Individualized care is important for women who are experiencing pre-menstrual symptoms.
Individualized care is important for women who are experiencing pre-menstrual symptoms.
Premenstrual syndrome, commonly referred to as PMS, is a cyclic, multisymptom disorder characterized by physical, behavioral, and emotional symptoms.1,2
PMS occurs during the luteal phase of a woman’s menstrual cycle and is followed by a resolution of symptoms within the first few days after the onset of menstrual bleeding.1,2
The exact cause of PMS is unknown, but normal ovarian function as well as fluctuations of estrogen and progesterone levels are considered possible causes of the symptoms commonly associated with PMS.1,3 Other factors that have been identified as contributors to PMS symptoms include genetics, stress, prior traumatic events, and sociocultural factors.1-8 Some theories suggest that chemical changes in the brain may be involved as well.1-7 Other theories suggest that PMS may be caused by multiple endocrine factors.9
In surveys, approximately 40% of women describe their premenstrual symptoms as bothersome, another 10% to 15% describe their symptoms as severe, and 3% to 5% perceive their symptoms as having a significant negative impact on their quality of life.1,6 As many as 50% to 60% of women between their late 30s and 40s experience worsening of symptoms as they approach the transition to menopause.8 Premenstrual dysphoric disorder (PMDD) is a severe form of PMS experienced by approximately 5% of women.1-4 Patients exhibiting severe PMS or PMDD symptoms should be encouraged to seek further medical evaluation or treatment.
Symptoms of PMS
The symptoms associated with PMS vary from woman to woman, but are typically consistent for an individual patient.1,7 Almost all women experience mild physical symptoms, food cravings, or mood changes before the onset of menses. These changes are considered normal signs of the ovulatory cycle, whereas PMS is defined as having at least 1 mood or physical symptom during the 5 days prior to menses.1-7
The number and severity of a patient’s symptoms and their impact on overall well-being can assist health care providers in ascertaining whether a patient has PMS syndrome or PMDD.1 The 2 most common physical PMS symptoms are bloating/weight gain/swelling and breast tenderness.1-7,9 Fatigue, anxiety, and irritability are also experienced by many women.1-7,9 Depressive and anxiety disorders are the most common conditions that overlap with PMS, and approximately half of women seeking treatment for PMS have one of these disorders.10
Treatment should be tailored to meet the specific needs of each patient and typically requires a combination of therapies.1 Many experts recommend nonpharmacologic measures, including lifestyle and dietary modifications, regular exercise, and stress-reduction techniques, as the first line of therapy.1-3,10 Studies have shown that women who exercise regularly may experience less frequent and milder PMS symptoms compared with those who do not exercise.1-3,10 Reducing or eliminating intake of caffeine, salt, and alcoholic beverages as well as eating foods rich in complex carbohydrates and low in protein during the premenstrual phase may also decrease the incidence of PMS symptoms.1-3
Approximately 80% of women use nonprescription products for symptomatic relief of PMS symptoms.1 Nonprescription agents that are marketed for management of PMS include nonsteroidal anti-inflammatory drugs (NSAIDs), diuretics, vitamins, minerals, and herbal products that contain evening primrose oil, chasteberry, or black cohosh.1 Combination products are also available that contain an analgesic (acetaminophen), a diuretic (pamabrom), and an antihistamine (pyrilamine maleate). Patients should be aware that combination products containing antihistamines may cause drowsiness.1
The FDA has approved 3 OTC diuretics—ammonium chloride, caffeine, and pamabrom—for relief of water retention, bloating, weight gain, and swelling.1 Pamabrom is the diuretic most commonly found in nonprescription menstrual products.1 Patients with a history of peptic ulcer disease or anxiety/insomnia disorders should not use products containing caffeine or pamabrom. Ammonium chloride is contraindicated in individuals with renal or hepatic impairment due to the possibility of metabolic acidosis.1 Patients taking monoamine oxidase inhibitors or xanthine derivatives such as theophylline should avoid the use of diuretics containing caffeine.1
Analgesics such as NSAIDs have been shown to provide relief for the physical symptoms of PMS such as headache, cramps, and pain when taken several days prior to and during the first days of menses.1 Patients should be advised to only take the recommended dose and be advised of possible adverse effects.1
Magnesium deficiency may lead to symptoms of irritability associated with PMS.1,11 Results from 1 clinical study demonstrated that a daily dose of 360 mg of magnesium taken during the luteal phase may provide some relief from PMS symptoms.1,11 Patients can be advised to take 360 mg of magnesium daily during the premenstrual phase only.1,11 Magnesium may cause diarrhea in some patients.1
Pyridoxine (Vitamin B6 )
Vitamin B6 has been used to treat PMS symptoms such as irritability, fatigue, bloating, and depression. 1,4,11 Studies have shown that a dose of 80 mg per day can improve mood and anxiety levels.1,4,11 Recommended doses should be limited to 100 mg daily to reduce the incidence of neuropathy.1
Calcium and Vitamin D
Results from 1 study showed that high dietary intake of calcium and vitamin D may prevent the development of PMS symptoms.1 Patients should take 1200 mg daily in divided doses, with no more than 500 mg per dose.1 Because calcium may cause gastric upset or constipation, it should be taken with food.1 Patients should be advised to also take at least 600 IU of vitamin D per day.1
Prior to recommending any of these products for the management of PMS symptoms, pharmacists should screen for possible drug—drug interactions and contraindications. In addition, patients should only use products to treat their specific symptoms. Patients who experience severe symptoms or do not achieve any relief from OTC treatments should be referred to their primary health care provider for further evaluation. In addition, patients with pre-existing medical conditions and lactating women should always seek advice from their primary health care provider before taking any of these products, including natural and herbal medications.
Pharmacists can further assist patients by making recommendations about nonpharmacologic measures that may prevent or decrease PMS symptoms, such as relaxation techniques, stress avoidance, establishing a daily exercise routine, eating a well-balanced diet, getting sufficient rest, and avoiding or limiting intake of salt, caffeine, and alcohol.
Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.
1. Shrimp L. Disorders related to menstruation. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 17th ed. Washington, DC: American Pharmacists Association; 2012.
2. Raines K. Diagnosing premenstrual syndrome. Medscape website. www.medscape.com/viewarticle/718973. Accessed April 8, 2012.
3. Campagne DM, Campagne G. The premenstrual syndrome revisited. Eur J Obstet Gynecol Reprod Biol. 2007;130(1):4-17.
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5. Jarvis CI, Lynch AM, Morin AK. Management strategies for premenstrual syndrome/premenstrual dysphoric disorder. Ann Pharmacother. 2008;42(7):967-978.
6. Johnson SR. Premenstrual syndrome, premenstrual dysphoric disorder, and beyond: a clinical primer for practitioners. Obstet Gynecol. 2004;104(4):845-859.
7. Premenstrual syndrome fact sheet. United States Department of Health and Human Services National Women’s Health Information Center website. www.womenshealth.gov/faq/premenstrual-syndrome.cfm. Accessed April 4, 2012.
8. Premenstrual syndrome. Medline Plus website. www.nlm.nih.gov/medlineplus/ency/article/001505.htm. Accessed April 10, 2012.
9. Premenstrual syndrome (PMS). Merck Manual for Healthcare Professionals Online Edition. www.merckmanuals.com/professional/gynecology_and_obstetrics/menstrual_abnormalities/premenstrual_syndrome_pms.html. Accessed April 7, 2012.
10. Premenstrual syndrome. American College of Obstetricians and Gynecologists (ACOG) website. www.acog.org/~/media/For%20Patients/faq057.pdf?dmc=1&ts=20120413T1431137968. Accessed April 8, 2012.
11. Whelan AM, Jurgens TM, Naylor H. Herbs, vitamins and minerals in the treatment of premenstrual syndrome: a systematic review. Can J Clin Pharmacol. 2009;16(3):e407-e429.
12. Thys-Jacobs S, Starkey P, Bernstein D, Tian J. Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms: Premenstrual Syndrome Study Group. Am J Obstet Gynecol. 1998;179(2):444-452.