Balton R. SSRI-associated sexual dysfunction. Am J Psychiatry. 2006;163(9):1504–9.
25. Cohen LS, Soares CN, Lyster A, et al. Efficacy and tolerability of premenstrual use of venlafaxine (flexible dose) in the treatment of premenstrual dysphoric disorder. J Clin Psychopharmacol. 2004;24:540–3.
26. Sulak PJ. Ovulation suppression of premenstrual symptoms using oral contraceptives. Am J Manag Care. 2005;11(16 Suppl):S492–7.
27. Pearlstein TB, Bachman GA, Zacur HA, Yonkers KA. Treatment of premenstrual dysphoric disorder with a new drospirenone-containing oral contraceptive formulation. Contraception. 2005;72:414–21.
28. Yonkers KA, Brown C, Pearlstein TB, Foegh M, Sampson-Landers C, Rapkin A. Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder. Obstet Gynecol. 2005;106:492–501.
29. 29. Sulak PJ, Kuehl TJ, Coffee A, Willis S. Prospective analysis of occurrence and management of breakthrough bleeding during an extended oral contraceptive regimen. Am J Obstet Gynecol. 2006;195(4):935–41.
30. Domoney CL, Vashisht A, Studd JW. Premenstrual syndrome and the use of alternative therapies. Ann N Y Acad Sci. 2003;997:330–40.
31. Campagne DM, Campagne G. The premenstrual syndrome revisited. Eur J Obstet Gynecol Reprod Biol. 2007;130(1):4–17.
32. Ford O, Lethaby A, Mol B, Roberts H. Progesterone for premenstrual syndrome. Cochrane Database Syst Rev. 2006;Oct 18(4):CD003415.
33. Oleson T, Flocco W. Randomized controlled study of premenstrual symptoms treated with ear, hand, and foot reflexology. Obstet Gynecol. 1993;82:906–11.
34. Van Zak DB. Biofeedback treatments for premenstrual and premenstrual affective syndromes. Int J Psychosom. 1994;41:53–60.

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Patient Counseling

Although a primary care clinician is often the first point of contact for many women seeking treatment for premenstrual disorders, women’s health practitioners may be more prepared to deal with this complex syndrome. Clinicians should refer women with premenstrual emotional and behavioral symptoms that do not respond to the measures highlighted in this guide for psychiatric evaluation and treatment.

Developing a treatment strategy to manage the symptoms of PMS and PMDD can be a complex and elusive process for both the clinician and the patient. Clinicians may be hampered by terms, definitions, and diagnostic criteria that continue to vary, a challenging patient evaluation, and an expanding therapeutic arsenal. Time and patience are required as different modalities, often in combination, are attempted before an effective approach is found. Treatment is highly individualized, and an empathetic approach contributes to therapeutic success.¹ An improved level of understanding of this disorder will enable clinicians to better inform and counsel their patients. Hence, education regarding available options is paramount.

Reference

1. Rapkin AJ. New treatment approaches for premenstrual disorders. Am J Manag Care. 2005;11(16 Suppl):pS489.

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Appendix A

Patient Resources

American College of Obstetricians and Gynecologists
Patient Education Pamphlet: Premenstrual Syndrome (No. AP057)
www.acog.org/publications/patient_education/bp057.cfm

Association of Reproductive Health Professionals
Menstruation Resource Center: www.arhp.org/menstruationresources

National Center for Complementary and Alternative Medicine (NCCAM)
nccam.nih.gov
Part of the National Institutes of Health, NCCAM is the government’s lead agency for scientific research on complementary and alternative medicine. NCCAM’s website includes a searchable database of the current scientific knowledge on commonly used alternative therapies and herbal remedies: http://nccam.nih.gov/health/bytreatment.htm.

National Institutes of Health
“Menstruation and Premenstrual Syndrome”:
http://health.nih.gov/result.asp/436

National Women’s Health Information Center (NWHIC)
www.4woman.gov
Part of the Office of Women’s Health within the U.S. Department of Health and Human Services, NWHIC offers reliable and current resources on women’s health. Information on more than 800 topics pertaining to women’s health is offered free of charge to the public through the NWHIC website and call center:
www.womenshealth.gov
(800) 994-9662 or 888-220-5446 (TDD)
Monday through Friday (9:00 am to 6:00 pm, Eastern time)

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Appendix B

Patient Screening Test for Premenstrual Dysphoric Disorder¹

FIRST: Check all the symptoms from both the A-List and the B-List that you have on a daily basis during the week before your period starts:

A-LIST SYMPTOMS (during the week leading up to my period)

___ I feel much more depressed and down in my mood.

___ I feel anxious, tense, keyed up, or on edge.

___ I feel hypersensitive (to rejection or criticism) or I feel very unstable and unpredictable in my emotions.

___ I feel much more irritable or I get angry easily.

Number of A-List symptoms I checked: ____

B-LIST SYMPTOMS (during the week leading up to my period)

___ I am much less interested than usual in my hobbies and daily activities.

___ I find it much harder to concentrate on things.

___ I feel much more tired and low in energy.

___ I have a tendency to crave carbohydrates or go on eating binges.

___ I find myself oversleeping or taking naps, or I’m not sleeping well at night.

___ I feel or have felt very overwhelmed or out of control.

___ I am very bothered by at least two of the following physical symptoms:

___ Breast tenderness or swelling

___ Increased headaches

___ Joint or muscle pain

___ Feeling “bloated”

___ Weight gain

Number of B-List symptoms I checked: ____

SECOND: Answer these 4 questions (circle the correct answer):

1. Does the number of A-List symptoms PLUS the number of B-List symptoms add up to 5 or more?

___ YES ___ NO

2. Is at least one of the symptoms you checked on the A-List?

___ YES ___ NO

3. Do most if the symptoms you checked disappear within 3 days of the start of your period?

___ YES ___ NO

4. When you are having these symptoms, do they interfere with your ability to function normally and perform your daily activities?

___ YES ___ NO

If the answer to ALL four questions is YES, then you may have PMDD. Speak with your clinician about the next step to get help with your symptoms.

Reference

1. Freeman EW, Sondheimer SJ. Premenstrual dysphoric disorder: recognition and treatment. Primary Care Companion J Clin Psychiatry. 2003;5:30–39.

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Publication Information

Clinical Advisory Committee

Andrew M. Kaunitz, MD
Professor and Associate Chairman
Department of Obstetrics and Gynecology
University of Florida College of Medicine
Jacksonville, FL

Emily L. Rowe, PharmD
Clinical Pharmacist
Children’s National Medical Center
Washington, DC

Sharon Myoji Schnare, RN, FNP, CNM, MSN, FAANP
Clinical Instructor
University of Washington Seattle School of Nursing
Seattle, WA

Contributing Staff

Shama Alam, MScPH
Education Associate

Elizabeth S. Callihan
Designer

Beth Jordan, MD
Medical Director

Wayne C. Shields
President and CEO

Deborah J. Shuman
Consulting Medical Writer/Editor

Amy M. Swann, MA
Director of Education

This publication has been made possible by an educational grant from Bayer HealthCare Pharmaceuticals.