Premenstrual Syndrome (PMS)

Treatment Overview

Up to 85% of women normally have one or more troubling physical and emotional symptoms between the time they ovulate and the first days of their menstrual period.¹ These are called premenstrual symptoms. When premenstrual symptoms interfere with your relationships or responsibilities, they are called premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD), a severe form of PMS.

Although PMS cannot be cured, you do have a number of lifestyle and medication choices that can reduce your symptoms and improve your quality of life.

Basic PMS treatment

Experts recommend that all women with PMS start by keeping a menstrual diary, making lifestyle changes, and using home treatment measures.⁴ After a few menstrual cycles, you should notice some improvement in symptoms. Whether or not you then decide to add medication treatment, be sure to continue helping your body weather its premenstrual days by:

• Taking daily calcium [1200 mg ] and vitamin B6 [50 mg to 100 mg ]. Both of these nutrients affect the hormone-producing endocrine system. Calcium is strongly linked to PMS symptoms and relief.⁵ Although research and expert opinions are mixed, daily vitamin B6 is thought to improve PMS depression and physical symptoms.⁹
• Reducing your caffeine, refined sugar, and sodium intake, at least during the premenstrual phase of your cycle. These substances are linked to emotional and physical PMS symptoms, such as insomnia, tension and anxiety, food cravings, pain, and bloating.⁵
• Getting regular exercise. Exercise is proven to reduce depression.⁵ Women often report that exercise helps relieve tension, pain, and mood-related PMS symptoms.
• Reducing stress. While stress is not a cause of PMS, it may make your symptoms worse. In turn, coping with stress can be more difficult during the premenstrual period.⁴
• Using nonprescription medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), for headache, joint or muscle pain, or cramps. NSAIDs work best when taken before and continued at regular dosage intervals throughout the premenstrual pain period. For some women, this continues into the first days of menstrual bleeding, to relieve painful cramps.

See an example of a menstrual diary(What is a PDF document?).

Additional treatments for PMS

If you still have moderate to severe symptoms after two or three cycles of healthy lifestyle and home treatment measures, talk your health professional about further treatment options. Consider the following for specific symptoms.

All physical and mood-related symptoms

The selective serotonin reuptake inhibitor (SSRI) class of antidepressants is often the first-choice medication for moderate to severe premenstrual symptoms, including aggression, depression, anxiety, and physical symptoms. Most women gain relief by taking an SSRI either continuously or only during their premenstrual days.¹⁰ If you try an SSRI but find it ineffective, it's a good idea to try another type of SSRI before moving on to another class of medication. For more information, see:

Should I try an SSRI medication for PMS symptoms?

The U.S. Food and Drug Administration (FDA) has sent out a warning on the SSRI Paxil (paroxetine). Taking this medicine in the first 12 weeks of pregnancy may increase your chance of having a baby with a birth defect.

The birth control pill with estrogen and drospirenone is another treatment option for moderate to severe PMS or PMDD. This pill is sold as YAZ (very low-estrogen) or Yasmin (low-estrogen). The drospirenone improves severe physical and emotional symptoms in 1 in 8 women. It has a unique hormone action, and also acts like a water pill (diuretic).¹¹ YAZ has been approved by the U.S. Food and Drug Administration for treating PMDD symptoms.

Bloating or breast tenderness

• Spironolactone, taken during the premenstrual phase, works as a diuretic and effectively reduces bloating and breast tenderness.¹
• Drospirenone, in the birth control pill called YAZ or Yasmin, acts like spironolactone. It relieves bloating, breast tenderness. In some women, it also relieves other emotional and physical PMS symptoms.¹¹
• Daily vitamin E (400 IU), taken during the premenstrual phase, is a recognized treatment for breast tenderness.¹
• Evening primrose oil contains essential fatty acids that may offer mild relief of breast tenderness.¹

For more information about complementary, alternative, and supplement therapies for PMS, see the Other Treatment section of this topic.

Other hormonal, sedative, or surgical treatments for severe PMS

The goal of hormonal and surgical treatments is to stop a part of the hormonal (endocrine) system that is linked to premenstrual symptoms. These treatments are not commonly used to treat PMS symptoms, either because they are now known to be ineffective or because they have severe side effects.

• Birth control pills (estrogen-progestin) are widely prescribed for PMS but are no longer recommended by experts in the field as a first-choice treatment.^{1, 10} Recent research has shown that birth control pills are not consistently effective for PMS. Although they may improve bloating, headache, abdominal pain, and breast tenderness for some women, other women report that they have worse symptoms or they develop mood problems. Birth control pills are known to be ineffective for treating mood symptoms.⁴Estrogen alone may offer some benefit for some women, but when taken without progestin, it increases the risk of uterine (endometrial) cancer.
• Progestin has been used in the past for PMS but is now proven to be ineffective or to actually make physical and emotional symptoms worse.¹
• Danazol (Danocrine) is a synthetic male hormone that can relieve breast pain by decreasing estrogen production. It isn't often prescribed because it can't be used long-term and causes weight gain, depression, deepening of the voice, smaller breasts, and cholesterol problems.
• Benzodiazepine treatment with alprazolam (Xanax) is occasionally used for PMS-related anxiety. It depresses the central nervous system, loses effectiveness over time, and can be addictive. Because long-term use can be complicated by withdrawal and life-threatening symptoms, this medication is only recommended for a few days' use when other treatments have been ineffective.
• Bromocriptine (Parlodel) can relieve breast pain by reducing prolactin production. However, it isn't often prescribed because side effects are common, including nausea and vomiting, headache, cramps, and fatigue. A lowered dose can reduce side effects.
• Gonadotropin-releasing hormone agonists (GnRH-a) are a last-resort treatment for severe PMDD symptoms. Although a GnRH-a does control PMS by "shutting down" the ovaries, the tradeoff is that it is causes menopausal symptoms such as hot flashes and vaginal dryness.
• Surgery to remove the ovaries (oophorectomy) is a rarely used, controversial treatment, because it is irreversibly causes early menopause. Menopause symptoms caused by surgery, such as hot flashes, depression, and insomnia, are often more severe than those of natural menopause.

What To Think About

No single therapy is effective for all women. You and your health professional may have to try more than one type of treatment before finding the right choice for you.

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Author:	Kathe Gallagher, MSW	Last Updated: July 7, 2006
Medical Review:	Renée M. Crichlow, MD - Family Medicine Kathleen Romito, MD - Family Medicine Deborah A. Penava, BA, MD, FRCSC, MPH - Obstetrics and Gynecology
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