Applied Evidence

Evidence-based tools for premenstrual disorders

J Fam Pract. 2020 January;69(1):E9-E17

Author(s):

A symptoms chart, an algorithm, and a treatment options resource are among the tools you’ll find here to diagnose and treat premenstrual symptoms.

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PRACTICE RECOMMENDATIONS

› Start calcium supplementation in all patients who report significant premenstrual symptoms. A

› Add a selective serotonin reuptake inhibitor (SSRI) to calcium supplementationfor patients who have more severe premenstrual psychological symptoms. A

› Consider hormonal treatment options for patients who require treatment beyond calcium and an SSRI. B

› Provide nutrition and exercise information to all patients who report significant premenstrual symptoms. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

1. Woods NF, Most A, Dery GK. Prevalence of perimenstrual symptoms. Am J Public Health. 1982;72:1257-1264.

2. Johnson SR, McChesney C, Bean JA. Epidemiology of premenstrual symptoms in a nonclinical sample. 1. Prevalence, natural history and help-seeking behavior. J Repro Med. 1988;33:340-346.

3. Campbell EM, Peterkin D, O’Grady K, et al. Premenstrual symptoms in general practice patients. Prevalence and treatment. J Reprod Med. 1997;42:637-646.

4. O’Brien PM, Bäckström T, Brown C, et al. Towards a consensus on diagnostic criteria, measurement, and trial design of the premenstrual disorders: the ISPMD Montreal consensus. Arch Womens Ment Health. 2011;14:13-21.

5. Epperson CN, Steiner M, Hartlage SA, et al. Premenstrual dysphoric disorder: evidence for a new category for DSM-5. Am J Psychiatry. 2012;169:465-475.

6. American College of Obstetricians and Gynecologists. Guidelines for Women’s Health Care: A Resource Manual. 4th ed. Washington, DC: American College of Obstetricians and Gynecologists; 2014:607-613.

7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.

8. Dennerstein L, Lehert P, Heinemann K. Epidemiology of premenstrual symptoms and disorders. Menopause Int. 2012;18:48-51.

9. Borenstein JE, Dean BB, Yonkers KA, et al. Using the daily record of severity of problems as a screening instrument for premenstrual syndrome. Obstet Gynecol. 2007;109:1068-1075.

10. Steiner M, Macdougall M, Brown E. The premenstrual symptoms screening tool (PSST) for clinicians. Arch Womens Ment Health. 2003;6:203-209.

11. Endicott J, Nee J, Harrison W. Daily Record of Severity of Problems (DRSP): reliability and validity. Arch Womens Ment Health. 2006;9:41-49.

12. Janda C, Kues JN, Andersson G, et al. A symptom diary to assess severe premenstrual syndrome and premenstrual dysphoric disorder. Women Health. 2017;57:837-854.

13. Farasati N, Siassi F, Koohdani F, et al. Western dietary pattern is related to premenstrual syndrome: a case-control study. Brit J Nutr. 2015;114:2016-2021.

14. Purdue-Smithe AC, Manson JE, Hankinson SE, et al. A prospective study of caffeine and coffee intake and premenstrual syndrome. Am J Clin Nutr. 2016;104:499-507.

15. Bertone-Johnson ER, Hankinson SE, Bendich A, et al. Calcium and vitamin D intake and risk of incident premenstrual syndrome. Arch Intern Med. 2005;165:1246-1252.

16. Chocano-Bedoya PO, Manson JE, Hankinson SE, et al. Dietary B vitamin intake and incident premenstrual syndrome. Am J Clin Nutr. 2011;93:1080-1086.

17. Prior JC, Vigna Y. Conditioning exercise and premenstrual symptoms. J Reprod Med. 1987;32:423-428.

18. Aganoff JA, Boyle GJ. Aerobic exercise, mood states, and menstrual cycle symptoms. J Psychosom Res. 1994;38:183-192.

19. El-Lithy A, El-Mazny A, Sabbour A, et al. Effect of aerobic exercise on premenstrual symptoms, haematological and hormonal parameters in young women. J Obstet Gynaecol. 2015;35:389-392.

20. Kroll-Desrosiers AR, Ronnenberg AG, Zagarins SE, et al. Recreational physical activity and premenstrual syndrome in young adult women: a cross-sectional study. PLoS One. 2017;12:1-13.

21. Jang SH, Kim DI, Choi MS. Effects and treatment methods of acupuncture and herbal medicine for premenstrual syndrome/premenstrual dysphoric disorder: systematic review. BMC Complement Altern Med. 2014;14:11.

22. Kim SY, Park HJ, Lee H, et al. Acupuncture for premenstrual syndrome: a systematic review and meta-analysis of randomized controlled trials. BJOG. 2011;118:899-915.

23. Lustyk MK, Gerrish WG, Shaver S, et al. Cognitive-behavioral therapy for premenstrual syndrome and premenstrual dysphoric disorder: a systematic review. Arch Womens Ment Health. 2009;12:85-96.

24. Thys-Jacob S, Starkey P, Bernstein D, et al. Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual syndromes. Am J Obstet Gynecol. 1998;179:444-452.

25. Ghanbari Z, Haghollahi F, Shariat M, et al. Effects of calcium supplement therapy in women with premenstrual syndrome. Taiwan J Obstet Gynecol. 2009;48:124-129.

26. Girman A, Lee R, Kligler B. An integrative medicine approach to premenstrual syndrome. Am J Obstet Gynecol. 2003;188(5 suppl):s56-s65.

27. Wyatt KM, Dimmock PW, Jones PW, et al. Efficacy of vitamin B-6 in the treatment of premenstrual syndrome: systematic review. BMJ. 1999;318:1375-1381.

28. Verkaik S, Kamperman AM, van Westrhenen R, et al. The treatment of premenstrual syndrome with preparations of vitex agnus castus: a systematic review and meta-analysis. Am J Obstet Gynecol. 2017;217:150-166.

29. Boyle NB, Lawton C, Dye L. The effects of magnesium supplementation on subjective anxiety and stress—a systematic review. Nutrients. 2017;9:429-450.

30. Mauskop A, Altura BT, Altura BM. Serum ionized magnesium levels and serum ionized calcium/ionized magnesium ratios in women with menstrual migraine. Headache. 2002;42:242-248.

31. Facchinetti F, Sances C, Borella P, et al. Magnesium prophylaxis of menstrual migraine: effects on intracellular magnesium. Headache. 1991;31:298-301.

32. Parsay S, Olfati F, Nahidi S. Therapeutic effects of vitamin E on cyclic mastalgia. Breast J. 2009;15:510-514.

33. London RS, Murphy L, Kitlowski KE, et al. Efficacy of alpha-tocopherol in the treatment of the premenstrual syndrome. J Reprod Med. 1987;32:400-404.

34. Whelan AM, Jurgens TM, Naylor H. Herbs, vitamins, and minerals in the treatment of premenstrual syndrome: a systematic review. Can J Clin Pharmacol. 2009;16:e407-e429.

35. Marjoribanks J, Brown J, O’Brien PM, et al. Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database Syst Rev. 2013;(6): CD001396.

36. Dimmock P, Wyatt K, Jones P, et al. Efficacy of selective serotonin-reuptake inhibitors in premenstrual syndrome: a systematic review. Lancet. 2000;356:1131-1136.

37. Shah NR, Jones JB, Aperi J, et al. Selective serotonin reuptake inhibitors for premenstrual syndrome and premenstrual dysphoric disorder. Obstet Gynecol. 2008;111:1175-1182.

38. Freeman EW. Luteal phase administration of agents for the treatment of premenstrual dysphoric disorder. CNS Drugs. 2004;18:453-468.

39. Freeman EW, Rickels K, Yonkers KA, et al. Venlafaxine in the treatment of premenstrual dysphoric disorder. Obstet Gynecol. 2001;98:737-744.

40. Lopez LM, Kaptein AA, Helmerhorst FM. Oral contraceptives containing drospirenone for premenstrual syndrome. Cochrane Database Syst Rev. 2012;(2):CD006586.

41. Halbreich U, Freeman EW, Rapkin AJ, et al. Continuous oral levonorgestrel/ethinyl estradiol for treating premenstrual dysphoric disorder. Contraception. 2012;85:19-27.

42. Ford O, Lethaby A, Roberts H, et al. Progesterone for premenstrual syndrome. Cochrane Database Syst Rev. 2012;(3):CD003415.

43. Wyatt K, Dimmock P, Jones P, et al. Efficacy of progesterone and progestogens in management of premenstrual syndrome: systematic review. BMJ. 2001;323: 776-780.

44. Dennerstein L, Spencer-Gardner C, Gotts G, et al. Progesterone and the premenstrual syndrome: a double-blind crossover trial. Br Med J (Clin Res Ed). 1985;290:1617-1621.

45. NaProTECHNOLOGY. The Medical and Surgical Practice of NaProTECHNOLOGY. Premenstrual Syndrome: Evaluation and Treatment. Omaha, NE: Pope Paul VI Institute Press. 2004;29:345-368. https://www.naprotechnology.com/naprotext.htm. Accessed January 23, 2020.

46. Dante G, Facchinetti F. Herbal treatments for alleviating premenstrual symptoms: a systematic review. J Psychosom Obstet Gynaecol. 2011;32:42-51.

47. Jarvis CI, Lynch AM, Morin AK. Management strategies for premenstrual syndrome/premenstrual dysphoric disorder. Ann Pharmacother. 2008;42:967-978.

48. Landen M, Eriksson O, Sundblad C, et al. Compounds with affinity for serotonergic receptors in the treatment of premenstrual dysphoria: a comparison of buspirone, nefazodone and placebo. Psychopharmacology (Berl). 2001;155:292-298.

49. Naheed B , Kuiper JH , Uthman OA , et al . Non-contraceptive oestrogen-containing preparations for controlling symptoms of premenstrual syndrome . Cochrane Database Syst Rev . 2017 ;( 3) :CD010503.

CASE

A 30-year-old G2P2 woman presents for a well-woman visit and reports 6 months of premenstrual symptoms including irritability, depression, breast pain, and headaches. She is not taking any medications or hormonal contraceptives. She is sexually active and currently not interested in becoming pregnant. She asks what you can do for her symptoms, as they are affecting her life at home and at work.

Symptoms and definitions vary

Although more than 150 premenstrual symptoms have been reported, the most common psychological and behavioral ones are mood swings, depression, anxiety, irritability, crying, social withdrawal, forgetfulness, and problems concentrating.^1-3 The most common physical symptoms are fatigue, abdominal bloating, weight gain, breast tenderness, acne, change in appetite or food cravings, edema, headache, and gastrointestinal upset. The etiology of these symptoms is usually multifactorial, with some combination of hormonal, neurotransmitter, lifestyle, environmental, and psychosocial factors playing a role.

Premenstrual disorder. In reviewing diagnostic criteria for the various premenstrual syndromes and disorders from different organizations (eg, the International Society for Premenstrual Disorders; the American College of Obstetricians and Gynecologists; the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), there is agreement on the following criteria for premenstrual syndrome (PMS)^4-6:

The woman must be ovulating. (Women who no longer menstruate [eg, because of hysterectomy or endometrial ablation] can have premenstrual disorders as long as ovarian function remains intact.)
The woman experiences a constellation of disabling physical and/or psychological symptoms that appears in the luteal phase of her menstrual cycle.
The symptoms improve soon after the onset of menses.
There is a symptom-free interval before ovulation.
There is prospective documentation of symptoms for at least 2 consecutive cycles.
The symptoms are sufficient in severity to affect activities of daily living and/or important relationships.

Premenstrual dysphoric disorder. PMDD is another common premenstrual disorder. It is distinguished by significant premenstrual psychological symptoms and requires the presence of marked affective lability, marked irritability or anger, markedly depressed mood, and/or marked anxiety (TABLE 1).⁷

Exacerbation of other ailments. Another premenstrual disorder is the premenstrual exacerbation of underlying chronic medical or psychological problems such as migraines, seizures, asthma, diabetes, irritable bowel syndrome, fibromyalgia, anxiety, or depression.

Differences in interpretation lead to variations in prevalence

Differences in the interpretation of significant premenstrual symptoms have led to variations in estimated prevalence. For example, 80% to 95% of women report premenstrual symptoms, but only 30% to 40% meet criteria for PMS and only 3% to 8% meet criteria for PMDD.⁸ Many women who report premenstrual symptoms in a retrospective questionnaire do not meet criteria for PMS or PMDD based on prospective symptom charting. The Daily Record of Severity of Problems (DRSP), a prospective tracking tool for premenstrual symptoms, is sensitive and specific for diagnosing PMS and PMDD if administered on the first day of menstruation.⁹

Ask about symptoms and use a tracking tool

When you see a woman for a well-woman visit or a gynecologic problem, inquire about physical/emotional symptoms and their severity during the week that precedes menstruation. If a patient reports few symptoms of a mild nature, then no further work-up is needed.

Continue to: If patients report significant...