This is an updated guideline from RCOG on PMS. It is also known as premenstrual disorder, or PMD, in some studies. There isn't too much new in this. I will summarise all the bits relevant to us. In short, we can try the COC, Vit B6 and SSRI in general practice. POPs do not work.
The cause of PMS is still uncertain. It is known that serotonin and GABA receptors are responsive to oestrogens and progesterones, so this may be a cause. It also seems that different hormone levels are not responsible, though people's sensitivity to the hormones may vary.
Do a symptom diary for at least 2 months, as people's recollection of symptoms is often unreliable. A good one to use is in the guideline's appendix.
There should normally be a symptom-free week after menstruation for a diagnosis of PMS. If there is no symptom free week, consider another diagnosis (eg depression). An underlying disorder could be being exacerbated by PMS if symptoms ease, but don't disappear after menstruation.
It is possible to have PMS even with no menstruation. The clue is very cyclical symptoms with a symptom free week. You can also get PMS when on hormonal treatment (eg POP).
- If patients have severe symptoms that are not settling with simple measures (eg COC, Vit B6 or SSRI).
- If there is doubt about diagnosis, GnRH analogues can be used to see if symptoms are controlled. This would be done in secondary care.
Management in General Practice
- Women should be advised that exercise is likely to be helpful.
- RCOG don't offer any other advice to give patients, but patient info leaflets give other simple advice for managing symptoms.
The guideline has a list of all the different remedies that have been studied. Most have limited studies looking at them, but it is useful if a woman wants to know about something specific.
RCOG lists this as a first line treatment. However, it then goes on to say that evidence for efficacy is mixed and in another area says that 'advice could not be given...' about its use. Other guidelines on PMS (eg CKS) advise GPs not to use it. Apparently the maximum Department of Health advised dose is 10mg, but it is the higher doses that have shown to be effective in studies (eg 100mg).
Lots of pills have evidence that they are beneficial. However, drospirenone containing pills (eg Yasmin and Lucette) have the best evidence. There is emerging evidence that off-label continuous use may be more effective that 21/7 regimes or 3m regimes.
There is good evidence for efficacy. For most of the SSRI there is little difference in efficacy between continuous use or luteal phase use (eg d15 to d28). There is some evidence that citalopram or escitalopram used during the luteal phase may be more effective than the other SSRIs, and may have fewer side-effects. RCOG advise trying citalopram or escitalopram even if other SSRIs have not been effective.
Cognitive behavioural therapy
They don't advise this as GP use, but of course we have access to it, so I think it is likely an option we can offer women. It should be considered routinely in severe PMS.
Do not offer:
- POP - there is evidence that they are not effective and can actually exacerbate symptoms.
- Mirena - again there is evidence that they are not effective and can exacerbate or bring on symptoms.
Management in secondary care
I'm not going to go into great detail here as we're not going to be prescribing these.
Transdermal oestrogen with cyclical progesterone. This doesn't give contraception, but is effective for severe PMS. Beware unscheduled bleeding if inadequate progesterone cover has been used. The Mirena can be used for the progesterone component.
Danazol. This is an androgenic steroid. It is effective for luteal phase breast symptoms. It has potential virilising effects, so women must use contraception.
GnRH analogues. These are highly effective in severe PMS. Women will need add on HRT if used for over 6m. Whilst on treatment, annual DEXAs are required.
Diuretics. Can help with physical symptoms.
Surgery. Eg hysterectomy with BSO. If all other treatments have failed and diagnosis is certain.