A critical review of methodological issues and approaches to managing premenstrual syndrome

Abstract

Medical management of premenstrual syndrome (PMS) has grown immensely during the last half of this century and still no one medication has emerged to produce lasting effects. The rationale and procedures for use of many of these substances are reviewed here and discussed, and attention is drawn to methodological problems inherent in research designs for both drug use and psychotherapy. Non-pharmacological interventions are also considered in the light of contemporary popular views on healthy lifestyle. These include diet, aerobic exercise and psychological methods of stress management. The multifactorial nature of PMS is reiterated and suggestions made for an individualized matching of symptoms to treatment. The acceptance of PMS as a psychosomatic disorder clearly requires psychological management as an indispensable part of a planned treatment approach, that, may or may not, also involve the use of some medication for certain specific symptoms.

The research literature on treatment outcome studies for PMS is voluminous, but only during the last 10 years have strong methodologies appeared. This has led to attempts at replication, comparison of findings between studies and greater confidence in the acceptance of those findings that was unwise in relation to many earlier reports. Even in the recent more acceptable studies, there are still flaws and inadequacies that must render the results acceptable only with caution.

The lack of sustained treatment outcomes suggests two things. First, the over-reliance on several theories of biological causation of the syndrome is not substantiated by the singular lack of success in management by drug therapy. The very nature of the syndrome with its many psychological, behavioral and cognitive symptoms, together with the persistent placebo response, indicate that treatment by drugs alone is a much too simplistic approach. It is clearly imperative to individually tailor treatment to each woman's symptom requirements. Second, PMS has been classed as a psychosomatic disorder arising from an interaction of biological, environmental and psychological factors. Therefore, an interactional explanatory model is required that adopts contemporary views of the relationship between stress and health. More importantly, a multimodal intervention that addresses each and all of these aspects is warranted. To accept this requirement is to open the way for research evaluation of a whole new body of treatment for PMS. A detailed model must be constructed, a complex intervention must be developed and tested for efficacy, and comparisons made with existing treatments. Subsequently, specific questions should be researched, which could include an evaluation of the placebo response, treatment component evaluations, time factors, single or group delivery issues. These aspects would all contribute to the evaluations required in sound ‘technique-building’⁷⁷.