Many women experience symptoms of Pre-menstrual Syndrome often these are not very severe but in 5% of women the symptoms are severe enough to affect lifestyle, relationships and work.

Symptoms of Pre-menstrual Syndrome include bloating, weight gain, aggression, lack of concentration, headaches, tiredness, depression, irritability, mood swings, breast tenderness, panic attacks and food cravings. These symptoms typically occur in the in the second half of the menstrual cycle and disappear or at least significantly improve during the remainder of the cycle.

Pre-menstrual Syndrome tends to worsen with age and the symptoms may be more severe at times of stress.

The diagnosis can often be difficult to make. The most reliable way of confirming the diagnosis is to keep a chart of the symptoms. If the symptoms are present throughout the cycle or there is no clear cyclical pattern, other causes will need to be excluded such as thyroid disorders, early menopause, depression or anxiety. . Blood tests are unhelpful in making this diagnosis, as hormone levels are normal in women with Pre-menstrual Syndrome

The cause of the PMS is unknown but it is in some way, that this not clear, related to the hormonal changes of menstrual cycle. It is for this reason that PMS improves when a woman is pregnant and therefore not experiencing a cycle. It is also for this reason that the hormonal treatment for this condition aims at suppressing the menstrual cycle.

Treatment of PMS

Lifestyle changes:

Exercise

Exercise can lead to some improvement in the symptoms of PMS and women with PMS should be encouraged to take some form of regular exercise.

Diet

Modifying the diet to include less fat, sugar, salt, caffeine and alcohol is often beneficial. Some studies suggest that certain vitamin supplements including vitamin B6 may be helpful however this remains unproven.

Stress

Stress can make many of the symptoms of PMS worse so steps to relieve stress by exercise of relaxation may be helpful. Reducing the amount of caffeine and alcohol that is consumed improves sleep and consequently reduces stress levels.

Hormonal treatment of PMS

Oestrogen

The hormonal treatment of PMS aims at suppressing the natural cycle with oestrogen, which can be given in the form of patches, gels or implants. Oestrogen cannot be given on its own as this will lead to irregular vaginal bleeding and lead to an increased risk of cancer of the lining of the womb (Endometrial cancer). A Progestogen hormone for between 7 and 12 days every month is therefore given to women receiving oestrogen, which results in regular bleeding and removes the risk of endometrial cancer. Unfortunately, Progestogen hormones can sometimes produce symptoms very much like PMS including bloating, breast pain, headaches and mood swings. These side effects are often not troublesome but if they are the dose or duration of the progestogen can be reduced. Alternatively the progestogen can be changed to a less potent one or it can be given in a different way such as vaginal pessaries. The mirena contraceptive coil can also be used which releases a progestogen hormone in the womb with minimal systemic absorption and therefore minimal side effects.

The oral contraceptive pill

The combined oral contraceptive is not usually helpful in the treatment of PMS as they contain both oestrogen and progestogen and the progestogen component can aggravate some of the symptoms of PMS. A relatively new pill called Yasmin contains a progestogen that is free from progestogenic side effects and may therefore be helpful in the treatment of PMS. 

GNRH Analogues

The GNRH analogues are potent drugs, which suppress ovarian function and will thus alleviate the symptoms of PMS but will result in typical menopausal symptoms, which are often very similar. Long-term use of GNRH analogues will also put the woman at risk of osteoporosis. GNRH analogues are, therefore, only used in severe cases of PMS and should be given with ad-back HRT to alleviate the menopausal side effects and prevent osteoporosis.

Anti-depressants.

Newer anti-depressants, SSRIs, (selective serotonin re-uptake inhibitors) have been shown to be highly effective in treatment of psychological symptoms of PMS. Many women are reluctant to consider taking anti-depressants because they feel they are suffering from a hormonal illness and are not depressed. However, these anti-depressants appear to be safe and are not addictive. They can also be effective if they are taken in the second half of the cycle only, from day 15 to 28.

Hysterectomy and removal of the ovaries.

Removal of the ovaries will cure PMS and this is usually carried out with a hysterectomy. It is usually only considered if other treatment has failed or if the woman has other menstrual or gynaecological symptoms requiring hysterectomy and she has completed her family. Women should be given oestrogen replacement therapy following a hysterectomy to suppress menopausal symptoms and avoid the risk of osteoporosis.

Summary

The symptoms of premenstrual syndrome may be relatively mild but in some women they are severe enough to affect a womans lifestyle, work or relationships. The treatment options include lifestyle changes as well as medical or hormonal therapy.

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