Management of Premenstrual Syndrome

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1 Background Information / Scope of Pathway

These pathways were developed to guide clinicians when managing premenstrual syndrome.
The pathways are not provider specific and so the guidance and forms apply to all providers.

http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=4194

Royal College of Obstetricians and Gynaecologists Green-top Guideline ‘Management of Premenstrual Syndrome’ - http://bit.ly/GTG48ePDF

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2 Information Resources for Patients and Carers

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3 Development and Updates to this Pathway

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4 Referral Forms

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5 Patient Presents with Premenstrual Syndrome Symptoms

Identify distressing physical and/or psychological symptoms occurring in the 2 weeks preceding the onset of menstruation that abate or significantly diminish with the onset of bleeding and that affect function significantly. (Most women have some symptoms and this is normal.)

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6 Patient Records Menstrual Symptoms and Effect on Daily Life for Two Consecutive Menstrual Cycles using Menstrual Diary Sheet

Ask women to keep a prospective diary for 2 consecutive months. (see link to symptom diary - http://www.pms.org.uk/assets/LeedsPathways/files/Menstrual_Chart.pdf)

Give lifestyle advice – diet and exercise, caffeine, alcohol and stress management, try for 3 months.

Additional professional information - http://patient.info/doctor/premenstrual-syndrome-pro

No investigations are needed. Explain that symptoms are likely to be related to neurotransmitter sensitivity not a hormonal imbalance and hormone tests are not helpful.

Explain that there is limited evidence for over the counter treatments but depending on symptoms patients may find certain products helpful – discuss according to individual patient.

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19 First line treatment (Provide lifestyle advice and consider complementary therapies)

See table below

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25 Second line treatment

See table below
Consider referral to SPA

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26 Third line treatment

See table below for treatment options.
Consider referral to SPA

Severity of PMS

Treatment

Mild

  • Lifestyle advice (diet, Caffeine, Alcohol, Smoking, Exercise, Stress)

Most lifestyle changes have no strong evidence to support them, but may benefit the overall health of women with mild symptoms.

Diet

  • Starch - ‘Three hourly Starch Diet’ - Starchy food with low glycemic index eaten regularly can reduce mood swings and sweet craving and provide more energy.
  • Sugar - Avoid sugary foods that cause fast rise of blood sugar followed by a quick fall
  • Fat - Reduce fat in diet
  • Caffeine - Caffeine may aggravate PMS symptoms and can reduce the absorption of vitamins and minerals. Encourage patients to drink water, herbal or fruit tea and decaffeinated drinks.

Alcohol
Limit to maximum 14 units of alcohol per week. This should ideally be spread over 7 days rather than all at the weekend.

Alcohol lowers blood sugar and mood.

Smoking
Refer to smoking cessation services if heavy smoker.

Exercise
There is evidence from non-randomised trials that exercise improves PMS symptoms. Aim for 30 minutes of exercise 5 times per week.

Stress
Yoga, meditation and breathing exercises may reduce stress and will help patients to cope better. Advise patient to plan stressful events outside the pre-menstrual time.

  • Evidence based advice regarding complementary/over the counter treatment  

Clinicians must be aware that complementary therapies may be of benefit but data from clinical studies are limited and underpowered.  Interactions with conventional medicines should be considered. Complementary medicines are not prescribed so would be obtained over the counter by women themselves and not prescribed. There is a lack of standardized quality of complementary therapies and lack of regulation. If in doubt, ask medicines information.

Ginko Biloba: Placebo-controlled trials are in favour of using Ginko-Biloba. However, further data is required before recommendation.
Isoflavones: Double-blinded randomised trials are in favour of using Isoflavones. However, further data is required before recommendation. (reference 14)
Magnesium: Weak evidence supports the effectiveness of magnesium for the treatment of the symptoms of PMS. Study findings were conflicting and methodological flaws limit interpretation. (reference 12-13)
Agnus Castus:  Agnus castus (chaste tree) may be more effective than placebo in the treatment of premenstrual symptoms. However, the method of its administration varied between studies, which had methodological flaws. This is based on randomised placebo-controlled trial. (reference 11)
Vitamin D and Calcium: Low-quality evidence suggests that calcium and vitamin D supplementation may reduce the risk of PMS, but further research is needed to confirm this. (reference 7-10)
Vitamin B6 (Pyridoxine): Based on a meta-analysis report, Vitamin B6 may not have much effect in treating PMS and there is the potential for adverse effects at high doses. Peripheral neuropathy may be caused with high doses (200mg). Department of Health and MHRA recommend a maximum daily dose of 10 mg. (reference 5, 6)
St. John’s Wort (Hypericum Perforatum): Benefits are unknown based on observational studies. Significant interactions with other conventional medicines are known. BNF advises to avoid concomitant use with SSRIs, also hormonal contraceptive, warfarin etc.
Evening Primrose Oil:  Evidence on evening primrose oil for treating the symptoms of PMS is weak and shows no benefit over placebo. This evidence is based on randomised double-blind, placebo controlled trial. It benefits cyclical mastalgia only.

Moderate

  • Lifestyle advice
  • Evidence based advice regarding complementary/over the counter treatment including Paracetamol and Ibuprofen.
  • Combined new generation COCP e.g. Yasmin (Cyclically or continuously) (licensed as oral contraception not for PMS)

  • Cognitive Behavioral Therapy

Severe

First line

  • Lifestyle advice
  • Evidence based advice regarding complementary/over the counter treatment including Paracetamol and Ibuprofen.
  • SSRI(fluoxetine,  citalopram/escitalopram ) not licensed for PMS
  • Cerelleor Combined new generation COCP e.g. Lucette for ovulation suppression(licensed as oral contraception not for PMS)
  • IUS if heavy periods and/or needs contraception (licensed for menorrhagia)
  • Cognitive Behavioral Therapy

Second Line

  • Above measures
  • IUS (mirena ) licensed for depot contraceptives, menopausal disorders and menorrhagia not for PMS
  • Estradiol Patches( estradiol 100mcg) not licensed for PMS+ oral or intrauterine progestogen for ovulation suppression (cyclogest )- licensed for premenstrual disorder(See section 4.3)

Third Line

  • Above measures
  • GnRH analogues for ovulation suppression (under specialist care, licensed for endometrosis, fibroids, infertility and menorrhagia not PMS
  • HRT(licensed for menopausal disorders not PMS)

Fourth line

  • Above measures
  • Laparoscopic BSO with HRT (licensed for menopausal disorders not PMS)