Review
Management of premenstrual syndrome: evidence-based guidelines

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Abstract

This review uses as its basis the green top Guideline No 48 on the management of premenstrual syndrome. The aim of the guideline was to review the diagnosis and management of premenstrual syndrome (PMS), in particular, the evidence for pharmacological and non-pharmacological treatments. The key aspects of the guidelines will be discussed in an easily digestible format and bring some of the aspects of the database up to date according to the new evidence base. Additionally, the review will take a wider view of the situation with particular emphasis on recent attempts to achieve a global consensus on definitions and management. The development of a consensus and guidelines on the definition and management of PMS are essential to encourage acceptance of condition by patients/health professionals and regulatory authorities.

Section snippets

Definition

Many women experience mild physical and emotional PMS symptoms which are not particularly troublesome. However, when severe these symptoms can lead to a breakdown in interpersonal relationships and interference with normal activities. A working definition of PMS is “a condition which manifests with distressing physical, behavioural and psychological symptoms not due to organic or underlying psychiatric disease, which regularly recurs during the luteal phase of each menstrual (ovarian) cycle and

Aetiology

The precise aetiology of PMS remains unknown but cyclical ovarian activity and the effect of oestradiol and progesterone on the neurotransmitters serotonin and gamma-aminobutyric acid (GABA) appear to be key factors. Absence of PMS before puberty, in pregnancy and after the menopause supports the theory that cyclical ovarian activity is important. Rapidly changing oestradiol levels, not only premenstrually but also postnatally and perimenopausally lead to this triad of hormone dependent

Prevalence

The reported prevalence of severe PMS is variable between 3% and 24%. The incidence of severe PMS or PMDD appears to be 5–8%. PMS appears more prevalent in women who are obese, perform less exercise and are of lower academic achievement. There is a lower incidence of PMS in women using hormonal contraception.

Diagnosis

Crucial to the management of PMS is the need to make the correct diagnosis. This cannot be accurately established by retrospective recall. It needs to be made by the prospective logging of symptoms by the patient, ideally over two cycles. A symptom questionnaire which can be filled in on line is available on the NAPS website (www.pms.org.uk). Alternatively, a well-established validated questionnaire (The Daily Record of Severity of Problems DRSP – Figure 1) can be used to document symptoms –

General principles of treatment

There are a number of principles which should be adhered to when managing women with PMS. Even though not evidence based, there is little doubt that reduction of stress for instance is a great help in ameliorating the symptoms. Also, dietary measures such as avoidance of carbohydrate binges and 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

Medical treatment of PMS

A suggested treatment algorithm as suggested in the RCOG green top guideline for PMS is shown in Figure 2. Most efficacious treatments for PMS are unlicensed. However, in this situation unlicensed treatments can be justified where a body of evidence and safety exist. The two chief evidence-based medical treatments of moderate to severe PMS are categorized by ovulation suppression and selective serotonin re-uptake inhibitors.

Conclusions

PMS continues to be poorly understood and in many cases inadequately managed. It can be the cause of considerable morbidity and at time even mortality. It is imperative that a consensus on definition is reached globally and that properly conducted research continues to be funded. It is only through this work that clinicians will be able to practice in a truly evidence-based way to effectively treat this condition.

The alternatives to traditional therapy, such as agnus castus, red clover and St

Key to superscripts

  • (1)

    ∗ Few treatments for PMS are actually licensed – the treatments with an asterisk are ones which for which sufficient evidence exists for a GP with an interest in women’s health to reasonably prescribe from a medico legal point of view

  • (2)

    OTC – over the counter medications

  • (3)

    IE – not recommended, insufficient evidence for efficacy

  • (4)

    IS – not recommended, insufficient evidence for safety

  • (5)

    HS – recommended for hospital specialist use

Practice points

  • Insufficient evidence is available regarding use of vitamin

References (0)

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