Premenstrual syndrome

Disease Description (Causes and Symptoms)

• Definition: A condition in which physical, psychological, and behavioral symptoms occur periodically during the luteal phase (after ovulation to just before menstruation) and interfere with daily activities. When symptoms are severe enough to cause functional impairment, it is classified as premenstrual dysphoric disorder (PMDD).
• Causes and pathophysiology:
  • The exact cause is unknown. Changes in the sensitivity of the central nervous system to hormonal changes after ovulation (changes in progesterone and estrogen) are involved.
  • Cyclical changes in neurotransmitters such as serotonin are associated with emotional symptoms.
  • Nutrient deficiencies (calcium, magnesium, vitamin E, etc.), excessive caffeine or sugary food intake, and other factors have been reported to worsen symptoms.
• Main symptoms:
  • Psychological and behavioral: anxiety, depression, irritability, mood swings, restlessness, social withdrawal, impulsive behavior (in severe cases, verbal abuse and interpersonal conflict), decreased concentration
  • Physical: breast pain, edema (swelling of the hands and feet), headache, back pain, fatigue, abdominal bloating, muscle pain, appetite changes (cravings for salty or sweet foods)
• Diagnostic points:
  • Consistency and cyclicity of symptoms (recurrent during the luteal phase and disappearing after menstruation begins)
  • Confirmation through a symptom diary documenting at least 2 cycles (including symptom severity and timing)
  • Exclusion of other medical conditions (hypothyroidism, hypoglycemia, brain, breast, or ovarian tumors, etc.) and medication effects

Treatment

• Lifestyle and non-pharmacological treatment (first-line recommendation)
  • Regular aerobic exercise (3–5 times per week), adequate sleep, and stress management (relaxation techniques and meditation)
  • Dietary changes: limit caffeine and alcohol and excessive salt and sugar intake; eat small, regular meals
  • Nutritional supplements: calcium (there is evidence that it may relieve symptoms); magnesium, vitamin B6, and vitamin E supplements may provide some benefit (consult a doctor)
  • Cognitive behavioral therapy (CBT) is beneficial for improving emotional symptoms
• Medication treatment
  • Selective serotonin reuptake inhibitors (SSRIs; e.g., fluoxetine, sertraline, etc.): first-line medication treatment for moderate to severe symptoms or functional impairment. Continuous (daily) or luteal-phase-only (intermittent) dosing may be used, at the doctor’s discretion.
  • Oral contraceptives (specific combination formulations): may help relieve symptoms (some effects have been reported, particularly with formulations containing drospirenone). Individual side effects and contraindications must be checked.
  • Diuretics (e.g., spironolactone): short-term use may be considered in cases of severe edema or substantial weight gain.
  • Analgesics/anti-inflammatory drugs (NSAIDs): used to relieve breast pain, back pain, and headache.
• In severe cases or when there is a risk of self-harm thoughts
  • Concurrent evaluation and treatment by the Department of Psychiatry (antidepressant dose adjustment, psychotherapy, and suicide risk management)
• Precautions, risk of complications, and self-care considerations
  • Treatment does not often result in a complete cure. Symptoms tend to improve after menopause, but may persist in some people.
  • Increased long-term risk of depression; symptoms may impair functioning at work and in interpersonal relationships.
  • Check medication side effects in advance (gastrointestinal symptoms and sexual-function changes with SSRIs, risks associated with oral contraceptives, etc.).
  • If you are planning a pregnancy or are pregnant, be sure to consult a doctor about the safety of specific medications.

Checklist Before an Outpatient Visit (Including Example Questions)

• Items and records to prepare
  • List of medications and supplements currently being taken (name, dosage, and duration of use)
  • Recent test results (blood tests, thyroid tests, etc.) and past medical certificates or medical opinions
  • Menstrual and symptom diary: for at least 2 months, record daily symptoms (type and severity, impact on daily functioning) and start and end dates
  • Lifestyle information: sleep, caffeine, alcohol, smoking, amount of exercise, and stressors
• Assessments that may be performed during an outpatient visit
  • Physical examination (including breast and pelvic examinations if necessary), blood tests (thyroid function, electrolytes, anemia, etc.), and imaging tests if necessary
• Example questions (it is useful to record these yourself before the appointment)
  • Please record the dates when premenstrual symptoms began and disappeared over the past two months.
  • Please record whether the symptoms caused absence from work, interpersonal problems, or impaired daily functioning.

Examples of General Questions to Ask the Doctor

• What are the expected effects and side effects of this medication (or treatment)?
• How severe are my symptoms, and what is the prognosis?
• How safe is it to plan a pregnancy or breastfeed while taking this medication?
• What effective non-pharmacological treatments are available in addition to medication (exercise, diet, psychotherapy)?
• When do you recommend that I return for a follow-up visit (when to assess effectiveness and what to do if side effects occur)?

Examples of Condition-Specific Questions

• Do my symptoms meet the criteria for PMDD (premenstrual dysphoric disorder), and if so, should I start an SSRI?
• If I take an SSRI, which is more appropriate: daily dosing or luteal-phase-only dosing, and how long is it generally necessary to take it?