Drug Update: Premenstrual Syndrome.

About 95% of women in their reproductive years are affected by premenstrual syndrome, and 5% of these women have a severe form of the condition known as premenstrual dysphoric disorder.

Premenstrual dysphoric disorder (PMDD) is cyclical and is often characterized by irritability, depression, and drastic mood swings. Unlike other mood disorders, it is also accompanied by symptoms such as bloating and breast tenderness.

Women with PMDD tend to respond quite well and quite rapidly to selective serotonin reuptake inhibitors (SSRIs) and to tricyclic antidepressants that inhibit serotonin reuptake. SSRIs can be used intermittently with an effect that may be as good as that with continual use. Women who fail to respond to these treatments may re quire suppression of their menstrual cycle to alleviate symptoms.

Milder premenstrual symptoms are usually treated with a nonsteroidal anti-inflammatory drug.

Diagnosis of PMS and PMDD is based on the timing and type of symptoms. Symptoms must occur the week before menses and must remit at onset or within a few days of the onset of menses. Symptoms should be charted with a daily diary for at least two cycles to identify patterns, and a careful history should be taken to rule out other diagnoses.

PMS symptoms include breast tenderness, bloating, headache, and minor mood changes. A PMDD diagnosis requires at least 5 of the following 11 symptoms, including at least 1 of the first 4, and the symptoms must have an adverse effect on daily life: dysphoria or depressed mood, anxiety or tension, affective lability, irritability, decreased interest in usual activities, concentration difficulties, lack of energy, overeating and food cravings or marked change in appetite, hypersomnia or insomnia, feeling overwhelmed, and physical symptoms such as breast tenderness and bloating.

Some patients with PMS respond to improved nutrition and supplementation with vitamin B6, vitamin E, calcium, and/or magnesium, as well as to exercise and stress reduction. But patients with PMDD get little relief from these measures and need pharmacologic treatment.