Appropriate Treatment Interventions

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Once a diagnosis has been established or refuted, results of the evaluation should be shared with the

Pre-Menstrual Syndrome Treatment Interventions patient and various treatment strategies should be considered.

1. For Women Thought Not to Have PMS

Women with symptoms caused by another illness, but without demonstrable PMS, should receive reassurance and clarity about possible sources of their discomfort. Accurate information about sexual health, experiences normally associated with the menstrual cycle, and symptom patterns may be tremendously helpful. Treatment of a previously unrecognized or poorly controlled physical illness (e.g., hypothyroid-ism, diabetes mellitus) may eliminate the premenstrual complaints. New or more intensive treatment of a psychiatric disorder such as depression may lead to improvement in symptoms attributed to the premenstrual phase. Doses of psychotropic medication may need to be increased during the late luteal phase and early follicular phase to control symptoms. It should be made explicit that women who are thought not to have PMS will receive continued health care and will not be abandoned to cope with their symptoms alone.

Women whose evaluations do not yield clear evidence of PMS or of another physical or mental illness should be shown that their daily symptom ratings do not reflect a PMS pattern, that their physical examination and laboratory tests do not suggest another physical illness, and that their psychological evaluation has ruled out a mental disorder. Some time should be spent with women with these experiences to acknowledge the reality of their symptoms, even though the meaning of their symptoms is unclear. For example, these women could be in the incipient phases of developing PMS where their symptomatology is inconsistent or of too low a severity to qualify for the diagnosis of PMS. These women should be encouraged to continue charting their daily symptoms, to return in 3 to 6 months for reevaluation, and to ensure adequate sleep, proper diet, and healthy exercise. Alternatively, other sources of symptoms that are not disclosed early in the evaluative process, such as stressful life situations, can be explored and appropriate supports offered at this time.

2. For Women Diagnosed with PMS

Once PMS is documented, a wide variety of psychosocial and preventive health interventions should be considered. These treatments have not been demonstrated to be helpful to all women and their clinical

Table VI Premenstrual Symptom Interventions

Symptoms

Intervention

Psychological Anxiety

Depression

Physical

Breast tenderness

Fatigue and/or insomnia Food cravings

Headaches

Multiple symptoms

Weight gain

Biofeedback Benzodiazepines Relaxation training Serotonergic anxiolytic, i.e., buspirone Cognitive-behavioral therapy Light therapy

Serotonergic antidepressants

(e.g., clomipramine, fenfluramine, fluoxetine, nefazadone, paroxe-tine, sertraline, and venlafaxine) Sleep deprivation

Tocopherol (vitamin E) Bromocriptine Tamoxifen Sleep hygiene

Serotonergic antidepressants High tryptophan (carbohydrate) diet Cognitive-behavioral therapy Serotonergic antidepressants

(e.g., fenfluramine) Aspirin (acetylsalicylic acid) Tylenol (acetaminophen) Ibuprofen Exercise

Cognitive-behavioral therapy Group therapy Psychoeducation Serotonergic antidepressants Support group

Wellness program (e.g., exercise, nutrition, stress reduction) Diuretics (e.g., spironolactone) Salt restriction scientific bases are not proven. Because the etiology of PMS is multifactorial and elusive, single pharmaco-logic interventions that "target" the causal mechanism of PMS have not been found. This fact should be reviewed carefully with each woman, and it should be understood that the goal of therapy is to find the unique approach that best addresses her specific needs and complaints (Table VI).

• Providing women with accurate information about their sexual health, the menstrual cycle, and PMS in general is crucial in dispelling myths and addressing the sense of helplessness a woman may feel in relation to her symptoms. Explanation of symp-

Pre-Menstrual Syndrome Treatment Interventions toms and the natural history of PMS, descriptions of various treatment strategies with anticipated benefits, risks, side effects, and alternatives may prove to be immensely reassuring.

• The temporal pattern of their symptoms should be reviewed with women who experience PMS. Visualizing the type, severity, and timing of her symptoms can bring to the woman a sense of control over her symptoms sufficient enough to relieve distress. Women should be encouraged to develop ways of ''planning ahead'' for their premenstrual symptoms and signs so that they can prepare their families, close associates, and themselves for their symptomatic times. Efforts to limit external stress as much as possible (e.g., not assuming extra obligations or tasks at certain times) may help some women to navigate their monthly cycles more effectively.

• Consuming large amounts of caffeine or its equivalent (theophylline and theobromine, or methyl-xanthines) has been associated with women's retrospective reports of more severe premenstrual symptoms. Because caffeine can cause irritability, insomnia, and gastrointestinal distress at any time of the month, it makes sense to limit the consumption of caffeine or related compounds throughout the month.

• Decreasing salt intake is commonly recommended as one way to minimize premenstrual bloating, although many women with this complaint do not actually gain weight premenstrually. As many women consume more salt than necessary and because some women do experience symptom relief from limiting their salt intake, it seems reasonable to recommend limiting salt intake at least prior to and during the usual symptomatic interval each month.

• Some researchers suggest that increased appetite and carbohydrate cravings have been linked to the need to increase sources of tryptophan for serotonin synthesis. A healthy diet of frequent meals including complex carbohydrates may relieve PMS symptoms and may be linked to the steady availability of tryptophan.

• Exercise has been shown to minimize some symptoms associated with fluid retention and to increase self-esteem. Except for women with obvious medical contraindications, women should be encouraged to participate all month in some kind of regular

Table VII Menstrual Cycle Interventions

Oral contraceptives GnRH analogues Oophorectomy Danazol

Estradiol implants and patches physical exercise. It is the frequency, not the intensity, of exercise that seems to make a difference.

If PMS symptoms persist after these measures have been tried, more rigorous pharmacologic and non-pharmacologic interventions may be necessary.

One approach to pharmacologic treatment of PMS is to control the overall menstrual cycle. This approach entails hormonal intervention. Four principal strategies have been used (Table VII):

• Oral contraceptives may minimize physical and psychological symptoms of PMS, as documented in both retrospective and prospective studies. Oral contraceptives may, however, also precipitate symptoms that resemble PMS, such as depression. In addition, risks and side effects of oral contraceptives include cardiovascular complications, migraine headaches, and increases in serum triglycerides. These considerations must be discussed and this strategy undertaken carefully.

• GnRH agonists and oophorectomy (i.e., surgical removal of ovaries) may effectively eliminate PMS symptoms, although this approach is associated with the unwanted effects of low estrogen production. Moreover, surgical risks must be balanced against the severity of PMS symptomatology to justify such an intervention. This strategy is best reserved for very debilitating PMS in older women, and only if less invasive methods have failed.

• Danazol is a synthetic androgen used to suppress the hypothalamic - pituitary - ovarian axis by inhibiting release of gonadotropin. It is superior to placebo when given daily, but many women cannot tolerate the side effects, which include weight gain and an imbalance of estrogen compounds and androgen (e.g., hirsutism, flushing, vaginitis).

• Estradiol implants have also been used successfully to treat PMS. The addition of synthetic progestin has been associated with a return of PMS symptoms but with significantly milder intensity than before hormonal treatment.

Pre-Menstrual Syndrome Treatment Interventions

A second approach is to manage specific psychological symptoms. With respect to severe psychological symptoms, it is crucial first to verify that the woman, despite her discomfort, is sufficiently safe. A woman who is depressed to the point of being suicidal, or who is so angry that she might harm someone else, should be carefully protected. Four psychiatric medicines that address depression and anxiety have been used effectively in some patients with PMS: Xanax (benzodiazepine anxiolytic, GABA agonist), buspirone (anxiolytic, serotonin 1a agonist), nor-tryptiline (tricyclic antidepressant, noradrenergic and serotonergic agonist), and fluoxetine, sertraline, and others (antidepressants, selective serotonin reuptake inhibitors). These medications have both proven benefits and numerous side effects, and their use must be dictated by clinical judgment. For example, Xanax is a medication that addresses time-limited, target anxiety symptoms extremely well, but is sedating and highly addicting. Nortryptiline helps depressive symptoms effectively, but it may cause dry mouth, constipation, and sexual dysfunction. The serotonergic medications (e.g., Prozac, Zoloft) alleviate PMS symptoms (even in the absence of depression), but usually are taken daily and, while generally well-tolerated, may have unpleasant side effects (e.g., jitteriness, headaches, nausea). For these reasons, all medication choices must be approached carefully and monitored closely. [See Psychopharmacology.]

A third approach is to manage the predominantly physical symptoms of women with PMS. Here the interventions will depend on the medical issues and complaints. Diuretics can be helpful if patients have documented weight gain and evidence of fluid retention. Spironolactone has been a preferred diuretic medication because of its potassium-sparing properties. Other diuretics may be used so long as the possibility of hypokalemia is monitored. Vitamin E, bromo-criptine (a dopamine agonist that can cause nausea), and tamoxifen (an oral nonsteroidal agent with anti-estrogen properties that can cause headaches and fatigue) have all been shown to be beneficial for breast pain. Over-the-counter analgesics may be very valuable and safe in treating PMS-related headaches. In addition to good sleep routines for insomnia and healthy eating routines for food cravings, serotonergic antidepressants may be helpful for addressing fatigue and fostering stable eating patterns.

The choice of treatment should be grounded in the understanding of the woman's needs in terms of which symptoms are most troublesome for her, which treatment interventions are likely to be most effective for these symptoms, and which treatment strategies will be most acceptable to the patient according to her values and way of life.

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