Introduction
Premenstrual syndrome (PMS) affects women of fertile and childbearing age. The syndrome has various signs and symptoms, including mood swings, depression, food cravings, tiredness, and irritability. The symptoms appear a week or two before the menstrual cycle and end soon after the start of menstruation. Studies suggest that three out of four menstruating women experience at least a few symptoms of PMS in their fertile age. Moderate to severe PMS can impair a woman’s daily activities and quality of life (QoL). It is because women have reduced work productivity, absenteeism, and more use of healthcare services. Due to the symptom variability underlying PMS and the lack of knowledge regarding the exact disease mechanism, scientists have tested many treatments. Various treatments and self-care techniques can control the symptoms in most women. Also, research on newer treatments for PMS is crucial for better symptom management and outcome.
What Are the Novel Treatment Approaches for Premenstrual Syndrome Management?
Most treatment and lifestyle changes have been studied to assess their impact on PMS. Observing and documenting symptoms during several menstrual cycles can help detect if the treatment was effective. The complex disease mechanism of PMS involves central neurotransmitters (chemical messengers through which the nerve cells communicate), hormones, and steroids produced within the brain. Hence, the main therapeutic approaches target these. Several medications and other options are used for PMS treatment. However, a few are approved for the same.
1. Pharmacological:
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Selective Serotonin Reuptake Inhibitors: Serotonin is a critical neurotransmitter in the brain regulating mood and behavior. Women with PMS have deranged serotonin transmission, fewer serotonin transporter receptors, and decreased blood serotonin levels. The first-line treatment for PMS comprises selective serotonin reuptake inhibitors (SSRIs, antidepressants that increase brain serotonin levels), namely, Paroxetine, Fluoxetine, Sertraline, and Escitalopram. The dose must be started 14 days before the expected menstruation. Further, SSRIs must be taken for a minimum of three months for full effect.
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Combined Hormonal Contraception: Combined hormonal contraception (CHC) maintains a steady level of estrogen and progesterone during the menstrual cycle. The most effective combination is the progestin Drospirenone and a low-dose estrogen. A 2020 study in Central Africa in 424 females of fertile age revealed that hormonal contraceptives were positively linked with reduced symptoms of PMS. Furthermore, the women handled life better, were more active, and were happier in personal relationships. The reported side effects are nausea, spotting, and breast tenderness.
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GnRH Agonists: GnRH (gonadotropin-releasing hormone) regulates the release of gonadotropins (sexual hormones). Gonadotropins lead to egg cell growth and maturation and cause ovulation. GnRH agonists treat severe PMS in rare cases. These medications interfere with the hormone balance in the body, reducing the ovarian production of hormones. However, they can cause hot flashes and insomnia (sleeplessness). Moreover, they can also mimic symptoms similar to those of PMS, such as depression and anxiety. One must note that these medications should not be taken for more than six months.
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Progesterone: Some women take progesterone before their period. As PMS characterizes low progesterone levels, external supplementation can optimize body levels of progesterone. However, the only approved progesterone-containing product for PMS treatment is a gel for reducing breast tenderness in Germany. Progesterone easily passes through the blood-brain barrier (BBB). Also, progesterone receptors (PRs) are widespread in the brain.
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Selective Progesterone Receptor Modulators: Selective progesterone receptor modulators (SPRMs) represent PMS treatment due to their opposite action on PRs. Ulipristal acetate, an SPRM, is a suitable option at a low dose of 5 milligrams (mg) daily to improve emotional and behavioral symptoms in women with PMS. Furthermore, SPRMs are an alternative treatment when SSRIs are not tolerated. Newer SPRMs can offer promising results in the future for women struggling with severe PMS.
2. Non-pharmacological:
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Herbal Products: Studies show that herbal products such as evening primrose oil, Vitex agnus castus (a shrub), Hypericum perforatum (St. John’s wort), saffron, or Ginkgo biloba are effective in reducing PMS symptoms. However, there is weak evidence regarding the use of herbal products for PMS.
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Complementary Therapies: Research suggests that calcium can relieve PMS symptoms at 1,000 to 1,200 mg daily. Pyridoxine (vitamin B6) may also help at 50 to 100 mg daily. One must note that these have to be continuously taken during the month. Magnesium is another tested supplement that reduces anxiety, breast tenderness, mood fluctuations, muscle pain, and bloating in about 90 percent of women. However, the studies on magnesium reveal mixed results.
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Other Treatments: Cognitive behavioral therapy (CBT) can help females live better with PMS. CBT aids women by identifying and altering deleterious thoughts and behavior. Studies show that women with mild to moderate PMS can benefit from relaxation techniques and psychoeducation (counseling and therapy). On the other hand, severe PMS requires CBT. Acupuncture and massages have also been tried, with conflicting results in studies. Also, regular physical activity is effective in relieving both physical and mental symptoms of mild to severe PMS. However, further research is warranted to study the impact of physical activity.
3. Surgical: Surgical management through oophorectomy (removal of ovaries) and hysterectomy (uterus removal) has also been studied. But, surgery is invasive and irreversible. Therefore, it should be only considered as the last treatment.
What Is the Role of Future Research in Newer Treatments for Premenstrual Syndrome?
Increasing research investigates a strong association between severe PMS and psychiatric disorders. Women with severe PMS are at higher risk of post-partum depression and suicidal tendencies. Further, they manifest increased occurrences of generalized anxiety disorder, bipolar disorder (BPD), eating disorders such as bulimia or anorexia nervosa, nicotine or alcohol dependence, and poor sleep quality. Exposure to traumatic events, physical and emotional abuse, and post-traumatic stress disorder (PTSD) correlate with PMS. Moreover, personality traits and negative attitudes toward menstruation cause maladaptation to physiological menstrual cycle changes. Based on these findings, identifying behavioral and cognitive features associated with PMS is crucial to provide proper treatment and improve QoL.
Conclusion
The current PMS treatments are insufficient. Selective serotonin reuptake inhibitors are not suitable for all women patients. Selective progesterone receptor modulators are a promising and well-tolerated alternative. Patients can maintain a diary that elaborates on their symptoms and yield early diagnosis and treatment. Nurses and physicians can be helpful if they collect a questionnaire from patients for their symptoms during the monthly visit. To increase knowledge on the disease mechanism of PMS and its treatment, future studies are needed to describe the association between mental health and PMS. Thus, it can promote the evolution of targeted treatments.
