Premenstrual syndrome (PMS), a common cyclic disorder of young and middle-aged individuals who menstruate, is characterized by emotional and physical symptoms that consistently occur during the luteal phase of the menstrual cycle and resolve with menstruation. It affects 20 to 32 percent of premenopausal persons. People with premenstrual dysphoric disorder (PMDD) experience affective or somatic symptoms that cause severe dysfunction in their social or occupational life, leading to significantly lower quality of life, increased absenteeism from work, decreased work productivity, and impaired relationships with others. PMDD affects 3 to 8 percent of premenopausal individuals .
The American College of Obstetrics and Gynecology ( ACOG) recommends the PMS diagnostic criteria developed by the University of California at San Diego and the National Institutes of Mental Health . PMS can be diagnosed if the patient reports at least one of the following affective symptoms including depression, angry outbursts, irritability, anxiety, confusion, or social withdrawal, and at least one of the somatic symptoms including breast tenderness, abdominal bloating, headache, or swelling of extremities during the 5 days before menses in each of the 3 prior menstrual cycles. In addition, these symptoms are typically relieved within 4 days of the onset of menses, without recurrence until at least cycle day 13 . People who menstruate who have more severe affective symptoms can meet the criteria for diagnosis of PMDD.
Figure 1. Effects of PMDD on the brain and body 
The etiology of PMS and PMDD remains unknown and is speculated to be complex or multifactorial. Several studies suggest that cyclical changes in estrogen and progesterone levels trigger the symptoms . Mood changes may be attributable to the effect estrogen and progesterone have on the serotonin, gamma-aminobutyric acid, and dopamine receptors in the brain. These hormones can also alter the renin-angiotensin-aldosterone system, which could explain some of the bloating and swelling that occurs during the luteal phase.
People with mild symptoms should be instructed about lifestyle changes including a healthy diet, sodium and caffeine restriction, aerobic exercise, and stress reduction techniques like yoga. For individuals with moderate symptoms, treatment includes both medications and lifestyle modifications.
Non-pharmacologic interventions for PMS include patient education, supportive therapy, and behavioral changes  [7}. Individuals who menstruate who have been educated about the biological basis and prevalence of PMS report an increased sense of control and relief of symptoms . Small trials have shown the benefits of relaxation therapy and cognitive behavioral therapy. Behavioral measures include keeping a symptom diary, getting adequate rest and exercise, and making dietary changes. Sodium restriction has been shown to help minimize bloating, fluid retention, and breast swelling. Caffeine restriction helps decrease premenstrual irritability and insomnia. Aerobic exercise and yoga have both been shown to significantly reduce pain intensity and PMS symptoms.
Many of the medications used to treat PMS and PMDD suppress ovulation, like birth control pills; whereas others affect the concentration of neurotransmitters such as serotonin, norepinephrine, or dopamine in the brain. The third group of medical agents used to treat PMS and PMDD are SSRIs (Selective Serotonin Reuptake Inhibitors).
Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for severe symptoms of PMS and PMDD . Sertraline (Zoloft), Paroxetine (Paxil), Fluoxetine (Prozac), Citalopram (Celexa), and Escitalopram (Lexapro) can be used to treat the psychiatric symptoms of PMS and PMDD and have been shown to relieve some of the physical symptoms . Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), such as Venlafaxine, has been used off-label to treat PMDD in individuals with predominantly psychological symptoms . Quetiapine (Seroquel) is an antipsychotic medication that has been studied as an adjunctive treatment with an SSRI or SNRI in patients with PMS or PMDD who did not respond to SSRI or SNRI alone .
Studies have suggested that oral contraceptive pills, when taken continuously, provide more benefit when treating physical and psychiatric symptoms of PMS and PMDD . Other medications which have been studied are Calcium, Vitamin D, Vitamin B6; but these have been studied in small studies, and more data is needed to recommend these as first-line treatment. Some Chinese herbal supplements and acupuncture have been studied for the treatment of PMS/PMDD. However, the evidence is too limited and the study quality is too poor to suggest benefit .
PMS and PMDD are disorders that affect a significant proportion of reproductive-aged individuals and create significant impairment amongst individuals of working age. Early diagnosis and effective treatment with lifestyle changes, exercise, dietary changes (including introducing dietary supplements like calcium, vitamin D, and vitamin B6), as well as medications like birth control pills and SSRIs help effectively control these disorders and help these people lead a more productive life.
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