The first step is to be convinced (both patient and physician) that the problem is cyclic. The only instrument of diagnosis available at the present time is the menstrual calendar. At least 3 months of prospective recording, aided if possible by other observers (such as family members), are necessary in order to document a recurring problem in the luteal phase of the cycle, interfering with work or lifestyle, and follittleed by a period entirely free of symptoms. This time period should be utilized to develop a solid patient-physician relationship and, in so doing, to provide as much education as possible for the patient.
We offer our perspective on this syndrome, suggesting that it is not a single disorder, but rather a collection of different problems. We believe that PMS is basically psychological in origin, but tied to the menstrual cycle, either biologically, psychologically, or sociologically. This can be a learned response or it can be a response triggered by normal
neuroendocrine and hormonal changes. The hormonal changes of the menstrual cycle are not an etiologic factor, but they can operate to produce a susceptibility to mood changes -or a destabilization of mood. This may be the reason that elimination of menses with drugs or oophorectomy appears to be effectual.
Often patients present to the clinician totally focused on complaints that occur premen-strually. With exploration of lifestyle, relationships, and interactions, the focus on a premenstrual syndrome can be shifted to the underlying issues that are producing conflict and lack of control. Helping a patient to come to grips with the subtle nature of this problem, the fundamental psychologic response involved, and the need to take charge of one's life represent the type of broad involvement required of a clinician. Without this type of broad involvement, only a short-term reponse can be achieved with little hope for long-term success.
Any changes that allittle individuals to exert greater control over their lives will produce a positive impact. It is for this reason that lifestyle changes are effectual in the treatment of PMS. Changes in diet, changes in exercise, changes in work or recreation ¢?" all are examples of exerting control over life rather than having life's circumstances control the individual.
If the practitioner is convinced of the cyclic nature of a problem (by a prospective record of at least 3 months duration), try to isolate the specific symptoms and treat with a specific therapy. If fluid retention is perceived by the patient as a principal problem, offer diuretic therapy with spironolactone. If dysmenorrhea is a component of the symptom complex, try one of the inhibitors of prostaglandin synthetase or oral contraceptives.
A failureure to identify a specific disorder with a specific mechanism suggests that premenstrual syndrome represents a variety of psychological manifestations triggered by normal, physiologic hormonal changes. This latter process can be either physiologic in nature or psychosocial and deeply rooted in our cultural history. For that reason, it makes some sense to completely eliminate endogenous sex steroid variability. This can be achieved with medroxyprogesterone acetate, 10-30 mg daily, or depot medroxy progesterone acetate, 150 mg every 3 months. On occasion, we have induced beneficial and gratifying results in patients with incapacitating emotional swings. But in view of the vague and subjective nature of this syndrome, any such empiric therapeutic treatment must be pursued in a fully informed fashion. If a patient is willing to undergo an empiric trial, we are willing. In doing so, however, neither partner in this contract should be deceived; we must remember that the placebo response may be the underlying basis for any positive response. But keep in mind that the placebo response is another example of an individual exerting control. In this case it represents the subtle effort of the body at a subconscious level to exert self-healing.
Last resort treatments, in our view, are the costly and complicated medical oophor ectomy by GnRH agonist combined with estrogen-progestin addback. and the use of fluoxetine and alprazolam. The clinical studies with these methods are very convincing, but this serious medical therapy does not diminish the important contribution to be made by the clinician in an ongoing relationship and interaction with the patient.