Premenstrual Syndrome Management
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Direct answer
Premenstrual syndrome — cyclical somatic and psychological symptoms confined to the luteal phase, resolving within days of menstruation — affects up to a third of menstruating women, with the severe form (premenstrual dysphoric disorder) in 3-8 per cent. Diagnosis is prospective, not retrospective: two cycles of a daily symptom diary proving luteal timing, because history alone conflates PMS with depression, thyroid disease and anaemia. Management climbs a graded ladder — lifestyle measures with calcium 1000-1200 mg daily, then SSRIs (continuous or luteal-only dosing), a drospirenone-containing combined pill, and for refractory cases gonadotrophin-releasing hormone agonists with add-back therapy, with oophorectomy the last resort.
What you must remember
- The numbers: PMS in up to 30-40 per cent of menstruating women; PMDD (DSM-5 criteria) in 3-8 per cent — severe irritability, anxiety, and mood swings impairing function.
- The diagnostic instrument: prospective daily ratings over two cycles; symptoms must be absent in the follicular phase — the single feature separating PMS from an always-present mood disorder.
- Core symptoms: affective — irritability (the hallmark), low mood, anxiety, lability; somatic — bloating, breast tenderness, headache, acne, cravings, sleep disturbance.
- Foundation therapy: regular aerobic exercise, sleep hygiene, reduced caffeine, alcohol and salt; calcium 1000-1200 mg daily (trial-proven benefit), vitamin B6 up to 100 mg (sensory neuropathy above); small trials support chasteberry and yoga.
- First-line drugs: SSRIs — fluoxetine 20 mg, sertraline 50-100 mg, escitalopram 10 mg — continuously or luteal-only (day 14 to menses), where benefit comes pleasingly fast; CBT is the non-drug companion.
- Hormonal options: a combined pill containing drospirenone (the anti-mineralocorticoid progestogen that also helps bloating), preferably continuous; conventional pills are inconsistent.
- Refractory disease: GnRH agonist with add-back hormone therapy for 3-6 months — diagnostic (it abolishes the cycle) and therapeutic; bilateral oophorectomy with replacement is the definitive last resort in extreme, completed-family cases.
- Exclude the mimics: depression and dysthymia (symptoms all month), hypothyroidism, anaemia, premenstrual exacerbation of chronic disease.
From diary to decision in three visits
A 29-year-old reports ten days before every period of rage at trivia, weeping, breast fullness, bloating and chocolate craving, with work warnings; between periods she is, in her words, a different person. Visit one: the diary is issued — the Daily Record of Severity of Problems scored daily for two cycles — and thyroid profile, complete blood count and fasting glucose exclude the mimics. Visit two, after the cycles: scores near zero in the follicular phase rising steeply after ovulation — the map of PMS, at severity crossing into PMDD territory. Management starts where evidence and her preferences meet: daily calcium 1200 mg, structured aerobic exercise, caffeine reduction, plus sertraline 50 mg — she chooses luteal-only dosing after learning it works nearly as well continuously. Visit three, three months later: symptoms halved, warnings withdrawn; she asks about the "water pill" her friend takes — the drospirenone-containing pill is discussed as the next step should she also want contraception, with the GnRH-agonist route reserved, at bone cost, for the truly refractory. The case teaches the architecture: confirm by diary, treat by ladder, escalate by measured severity.
The Indian consultation
Indian women with PMS reach the gynaecology clinic late and sideways — the presenting complaint is usually somatic (mastalgia, bloating, "gas", migraine) rather than mood, because irritability before a period is culturally normalised as "those days" and psychological vocabulary carries stigma; the diagnosis emerges only when the clinician asks directly about luteal-phase timing of mood change. Two exam angles matter. First, the investigation of choice — the prospective two-cycle diary, not any blood test — is a standing viva question whose wrong answers (oestrogen level, progesterone level, ultrasound) are precisely the reflexes to unlearn; no laboratory test diagnoses PMS. Second, therapy economics: calcium and vitamin B6 are over-the-counter and cheap, sertraline is off-patent and affordable, while the drospirenone pill and GnRH agonists are private-pocket items. Small Indian studies of yoga get cited in textbooks, and exercise prescriptions cost nothing. The severity marker to ask about: impairment — missed work, conflicts, hopelessness — the difference between syndrome and disorder, and the trigger for psychiatric co-management.
Frequently asked questions
How is PMS diagnosed definitively?
Prospective daily rating over at least two consecutive cycles showing luteal onset and follicular resolution — recall is unreliable, and no blood test confirms it.
What distinguishes PMDD from PMS?
Severity and impairment — at least five symptoms including a core mood symptom (irritability, mood lability, depression, anxiety) causing marked disruption, in 3-8 per cent.
Which pharmacological therapy is first line?
SSRIs, effective continuously or dosed only from mid-cycle to menses — luteal dosing suits women who prefer not to take a daily drug.
What is the evidence for calcium?
Trials of 1000-1200 mg calcium daily show substantial symptom reduction — a rational foundation alongside exercise before prescription drugs.
When is a GnRH agonist used, and with what companion?
For refractory or diagnostically uncertain disease — 3-6 months of an agonist with add-back therapy to protect bone; relief confirms the diagnosis and opens definitive surgery in extreme cases.