Premenstrual Syndrome (PMS): Symptoms, Causes, and Management Options

Premenstrual syndrome (PMS) encompasses recurrent physical and emotional symptoms in the luteal phase (1–2 weeks before menses) that resolve with menstruation. Affects ~90% of menstruating women; ~20–40% seek care; 3–8% meet criteria for PMDD (severe form).

Common Symptoms

Physical	Emotional/Behavioral
Bloating, weight gain	Irritability, anger
Breast tenderness/swelling	Anxiety, tension
Headaches/migraines	Mood swings, tearfulness
Fatigue, insomnia	Depressed mood, hopelessness
Acne flare	Difficulty concentrating
Joint/muscle pain	Food cravings, appetite changes
Constipation/diarrhea	Social withdrawal

Pathophysiology

• Sensitivity to normal cyclical hormonal fluctuations (estradiol, progesterone), not hormone levels per se.
• Serotonin and GABAergic system dysregulation implicated.
• Genetic predisposition (heritability ~50–60%).
• Stress, diet, inactivity, smoking exacerbate.

Diagnosis

Prospective daily symptom rating for ≥2 cycles (e.g., DRSP, COPE). Symptoms must impair function and be absent in follicular phase.

Management

Lifestyle (First-Line for Mild)

• Regular aerobic exercise (150 min/week).
• Balanced diet: complex carbs, calcium-rich, limit salt/caffeine/alcohol/sugar.
• Stress reduction: CBT, mindfulness, yoga.
• Sleep hygiene.

Pharmacologic

• SSRIs (first-line for moderate/severe): Fluoxetine, sertraline, paroxetine — continuous or luteal-phase only. Rapid onset for PMS.
• Combined oral contraceptives: Especially drospirenone-containing (Yaz) — suppress ovulation, stabilize hormones.
• NSAIDs: For physical symptoms (breast pain, headaches, cramps).
• Spironolactone: For fluid retention/bloating.
• GnRH agonists (+ add-back): Severe refractory cases.

Supplements (Limited Evidence)

• Calcium 1200 mg/day (best evidence).
• Vitamin B6 ≤100 mg/day.
• Magnesium, Vitex agnus-castus — mixed data.

Track symptoms, discuss with your clinician. Effective treatment exists—don't suffer silently.