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Premenstrual syndrome (PMS) is characterized by recurring physical and emotional symptoms and behavioral changes that occur during the luteal phase of the ovulatory menstrual cycle and disappear within several days of the onset of menstruation. Women with PMS may experience many symptoms (see the box); the most common are bloating, breast tenderness, headache, fatigue, irritability, depression, hostility, and food cravings.

To fulfill diagnostic criteria for PMS the symptoms must not be due to underlying physical diseases (eg, thyroid dysfunction, lupus erythematosus), emotional diseases (eg, bipolar disorder, anxiety disorders, chronic depression), or recurring environmental stress. The symptoms must be severe enough to adversely affect the woman's functional level or sense of well-being. Approximately 5% of women of reproductive age experience premenstrual symptoms severe enough to interfere with normal activities.

The cause of PMS is unknown. Proposed etiologies include nutritional deficiencies, allergies, hypoglycemia, and hormone excesses or deficiencies. In the past several years, however, there has been increasing evidence that neurotransmitters, such as serotonin, may play a central role in the pathophysiology of some premenstrual symptoms. It is likely that premenstrual symptoms may not be the result of a single biochemical abnormality but may occur in response to biologic, psychologic, and social factors working in premenstrual syndrome.

Physical, Cognitive, and Emotional Symptoms and Behavioral Changes

in Women with Premenstrual Syndrome

Physical Symptoms Cognitive Symptoms

Bloating Suicidal ideation

Breast tenderness Sensitivity to rejection

Weight gain Decreased concentration

Headache Forgetfulness

Fatigue Feeling overwhelmed

Joint pain Feeling out of control

Constipation Behavioral Changes

Emotional Symptoms Food cravings

Anxiety Social isolation

Irritability Verbally abusive

Sadness Physically abusive

Labile mood Lack of motivation

Anger Overly critical of others



When PMS coexists with other physical or psychiatric illnesses or exists within a stressful social environment, it may be difficult to determine the contribution of PMS to a patient's symptoms. Therefore, it is important to approach the evaluation of a woman with the complaint of premenstrual symptoms.


Most treatments for PMS are aimed at alleviating symptoms. This can be done primarily with a combination of exercise and medications. Mental health assistance combined with medication may be more helpful.

Women who exercise have milder PMS symptoms. Although dietary changes have been widely recommended, there is no evidence of their effectiveness. The elimination of caffeine and chocolate.

Diuretics have been used to relieve fluid shifts that may result in soft-tissue swelling. Spironolactone may be useful in treating the physical symptoms of PMS. In cases in which spironolactone does not improve physical symptoms, hydrochlorothiazide may be used for the week preceding menses. Vitamin B6 has been effective.

Studies have shown marked reduction of PMS symptoms in patients receiving the serotonin reuptake inhibitor fluoxetine throughout the menstrual cycle. Other serotonin reuptake inhibitors (eg, sertraline hydrochloride, paroxetine hydrochloride) may also be effective. Alprazolam, a benzodiazepine.

Long-acting GnRH agonists can relieve symptoms of PMS. If symptoms improve with complete ovarian suppression.