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Need to know: Premenstrual syndrome

GP Dr Pam Brown wanted to know how to diagnose PMS, the best first-line treatments and the evidence base for complaementary treatments. Dr Nick Panay answered her questions

1. What diagnostic criteria should we use for premenstrual syndrome/pre-menstrual dysphoric disorder? Is there a validated questionnaire for diagnosis?

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When assessing women with PMS symptoms should be recorded prospectively, over two cycles using a symptom diary, as retrospective recall of symptoms is unreliable.

There are many symptoms diaries available but the Daily Record of Severity of Problems (DRSP) is well-established and simple for patients to use. A copy can be downloaded and given to patients at www.pulsetoday.co.uk.

Typical psychological symptoms include mood swings, irritability, depression and feeling out of control. Physical symptoms include breast tenderness, bloating and headaches. Behavioural symptoms include reduced visuo-spatial and cognitive ability and an increase in accidents.

2. Why do some women get predominantly physical and some predominantly psychological symptoms?

The degree and type of symptomatology can vary significantly from woman to woman. The reason for this is unknown but may be related to a polygenic mode of inheritance coupled with environmental factors.

Symptoms of PMS are distinguished from normal physiological premenstrual symptoms because they cause significant impairment to daily activity.

3. Is there evidence for hormonal deficiencies or imbalances in women with PMS? Is the COCP likely to improve symptoms?

The precise aetiology of PMS remains unknown, but cyclical ovarian activity and the effect of estradiol and progesterone on the neurotransmitters serotonin and gamma-aminobutyric acid (GABA) appear to be key factors.

Absence of PMS before puberty, in pregnancy and after the menopause supports the theory that cyclical ovarian activity is important.

The prevalence of severe PMS is variable – between 3% to 30%. PMS appears more prevalent in women who are obese and do less exercise. There is a lower incidence of PMS in women using hormonal contraception.

4. What are the main pharmacological treatments available for PMS?

First-line treatments are:

• Exercise, cognitive behavioural therapy, vitamin B6

• Combined new generation pill such asYasmin, Cilest (cyclically or continuously)

• Continuous or luteal phase – day 15 to 28 low dose SSRIs

Second-line:

• Estradiol patches (100µg) plus oral progestogen (for example, duphaston 10mg d17-d28 or Mirena)

• Higher-dose SSRIs, continuously or luteal-phase

Third-line:

GnRH analogues plus addback HRT (continuous combined oestrogen plus progestogen or tibolone)

Fourth-line

• Total abdominal hysterectomy and bilateral salpingo-oopherectomy plus HRT (including testosterone).

5. What dosing regimen and SSRI should we use in the management of PMS? Will they only benefit women with predominantly mental symptoms?

Physical and psychological symptoms of PMS improve with SSRIs. In view of their proven efficacy and safety in adults, SSRIs/SNRIs should be considered one of the first-line pharmaceutical management options in severe psychological PMS.

However, prescribing should be restricted to those health professionals – gynaecologists, psychiatrists or GPs – who have a particular expertise in this area.

The Committee on Safety of Medicines endorses the view that SSRIs are effective medicines in the treatment of depression and anxiety conditions and that the balance of risks and benefits in adults remains positive in their licensed indications.

6. The homeopathic remedies Lachesis, Pulsatilla and Nat Mur 30c can be used mid -cycle for PMS. Is there evidence of their efficacy? Which symptom picture fits each remedy?

There is only a little data for homeopathic treatments and PMS from small uncontrolled studies with no clear evidence for benefit beyond placebo effect.

7. What are the current recommendations on use of high doses of vitamin B6 for PMS?

Insufficient evidence of efficacy is available to give a recommendation for using vitamin B6 in the treatment of premenstrual syndrome. There is no rationale for giving daily doses of vitamin B6 in excess of 100mg, especially following recommendation from the Department of Health and the Medicine Control Agency in 1999 to restrict the dose of vitamin B6 available generally to 10mg and to limit the dose sold by a pharmacist to less than 50mg.

8. If women prefer lifestyle interventions rather than drug therapy, what should we recommend? Is there any evidence for magnesium, calcium, acupuncture or herbal therapies in managing PMS? If so, what dose is needed?

The clinical experience of health professionals managing PMS patients suggests that lifestyle interventions – reducing stress, exercise and so on – are of benefit and should be instituted in addition to any other therapeutic intervention. However, thre is no randomised controlled data for any of these strategies, only the clinical experience of health professionals dealing with PMS sufferers.

In practice, only women with mild to moderate PMS are able to deal with their symptoms using lifestyle measures alone.

The evidence-base for complementary therapies is summarised in the box below.

Dr Nick Panay is chair of the National Association for Premenstrual Syndrome; director of the Menopause and PMS Centre; and consultant obstetrician and gynaecologist, Queen Charlotte's and Chelsea Hospital, London

Competing interests: I have received honoraria for lecturing, and advisory board work from various pharma companies

What I will do now

Dr Brown reflects on the answers to her questions

• I will download a copy of the Daily Record of Severity of Problems diary and use it with patients who may have PMS.
• This evidence-based treatment algorithm is useful and I will share it with patients as well as our registrar.
• I will continue to use homeopathic remedies as taught by the Royal National Homoeopathic Hospital course, as they produce good results in my patients, and I am sure they do not mind if this is largely a placebo response, so long as they feel better with no side-effects from medication.
• I will continue to recommend lifestyle interventions as part of a holistic programme of management for women with PMS.
• I will be more likely to offer SSRI therapy to women, particularly those with severe PMS, and will try luteal phase use as well as continuous use.
• I will be more likely to use Yasmin or Cilest first-line in women with PMS, and will recommend tri-cycling packs since this seems logical if the original symptoms are due to cyclical hormonal changes.
• In women reluctant to use drug therapies, I will consider recommending pre-menstrual magnesium, with lifestyle interventions.

Dr Pam Brown is a GP in Swansea

Take home points Download a PMS diary sheet to give to your patients PMS diary sheet Summary of complementary therapies to download Summary of complementary therapies to download

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