Assessment and treatment of premenstrual syndromes

A majority of the women who present to specialists with the complaint of premenstrual syndrome (PMS) have other disorders. Medical, gynaecologic, and psychiatric screening as well as 2 months of perspective charting of symptoms are therefore required in order to accurately diagnose the woman’s problem or disorder. Premenstrual Dysphoric Disorder (PMDD) occurs in only 3–8% of ovulating women. The DSM-IV criteria emphasize distressing emotional symptoms in the luteal phase only, in most menstrual cycles, that severely impact lifestyle. A pattern of less severe luteal symptoms, which are mainly physical complaints, is diagnosed as PMS. The key diagnostic point in differentiating PMS and PMDD from other disorders is that the follicular chart is clear of symptoms. Women can also be diagnosed with premenstrual magnification, which occurs when symptoms of a concurrent psychiatric or medical disorder are magnified during the premenstrum. The current etiologic hypothesis of PMDD is that normal ovarian function is the cyclical trigger for biochemical events that involve the serotonin system. Conservative treatment options such as lifestyle advice and low risk treatments such as vitamin therapy are recommended for all women with a premenstrual spectrum diagnosis. Those diagnosed with PMS are offered symptom specific treatments. Women with PMDD generally find these treatments insufficient. Results from several randomized placebo-controlled trials in women with PMDD have clearly demonstrated that the serotonin reuptake inhibitors (SSRIs) have excellent efficacy and minimal side effects. Recent studies indicate that intermittent (luteal phase only) treatment with SSRIs is effective in PMDD. There is also randomized placebo-controlled evidence for the efficacy of clomipramine, busiprone, alprazolam, mefenamic acid, and various ovulation-suppression regimes, but these tend to have more side effects than the SSRIs.