Panay, Nick
Consultant Gynaecologist: Queen Charlotte’s & Chelsea Hospital
Professor of Practice: Imperial College London
Many women experience mild physical and emotional PMS symptoms which are not particularly troublesome. However, when severe these symptoms can lead to a breakdown in interpersonal relationships and interference with normal activities. These symptoms can be particularly troublesome in the late reproductive and perimenopause years due to increasing hormonal fluctuations which can trigger symptoms in genetically predisposed, hormonally vulnerable, women. When PMS in severe, it may satisfy the American Psychiatric Association DSM-V criteria for premenstrual dysphoric disorder (PMDD). The International Society for Premenstrual Disorders (ISPMD) has made recommendations for a new classification with core (typical, pure or reference disorders associated with spontaneous ovulatory menstrual cycles) and variant premenstrual disorders (such as symptoms of an underlying psychological or somatic disorder significantly worsening premenstrually). PMS/PMDD continues to be poorly understood and in many cases inadequately managed. It can be the cause of considerable morbidity and at time even mortality. It is imperative that a consensus on definition is reached globally and that properly conducted research continues to be funded. It is through this work that clinicians will be able to practice in an evidence-based way to effectively treat this condition.
The alternatives to traditional therapy, such as agnus castus, red clover and St John’s Wort, are showing promising results in randomized studies but more data are needed. Data on natural progesterone remain controversial, although many women derive considerable benefit from this preparation. Progestogens should not be used as they are good at reproducing the symptoms of PMS/PMDD! The more established therapies for which randomized controlled data exist are the combined “fourth” generation pills (e.g. the 24/4 or flexible regimen 20mcg ethinylestradiol / 3mg drospirenone), transdermal estradiol, selective serotonin re-uptake inhibitors and the GnRH analogues with add back HRT. Hysterectomy with BSO and adequate HRT remains an important option for severely afflicted women whose family is complete and have not responded to other therapies. The presentation will follow the UK RCOG Green Top Guideline No 48 on the Management of Premenstrual Syndrome https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/premenstrual-syndrome-management-green-top-guideline-no-48/.
Support for patients and health professionals is available from the National Association for Premenstrual Syndrome https://www.pms.org.uk/