Premenstrual Syndrome

Premenstrual syndrome is a cyclical pattern of physical and emotional symptoms in the luteal phase (the 1 to 2 weeks before a period). They settle within a few days of the start of bleeding and are severe enough to disturb daily life.

The cause is an abnormal response of the brain to normal changes in ovarian hormones, involving serotonin and gamma-aminobutyric acid. It is common in women of reproductive age, and matters because it reduces work, relationships and quality of life, and can be treated.

• Risk factors: age 25 to 40 years, family history, past depression or anxiety, stress, obesity, smoking, high caffeine intake.
• Symptoms must be present in at least two cycles and absent in the week after the period.
• A prospective symptom diary for 2 cycles is needed.

Women have bloating, breast tenderness, headache, tiredness, joint and muscle pain, food cravings, irritability, mood swings, anxiety, low mood and poor concentration in the week or two before a period, with relief within 4 days of its start.

• Symptom free week after the period.
• Examination is normal.
• Differential diagnosis: premenstrual dysphoric disorder, depression and anxiety with premenstrual worsening, perimenopause, thyroid disease, anaemia, migraine, chronic fatigue, endometriosis, polycystic ovary syndrome, hormonal contraceptive effect, substance misuse.
• Complications: relationship and work difficulty, depression, self harm thoughts, absenteeism, overuse of analgesics, reduced quality of life.

The approach is a prospective symptom diary and exclusion of other causes.

• Daily symptom record for at least 2 consecutive cycles, rating each symptom from 0 to 3, showing symptoms in the luteal phase and a symptom free week after menses.
• Examination, blood pressure and body mass index; screening for depression and anxiety.
• Full blood count, thyroid stimulating hormone; follicle stimulating hormone if age is above 40 years; urine hCG.
• Review of drugs and contraceptives.

The principle is lifestyle measures and cognitive behavioural therapy for mild disease, then a selective serotonin reuptake inhibitor or ovulation suppression for moderate or severe disease.

• Supportive: regular aerobic exercise for 30 minutes on most days; regular small meals with complex carbohydrates; reduced caffeine, salt and alcohol; sleep regularity; stress reduction; cognitive behavioural therapy for 6 to 12 sessions; symptom diary; family and partner education.
• Pharmacological, supplements: elemental calcium 1200 mg (as carbonate) oral once daily; pyridoxine 50 mg oral once daily (maximum 100 mg daily).
• Pharmacological, antidepressants: fluoxetine 20 mg oral once daily, either throughout the cycle or from day 14 to the onset of bleeding (maximum 60 mg daily).
• Or sertraline 50 mg oral once daily (start 25 mg for 3 days) given in the luteal phase or continuously.
• Pharmacological, hormonal: combined oral contraceptive pill with drospirenone 3 mg and ethinylestradiol 20 micrograms oral once daily for 24 days then 4 days free.
• Or the pill with ethinylestradiol 30 micrograms and levonorgestrel 150 micrograms oral once daily taken continuously.
• Pharmacological, symptomatic: mefenamic acid 500 mg oral 8-hourly with food for 3 days for pain; spironolactone 100 mg oral once daily from day 14 to the onset of bleeding for bloating and breast tenderness.
• Pharmacological, severe disease unresponsive to other treatment: goserelin 3.6 mg subcutaneous every 28 days for up to 6 months with tibolone 2.5 mg oral once daily as add back.
• Procedures: bilateral oophorectomy with hysterectomy for severe disease that fails all other treatment, after a course of ovarian suppression, and only after childbearing is complete.
• Special groups: women planning pregnancy use lifestyle measures and cognitive behavioural therapy, and stop drugs when pregnancy is confirmed.
• Women with depression or anxiety use continuous fluoxetine or sertraline and have mental health review.
• Women with migraine with aura, hypertension or previous clot avoid oestrogen containing pills.
• Women who are breastfeeding use sertraline.
• Red flags: suicidal thoughts, severe depression, symptoms continuing throughout the cycle, psychosis, self harm, symptoms starting after age 45 years.
• Follow-up: review at 2 to 3 cycles with diary; adjust or stop the drug after 6 months if symptoms are controlled; review at 12 months; refer to a specialist for symptoms resistant to two drug classes.