Treatment Options

Self-help

In the weeks before menstruation there are several simple lifestyle changes you can try which may improve symptoms. These include:

• Reduce or eliminate intake of tea, coffee and other caffeinated drinks
• Avoid sugary food and snacks such as chocolate. Try to keep your blood sugar levels stable
• Regular aerobic exercise, relaxation exercises, yoga or meditation

Conventional Medicine

A specialist will make the diagnosis from a description of your symptoms. You may be asked to keep a symptom calendar to establish the cyclical nature of your symptoms. It is important to differentiate PMS from other common conditions, which may cause similar symptoms. These include:

• Psychological disorders such as depression and manic-depression
  
• Psychosexual problems affecting sexual function
• Causes of pelvic pain such as endometriosis
• Breast disorders
• Thyroid problems
• Menopause

If there is a doubt about the diagnosis you may be given a three month long course of injections of a Gonadotrophin releasing hormone analogue (GnRH analogue). This turns off the signal from the Pituitary Gland in the brain, which normally stimulates hormone production by the ovary. If the symptoms persist despite this test, then PMS is unlikely.

There is a wide range of alternative treatments used by conventional medical specialists to treat the symptoms of PMS. These include health measures & dietary advice, supplements with Vitamin B6 and evening primrose oil. These are considered along with more conventional treatments such as anti-depressants and hormones. In severe cases surgical removal of the ovaries with or without the uterus may be necessary.

It is also important to acknowledge the large placebo effect seen in the treatment of PMS. Using placebos in PMS, results in an improvement in symptoms in up to 90% of patients in some studies.

Psychological Support

Acknowledgement of the problem and reassurance may be all that is needed to help women and their families to cope.

General Health Measures

Improved diet, reduced caffeine intake, reducing smoking and alcohol, increased exercise and relaxation.

First Line Treatments

The nutritional supplement, Vitamin B6 (Pyridoxine), is used as a first line treatment for PMS. The herbal remedy Evening Primrose Oil is also widely used particularly for the treatment of breast tenderness.

Treatment of Specific Symptoms

The antidepressants known as Selective Serotonin Reuptake inhibitors (SSRIs) have been shown to relieve the psychological symptoms associated with PMS. The diuretic Spironolactone improves symptoms of PMS associated with fluid retention, such as breast tenderness and bloating.

Treatment of Severe Symptoms

Premenstrual progesterone is often used to treat PMS. However, there is now considerable evidence suggesting that progesterone actually makes the condition worse.

The symptoms of PMS follow the hormonal changes that occur with release of an egg by the ovary (ovulation). Therefore, these cyclical PMS type symptoms do not occur in women before puberty, after the menopause or during pregnancy. Neither do they occur after the uterus and ovaries are removed (hysterectomy and bilateral salpingo-oophorectomy).

However, the typical cyclical symptoms can remain after a hysterectomy if the ovaries are conserved. The syndrome should therefore be considered a disorder of the ovarian cycle rather than a disorder of the menstrual cycle.

Proven hormonal therapies for PMS are based on suppressing the monthly production of eggs by the ovary (ovulation). These are:

• Gonadotrophin Releasing Hormone Analogues (GnRH analogues). This is often used to confirm the diagnosis and does remove the symptoms. It is not however appropriate for long term therapy without add back oestrogen and progesterone hormone replacement therapy to prevent the side-effect of osteoporosis developing. GnRH analogues are expensive and are not licensed for long term use.
• Ovulation is also suppressed by taking continuous oestrogen as a patch, tablet or implant. Progesterone needs to be given to prevent overgrowth of the lining of the uterus. This can be given using cyclical progesterone for 7-10 days a month or continuously using the Levonorgestrel impregnated intra-uterine system (Mirena IUS). The intra-uterine device act locally on the lining of the uterus and there is only a very tiny amount of progesterone absorbed into the blood stream. This is an advantage over oral therapy, as women with PMS are sensitive to progesterone.

The combined oral contraceptive pill suppresses ovulation but it is not usually effective in severe cases of PMS. It is worth trying however, if symptoms are mild.

Surgery

Medical treatment may not be successful in some women. This might be due to bleeding problems on hormone treatment or progesterone side effects. Surgery may therefore be necessary. The operation should remove both ovaries (Oopherectomy). This can be performed either as an open procedure or more commonly by the keyhole approach (Laparoscopy). Sometimes it may be appropriate to remove the uterus at the time of surgery (Hysterectomy).

Long-term hormone replacement therapy with oestrogen is necessary to prevent osteoporosis after the ovaries have been removed. If the uterus is conserved rather than being removed, progesterone hormone replacement is also necessary. This may be a problem in women particularly sensitive to progesterone and in this circumstance removing the uterus, in addition to both ovaries, would be appropriate.