Premenstrual Disorders: Guidelines From the American College of Obstetricians and Gynecologists

Premenstrual disorders comprise a spectrum of conditions that occur discretely in the luteal phase of menstruation and resolve during or shortly after menstruation. Up to 90% of reproductive-aged women experience at least one premenstrual symptom, and up to 30% experience a constellation of physical and affective symptoms severe enough to affect daily functioning (ie, premenstrual syndrome [PMS]). Approximately 5% of reproductive-aged women report severe, disabling cyclic affective symptoms classified as premenstrual dysphoric disorder. Premenstrual disorders may be even more common in adolescents. These disorders are often untreated, with one study showing that three-fourths of women with premenstrual disorders not having had any treatment in the past 5 years. The American College of Obstetricians and Gynecologists has released recommendations for the management of premenstrual disorders in reproductive-aged adults and adolescents.

Although premenstrual disorders are a diagnosis of exclusion, the timing of symptoms is the most important element of diagnosis. Common symptoms include bloating, breast tenderness, irritability, lethargy, and mood lability. Cyclic symptoms limited to the premenstrual phase and first few days of menses are most characteristic. Underlying disorders are most often the cause if symptoms occur intermittently across the menstrual cycle or are chronic but worsen during the premenstrual phase.

The guidelines recommend an approach to treatment that involves an understanding of the patient's treatment preferences and goals, the benefits and risks of each option, and whether more than one therapy should be initiated. Treatments are listed in order of their evidence of benefit.

Antidepressant Medications

Selective serotonin reuptake inhibitors (SSRIs) are a moderately effective treatment for improving psychological symptoms, functional impairment, and irritability. SSRIs also improve physical symptoms with a small effect size. The most common adverse effects include somnolence, nausea, decreased energy, sweating, and sexual dysfunction.

For premenstrual symptoms, SSRIs have a rapid onset of action and can be effective in a few days. Intermittent use of SSRIs starting 1 week before the period and ending 3 days after the start of menses is effective and an option instead of continuous dosing. If patients struggle to remember to start medication or experience limited improvement with the intermittent option, switching to continuous dosing may be more effective.

There is limited study of SSRI use for adolescents with premenstrual disorders, and their use is associated with an increased risk of suicidal ideation and behavior in this age group. A US Food and Drug Administration boxed warning stems from 24 trials of up to 16 weeks of treatment that showed that adolescent antidepressant use resulted in double the rate of suicidal thoughts or attempts compared with placebo. No completed suicides were reported in these trials.