Premenstrual Syndrome (PMS) is characterised by physical, behavioural and psychological symptoms that impact on women’s lives in a cyclical fashion during the luteal phase of the menstrual cycle. The luteal phase of the menstrual cycle is the 2nd part of the menstrual cycle between ovulation and the next period. Physical symptoms include breast tenderness, bloating, headaches, acne, constipation, diarrhoea and joint pains, Psychological and behavioural symptoms include tearfulness, feeling low, anxiety, irritability, mood swings, aggression, anger, fatigue, lethargy, food cravings, poor sleep. Diagnosis is based on the cyclical nature of symptoms within the menstrual cycle and not on specific blood tests. PMS is often severe around the perimenopause and after the onset of menstruation during adolescence.

Lifestyle factors such as diet, sleep hygiene and exercise can help mild to moderate PMS along with complementary therapies such as acupuncture, magnesium, vitamin B6, agnus castus and evening primrose oil. Moderate to severe PMS, or the most severe form of PMS called premenstrual dysphoric disorder (PMDD) will often require medical treatment which falls into 2 categories: hormonal treatment and selective serotonin reuptake inhibitors (SSRIs).

Hormonal treatment works by suppressing ovulation in the case of the combined oral contraceptive pill (COCP) or some progesterone only pills. They also have the added benefit of providing contraception. However, some women can get PMS symptoms from the hormones in these pills thus counteracting any benefit from ovulation suppression. Some women gain benefit from an intra-uterine progesterone coil such as the Levonorgestrel-releasing Mirena or Kyleena coil which gives a steady continuous release of low dose progesterone to the womb rather than into the bloodstream. However, again, some women might be sensitive to the progesterone in the coil.

Body-identical HRT has been shown to be of benefit in some women by providing a continuous release of oestrogen in the form of a patch or gel with either a steady release of progesterone via a Mirena coil or the use of body-identical micronised progesterone.

It is thought that the fluctuations in oestrogen and progesterone can affect chemicals in the brain, including the neurotransmitter serotonin, and hence taking an SSRI can also help symptoms by increasing serotonin. SSRIs can be taken during the 2nd part of the menstrual cycle when a woman has symptoms, or throughout the menstrual cycle.

Finally, if there is no improvement with these options, gonadotrophin-releasing hormone (GnRH) agonists are a form of medication which induces a temporary menopause as it suppresses the release of hormones from the ovary. As it induces menopausal symptoms, it can be associated with hot flushes and menopausal symptoms in some women and long-term use can lead to osteoporosis. An oophorectomy (surgical removal of the ovaries) with or without a hysterectomy is a last resort reserved for severe refractory symptoms which are majorly impacting on a woman’s quality of life.