Managing Premenstrual Syndrome

Pharmacists should help women with premenstrual syndrome to choose OTC treatment that targets their specific symptoms.

Premenstrual syndrome, commonly referred to as PMS, is characterized by a combination of both physical and emotional symptoms that can occur during the luteal phase of a woman’s menstrual cycle, followed by a resolution of symptoms within the first few days after the onset of menstrual bleeding.^1,2 Although the exact cause of PMS is unknown, it is believed that normal ovarian function and fluctuations of estrogen and progesterone levels may be the trigger for the symptoms associated with PMS.^1,3 Premenstrual dysphoric disorder (PMDD) is a severe form of PMS experienced by approximately 5% of women.^1-4

The symptoms associated with PMS vary from woman to woman (Table^1-5 ), but typically are consistent for an individual woman each month.¹ Almost all women experience some physical symptoms, food cravings, or mood changes before the onset of menses.¹ According to a report from the American Congress of Obstetricians and Gynecologists (ACOG), an estimated 85% of menstruating women experience at least 1 PMS symptom.²

Approximately 40% of women describe their premenstrual symptoms as bothersome and another 10% to 15% describe their symptoms as severe, whereas 3% to 5% feel their symptoms have a considerable negative impact on their quality of life.¹ The symptoms of PMS can occur at least 5 to 11 days prior to the start of menses and typically cease upon initiation of menses or shortly thereafter.^1,4 The 2 most common physical PMS symptoms are bloating/ weight gain/swelling and breast tenderness.¹ Fatigue, anxiety, and irritability are also commonly experienced by many women.¹

Depressive and anxiety disorders are the most common conditions that overlap with PMS. 6 Furthermore, an estimated 50% of women seeking treatment for PMS have one of these disorders.⁶

Treating PMS

Many experts recommend the implementation of nonpharmacologic options, such as dietary modifications, regular exercise, and stress-reduction techniques, as first-line therapy. 1-3 Studies have shown that women who exercise regularly may experience PMS symptoms less often and experience milder symptoms compared with women who do not exercise.^1-3 Reducing or eliminating intake of caffeine, salt, and alcoholic beverages and eating foods rich in complex carbohydrates and low in protein during the premenstrual phase of a cycle may also decrease the incidence of PMS symptoms.^1-3

There are also OTC products marketed for women to manage PMS symptoms. Statistics report an estimated 20% to 50% of women use nonprescription products, primarily analgesics and vitamins, for symptomatic relief from PMS symptoms.¹

Treatment of the symptoms of mild to moderate PMS typically involves the incorporation of OTC agents that are formulated with nonsteroidal antiinflammatory drugs (NSAIDs), diuretics, and vitamins and minerals, and sometimes includes herbal ingredients, such as evening primrose oil, chasten berry, or black cohosh.¹ Combination products, such as Midol and Pamprin, contain an analgesic (acetaminophen), a diuretic (pamabrom), and an antihistamine (pyrilamine maleate). Patients should be aware of the adverse effects of drowsiness that may be associated with the use of combination products containing antihistamines.¹

The FDA has approved 3 nonprescription diuretics for relief of water retention, bloating, weight gain, and swelling.¹ These include ammonium chloride, caffeine, and pamabrom.¹ Pamabrom is the diuretic most commonly found in OTC menstrual products.¹ Patients with a history of peptic ulcer disease or anxiety/insomnia disorders should not use products containing caffeine or pamabrom. In addition, the use of ammonium chloride is contraindicated in individuals with renal or hepatic impairment due to the possibility of metabolic acidosis.¹ Patients taking monoamine oxidase inhibitors or xanthine medications, such as theophylline, should avoid the use of diuretics containing caffeine.¹

Miscellaneous Therapies

Analgesics

Analgesics (acetaminophen or NSAIDs) may reduce physical symptoms such as headache, cramps, and/or pain when taken for 1 week prior to and during the first days of menses. Patients should be advised to take only the recommended dose and be advised of the adverse effects associated with its use.¹

Vitamin E

Although more studies are needed, vitamin E has been shown to ease the discomfort associated with breast tenderness.^1,3 Patients should take only the recommended amount of 400 IU daily. ¹

Calcium and Vitamin D

Studies have shown that calcium eases both emotional and behavioral symptoms, such as mood swings, food cravings, and depression, and physical symptoms, such as breast tenderness, backaches, abdominal cramping, and fluid retention.¹ Patients should take 1200 mg daily in divided doses and take no more than 500 mg per dose. Because calcium may cause gastric upset or constipation, it should be taken with food. Results from other studies report that daily intake of 1200 mg of calcium and 400 IU of vitamin D may prevent the development of the symptoms associated with PMS.^1,6

Magnesium

A trial study showed that a daily dose of 360 mg of magnesium taken during the luteal phase may provide some relief of PMS symptoms.^1,6,7 Theories suggest that magnesium deficiency may lead to symptoms of irritability associated with PMS.^1,3 Patients should be advised to take 360 mg of magnesium daily during the premenstrual phase only.^1,6,7 Magnesium may cause diarrhea in some patients.^1,4

Pyridoxine (Vitamin B₆ )

Vitamin B₆ has also been used for treating PMS symptoms such as irritability, fatigue, bloating, and depression. Recommended doses should be limited to 100 mg daily to reduce the incidence of neuropathy.¹

Counseling Points

Pharmacists are instrumental in ascertaining if the use of these OTC medications is appropriate. Prior to recommending the use of any of these products, pharmacists should screen for possible drug—drug interactions and contraindications.

Selection of treatment for PMS symptoms should be individualized and dependent upon the severity of the patient’s symptoms, as well as medical history, allergy history, and current medication profile, including alternative medications. Patients should only use products to treat their specific symptoms and avoid the use of unnecessary products to prevent possible complications.

It is important to refer women whose symptoms do not improve after use of OTC products, or those with more severe symptoms such as those associated with PMDD, to seek medical advice from their primary health care provider for further evaluation. In addition, patients with preexisting medical conditions and lactating women should always seek advisement from their primary health care provider before taking any of these products, including herbal medications.

Pharmacists should ensure that patients understand the proper use of these products and the adverse effects associated with their use. In addition, pharmacists can make recommendations about nondrug measures, such as using relaxation techniques, establishing an exercise routine, eating a balanced diet that includes avoiding or limiting intake of salt, caffeine, and alcohol, getting sufficient rest, and avoiding stress. PT

Table 2: Examples of Nonprescription Combination Menstrual Products

Brand Name

Active Ingredients

Excedrin Menstrual Relief

Acetaminophen 250 mg, aspirin 250 mg, caffeine, 65 mg

Midol Maximum Strength Menstrual Complete

Acetaminophen 500 mg, caffeine 60 mg, pyrilamine maleate 15 mg

Midol Extended Relief Menstrual Complete

Acetaminophen 500 mg, caffeine 60 mg, pyrilamine maleate 15 mg

Midol PM

Naproxen sodium 220 mg

Midol Teen

Acetaminophen 500 mg, pamabrom 25 mg

Pamprin Multisymptom Caplets

Acetaminophen 500 mg, pamabrom 25 mg, pyrilamine maleate15 mg

Premsyn PMS Maximum Strength Premenstrual Relief

Acetaminophen 500 mg, pamabrom 25 mg, pyrilamine maleate 15 mg

AquaBan Tablets

Ammonium chloride 325 mg, caffeine 100 mg

Diurex PMS Tablets

Pamabron 25 mg, acetaminophen 500 mg, pyrilamine maleate 15 mg

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

References

1. Lodise N, Shrimp L. Disorders related to menstruation. In: Berardi R, Newton G, McDermott JH, et al, eds. Handbook of Nonprescription Drugs. 16th ed. Washington, DC: American Pharmacists Association; 2009:145-153.

2. Raines K. Diagnosing premenstrual syndrome. Medscape Web site. www.medscape.com/viewarticle/718973. Accessed May 3, 2011.

3. Premenstrual syndrome. United States Department of Health and Human Services. National Women’s Health Information Center Web site. www.womenshealth.gov/faq/premenstrual-syndrome.cfm. Accessed May 3, 2011.

4. Premenstrual syndrome. Medline Plus Web site. www.nlm.nih.gov/medlineplus/ency/article/001505.htm. Accessed May 4, 2011.

5. Premenstrual syndrome (PMS). The Merck Manuals Online Medical Library Web site. www.merck.com/mmpe/sec18/ch244/ch244g.html. Accessed May 4, 2011.

6. Premenstrual Syndrome. American College of Obstetricians and Gynecologists (ACOG) Web site. www.acog.org/publications/patient_education/bp057.cfm. Accessed May 4, 2011.

7. Facchinetti F, Borella P, Sances G, Fioroni L, Nappi RE, Genazzani AR. Oral magnesium successfully relieves premenstrual mood changes. Headache. 1991; 31(5):298-301.