Book Review

Modern Management of Premenstrual Syndrome

N Engl J Med 1993; 329:1589November 18, 1993

Article

Modern Management of Premenstrual Syndrome
Edited by Samuel Smith and Isaac Schiff. 205 pp. New York, W.W. Norton, 1993. $79. ISBN: 0-393-71018-1

This book covers the management of the psychological symptoms of the premenstrual syndrome (PMS), but neglects the equally distressing physical symptoms. Management is approached on an ad hoc basis that does not take into consideration the chronicity of PMS, which may start at puberty and last until menopause. Nor is consideration given to the possibility of future biologic and hormonal findings that may alter management. There must surely be a better approach to therapy for teenagers than 30 years of treatment with psychotropic drugs, ovulation suppression, danazol, or gonadotropin-releasing hormone analogues. Women require long-term care that does not involve the possibility of addiction, side effects, or interference with their fertility.

This book must have taken some years to prepare, since most of the references are out of date. Only 15 percent were published in the past three years. Forty percent were published before 1983.

The emphasis on diagnosis by prospective charting is commendable, as is the appreciation that symptoms can still occur after a hysterectomy. Well-motivated women with mild or moderate PMS may have no difficulty charting 30 symptoms daily on a four-point scale, but simpler methods may be needed for the severely ill.

All the authors have extensive experience in their own field, but my impression is that their experience in PMS has been based on patients with mild-to-moderate acute disease, rather than on patients who have had severe PMS for 10 or more years. Experience with the latter group of patients could provide insight into the changes resulting from pregnancies and stress in the years before menopause. Lifestyle changes are important, and I regret that stress management is glossed over in a mere six lines in the description of the treatment of physical symptoms. The chapter on group psychotherapy is excellent. Dr. Ulman wisely limits the participants in her group, excluding those who are excessively paranoid, hostile, bizarre, or violent.

Nutrition is essential in the management of PMS, but there is little etiologic foundation for the dietary advice given, which merely mirrors the accepted rules for good health.

Hormonal treatment is not mentioned favorably. Unfortunately, the progestogens given to promote bleeding in estrogen therapy cause PMS-like symptoms severe enough for some women to request hysterectomy. Danazol and gonadotropin-releasing hormone agonists are limited by their side effects and risks of chronic hypoestrogenemia. The chapter on progesterone therapy begins by stating that progesterone suppositories are the most widely used treatment, but Dr. Freeman bases her view on the failure of double-blind placebo-controlled trials, which used low-dose progesterone in mild-to-moderate cases. In Britain, women with severe PMS may not be included in clinical trials if they are receiving psychiatric medication, have been hospitalized for a psychiatric illness, have attempted suicide or self-mutilation, or have committed a criminal act, yet it is just these women who benefit from high-dose progesterone therapy.

Despite its limitations, this book will prove useful to psychiatrists, gynecologists, neurologists, endocrinologists, and family physicians in managing one of the world's commonest diseases. It provides good background information on the cause and diagnosis of PMS and the psychological management of mild and moderate cases.

Katharina Dalton, F.R.C.G.P.
100 Harley St., London W1N 1AF, United Kingdom