INTRODUCTION:

Menstruation is a huge problem in every woman's life. It can start as late as 17 years old or as early as 9 years old, but the typical beginning age is 12. Menstrual periods are not always stable or regular; several types of illnesses that are typically associated with the extremes of reproductive age might cause abnormalities to the cycle. Over the course of a woman's lifetime, her body goes through several changes¹. The two primary changes that take place throughout the teenage stage are the attainment of puberty and the beginning of menstruation. The menstrual cycle, which can be related to a variety of physical, behavioural, and psychological symptoms that may occur before or during the menstrual flow, is one of the major changes that begin in adolescence². Premenstrual syndrome is defined by physical, emotional, and behavioural symptoms that appear during the luteal phase and disappear on their own within a few days of the commencement of menstruation. Most women who are of reproductive age have menstruation symptoms of some kind. These symptoms severely hamper women’s daily life, including their personal and professional lives³. Every month, the symptoms last an average of six days, with the severity of the symptoms typically peaking two days before or on the first day of the menstrual flow. A more severe illness known as premenstrual dysphoric disorder (PMDD) includes disruption of personal relationships, functional disability, and chronic depression⁴. A variety of symptoms and signs associated with mental state, behaviour and physical markers are indicated of PMS. Tension, irritability, despair, anxiety, mood swings, cravings for foods that contain carbohydrates, insomnia, and physical complaints such as breast tenderness, peripheral wounds, and stomach bloating are the most commonly reported⁵. Although 150 symptoms and biomarkers have been attributed to PMS, there isn't a confirmed laboratory test for this disorder⁶. There are several proposed aetiologies for PMS. The primary cause of PMS is an aberrant hypothalamic-pituitary-adrenal (HPA) axis that results in an adrenal hormone secretion abnormality. Other contributing variables include environmental influences and nutritional deficiencies⁷. One of the most important theories to explain the physio pathological process of premenstrual syndrome is the endocrine system⁸. The symptoms range from mild to moderate to severe, with 5-8% of cases causing significant distress or functional impairment. Menstrual disorders affect 75% of adolescent females and are a common reason for them to seek medical care⁹. According to data from the Zurich cohort studies, 14% of women in the age group of 21 to 35 have mild symptoms and 8% have severe premenstrual disorders¹⁰. Clinically significant premenstrual symptoms were referred to as premenstrual tension (PMT) or premenstrual syndrome (PMS) in the earliest research papers on this issue¹¹. "Premenstrual tension syndrome" is included in the WHO's International Classification of Diseases (ICD) under the category "Diseases of the Genitourinary Tract¹². “Clinicians and the general public need to be better informed about PMS because it has been linked to higher rates of healthcare expenditure. However, some medical professionals continue to view PMS as a non-serious clinical condition, and as a result, they lack concern for women who experience it¹³.

Epidemiology:

During the luteal phase of women's menstrual cycle, up to 80% of women report one or more behaviour- related, psychological or physical symptoms without experiencing an important interruption to their regular functioning. 20 to 32% of premenopausal women suffer mild to moderate PMS symptoms that interfere with some aspect of their lifestyle; 3 to 8% of premenopausal women suffer more severe PMDD symptoms¹⁴. However, the prevalence of PMDD varies significantly amongst studies, most likely as a result of various study definitions for PMDD. In the beginning, PMS and PMDD seemed to be exclusive to women in Western societies, but recent study data has shown symptoms indicating that PMS and PMDD occur globally at comparable rates^15-17.

Aetiology

Though the exact cause of PMS is unreliable, ovarian hormone levels are related to the occurrence of symptoms. PMS-affected women are most susceptible to the regular fluctuations in hormone levels that take place during the menstrual cycle¹⁸. By using ovulation inhibitors, during pregnancy, and after menopause, symptoms frequently improve. This gives compelling proof for ovarian cyclic function. It is yet unknown, nevertheless, exactly how ovarian function correlates to the development, appearance, and cure of symptoms. Single-nucleotide polymorphisms in the oestrogen receptor alpha (ESR1) gene have been associated with PMDD, according to a study¹⁹. Premenstrual symptoms can also be decreased by regulating neurotransmitters including serotonin and amino butyric acid (GABA) dysregulation using antidepressants or anxiolytic agents. Thus, it looks like that these neurotransmitters are crucial for the symptoms associated with pre mensuration²⁰. Although PMS and the luteal phase have some similarities, the exact causes of PMS are unknown, though a number of variables may be at issue. Hormone fluctuations during the menstrual cycle appear to play a significant role; some women are more affected than others. PMS does not appear to be caused by chemical changes in the brain, stress, or mental issues like depression, but they can worsen it. Bloating and water retention can be made severe by low vitamin and mineral levels, high sodium, alcohol, and/or caffeine²¹.

Pathophysiology:

There is still unclear pathophysiological explanation for PMS in research. Early hypotheses suggested that there might be abnormalities in ovarian sex steroid levels; however, they have been contradicted because no research has shown variations in progesterone levels or between symptomatic and asymptomatic women. The ovarian cycle is thought to be of primary aetiology and this view is corroborated by the absence of symptoms prior to puberty, during pregnancy, beyond menopause and when receiving gonadotrophic releasing hormone (GnRH) analogue therapy. Sex steroids possess a large number of receptors throughout the brain, including the amygdala and hypothalamus, and they can readily cross the blood–brain barrier²². Progesterone is thought to be metabolized in the brain to allopregnanolone and pregnanolone, which activate the inhibitory neurotransmitter system of gamma-amino butyric acid (GABA). GABA A receptors has been correlated to changes in affect, mood, and ways of thinking. Pregnanolone and allopregnanolone have anxiolytic, sedative, and anaesthetic activities at high concentrations; at lower concentrations, allopregnanolone can induce aggression, anxiety, and depressive symptoms. After exposure to high amounts of allopregnanolone, the GABA receptors lose their sensitivity to the hormone, which results in exacerbated luteal phase symptoms²³. Progesterone and oestrogen also influence brain serotonergic function. Depression is caused by progesterone's increased levels of monoamine oxidase (MAO), which reduces 5-hydroxytryptamine (5-HT) availability. Oestrogen on the other hand, causes the breakdown of MAO, which raises free tryptophan levels in the brain. This, in turn, promotes serotonin transport, activates 5-HT binding sites in the brain, and has an antidepressant effect²⁴.

Classification:

Using specific criteria, the International Society of Premenstrual Disorders (ISMDs) separates PMS into "core" and "variant" categories. Premenstrual disorders, also known as core or typical PMDs, are the most prevalent type of PMS. Similar to other PMDs, symptoms should interfere with day-to-day activities, performance at work or school, and relationships between people. The nonspecific (often physical, emotional, or mixed) symptoms of core PMDs repeat during spontaneous ovulatory cycles²⁵.

The term "variant" refers to PMDs that do not meet the requirements of "core," and there are four categories of these disorders:

1. Patients with diabetes, depression, epilepsy, asthma, and migraine might experience premenstrual worsening of a medical condition. Throughout the whole menstrual cycle, they will suffer symptoms related to their disease; however, during the luteal phase, these symptoms are most severe.

2. Non-ovulatory PMDs develop when the ovaries are functioning without actually ovulating. It arises in women using medicine to suppress their menstrual cycle, but the ovarian follicular activity still exists and can still result in discomfort.

3. Exogenous progestogens found in hormone replacement treatment (HRT) and the combined oral contraceptive pill (COC) are the cause of progestogens-induced PMDs. These medications may trigger recurrence in symptoms in women who are progesterone sensitive.

4. Women who still have an ovarian cycle but discontinue menstrual as a result of a hysterectomy, endometrial ablation, or levonorgestrel-releasing intrauterine system (LNG-IUS) suffer PMDs with absent menstruation²⁶.

Symptoms of Pms:

The existence of a menstrual-related disease, in which symptoms are entrained to the menstrual cycle, has been successfully proven by empirical data derived from women's daily rating of symptoms during two or more menstrual cycles. The condition has been associated with a wide range of symptoms in the physical, behavioural, and emotional domains. Symptoms most frequently reported by women seeking PMS treatment are listed in Table 1^27,28,29.

Table 1 - Common symptoms of PMS

Physical	Mood	Behavioural
Swelling	Anxiety/tension	Social withdrawal
Breast tenderness	Mood swings	Poor concentration
Aches	Depression	Appetite changes
Headache	Feeling out of control	Sleep disturbances
Bloating/weight	Irritability	Decreased interest

A woman whose condition is severe enough to need medical care typically feels several kinds of symptoms in all categories, with mood and behavioural problems being the most difficult. It is evident that emotional symptoms including stress, depression, mood swings, and irritability are all signs of severe PMS. One of the primary symptoms of this disease could be irritability³⁰. While many women recognise premenstrual increases in symptoms, most of women do not find these symptoms to be especially disturbing. In addition, women usually report greater premenstrual increases for physical pain symptoms rather than the depressive symptoms that define severe PMS³¹.

DIAGNOSIS:

PMS symptoms must start during the luteal phase and end a few days after starting of menstruation in order to meet the diagnostic criteria. It is typically obtained by a prospective gathering of clinical and symptom data as opposed to a retrospective recall. one useful tool for accurately diagnosing PMS is the Daily Record of Severity of Problems (DRSP). The frequency and severity of mental and physical symptoms related to the menstrual cycle are recorded daily. Patients are asked to report their symptoms prospectively after going at least two months without receiving any treatment³². Physicians make their conclusions on the timing of symptoms, which typically begin at any time before the onset of menstruation, as well as the cyclical fluctuation of symptoms and their relief within a day or two after starting of menstruation. After beginning treatment, the symptom report is kept up to date to enable thorough monitoring of any changes in symptoms caused on by the medicine³³.

It has been recommended that women with PMS record their symptoms in great detail so that various symptom profiles can be identified; if drugs are designed to precisely target well-defined patient subgroups, this may enhance therapy response rates³⁴. According to the American College of Obstetricians and Gynaecologists’ criteria, a woman cannot be diagnosed with PMS if she is receiving pharmaceutical treatment, taking hormone supplements, drinking alcohol, or having a socioeconomic performance disability. Symptoms must also be relieved within 4 days of the onset of the menstrual cycle and must not recur until at least menstrual cycle day 13. While keeping a symptom report might be helpful in diagnosing PMS, certain laboratory tests can offer further information to aid in differential diagnosis³⁵. Tests for thyroid function can detect thyroid issue, which can resemble PMS symptoms. Anaemia and electrolyte imbalances can be detected by a chemical test panel and a complete blood cell count, respectively. Premenstrual syndrome is a time when certain medical conditions, like migraines, asthma, epilepsy, irritable bowel syndrome, diabetes, allergies, and autoimmune disorders, can become worse. It is thought that these conditions are affected by changes in gonadal hormones that correlate with the menstrual cycle³⁶.

Figure 1 -Differentiating premenstrual symptoms, premenstrual syndrome and premenstrual dysphoric disorder

Risk Factors:

Studies have proven a hereditary susceptibility towards PMS, with identical twins suffering the condition twice as frequently as fraternal twins³⁷. Severe depression risk is also enhanced in first-degree relatives of PMS-affected women³⁸. Because women with fewer pregnancies experience more menstrual cycles and are more experiencing cyclic variations in progesterone and oestrogen, low parity may be related to an increased risk of PMS and PMDD^39,40. On the other hand, women who take oral contraceptives (OCs) might suffer from fewer premenstrual symptoms, showing that PMS may be prevented by reduced exposure to variations in progesterone and oestrogen^41,42. However, there is not any reliable proof associating parity, menstrual cycle characteristics, OC use, and socioeconomic or cultural variables to PMS and PMDD in epidemiologic investigations of women with these conditions⁴³.

Management:

The aim of treatment for PMS and PMDD is to relieve symptoms because the aetiology of these conditions is unclear. The suggested physiological reasons of symptoms, such as the ovulatory hormonal cyclist of menstruation or the neurotransmitters regulating mood in the central nervous system, are addressed by general strategies^44,45,46.

Non pharmacologic Treatments

a) Life style change - The primary line of treatment for PMS, according to the ACOG and AAFP, is a change in lifestyle, for people with mild to moderate symptoms, it might be helpful and improve their general health⁴⁷.

Diet:

Dietary changes often relieve premenstrual symptoms. Salt reduction helps with oedema and bloating; reducing alcohol, sweets, and caffeine can help with irritability and anxiety. Increasing your intake of fruits, vegetables, whole grains, legumes, and water is also beneficial⁴⁸.

Exercise:

Moreover, symptoms are reduced by 20–30 minutes of aerobic exercise, three to four times a week. A fair objective is to reduce body weight to within 20% of optimum⁴⁹.

Sleep hygiene:

Adopting a regular sleep-wake schedule may be beneficial to reduce the related pain and discomfort since PMS is related to sleep disturbances⁵⁰.

Stress reduction:

It can be beneficial to advise women not to schedule stressful activities during the premenstrual period wherever feasible. Reduced stress and PMS symptoms can be helped by light therapy using 10,000 Lx cool-white fluorescent light⁵¹.

b) Psychotherapy and group support:

Supportive therapy and patient education - Group support might be useful in PMS management. Anger control and assertiveness training aid in reducing symptoms and interpersonal disputes. It is possible to increase understanding of the condition by educating patients and their relatives about it.

Behavioural therapy (CBT):

This type of therapy may decrease further symptoms and improve interpersonal effectiveness and self-esteem⁵².

Reflexology:

All age groups, from infants to elders, can use it. A natural therapy called reflexology is very successful in treating a wide range of medical issues. Foot reflexology has a long-lasting effect on promoting balance and wellness. Premenstrual syndrome decreases, stress and tension are released, blood circulation is improved, lymph drainage is activated, toxins are helped to be eliminated, the immune system is strengthened, vital functions are harmonised, a deep state of relaxation and well-being is enabled, and pregnancy, labour, and delivery are made easier with reflexology⁵³.

c) Nutritional Supplements:

Calcium - Women with PMS might help from taking 1,200–1,600 mg of calcium carbonate daily as a therapy. Consuming skimmed or low-fat milk has also been associated to a decreased incidence of PMS^{54, 55}.

Vitamin B6: It has been determined that vitamin B6 at dosages of up to 100 mg per day is likely to aid individuals with premenstrual symptoms and premenstrual depression. It can relieve premenstrual symptoms through its effects on serotonin⁵⁶.

Magnesium: Magnesium 200–400 mg has been reported to potentially reduce premenstrual pain. The presence of magnesium may have a biological basis, as it inhibits PGF2α and promotes vasodilatation and muscle relaxation^{57, 58}.

Vitamin E: Antioxidant vitamin E helps to relieve PMS's physical and emotional symptoms. Treatment for PMS in women may involve taking 440 IU of vitamin E per day⁵⁹.

d) Herbal therapies:

Ginkgo biloba L: A special tree called ginkgo (Ginkgo biloba L) is utilised in both traditional Chinese medicine and medicinal products⁶⁰. Flavonoid glycosides and terpenoids found in extracts have the ability to modify blood flow, prevent oxidative cell damage, and inhibit the effects of platelet-activating factor. A study demonstrated the tolerability and efficacy of Ginkgo biloba extract (EGB761) in reducing congestive symptoms associated with premenstrual syndrome⁶¹. Most of study showed that the Ginkgo group greatly reduced the severity of their symptoms. Thus, it was determined that Ginkgo biloba L. may decrease the intensity of PMS symptoms⁶².

Agnus castus: The chaste tree's (Vitex agnus castus) fruits are rich in flavonoids and iridoids. The shrub Vitex agnus-castus, also known as the "chaste tree," is indigenous to Asia and the Mediterranean. The fruit has been used traditionally to decrease sexual desire. The mechanism of action might involve dopamine's control of stress-induced prolactin release, without having an immediate impact on luteinizing or follicle-stimulating hormones⁶³.

Isoflavones: Menstrual migraine has significantly improved with treatment with soy isoflavones, dongquai, and black cohosh extracts⁶⁴. Phytoestrogens is another term for isoflavones. This is because they are derived from plants ("Phyto" meaning "from plants") and have structural similarities with oestrogen. As a result, isoflavones are capable of binding to oestrogen receptors. Isoflavones can have the same effects as oestrogen, producing estrogenic or antiestrogenic effects, depending on the individual's hormone condition. There have been some reported benefits of using isoflavone supplements for menopausal symptoms, including reduced hot flashes, improved irritability, and improved exhaustion⁶⁵.

Zingiber officinale: Many traditional Indian remedies have long been used to cure minor illnesses like dysmenorrhea, sickness, and indigestion. It is a common ingredient in over 50% of traditional herbal treatments. Ginger root contains 115 different chemical components, but gingerols an oily resin that works as a strong antioxidant and anti-inflammatory are the source of the root's medicinal properties. Chewing on a ginger candy piece can reduce discomfort from motion sickness, nausea, GI distress, inflammation, and other types of pain. Additionally, ginger has been used as a spasmodic, anti-inflammatory, and circulatory stimulant to treat dysmenorrhea. The results of the study demonstrated that group 29's (82.85%) pain was significantly higher than group 16's (47.05%) suffering. Thus, it can be said that ginger is useful in reducing the intensity of pain associated with primary dysmenorrhea⁶⁶.

Pharmacologic Treatment:

Women who experience severe symptoms or who don't respond to non-medical treatments need to think about getting medication therapy. The two main evidence-based medicinal therapies for moderate to severe PMS are selective serotonin reuptake inhibitors (SSRIs) and ovulation suppression⁶⁷.

Selective Serotonin Reuptake Inhibitors:

SSRIs are commonly recommended as the first-line treatment for PMS with emotional symptoms. SSRIs relieve both mental and physical issues. SSRIs have a short period of action, making them effective for the symptomatic luteal phase in women with core premenstrual conditions. They are also likely to have a positive effect during the first menstrual cycle⁶⁸. One study reported that active treatment significantly reduced PMS symptoms in comparison to placebo (90% vs.40%)⁶⁹. A systematic review of SSRI administration concluded that fluoxetine, sertraline, paroxetine, citalopram, and fluvoxamine were administered daily throughout the menstrual cycle, while sertraline and citalopram were administered intermittently during the luteal phase^.The authors reported that both continuous and intermittent therapies had similar outcomes⁷⁰. A meta-analysis found continuous dosing of SSRIs more effective for PMS management than intermittent treatment. However, many women experience recurring symptoms and worsening after quitting, with common adverse effects being dose-dependent. The most common negative effects include nausea, weakness, fatigue decreased libido, and sweating. Current evidence on long-term treatment recommendations is limited⁷¹.

Combination Oral Contraceptives (COCs):

Multiple studies indicate that combined oral contraceptives offer reliable and beneficial outcomes. PMDD symptoms were shown to be improved in recent studies using COCs that contained 0.02 mg of ethinyl oestradiol and 3 mg of drospirenone (compound hormone pills for 24 days, followed by hormone-inactive pills for the final 4 days)^72,73. The FDA approved COCs containing 3 mg of drospirenone and 0.02 mg of ethinyl oestradiol in 2006 to treat PMDD symptoms. Because this 24/4COC regimen is associated with a more stable hormonal balance and a decrease in the adverse effects of withdrawal bleeding, it may be able to reduce both the mental and physical symptoms of PMS⁷⁴. Women who use COCs report more symptoms related to hormones throughout the seven-day hormone-inactive phase. Therefore, COCs with a lower inactive hormone day count might reduce these symptoms. However, nothing is known regarding the comparative effectiveness of COCs, like drospirenone, for conditions other than PMDD. Breast soreness, nausea, and vaginal bleeding during menstruation are among the adverse outcomes that using COCs may produce⁷⁵.

Gonadotropin-Releasing Hormone Analogues (GnRH):

GnRH agonists have been reported in a meta-analysis to reduce PMS symptoms, with an odds ratio of 8.66. Physical symptoms were more effectively treated by GnRH agonists than psychological ones, but the difference was not statistically significant⁷⁶. GnRH agonist use, however, results in a medically produced menopausal state that is marked by amenorrhoea, bone loss, vasomotor symptoms, and flushing all classic postmenopausal symptoms. Most often, add-back therapy is used to reduce these adverse effects. A progestogen must be taken during this therapy to protect the endometrium, but it may also result in symptoms similar to PMS. Tibolone can thus be taken in place of the previous medication to prevent symptom recurrence⁷⁷.

Other Psychotropic Agents:

Tricyclic antidepressants like clomipramine have a strong serotonergic effect and are useful for PMS at small dosages. Benzodiazepines might be an option for patients whose primary symptom is irritability. In comparison to SSRIs, these drugs are less effective for treating PMS. Prescription Medications Commonly Used in the Treatment of Premenstrual Syndrome/ Premenstrual dysphoric disorder^78,79.

Surgical treatment:

Hysterectomy and bilateral salpingo-oophorectomy are surgical options for removing the ovarian cycle and ovulation, eliminating progesterone resistance. However, it should only be considered in extreme cases and after extensive discussion. Preoperative GnRH analogues should be used as a test of cure, especially for women under 45 considering surgery for PMS. After surgery, oestrogen-based HRT is recommended⁸⁰.

Inclusion:

The use of pharmaceuticals to treat PMDD and severe PMS has risen over the last 25 years, as evidenced by the effectiveness of several medication classes. It is necessary to use medications to treat severe PMS/PMDD along with social or economic problems. SSRIs along with hormonal contraception is currently the recommended course of treatment for women who do not have any contraindications⁸¹.

The efficacy rate of SSRIs is 60%, and the effect of OC with DRSP is comparable. With further information on SSRIs, fluoxetine, sertraline, and Paroxetine, clinicians and patients can decide between continuous versus luteal-phase dosing for PMDD⁸². Medication should be started two weeks prior to menstruation in women with regular cycles and stopped one or two days later. For those without mood symptoms, those worried about long-term adverse responses, and those experiencing side effects, intermittent dosing is advised. If these requirements are not met, further treatment is advised. Consider switching to a continuous regimen or dose if intermittent therapy doesn't work after two cycles⁸³. Change to a different SSRI or serotonergic antidepressant for non-responders or those experiencing side effects. Side effects include decreased libido, nausea, anxiety, and sedation affect about 15% of people with PMDD. Extra medication could be helpful in treating sexual dysfunction^84,85. For PMDD women considering hormonal contraception, a 24/4 regimen combining OC with DRSP and EE 20 µg is recommended. Headache, breast discomfort, irregular bleeding, and nausea are typical side effects. There have been fewer vascular adverse effects, including stroke and venous thromboembolism. Studies show no increased risk of myocardial infarction, haemorrhagic stroke, or ischemic stroke in healthy, nonsmoking women. OC risks have also declined with increasing oestrogen dosages⁸⁶. Compared to other low-dose OC preparations, DRSP-containing OCs don't increase the risk of venous or arterial thromboembolic conditions. The product label, however, cautions against usage in females who have hypercalcemia or have renal, hepatic, or adrenaline sufficiency. ACE inhibitors, angiotensin II receptor antagonists, potassium-sparing diuretics, heparin, and NSAIDs are among the long-term diseases that require women to monitor their serum potassium levels during the first cycle of treatment^87,88. Although there aren't many extensive trials, the transdermal oestradiol patch or gel plus progestogen intrauterine device is promising. Third-line GnRH agonists are those that have hormone add-back. Surgical oophorectomy and hysterectomy with oestrogen replacement may be considered if GnRH is successful^89,90.

DISCUSSION:

This review paper is part of a series of exploratory studies on premenstrual syndrome. Premenstrual syndrome (PMS) is a set of behavioural, physical, and affective symptoms that occur during the luteal menstrual cycle and subside a few days after. It appears during the luteal menstrual cycle and disappears away a few days later. 5 to 8 % of women suffer from premenstrual dysphoric disorder (PMDD), with the majority having severe PMS. According to Endicott J in the phenomenological study, PMS is a painful and depressing experience for a woman that negatively impacts their mental and physical health. Mood fluctuations, impatience, and physical problems are among the symptoms. Though the exact cause is uncertain, theories point to heightened vulnerability to changes in hormone levels and neurotransmitter activity. Because of these symptoms' negative impact on quality of life, facilities for acknowledging and believing in the issues should be created, educational and therapeutic programs should be carried out, and suitable treatments should be provided for the affected women. We hope those PMS-affected women’s everyday struggles, restrictions, and stress levels will decrease^.

CONCLUSION:

Ovulation is inhibited during treatment using medication or surgery. Modifying one's lifestyle and using calcium supplements are suitable non pharmacological therapy approaches. If a medicine is given, COCs or SSRIs may be taken into consideration. COCs need to be taken into consideration initially in the gynaecological position. Increased sensitivity to the raised progesterone level that follows ovulation appears to be related to PMS symptoms. Premenstrual symptoms that are both behavioural and physical seem to be caused by the inhibition of ovulation. Ever since the FDA approved COCs to treat PMS symptoms in individuals needing contraception, they may be the first-line treatment for these patients. COCs include 0.02 mg of ethinyl oestradiol and 3 mg of drospirenone.
Additionally, SSRIs act effectively to treat anxiety and irritability symptoms; they are less successful at treating "atypical" premenstrual symptoms. It has also been proven that SSRIs are beneficial when used during the whole cycle or just during the luteal phases.

ACKNOWLEDGEMENT:

The author would like to acknowledge Dr. V.K. Redasani Director and Principle of YSPM, YTC Satara for her encouragement and guidance.

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Received on 25.04.2024 Revised on 15.08.2024

Accepted on 05.10.2024 Published on 08.03.2025

Available online from March 12, 2025

Res.J. Pharmacology and Pharmacodynamics.2025;17(1):37-46.

DOI: 10.52711/2321-5836.2025.00007

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

Drug class and Agent	Dosage	Recommendations for use	Adverse Effects
SSRIs
Fluvoxamine	25-50mg/day	For intermittent therapy, administer during luteal phase (14 days before menses.)	Insomnia, Drowsiness, Fatigue, Mild Tremor, Sexual dysfunction
Sertraline	50-100mg/day	First line for somatic and mood symptoms; continuous and intermittent therapy	Sleep disturbances, GI distress, Fatigue, Head-ache
Paroxetine	10-30mg/day	Clearly effective in alleviating behavioural and physical symptoms of PMS and PMDD.	Head-ache, Diarrhoea, Nausea
GnRH agonists
Leuprolide	3.75mg IM every month or 11.25mg IM every three month	Effective in alleviating physical and behavioural symptoms of PMS. “Add-back” therapy with oestrogen and/or progesterone is necessary if GnRH agonists are used more than 6 months.	Hypo estrogenic adverse effects including Atrophic vaginitis, Osteoporosis
Spironolactone	25-200mg/day during luteal phase	Effective in alleviating breast tenderness and bloating	Antioestrogen effects, Hyperkalaemia
Other Drugs
Buspirone	20mg/day	Daily dose	Headache, no risk of tolerance
Alprazolam	4 mg/day	Intermittent therapy	Sedation, Drowsiness