Treatment of premenstrual syndrome: a decision-making algorithm

General principles of treatment

There are a number of principles that should be adhered to, when managing women with premenstrual syndrome (PMS). Even though not evidence based, there is little doubt that reduction of stress, for instance is a great help in ameliorating symptoms. Also, dietary measures such as avoidance of carbohydrate binges, limitation of alcohol and caffeine intake are often of benefit. There are data from non-randomized trials that exercise improves PMS symptoms. However, in cases of moderate to severe PMS, it is important that medical therapy is instituted sooner rather than later to avoid unnecessary suffering. Women with marked underlying psychopathology as well as PMS should be referred to a psychiatrist. Symptom diaries (e.g. the Daily Record of Severity of Problems [DRSP]) should be used to establish diagnosis and assess the effect of treatment.

Service delivery

Primary care should deal with most cases of PMS. Awareness of the condition and training in its management is essential. Ideally, women with severe PMS should be managed by a multidisciplinary team, which might comprise a hospital or community gynaecologist, psychiatrist or psychologist, dietician and counsellor. Although such services are rarely provided in an National Health Service (NHS) setting, referral to gynaecologists and psychiatrists should be reserved for women who have been fully evaluated as having severe PMS and when simpler forms of therapy have been explored. Where there is multidisciplinary provision of care, this is of benefit both from the diagnostic and from therapeutic point of view, giving the ability to offer a broad range of interventions from lifestyle interventions and cognitive-behavioural therapy to gynaecological interventions.

Complementary therapies

Most women with PMS would have tried a number of over the counter remedies before seeing the general practitioner or hospital specialist. When treating women with PMS, complementary medicines may be of benefit, but clinicians need to consider that data from clinical studies are limited and underpowered. Interactions with conventional medicines should also be considered, particularly St John's Wort and SSRIs (selective serotonin reuptake inhibitors). The referring clinician retains legal responsibility for the patient's wellbeing when they refer patients to complementary therapists. It is difficult to assess the true value of most of these therapeutic interventions owing to the fact that they are freely available without prescription or physician recommendation, with little regulation of efficacy or safety, or indeed any published research for the majority. If a complementary therapy is recommended, it is essential that the clinician is familiar with the evidence base for efficacy and safety of the product.

Medical treatment of PMS

A suggested treatment algorithm modified from the RCOG Green Top Guideline for PMS is shown in Figure 1. Most of the efficacious treatments for PMS are unlicensed in the UK. However, in this situation, unlicensed treatments can be justified where a body of evidence for efficacy and safety exist. The two chief evidence-based medical treatments of moderate to severe PMS are categorized by ovulation suppression and selective serotonin reuptake inhibitors (SSRIs). In making the decision between ovulation suppression and SSRIs, the clinician should take the following into account:

Are the symptoms predominantly psychological, physical or a combination of both?

If symptoms have a significant physical component, it is logical that SSRIs and cognitive-behavioural therapy may not be of benefit for these symptoms;

OPEN IN VIEWER

Figure 1

Updated algorithm for the management of severe premenstrual syndrome (modified from RCOG Green Top Guideline 48) ¹

Practice points for medical treatments of PMS:

Newer contraceptive pill types may represent effective treatment for PMS and should be considered as one of the first-line pharmaceutical interventions – i.e. those that do not re-stimulate PMS-like symptoms;

Assessing response to treatment

There are a number of good clinical practice principles that should be observed in assessing response to treatment:

Response to treatment should not be assessed earlier than a minimum of three cycles. The reasons for this are as follows:

adverse events are more common with initiation of treatment e.g. nausea with SSRIs/SNRIs and bleeding problems/progestogenic side-effects with hormonal regimens;

Duration of treatment

The only ‘cures’ for PMS are removal of the ovaries or menopause. Most interventions are therefore ‘treatments’ and not ‘cures’ – the benefits only last for as long as the intervention continues. Indefinite treatment should therefore be described as the norm rather than the exception. Discontinuation of treatment should be considered when pregnancy is contemplated, and obviously this is essential if the method is contraceptive. Treatment should be continued during the perimenopause as this is a time associated with potentially worsening of symptoms, but can be tentatively withdrawn when the patient is thought to be postmenopausal. There may be a need to restart treatment if ovarian activity persists.

Key messages

PMS continues to be poorly understood and in many cases inadequately managed. It can be the cause of considerable morbidity and at times, even mortality;

Competing interests

Nick Panay has lectured and acted in an advisory capacity for a number of pharmaceutical and nutraceutical companies. He has received research grants from a number of pharmaceutical and nutraceutical companies.