The National Association for Premenstrual Syndrome

(NAPS)
Guidelines on Premenstrual Syndrome

Nick Panay
BSc MRCOG MFSRH
 NAPS Guidelines on Guidelines on Premenstrual Syndrome

Nick Panay BSc MRCOG MFSRH

Chairman of the National Association for Premenstrual Syndrome
Director of West London Menopause & PMS Centre
Consultant Gynaecologist
Imperial College Healthcare NHS Trust & Chelsea and Westminster
NHS Foundation Trust
Honorary Senior Lecturer, Imperial College London

INTRODUCTION dition which manifests with distressing physical,

behavioural and psychological symptoms not due
These guidelines have been prepared by Mr Nick
to organic or underlying psychiatric disease,
Panay, Chairman of NAPS for the benefit of both
which regularly recurs during the luteal phase of
sufferers and health professionals. The guidelines
each menstrual (ovarian) cycle and which disap-
aim to provide clear information at a time when
pears or significantly regresses by the end of men-
so much controversy exists as to the causality and
struation.” The severity of symptoms is judged
management of PMS. Guidelines on the definition
according to the degree of interference with day-
and management of PMS are essential to encour-
to-day activities and relationships. Premenstrual
age the acceptance of the condition by patients,
exaggeration or exacerbation of symptoms can
health professionals and regulatory authorities.
also occur, though this is not regarded as the
The text aims to distil the evidence base into eas-
“core” diagnosis. Premenstrual Dysphoric Disor-
ily digestible and understandable prose – as such,
der (PMDD) is the American Psychiatric Associa-
extensive references will not be provided but are
tion‟s definition of severe PMS in the Diagnostic
available from the Green Top Guidelines of the
and Statistics manual - Version IV
Royal College of Obstetricians and Gynaecolo-
gists www.rcog.org.uk for the interested reader. AETIOLOGY
The treatment algorithm provides a summary of The precise aetiology of PMS remains unknown
interventions which might be instituted at levels but cyclical ovarian activity and the effect of es-
of the severity of symptoms. In the Appendix, tradiol and progesterone on the neurotransmitters
levels of recommendation are given for the medi- serotonin and gamma-aminobutyric acid (GABA)
cal interventions according to accepted RCOG appear to be key factors. Absence of PMS before
evidence levels with also key references and fur- puberty, in pregnancy and after the menopause
ther supports the theory that cyclical ovarian activity is
reading. important. Rapidly changing estradiol levels, not
only premenstrually but also postnatally and peri-
DEFINITION
menopausally lead to this triad of hormone de-
Many women experience mild physical and emo-
pendent depressive disorders often in the same
tional PMS symptoms which are not particularly
predisposed individual. Recent work has shown
troublesome. However, when severe, these symp-
that the risk for PMDD is associated with a ge-
toms can lead to a breakdown in interpersonal
netic variation in ESR1 (Estrogen Receptor [ER]
relationships and to an interference with normal
alpha) gene but more work is required to confirm
activities. A working definition of PMS is “a con-
and define this genetic predisposition.
PREVALANCE that reduction of stress, for instance, is a great
The reported prevalence of moderate to severe help in ameliorating symptoms. Also, dietary
PMS varies between 3% and 30%, depending on measures such as avoidance of carbohydrate
the population studied, and is likely to be under binges and limitation of alcohol and caffeine in-
reported, especially by the ethnic minorities. The take is often of benefit. There are data from non-
incidence of severe PMS or PMDD appears to be randomised trials that exercise improves PMS
5 to 8%. PMS appears less prevalent in women symptoms. However, in cases of moderate to se-
who are on hormonal contraception, of normal vere PMS, it is important that medical therapy is
weight and perform exercise. instituted sooner rather than later to avoid unnec-
essary suffering. Women with marked underlying
DIAGNOSIS
psychopathology as well as PMS should be re-
Crucial to the management of PMS is the need to
ferred to a psychiatrist. Symptom charts/diaries
make the correct diagnosis. This cannot be accu-
should be used to assess the effect of treatment.
rately established by retrospective recall. It needs
to be made by the prospective logging of symp- Service Delivery
toms by the patient, ideally over two cycles. A Primary care should be able to deal with most
symptom chart/diary which can be filled in online cases of PMS. Awareness of the condition and
is available on the NAPS website training in its management are essential. Ideally,
(www.pms.org.uk). Alternatively, the „blue women with severe PMS should be treated by a
moons‟ diary could be used. The chart/diary multidisciplinary team which might comprise a
should continue to be filled in when treatment has hospital or community gynaecologist, psychiatrist
been started to give an objective indication of re- or psychologist, dietitian and counsellor. While
sponse to therapy. such services are rarely provided in any NHS set-
ting, referral to a gynaecologist should be re-
Common Symptoms of PMS served for women who have been fully evaluated
(over 150 identified)
as having severe PMS and when simpler forms of
PSYCHOLOGICAL & BEHAVIOURAL SYMPTOMS therapy have been explored.
Mood swings, depression COMPLEMENTARY THERAPIES
Tiredness, fatigue or lethargy, irritability
(CAMs)
Anxiety, feeling out of control When treating women with PMS, complementary
Reduced cognitive ability, aggression, anger medicines may be of benefit, but clinicians need
to consider that data from clinical studies are lim-
Sleep disorders, , food cravings
ited and underpowered. Interactions with conven-
PHYSICAL SYMPTOMS tional medicines should also be considered. It is
difficult to assess the true value of most of these
Breast tenderness, skin rashes
therapeutic interventions because they are freely
Bloating, weight gain, clumsiness available without prescription or physician recom-
Headaches, backache mendation, and with little regulation of efficacy or
safety. Most are not licensed or registered for the
treatment of PMS. The regulatory authorities are
TREATMENT
aiming to rectify the situation by insisting that all
General Principles of Treatment
complementary therapies are registered by 2011
When managing women with PMS, there are cer-
or withdrawn from sale. This section reviews the
tain principles which should be adhered to. Even
recent evidence for some of the evidence-based
though not evidence-based, there is little doubt
„alternative‟ interventions which have been used women in the highest quintile of total Vitamin D
to treat PMS. Treatments have been selected intake (median, 706 IU/d) had a relative risk of
where reasonable efficacy data exist (randomised 0.59 (95% confidence interval, 0.40-0.86) com-
controlled data if possible). pared with those in the lowest quintile (median,
112 IU/d) (P = .01 for trend). The intake of
Vitamin B6OTC IS
skimmed or low-fat milk was also associated with
Vitamin B6 is often used to treat premenstrual a lower risk (P<.001). A high intake of calcium
syndrome without clear evidence of its efficacy. and Vitamin D may therefore reduce the risk of
The recommended dietary allowance for Vitamin PMS but large-scale clinical trials addressing this
B6 is around 2.0mg/day and deficiency of Vitamin issue are required. At present, the only interven-
B6 is rare. Due to the unproven efficacy of Vita- tional data are from small trials.
min B6 in treating premenstrual syndrome, a sys- Recommendation (B): Given that calcium and
tematic review of published and unpublished ran- Vitamin D may also reduce the risk of osteopo-
domised placebo controlled trials of effectiveness rosis and some cancers, clinicians may consider
of Vitamin B6 in the management of premenstrual recommending these nutrients even for women
syndrome has been undertaken. This showed a with PMS but more data are required to deter-
marginal benefit for using Vitamin B6. There is no mine efficacy and to optimise regimens.
rationale for giving daily doses of Vitamin B6 in
excess of 100mg, especially following recommen- Isoflavones e.g. Soy/Red CloverOTC
dation from the Department of Health and the In a 24-week, double-blind study, 49 women with
Medicine Control Agency in 1999 to restricting menstrual migraines received either placebo or a
the dose of Vitamin B6 available generally to combination supplement containing Soy isofla-
10mg and to limit the dose sold by a pharmacist to vones, Dong Quai, and Black Cohosh extracts.
less than 50mg. The treatment group showed a significantly
Recommendation (A): Insufficient evidence greater improvement than the placebo group. Re-
of efficacy is available to give a recommenda- cent randomised controlled trial data from the au-
tion for using Vitamin B6 in the treatment of thor‟s unit, in 19 women with severe PMS, dem-
onstrate a benefit with Red Clover isoflavones.
premenstrual syndrome.
There was a statistically significant improvement
MagnesiumOTC in symptoms from baseline but not significantly
Preliminary small studies suggest that magne- different from placebo – a larger study may have
demonstrated such a difference.
sium may also be helpful in PMS. More data
would be desirable. Recommendation (B): More data are re-
Recommendation (B): There is some evidence quired before a clear recommendation can be
that regular use of magnesium supplements is made for isoflavone usage but preliminary data
of benefit in managing premenstrual syndrome. are encouraging.

Calcium / Vitamin DOTC Agnus CastusOTC

The fruits of Vitex agnus castes (The chaste tree)
Studies suggest that blood calcium and Vitamin D
contain a mixture of iridoids and flavonoids. The
levels are lower in women with PMS and that cal-
mechanism of action may be related to modulation
cium supplementation may reduce symptom se-
of of stress induced prolactin secretion via dopa-
verity, but it is unknown whether this may prevent
mine without directly affecting lutenising or folli-
the initial development of PMS. In a recent case
cle stimulating hormones A number of small
control study, after adjustment for risk factors,
randomised controlled trials show a benefit versus
placebo. NAPS is a registered charity set up in
1984 which aims to help all sufferers of
Recommendation (B): Agnus Castus is the best PMS by providing information and sup-
researched CAM for PMS but a lack of stan- port so that the condition can be success-
dardised quality controlled preparations is a fully managed. The Association works
problem. with health professionals both to promote
research and to help ensure that PMS suf-
St John’s WortOTC ferers can access treatments appropriate
to their needs.
Hypericum perforatum is a herbal remedy (St
John‟s Wort) shown to alleviate mild to moderate If you would like to purchase further cop-
depression. However, there have been no clinical ies of the NAPS Guidelines price £5.00
please contact NAPS at: www.pms.org.uk
investigations on its effectiveness in treating pre-
menstrual syndrome apart from one case report
by telephone on 0844 815 7311
and a small prospective, open, uncontrolled, ob-
servational pilot study. Symptoms which im- or by post to
proved the most were emotional and cognitive,
which correlates with evidence showing that Hy- NAPS
pericum has positive effects on mood and that it 41 Old Road, East Peckham, Kent
may moderate brain neurotransmitters but caution TN12 5AP
should be exercised in its usage in view of its Your patients can contact NAPS for
multiple interactions. information and support at:
Recommendation B: Initial data appear en- www.pms.org.uk or at the above address
couraging but larger studies are required be-
fore St John’s Wort can be recommended for
use in PMS How to join NAPS as a professional member

Evening Primrose OilOTC IE By post to the address above

Evening Primrose Oil, a rich source of gamma Include the following details
linoleic acid, is often used as a treatment for se- Title, Surname, Forename, Address,
vere premenstrual syndrome. However, the evi- Postcode, Telephone No. Email address,
dence for efficacy in this condition is poor. A Position held, Organisation and address.
meta-analysis of the data has also concluded that Make cheques available to NAPS
Evening Primrose Oil is ineffective in the treat-
ment of severe PMS. Only cyclical mastalgia Or via the website at www.pms.org.uk
(breast pain) has been shown to respond to this
Subscriptions
treatment.
 Qualified health professional £50.00
Recommendation (A): Evening Primrose Oil  Health professional student £25.00
should be avoided as a treatment for severe
PMS unless the treatment is specifically tar-
geted for cyclical mastalgia. Benefits of membership

 Free admission to NAPS study days

 All benefits of standard membership
(see website)
 Free copy of NAPS Guidelines
MEDICAL TREATMENT OF PMS
Most efficacious treatments for PMS are unlicensed for use in women with severe PMS. However, in this
situation unlicensed treatments can be justified where a body of evidence and safety exist. The two chief
evidence-based medical treatments of moderate to severe PMS are categorised by ovulation suppression
and selective serotonin reuptake inhibitors

Ovarian suppression
Although the underlying cause of severe PMS remains unknown, cyclical ovarian activity appears to be an
important factor. A logical treatment for severe PMS, therefore, is to suppress ovulation and thus suppress
the cyclical endocrine/biochemical changes which cause the distressing symptoms. A number of drugs are
capable of performing this function, but they are not without their own side-effects which may influence
the efficacy of the treatment or the duration for which they may be given.

The combined oral contraceptive pill*

Although able to suppress ovulation, and used commonly to improve PMS symptoms, the combined pill
was initially not shown to be of benefit in randomised prospective trials. This is probably because it was
used with a pill-free week and because the daily progestogen in the second generation pills e.g.
levonorgestrel, regenerated PMS-type symptoms. The relatively new combined contraceptive pill
(Yasmin), containing an anti-mineralocorticoid and anti-androgenic progestogen, drospirenone showed
considerable promise in the treatment of severe PMS as it minimised progestogenic side-effects with a mild
diuretic and anti-androgenic effect. Both observational and small randomised trial data supported efficacy.
However, the development of Yasmin has now been succeeded by Yaz®, a 20 microgram ethinylestradiol /
3 mg drospirenone pill but in a 24/4 rather than the conventional 21/7 regimen. The reduction of the hor-
mone free interval to four days reduces the risk of cycle-related symptoms. Two randomised prospective
studies trials have demonstrated efficacy of Yaz® over placebo in the treatment of PMDD.If the
“conventional” 21/7 regimen pill is used to treat severe PMS, pill packets should be used back to back
(bicycling/tricycling) to avoid the regeneration of cycle-related symptoms during the hormone free interval.
There are data supporting the continuous use of the pill with a break only introduced if breakthrough bleed-
ing occurs.
Recommendation A:
When treating women with PMS, newer contraceptive pill types may represent effective treatment
for PMS and should be considered as one of the first-line pharmaceutical interventions.

Transdermal estradiol*
Placebo-controlled trials have demonstrated that implanted and transdermal (patch) 17β estradiol combined
with cyclical progestogen is effective for the management of physical and psychological symptoms of se-
vere PMS. Implants are less commonly used for PMS since patches have become available due to their
long lasting effects. A recently concluded study from the author‟s unit has shown benefits of 100mcg
patches over placebo with benefits lasting up to 14 months. Additional barrier or intrauterine methods of
contraception should be used when estradiol (patches and implant) are used in PMS as ovulation suppres-
sion cannot be guaranteed. There are insufficient data to confirm long-term endometrial and breast safety
because long-term randomised prospective safety studies are lacking. However, logic dictates that the hor-
monal environment is not significantly different from how it would otherwise be in this premenopausal
population and observation has not shown any problems over 20 years of usage.
Recommendation A:
Percutaneous estradiol, either as an implant or as a patch, combined with cyclical progestogen, has
been shown to be effective for the management of physical and psychological symptoms of severe
PMS.

Progestogen intolerance
Use of continuous estradiol normally necessitates the addition of cyclical progestogen (10 - 12 days) to
avoid endometrial build-up in women who have a uterus. The progestogen releasing system (Mirena) can
maximise efficacy by minimising PMS-like adverse effects. Even the low systemic levels of levonorgestrel
released by the Mirena, can initially produce PMS-type adverse effects in the progestogen intolerant
woman. Despite this, it might still be of advantage to use a Mirena or vaginal progesterone (Cyclogest pes-
saries or Crinone gel 8% – not licensed for this indication) in the progestogen intolerant woman.
Recommendation: A
When treating women with PMS, treatment with the lowest possible dose of progestogen is recom-
mended to minimise adverse effects.

DanazolHS
Cycle suppression may be achieved using Danazol, an androgenic steroid. Studies have demonstrated bene-
fit for several symptoms, but due to masculinizing side-effects, especially at higher, cycle-suppressing
doses, it is not commonly used.
Recommendation: A
Effective in PMS but side effects and risks outweigh benefits

Gonadotrophin releasing hormone (GnRH) analoguesHS

GnRH analogues have been very successfully employed for many years to suppress ovarian steroid produc-
tion. Early resort to GnRH therapy for PMS is not recommended due to the potential side-effects and cost.
Prolonged use should be retained for women with the most severe symptoms. A recent meta-analysis of
GnRH analogues has confirmed their efficacy compared with placebo. Data show that symptoms due to the
hypoestrogenic state can be virtually eliminated and bone mineral density can be maintained by the use of
HRT. Continuous combined therapy or Tibolone is preferable to sequential combined therapy in order to
minimise the risks of symptom re-appearance of PMS-like progestogenic effects.

When treating women with PMS, with GnRHa therapy, treatment should only be continued for 6 months
when used alone. Treatment should be combined with HRT to reduce bone density loss. Women on long-
term treatment should have annual measurement of bone mineral density (ideally by dual energy X-ray ab-
sorptiometry). Treatment should be stopped if bone density declines significantly in scans performed one
year apart. General advice about how exercise, diet and smoking affect bone mineral density should be
given.
Recommendation A
GnRH analogue therapy results in profound cycle suppression and elimination of premenstrual
symptoms. Lack of effectiveness suggests a questionable diagnosis rather than a limitation of ther-
apy.
ProgesteroneIE and ProgestogensIE
A recent meta-analysis of all published studies for progestogen and progesterone treatment of PMS demon-
strated no benefit for treatment. The objective of this systematic review was to evaluate the efficacy of pro-
gesterone and progestogens in the management of premenstrual syndrome. All the trials of progesterone
(by both routes of administration) showed no clinically significant difference between progesterone and
placebo. The findings of this study were not entirely surprising. Synthetic progestogens actually have PMS-
like side effects! Natural progesterone could actually have some benefits as it can have an anxiolytic effect
and act as a mild diuretic. Some women find it very therapeutic, even over long periods of time. However,
of the few underpowered studies conducted only one has shown benefit and better data are needed.

Depot medroxyprogesterone acetate (Depo Provera), Etonorgestrel rods (Implanon) and the ovulation sup-
pressing progestogen-only pill (Cerazette) all have ovulation suppressant activity. However, cyclical symp-
toms can be replaced by continuous low grade symptoms due to the PMS-like side-effects of synthetic pro-
gestogens. Data regarding efficacy are therefore either absent or at best contradictory.
Recommendation Ia A:
There are insufficient data to recommend the routine use of progestogens or natural progesterone in
the treatment of PMS.

Hysterectomy

Total abdominal hysterectomy and bilateral salpingo-oophorectomy is the ultimate form of ovulation sup-
pression and the only true cure for PMS as this removes the ovarian cycle completely. The procedure is
only rarely performed for this indication, as a lesser alternative can usually be found. When treating women
with PMS, surgery should not be contemplated without pre-operative use of GnRH analogues as a test of
cure and to ensure that HRT is tolerated. Such therapy should be reserved for sufferers of extremely severe
PMS in whom other treatment has failed. When appropriately targeted, this intervention can have life al-
tering benefits. It is essential that adequate hormone therapy is given (including consideration of testoster-
one replacement) to prevent simply replacing one set of symptoms with another. Women who have had a
hysterectomy with ovarian conservation will often continue to have cyclical symptoms in the absence of
menstruation.
Recommendation C:
When treating women with severe PMS, hysterectomy and bilateral salpingo-oophorectomy has been
shown to be of benefit.

Selective serotonin reuptake inhibitors (SSRIs)

There is increasing evidence that serotonin may be important in the causality of PMS. A number of SSRIs
have been used to treat severe PMS/PMDD. There are also data suggesting improvement of physical symp-
toms with SSRIs though this is probably due to the improved perception rather than genuine reduction in
symptom severity. A meta-analysis of all available randomised controlled trials involving SSRIs used in
premenstrual syndrome confirmed superior efficacy compared with placebo.
The Commission on Human Medicines endorses the view that SSRIs are effective medicines in the treat-
ment of depression and anxiety conditions and that the balance of risks and benefits in adults remains posi-
tive in their licensed indications. Prescribing should be restricted to those health professionals who have a
particular expertise in this area. Randomised studies have now shown that half-cycle SSRI treatment is as
efficacious as continuous administration. The results of a recent trial showed that the total premenstrual
scores were lower in the luteal-phase dosing group in each of the three treatment months but the differences
were not statistically significant from full-cycle dosing group. Further analysis of each of the symptoms
showed significant differences (P < 0.05) in favour of luteal-phase dosing for mood swings, nervous ten-
sion, feeling out of control and confusion.

The importance of this is that PMS sufferers are less likely to develop dependence on this regimen, benefit
is immediate and women are more likely to accept the treatment as it can be regarded as being different
from the regimens used for psychiatric disorders. In the author‟s opinion, the optimum regimens for PMS
are half-cycle citalopram or escitalopram, 20mg per day from day 15 to day 28 of the cycle. This regimen
appears to be effective even in women whose previous SSRI treatment has failed. Severe PMS also im-
proves significantly with either luteal-phase or symptom-onset dosing of escitalopram with good tolerabil-
ity.
Recommendation A:
In view of their proven efficacy and safety in adults, SSRIs should be considered one of the first line
pharmaceutical management options in severe PMS.

Cognitive Behavioural Therapy

A recent study examined the relative effectiveness of fluoxetine (20 mg daily) and cognitive behavioural
therapy (CBT) (ten sessions), and combined therapy (fluoxetine plus CBT) in women with Premenstrual
Dysphoric Disorder (PMDD). This was a randomised treatment trial lasting 6 months; follow-up was un-
dertaken 1 year post-treatment. Significant improvement occurred in all three treatment groups after 6
months of treatment. Fluoxetine was associated with a more rapid improvement but at follow-up, CBT was
associated with better maintenance of treatment effects compared with fluoxetine. There appeared to be no
additional benefit of combining the treatments and no difference in efficacy between the treatment groups.
A clinical psychology service should be available for women with PMS, ideally as part of the MDT.
Recommendation A:
When treating women with severe PMS, cognitive behavioural therapy should be considered rou-
tinely as a treatment option.

CONCLUSIONS on natural progesterone remain controversial, al-

though many women appear to derive consider-
PMS continues to be poorly understood and in
able benefit from being on this preparation. Pro-
many cases inadequately managed. It can be the
gestogens should not be used as they are very
cause of considerable morbidity and at time even
good at reproducing the symptoms of PMS. The
mortality. It is imperative that a consensus on
more established therapies for which randomized
definition is reached globally and that properly
controlled data exist are the combined third gen-
conducted research continues to be funded. It is
eration pills (esp.Yaz), transdermal oestradiol,
only through this work that clinicians will be able
selective serotonin re-uptake inhibitors and the
to practise in a truly evidence-based way to treat
GnRH analogues. Hysterectomy with bilateral
effectively this condition.
salpingo-oophorectomy and adequate hormone
replacement therapy remains an option for the
The alternatives to traditional therapy, such as
severely afflicted woman whose family is com-
Agnus Castus, Red Clover and St John‟s Wort,
plete and has not responded fully to other thera-
are showing promising results in randomized con-
pies.
trolled studies but more data are needed. The data
KEY REFERENCES / FURTHER READING
National Association for Premenstrual Syndrome: Advice for
sufferers and health professionals. Web address:
www.pms.org.uk Key to Superscripts
1. Susan Kelsey and Dr Russell Kelsey, blue moons diary
Susan Russell Publishing 2008
* Few treatments for PMS are actually licensed –
2. Panay N. Management of Premenstrual Syndrome.
the treatments with an asterisk are ones for which
Journal of Family Planning and Reproductive Health
care 2009; 35(3):187-194. sufficient evidence exists for a GP with an interest in
women‟s health to prescribe reasonably from a
3. Panay N, Studd J. The Management of PMDD
through Ovarian Cycle Suppression. PP121-130. medico legal point of view.
In: Premenstrual Syndromes: PMS and PMDD by
S O'Brien, AJ Rapkin , PJ Schmidt (Eds) Informa OTC - over the counter medications
2007
IE – not recommended, insufficient evidence for
4. Premenstrual Syndromes: PMS and PMDD by Shaughn
O'Brien (Editor), Andrea J Rapkin (Editor), Peter J efficacy
Schmidt (Editor) Informa 2007.
IS – not recommended, insufficient evidence for
5. RCOG Green Top Guideline No 48 The management of
Premenstrual Syndrome Ed. Panay N Dec 2007 safety
www.rcog.org.uk

6. Dr Farah Ahmed and Dr Emma Cordle, Coping with

PMS, Sheldon Press 2009

Classification of evidence levels Grades of recommendations

Ia Evidence obtained from meta-analysis of random- Requires at least one randomised controlled trial
ised controlled trials. A as part of a body of literature of overall good
quality and consistency addressing the specific
Ib Evidence obtained from at least one randomised recommendations (Evidence levels 1a, 1b)
controlled trial.
Requires the availability of well-controlled clini-
IIa Evidence obtained from at least one well-designed B cal studies but no randomised clinical trials on
Controlled study without randomisation the topic of recommendations.
(Evidence levels IIa, IIb, III)
IIb Evidence obtained from at least one other type of
well-designed quasi-experimental study. Requires evidence obtained from expert commit-
C tee reports or opinions and/or clinical experi-
III Evidence obtained from well-designed non-experi ences of respected authorities. Indicates an ab-
mental descriptive studies, such as comparative studies, sence of directly applicable clinical studies of
correlation studies and case studies. good quality. (Evidence level IV)

IV Evidence obtained from expert committee reports

Good practice point
or opinions and/or clinical experience of respected
Recommended best practice based on the clinical
authorities
 experience of the guideline development group.

Definitions of the different types of premenstrual syndrome

Type Definition

Mild Does not interfere with personal/social and professional life

Moderate Interferes with personal/social and professional life but still able to function and interact, although may
be suboptimally
Severe Unable to interact/socially/professionally-withdraws from social and professional activities
(treatment resistant)
Premenstrual exaggeration Background psychopathology, physical or other condition with incomplete relief of symptoms when
menstruation ends
Premenstrual Dysphoric Disorder This is a research criteria, not in general use outside the USA. This definition of severe PMS has
been adopted by the American Psychiatric Association
 Treatment guidelines for PMS
Nick Panay BSc MRCOG MFSRH
Chairman of the National Association for Premenstrual Syndrome, Director of West London Menopause
& PMS Centre, Consultant Gynaecologist Imperial College Healthcare NHS Trust & Chelsea and
Westminster NHS Foundation Trust, Honorary Senior Lecturer, Imperial College London

Mi l d to m o d er a t e P M S

Severe PMS sometimes En co u r ag em ent of hea lth ie r l ifest yle

improves with treatments
from the first two levels,
Im p r o ved n ut rit ion an d r egula r exe r cis e
but may require more
aggressive forms of man- 1. Less fat, sugar, salt, caffeine and alcohol
agement sooner rather 2. Frequent starchy meals, preferably high in fibre
than later 3. More fibre, fruit, vegetables

S tr e s s m a n a g e m e n t C o m p l e m e n ta r y T h e r a p i e s V i ta m i n s & M i n e r a l s

Relaxation / Yoga / meditation / Agnus Castus 20 -40mg / day Vitamin B6 max 50mg/day (with GP
breathing techniques supervision)
Red Clover Isoflavones 40 – 80mg /
Counselling /Support day Magnesium 250mg/day,
St John’s Wort (beware drug interac- Calcium 1g/day + Vitamin D 10 mcg/
Family / friends / tions)
professional counsellor/ NAPS day especially for migraine

M o d er at e t o s ev er e P MS

PSYCHOLOGICAL APPROACH CY CL E S UP P RE S S I O N

Selective serotonin reuptake Some combined oral contraceptive pills

inhibitor antidepressants (e.g. Yasmin/Yaz)
Fluoxetine (Prozac) 20 -40 mg/day
Citalopram (Cipramil) 10 -20mg/day, Suppression of cycle with transdermal
Escitalopram (Cipralex) 10 -20mg/day estradiol (100mcg patches or 4 doses
Continuous or in luteal phase oestrogel 0.06%)
+
Progestogenic opposition (utrogestan
Cognitive Behavioural Therapy 200mg D17-D28 or Mirena)

R e s i s ta n t P M S o r p e r s i s te n t p r o g e s to g e n i c s i d e - e f f e c t s — r e fe r to g y n a e c o l o g i s t

GnRH analogues + Add -back HRT

e.g. goserelin 3.6mg sc/month or triptorelin 3.0mg sc/month with add -back continuous combined HRT
or Tibolone

Surgery
H y s te r e c to m y a n d BS O + o e s tr a d i o l + / - te s to s te r o n e HRT

Transdermal estradiol 50 -100mcg or 50-75mg estradiol implants+/ - 100mg testosterone implants 6

monthly
 N •A•P•S
41 Old Road, East Peckham,
Kent
TN12 5AP
Patients can contact NAPS for
information and support at:
www.pms.org.uk
0844 815 7311
or at the above address

NAPS would like to thank

Bayer Schering Pharma for
their support in
providing funding for the
printing and production of
these Guidelines

Published by NAPS with special thanks to Nick Panay (Content), Moira Feehily (Design), Jackie Howe (Editing),
TMS Print Shop, 94 Commercial Road, Paddock Wood, Kent TN12 6DP