Pharmacologic strategies for managing premenstrual syndrome

The diagnosis and pharmacologic management of premenstrual syndrome (PMS) are reviewed. PMS refers to physical or affective symptoms that appear during the latter half of the menstrual cycle, remit during menses, and affect the woman's relationships or ability to function. Pharmacologic treatments proposed for PMS include (1) hormonal treatments that alter the menstrual cycle, (2) hormonal treatments based on specific proposed etiologies, (3) drugs that affect fluid balance, (4) inhibitors or precursors of prostaglandins, (5) nutritional supplements, (6) psychotropic medications, and (7) nonprescription preparations. The menstrual cycle can be manipulated with transdermal estrogen and cyclic oral progesterone, oral contraceptives, danazol, or gonadotropin-releasing hormone agonists with steroid hormone replacement. Psychological symptoms may be treated with fluoxetine, clomipramine, or alprazolam. Patients may be given a diuretic for fluid retention; bromocriptine, tamoxifen, or danazol for mastodynia; and nonprescription analgesics for headaches. PMS can be managed through (1) a symptom-oriented management approach or (2) modification of the menstrual cycle. Pharmacotherapy should be initiated only after simpler measures have failed, and the medication must be chosen carefully, with the severity of the impairment weighed against adverse effects of the treatment.