Premenstrual Syndrome (PMS) & Premenstrual Dysphoric Disorder (PMDD)

Definition

• Premenstrual syndrome (PMS) comprises a range of psychological and physical symptoms occurring cyclically in the luteal phase of the menstrual cycle

• Premenstrual dysphoric disorder (PMDD) represents a severe form of PMS with marked mood disturbances that significantly impair daily functioning

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Presentation

Psychological Symptoms

• Mood swings, irritability, depression and anxiety

• Emotional lability and inability to cope with daily stressors

• Increased interpersonal conflicts and decreased social functioning

Physical Symptoms

• Bloating and breast tenderness

• Headaches and fatigue

• Other somatic complaints such as joint or muscle pain

Management

Lifestyle Modifications

• Regular exercise, particularly aerobic activities, to improve mood and reduce stress

• Cognitive behavioural therapy (CBT) to address negative thought patterns and coping strategies

• Use of relaxation techniques such as yoga, meditation or progressive muscle relaxation

• Dietary modifications including balanced nutrition and reduced caffeine intake

Pharmacological Treatments

• First-line treatment with SSRIs for PMDD using either continuous or luteal-phase dosing (approximately 14 days pre-menses) for optimal symptom control

• Combined oral contraceptive pills containing drospirenone and low-dose oestrogen, which may offer modest symptom relief

• Adjunctive use of analgesics and NSAIDs for alleviating physical symptoms

• Consider calcium supplementation as an additional option in some cases

Severe or Refractory Cases

• Referral to specialist care for further evaluation in cases refractory to first-line treatments

• Last-line option includes bilateral salpingo-oophorectomy, which induces surgical menopause and necessitates subsequent hormone replacement therapy

• Short-term use of anxiolytics may be considered during acute episodes of severe distress

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Notes

• Lifestyle modifications are essential; however, severe cases of PMDD often require pharmacological intervention

• PMDD symptoms tend to worsen with age and stress but typically resolve at menopause

• Continuous dosing of SSRIs generally provides superior symptom control compared with intermittent dosing

• The efficacy of COCPs in PMDD is modest and may be influenced by placebo effects

• Patient education, psychological support and regular follow-up are critical components of management