Premenstrual Syndrome

Premenstrual syndrome (PMS) describes the psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation. These symptoms can be distressing and significantly impact quality of life. 

Most women will experience some of the symptoms of premenstrual syndrome. The critical aspects are the severity of the symptoms, and the impact these symptoms have on the woman’s functioning and quality of life. 

The symptoms of PMS resolve once menstruation begins. Symptoms are not present before menarche, during pregnancy or after menopause. These are key things to note when you take a history.

 

Cause

Premenstrual syndrome is though to the caused by fluctuation in oestrogen and progesterone hormones during the menstrual cycle. The exact mechanism is not known, but it may be due to increased sensitivity to progesterone or an interaction between the sex hormones and the neurotransmitters serotonin and GABA.

 

Presentation

There is a long list of symptoms that can occur with premenstrual syndrome, and these will vary with the individual. Common symptoms include: 

  • Low mood
  • Anxiety
  • Mood swings
  • Irritability
  • Bloating
  • Fatigue
  • Headaches
  • Breast pain
  • Reduced confidence
  • Cognitive impairment 
  • Clumsiness
  • Reduced libido

These symptoms can occur in the absence of menstruation after a hysterectomy, endometrial ablation or on the Mirena coil, as the ovaries continue to function and the hormonal cycle continues. They can also occur in response to the combined contraceptive pill or cyclical hormone replacement therapy containing progesterone, and this is described as progesterone-induced premenstrual disorder.

When features are severe and have a significant effect on quality of life, this is called premenstrual dysphoric disorder.

 

Diagnosis

Diagnosis is made based on a symptom diary spanning two menstrual cycles. The symptom diary should demonstrate cyclical symptoms that occur just before, and resolve after, the onset of menstruation. A definitive diagnosis may be made, under the care of a specialist, by administering a GnRH analogues to halt the menstrual cycle and temporarily induce menopause, to see if the symptoms resolve. 

 

Management

This section is based on the RCOG Green-top guidelines from 2016, and the NICE CKS updated May 2019. The following management options can be initiated in primary care:

  • General healthy lifestyle changes, such as improving diet, exercise, alcohol, smoking, stress and sleep
  • Combined contraceptive pill (COCP)
  • SSRI antidepressants
  • Cognitive behavioural therapy (CBT)

RCOG recommends COCPs containing drospirenone first line (i.e. Yasmin). Drospironone as some antimineralocortioid effects, similar to spironolactone. Continuous use of the pill, as opposed to cyclical use, may be more effective.

Severe cases should be managed by a multidisciplinary team, involving GPs, gynaecologists, psychologists and dieticians.

Continuous transdermal oestrogen (patches) can be used to improve symptoms. Progestogens are required for endometrial protection against endometrial hyperplasia when using oestrogen. This can be in the form of low dose cyclical progestogens (e.g. norethisterone) to trigger a withdrawal bleed, or the Mirena coil.

GnRH analogues can be used to induce a menopausal state. They are very effective at controlling symptoms; however, they are reserved for severe cases due to the adverse effects (e.g. osteoporosis). Hormone replacement therapy can be used to add back the hormones to mitigate these effects.

Hysterectomy and bilateral oophorectomy can be used to induce menopause where symptoms are severe and medical management has failed. Hormone replacement therapy will be required, particularly in women under 45 years.

Danazole and tamoxifen are options for cyclical breast pain, initiated and monitored by a breast specialist. 

Spironolactone may be used to treat the physical symptoms of PMS, such as breast swelling, water retention and bloating.

 

Last updated June 2020
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