Premenstrual Syndrome: Management
Definition and Classification
PMS is defined as distressing physical, behavioural and psychological symptoms, in the absence of organic or underlying psychiatric disease, that regularly recur during the luteal phase of each menstrual cycle and resolve or significantly regress by the end of menstruation. Severity is graded mild (no functional interference), moderate (interferes with but does not prevent social/occupational function) and severe (loss of social/occupational function, treatment-resistant). Premenstrual dysphoric disorder (PMDD) is a research-defined, predominantly psychological severe variant recognised in US psychiatric classification. PMS affects up to 95% of women to some degree, with severe, life-disrupting symptoms in approximately 5%.
Diagnosis
Retrospective recall of symptoms is unreliable, so PMS should be diagnosed prospectively using a symptom diary completed daily over a minimum of two menstrual cycles. The Daily Record of Severity of Problems (DRSP) is the well-established, patient-friendly tool recommended for this purpose. The diary should confirm that symptoms are absent or minimal in the follicular phase and cluster in the luteal phase, resolving with (or shortly after) the onset of menstruation. Where diagnostic doubt remains in women with severe symptoms, a GnRH analogue trial can be used to abolish ovarian cyclicity and confirm that symptoms are hormonally driven before committing to more invasive hormonal or surgical treatment.
General Principles of Management
- General advice on exercise, diet and stress reduction should be considered before starting any specific treatment.
- Symptom diaries (DRSP) should also be used to assess the effect of treatment.
- Women with PMS and marked underlying psychopathology should be referred to a psychiatrist.
- An integrated, holistic approach — including complementary options where evidence-based treatments have failed or are declined — benefits most women, though many complementary therapies lack robust evidence.
- Referral to a gynaecologist should be considered when simple measures have failed and severity warrants gynaecological intervention; severe PMS is ideally managed by a multidisciplinary team (gynaecologist, psychiatrist/psychologist, dietitian, counsellor).
Management Ladder
First line
- Lifestyle measures: exercise, cognitive behavioural therapy (CBT — recommended routinely as a treatment option), and vitamin B6.
- Combined new-generation oral contraceptive pill (e.g. a drospirenone-containing pill), used cyclically or continuously.
- Low-dose SSRIs, given continuously or luteal-phase only (days 15–28).
Second line
- Oestrogen (transdermal patches, typically 100 micrograms) plus a low-dose progestogen (e.g. oral or via the levonorgestrel intrauterine system) to protect the endometrium.
- Higher-dose SSRIs, continuous or luteal-phase.
Third line
- GnRH analogues with add-back HRT (continuous combined oestrogen and progestogen, or tibolone) to prevent hypo-oestrogenic effects and bone loss. GnRH therapy should not be used as first-line treatment (except in the most severe cases) and, when used alone, should generally be limited to six months; if continued longer, add-back therapy and monitoring (e.g. bone mineral density) are required.
Fourth line / surgical
- Total abdominal hysterectomy and bilateral oophorectomy, with HRT (including consideration of testosterone replacement) afterwards, reserved for the most severe, treatment-resistant cases. Surgery should not be undertaken without a preceding trial of GnRH analogues to confirm that symptoms are ovarian-cycle dependent and that HRT will be tolerated.
Adjuncts and Evidence Notes
- SSRI/SNRI prescribing should be restricted to clinicians with particular expertise in the area; patients should be warned of adverse effects (nausea, insomnia, reduced libido) and, if on continuous dosing, withdrawn gradually to avoid discontinuation symptoms.
- Progesterone and progestogens alone are not recommended for PMS — meta-analysis shows no clinically significant benefit over placebo.
- Danazol can relieve PMS but carries irreversible virilising risk and is not a preferred option.
- Evidence for complementary therapies is mixed; calcium/vitamin D, magnesium and Agnus castus have the best (though still limited) supporting data.
High-Yield Exam Points
- Diagnosis requires prospective symptom charting (DRSP) over at least 2 cycles — retrospective recall is unreliable.
- Symptoms must cluster in the luteal phase and resolve by the end of menstruation to confirm the diagnosis.
- Management follows a stepwise ladder: lifestyle/CBT/vitamin B6/COCP/low-dose SSRI → oestrogen patch + progestogen or higher-dose SSRI → GnRH analogue + add-back HRT → hysterectomy and bilateral oophorectomy + HRT as a last resort.
- GnRH analogue trial can be used pre-operatively to confirm ovarian-cycle dependence before hysterectomy and bilateral oophorectomy.
- SSRIs can be given continuously or luteal-phase only, and are considered first-line pharmacological therapy for severe PMS.
- Progestogens/progesterone alone are not recommended — no proven benefit over placebo.
- CBT is a recommended first-line, evidence-based non-pharmacological option (Grade A).
Source: RCOG Green-top Guideline No. 48 (Second edition published February 2017 (first edition December 2007). RCOG lists a last review date of May 2023, with an update to this guideline noted as under development — the February 2017 second edition remains the current published version.)
Read the original on rcog.org.uk
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