Premenstrual Syndromes : PMS and PMDD - Rutuja :: The site ...

anxiety, or bipolar disorders, postpartum illness, eating
disorders, substance abuse, or personality disorders.
Women with PMDD commonly have past episodes,
postpartum episodes, or a family history of depressive
and/or anxiety disorders. 10 Several studies have reported
that women with severe premenstrual symptoms
have a greater possibility for psychopathology and other
significant difficulties. 16–19
PMDD and psychiatric disorders may also be coexisting
conditions. There is a high comorbidity of PMS
and PMDD with anxiety, depressive, and other psychiatric
disorders, 17 although PMDD is a distinct diagnostic
entity separate from other affective disorders. The
patient may have a history of mood disorder with
current PMDD or the patient may have no mood disorder
outside of PMDD. Symptoms of major depressive
disorder, anxiety disorder, or personality disorder will
not demonstrate a cyclic pattern with a constant
symptom-free interval prior to ovulation.
Therapeutic approaches
Non-pharmacological or over-the-counter medical
approaches are recommended during the 2-month prospective
rating period. There is level A and B evidence
for each of several modalities, including exercise,
dietary supplements, and psychological interventions.
Even daily recording can be therapeutic for the patient
and her family.
Initiation of or increase in exercise, particularly the
aerobic variety, can reduce premenstrual mood and
physical symptoms and has other obvious potential
health advantages. At least 3 days per week, 20–30
minutes of aerobic exercise should be performed. 20,21
Dietary changes or calcium supplementation can be
initiated. Calcium carbonate, 1200 mg/day in divided
doses, has also shown efficacy in at least one randomized
controlled trial for PMS. 22 Furthermore, in 105
women meeting DSM-IV criteria for PMDD, there was
a statistically significant negative relationship between
milk consumption and the following premenstrual
complaints: abdominal bloating, cramps, craving for
some foods, and increased appetite. 23 Vitamin supplementation
with pharmacological doses of vitamin B 6
can also be initiated if the patient is not already taking
a vitamin supplement. Vitamin B 6 intake in excess of
100 mg/day is not recommended and can be neurotoxic.
24 A review of published and unpublished randomized
placebo trials of the use of vitamin B 6 in PMS
concluded that doses up to 100 mg/day are likely to be
helpful in the treatment of premenstrual symptoms,
including depression. 25 Limited data indicate a possible
benefit of a complex and simple carbohydrate-containing
beverage taken twice per day premenstrually, allowing
CLINICAL EVALUATION AND MANAGEMENT 153
for greater absorption of L-tryptophan, the amino acid
precursor of serotonin. 26,27 However, the availability of
this product is limited and each serving contains at least
200 calories.
For women with premenstrual mastalgia, abdominal
discomfort, and headache, non-steroidal antiinflammatory
medication is helpful, but limited data
investigating small groups of women given mefenamic
acid or naproxen sodium suggest the psychological
symptoms of PMS may also improve. 28,29
Cognitive behavioral therapy (CBT) can also be initiated
during the initial treatment or daily recording
months. At least three studies have demonstrated reduction
in PMS symptom severity with CBT. 30–32 Additionally,
CBT added to the SSRI fluoxetine demonstrated
longer maintenance of treatment effects than fluoxetine
alone, but combining CBT and fluoxetine did not
confer added benefit in terms of degree of response or
rate of response. 30 The disadvantage of CBT is cost, but
some practitioners offer CBT groups which are more
affordable than individual therapy, and the skills
acquired in CBT can also represent an important
investment in one’s own psychological well-being, as
the approach is non-pharmacological and is useful for
general stress reduction and coping with future adverse
life events.
PHARMACOLOGICAL MANAGEMENT
Combined oral contraceptives
Many reproductive women request contraception, and
hormonal contraception is the most commonly used
reversible method worldwide. Other potential noncontraceptive
benefits of oral contraceptives (OCs) are
significant and include cycle regulation, reduction
development of anemia and functional ovarian cysts,
control of acne, decreased dysmenorrhea and pelvic
pain for those with early endometriosis, and risk reduction
for ovarian and endometrial carcinoma. For those
women who also desire hormonal contraception, there
is now evidence that OCs can be beneficial for PMS
and PMDD; however, progestin-only methods have not
been reliably studied for this indication and currently
cannot be recommended.
Historically, OCs were not uniformly beneficial for
women with PMS, despite the elimination of ovulation,
but the higher doses of sex steroids in most of the
earlier generations of OCs may provoke more symptoms.
33 The 7 days off active pills can also allow for
follicular development and a minicycle of exposure to
and withdrawal from endogenous steroids and residual
PMS-like symptoms in susceptible women.