Premenstrual syndrome - Pathogenesis: The exact cause of premenstrual syndrome is unknown, however some hypotheses postulate that alteration in the level of estrogen and progesterone starting from midluteal phase, either altered estrogen: progesterone ratio or diminished progesterone level, another hypothesis relates this syndrome to neuroendocrine factors observed to be decreased in females with premenstrual syndrome such as serotonin, endorphin and GABA. -Clinical presentation: Women aged 30-45 often present to the doctor with physical symptoms; including edema and breast tenderness, and psychological symptoms; including tension, anxiety and depression, all of these symptoms appear up to 14 days before the start of a period and subside once menstruation begins. -Diagnosis: No lab tests of physical findings are available to confirm positive results for premenstrual syndrome, if symptoms are part of a predictable premenstrual pattern then the doctor will tend to attribute these symptoms to premenstrual syndrome. -Treatment: Treatment is generally symptomatic for both physical and psychological symptoms: Ammonium chloride + caffeine is a mild diuretic combination to relieve edema and other fluid retention symptoms, ammonium chloride is converted into urea in the liver, which has an acidifying effect to urine leading to transient diuresis, caffeine also acts as a mild diuretic and it is also a CNS stimulant that aids in lifting mood. Two tablets t.i.d. for 4-5 days before a period are recommended. Pyridoxine (Vitamin B6) is involved in the final step of serotonin synthesis (whose deficiency is hypothesized to be a cause for the syndrome), thus it has been found to relieve depression somewhat, the recommended dose is 100-200mg daily for 3 days before the onset of symptoms until 2 days after the start of menstruation. Evening primrose oil (EPO) is precursor of prostaglandin E1, which has a down-regulating effects for prolactin, thus depletion of prostaglandin E1 can lead to breast pain manifested in premenstrual syndrome. Vitex agnus castus has traditionally been used in the treatment of premenstrual syndrome, and placebocontrolled studies have found it to be effective against a wide range of symptoms. References: 1- Alan Nathan, non-prescription medicines, 4th edition, pharmaceutical press 2010. 2- DC Dutta’s textbook of gynecology, edited by: Hiralal Konar, Jaypee brothers medical publishers 6th edition, 2013.