Premenstrual syndrome

Abstract

Most women of reproductive age have some physical discomfort or dysphoria in the weeks before menstruation. Symptoms are often mild, but can be severe enough to substantially affect daily activities. About 5-8% of women thus suffer from severe premenstrual syndrome (PMS); most of these women also meet criteria for premenstrual dysphoric disorder (PMDD). Mood and behavioural symptoms, including irritability, tension, depressed mood, tearfulness, and mood swings, are the most distressing, but somatic complaints, such as breast tenderness and bloating, can also be problematic. We outline theories for the underlying causes of severe PMS, and describe two main methods of treating it: one targeting the hypothalamus-pituitary-ovary axis, and the other targeting brain serotonergic synapses. Fluctuations in gonadal hormone levels trigger the symptoms, and thus interventions that abolish ovarian cyclicity, including long-acting analogues of gonadotropin-releasing hormone (GnRH) or oestradiol (administered as patches or implants), effectively reduce the symptoms, as can some oral contraceptives. The effectiveness of serotonin reuptake inhibitors, taken throughout the cycle or during luteal phases only, is also well established.

Figure 1. Timing of PMDD symptom severity across menstrual period

DRSP=Daily Rating of Severity of Problems. Total symptoms were averaged for the corresponding day of the menstrual cycle. Day 14 indicates the beginning of the luteal phase. Day 1 is the first day of the following menstrual cycle. The follicular phase average score for the entire cohort was 33·5 and is indicated by a horizontal line. Adapted from Pearlstein et al, 2005.

Figure 2. Severity of PMDD symptoms according to menstrual cycle stage

DRSP=Daily Rating of Severity of Problems. *The symptom peak occurred on day –2 (ie, 2 days before onset of menses) for depressive symptoms; day –1 for physical symptoms; day –2 for anger, irritability, or tendency towards conflict; day –3 for food cravings. Mean symptom scores for each factor are shown. Adapted from Pearlstein et al, 2005.