Premenstrual syndrome (PMS) is characterized by physical, behavioral, and psychological symptoms that occur during the luteal phase of the menstrual cycle and resolve after the onset of menstruation. It affects around 80% of women to some degree. Diagnosis involves tracking symptoms over at least two menstrual cycles using a daily diary. Treatment involves lifestyle modifications as well as potential use of complementary therapies, cognitive behavioral therapy, oral contraceptives, SSRIs or SNRIs, ovulation suppression therapies like GnRH analogues, or as a last resort, surgical removal of the ovaries and uterus. A multidisciplinary approach is ideal for managing severe cases of PMS.

1. Dr. Sami Shawer
P.M.S.
Premenstrual Syndrome

2. Definition
“A condition which manifests with distressing
physical, behavioural and psychological symptoms, in
the absence of organic or underlying psychiatric
disease, which regularly recurs during the luteal phase
of each menstrual cycle and which disappears or
significantly regress by the end of menstruation”
RCOG green-top guideline No. 48

3. History
Katharina Dalton wrote about it for
the first time in 1953.
In 1980, took it to the British court
to defend Anna Reynolds which was
accepted by the court in this and
other later trials.
Nowadays; promoting PMDD as a
psychiatric disorder.

4. Epidemiology
Varies with different definitions of PMS. (RCOG –
American Psychiatric Association – WHO).
80% of women experienced at least one symptom
attributed to PMS.
5% suffer from severe PMS (withdrawal from social
and professional activities).

5. Service Delivery
GPs should deal with most cases of PMS.
Ideally, severe PMS should be managed by a
multidisciplinary team (gynaecologist, psychiatrist,
dietician and counsellor).
Practically, gynaecologist and psychiatrist should be
involved in severe cases.

6. Types of P.M.S.
Mild: Does not interfere with personal/social and
professional life.
Moderate: Interferes with personal/social and
professional life but still able to function and interact.
Severe: Unable to interact personally/socially or
professionally – withdraws from social and professional
activities.
PMDD (Premenstrual Dysphoric Disorder): Severe
PMS (USA institutes).

7. Aetiology
 Remains unknown.
 Effect of cyclic ovarian hormones on neurotransmitters (Serotonin – GABA)
appears to be a key factor.
 Recent studies: high glutamate levels prior to menstruation in rats.
 40% of symptomatic women have significant decline in beta-endorphins.
 In one study, elevated serum psedocholinesterase were found.
 May have genetic factor: (93% of identical twins will both C/O PMS compared
to 44% in dizygotic twins).
 Cultural factors (reported to be of less intensity in war times).
 Evolutionary rationales.

9. Risk Factors
High caffeine intake.
Alcohol abuse.
Stress.
Anxiety.
History of Depression.
Increasing age (worse in late 30s).
Overweight.
Family history.
Dietary Factors (low levels of certain vitamins and
minerals).

10. Symptoms
Psychological:Psychological:
Irritability.
Mood swings.
Depression.
Feeling out of control
Behavioural:Behavioural:
Aggression.
Reduced cognitive abilities and forgetfulness.
Increase in accidents (reduced concentration).

11. Symptoms
Physical:Physical:
Fatigue.
Headaches.
Breast tenderness.
Bloating.
Pelvic pain.
Joints pain.
Acne.
Appetite changes.
Swelling.

12. How to
diagnose?!
Symptoms
should be
recorded
prospectively for
at least two cycles
using symptoms
diary.
Daily record of
severity of
problems (DRSP):

13. Treatment
Traditional and Complementary medicines should be
considered.
Although many complementary therapies are not
evidence-based but it is generally agreed that it is
beneficial and may be used.
Most efficacious treatments used in PMS are
unlicensed for PMS.

15. Complementary therapies
Data limited .
Interactions with conventional medicines should be
considered.
Regular monitoring of the response using charts
should be done.
Best data appear to exist for:
Vitamin D/Calcium
Magnesium
Agnus Castus

17. Cognitive Behavioural Therapy (CBT)
In a RCT lasting 6 months; CBT proved to have same
efficacy as Fluoxetine but with better maintenance.

18. SSRIs and SNRIs
Should be considered as 1st
line of treatment in severe
PMS.
Prescribing restriction to health professionals with
expertise in this area. (few suicides in young women
using SSRIs for depression reported)
Luteal phase use is superior to continuous use in
relation to symptoms resolution and withdrawal.
Citalopram may be effective where other SSRIs failed.
No evidence for better results if combined therapy
with ovulation suppression.

19. Ovulation Suppression
1. Combined oral contraceptive pills: (Yasmin, Yaz)
- should be considered as a 1st
line of treatment.
- continuous use is superior to cyclic (risk ?!)
2. Percutaneous Estradiol: (patch, implant)
- 100 micrograms twice weekly as effective as 2oo.
- alternative contraception should be used as barrier or intrauterine
method.
- low-dose progestogen to be added minimize adverse effects
(cyclogest pessary – crinone 8% gel)
- not licensed for treatment of PMS.
3. Danazol: (200 mg BD)
- beneficial.
- potential irreversible virilising effects.
- advise to use contraception.
- not licensed for treatment of PMS.

20. 4. GnRHa:
-Retained for those with the most severe symptoms.
-Should be considered as a 2nd
or 3rd
line of treatment.
-Add-back hormone therapy should be used.
-Low-dose therapy in not recommended (no benefit).
-Treatment for 6 months if used alone.
-If combined with HRT; annual bone density measurement.
-Not licensed for treatment of PMS.
5. Progesterone: of no benefit in most of the clinical trials.
Ovulation Suppression

21. Surgical Approach (TAH + BSO)
Rarely done for treatment of
PMS.
For severe cases where
medical treatment failed.
GnRHa should be use pre-
operative as test of cure.
HRT should be considered.

22. Summary
PMS is usually underestimated.
Symptoms diary should be used at least for 2 cycles
before making a diagnosis and to evaluate treatment
plans.
Multi-disciplinary team should be involved.
Lifestyle change, diet, exercise and complementary
therapies should be considered.
C.O.C. and SSRIs in severe cases.
GnRHa and Surgical approach as last lines of
treatment.