Management

Before any form of treatment is initiated, symptom diaries should be completed over at least two consecutive menstrual cycles (1).

In addition patients with presumed premenstrual disorders (PMDs) should initially be assessed for other conditions and referred to appropriate medical speciality if required.

• a through medical history and physical examination should be carried out to rule out any underlying medical disorders e.g. - such as depression, anxiety disorders, and hypothyroidism (2).
• social history of the patient is also important to identify any incidents of domestic violence, physical or emotional trauma, or substance abuse, owing to the close association between PMS/ premenstrual dysphoric disorder (PMDD) with such a history (2).

Management of PMD is usually carried out in a step-wise manner, from non-pharmacological strategies, antidepressant medications, hormonal strategies, with surgical options being a last resort (3). Explanation, reassurance and support may be all that are required.

• the level of invasiveness of an intervention is determined by the severity of symptoms and the degree of impairment
• review patient’s previous treatment and her future plans for pregnancy or contraception
• inquire from patient whether non medical, behavioural therapy, psychotropic therapy, endocrine agents, surgery, or an intrauterine system are acceptable (4)

In severe PMDs:

• referral to a gynaecologist should be considered when simple measures (e.g. COCs, vitamin B6, SSRIs) have been explored and failed and when the severity of the PMS justifies gynaecological intervention
• patients may benefit from being managed by a multidisciplinary team comprising a general practitioner, a general gynaecologist or a gynaecologist with a special interest in PMS, a mental health professional (psychiatrist, clinical psychologist or counsellor) and a dietician. (1)

Treatment for regimen for the management of severe PMS has been outlined by the RCOG (1)

• first line
  • exercise, cognitive behavioural therapy, vitamin B6
  • combined new-generation pill (cyclically or continuously)
  • continuous or luteal phase (day 15-28) low-dose SSRIs e.g. citalopram 10 mg
    • SSRIs should be considered one of the first-line pharmaceutical management options in severe PMS (1)
      • when treating women with PMS, either luteal or continuous dosing with SSRIs can be recommended
      • women with PMS treated with SSRIs should be warned of the possible adverse effects such as nausea, insomnia, somnolence, fatigue and reduction in libido
      • women should be provided with pre-pregnancy counselling at every opportunity. They should be informed that PMS symptoms will abate during pregnancy and SSRIs should therefore be discontinued prior to and during pregnancy
        • women with PMS who become pregnant while taking an SSRI/SNRI should be aware of the possible, although unproven, association with congenital malformations. They should be reassured that if such an association does exist, it is likely to be extremely small when compared to the general population (5)
          
• second line
  • estradiol patches (100 micrograms) + micronised progesterone (100 mg or 200 mg [day 17–28], orally or vaginally) or LNG-IUS 52 mg
  • higher-dose SSRIs continuously or luteal phase e.g. citalopram/escitalopram 20–40 mg
    
• third line
  • GnRH analogues + addback HRT (continuous combined estrogen + progestogen or tibolone) e.g. 50–100 micrograms estradiol patches or2–4 doses of estradiol gel combined with micronised progesterone 100 mg/day] or tibolone 2.5 mg)
    
• fourth line
  • total abdominal hysterectomy and bilateral oophorectomy + HRT (including testosterone) (1)

Reference:

1. Management of Premenstrual Syndrome: Green-top Guideline No. 48. BJOG. 2017;124(3):e73-e105.
2. Rapkin AJ, Lewis EI. Treatment of premenstrual dysphoric disorder. Women's Health. 2013;9(6): 537–556
3. Walsh S, Ismaili E, Naheed B, O’Brien S. Diagnosis, pathophysiology and management of premenstrual syndrome. The Obstetrician &Gynaecologist 2015;17:99–104
4. O'Brien S et al. Diagnosis and management of premenstrual disorders. BMJ. 2011;342:d2994.
5. Gao S. et al. Selective serotonin reuptake inhibitor use during early pregnancy and congenital malformations: a systematic review and meta-analysis of cohort studies of more than 9 million births. BMC Med. 2018; 16: 205