DOI: 10.1111/tog.

12180

2015;17:99104

Review

The Obstetrician & Gynaecologist

http://onlinetog.org

Diagnosis, pathophysiology and management of

premenstrual syndrome
Sally Walsh

a,
MBCHB, *

Elgerta Ismaili

b
MBBS,

Bushra Naheed

MBBS DGO,

Shaugn OBrien

DSc MD FRCOG

FY2, University Hospital North Staffordshire, City General Hospital, Stoke-on-Trent ST4 6QG, UK
SHO, Royal London Hospital, Whitechapel Road, London E1 1BB, UK
c
PhD student (clinical science), Institute for Science and Technology in Medicine, Keele University, Stoke-on-Trent ST4 7QB, UK
d
Professor of Obstetrics and Gynaecology, Keele University School of Medicine, Clinical Director Obstetrics and Gynaecology and Consultant
Obstetrician and Gynaecologist University Hospital North Staffordshire NHS Trust, City General Hospital, Newcastle Road, Stoke-on-Trent ST4
6QG, UK
*Correspondence: Sally Walsh. Email: sally.walsh@uhns.nhs.uk
b

Accepted on 28 January 2015

Key content

An overview of current information available on premenstrual

syndrome (PMS), which is in accordance with the new RCOG
Green-top Guideline.
 Definition of PMS and explanation about the different types of
premenstrual disorders.
 How to accurately diagnose PMS.
 Discussion about various treatment options available in
accordance with the current literature.
Learning objectives


Develop an understanding of the pathophysiology behind PMS.

 How to diagnose PMS accurately and understand the different
classifications of PMS.

How to treat PMS, including the different treatment options

available and discussion about side effects and benefits.

Ethical issues


Discussion about the long-term risks of GnRH analogue use, and

the impact of long-term estrogen deficiency following a
bilateral salpingoophorectomy.
 Misdiagnosed PMS in patients with underlying psychiatric and
medical conditions.
Keywords: epidemiology / gynaecology / HRT regimens /

menopause / pathology / psychiatry

Please cite this paper as: Walsh S, Ismaili E, Naheed B, OBrien S. Diagnosis, pathophysiology and management of premenstrual syndrome. The Obstetrician &
Gynaecologist 2015;17:99104.

Introduction
Premenstrual syndrome (PMS) is defined as a condition with
emotional, physical and behavioural symptoms that increase
in severity during the luteal phase of the menstrual cycle, and
resolve by the end of menstruation. By definition, there must
be a symptom-free interval after menstruation and
before ovulation.1,2
Symptoms are usually up to 14 days before the start of
menses, causing impairment of life, with anger and irritability
being the most severe and longer lasting symptoms.3,4
Studies have shown that 38% of menstruating women are
affected by PMS, and that 1520% of women meet the
criteria for subclinical PMS.5

Classification
The International Society for Premenstrual Disorders
(ISPMD) defined precise criteria for diagnosing
premenstrual disorders (PMD), and divided PMS into core

2015 Royal College of Obstetricians and Gynaecologists

and variant. In all PMD, symptoms should cause impairment

of daily activities at work, social activities and
interpersonal relationships.
Core (or typical) PMD is associated with spontaneous
ovulatory menstrual cycles and may be subdivided into
predominantly
physical
symptoms,
predominantly
psychological or mixed.1,6,7
Women whose symptoms are predominantly psychological
or mixed may also fulfil the criteria for premenstrual
dysphoric disorder.
Variants of PMD encompass more complex features,
divided into the four following categories: premenstrual
exacerbation of an underlying condition; PMS in the absence
of menstruation; progestogen-induced PMS; and PMS with
anovulatory ovarian activity.6,7
For an accurate diagnosis of PMS, symptoms must
occur regularly in ovulating women during the luteal
phase of the cycle, with resolution by the end of
menstruation (Box 1).6

99

An overview of the current management of PMS

Box 1. Criteria for diagnosing core premenstrual disorder6











It is precipitated by ovulation
Symptoms are not dened, although typical symptoms exist
Any number of symptoms can be present
Physical and psychological symptoms are important
Symptoms recur in the luteal phase
Symptoms disappear by the end of menstruation
A symptom-free week occurs between menstruation and ovulation
Symptoms must be prospectively rated
Symptoms are not an exacerbation of an underlying psychological
or physical disorder
 Symptoms cause signicant distress and impairment of daily
activities, such as work commitments, social interactions and
family activities.

Pathology
Research is yet to find a conclusive pathophysiological
explanation for PMS. Early theories thought there were
abnormalities in ovarian sex steroid levels, however this has
been disproved, as no differences have been demonstrated
between symptomatic and asymptomatic women, and no
study has demonstrated differences in progesterone levels.5,9
It is recognised that aetiology is centred around the ovarian
cycle, and this theory is supported by the lack of symptoms
before puberty, during pregnancy, after menopause, and
during treatment with gonanotrophin-releasing hormone
(GnRH) analogues.
Sex steroids easily pass the bloodbrain barrier, and their
receptors are abundant in many areas of the brain including
the amygdala and hypothalamus.5 It has now been
hypothesised that progesterone is metabolised in the brain
to allopregnanolone and pregnanolone, which stimulates the
gamma-aminobutyric
acid
(GABA)
inhibitory
neurotransmitter system. GABAA receptors are associated
with alterations in mood, cognition, and affect.9
In
high
concentrations
pregnanolone
and
allopregnanolone produce anxiolytic, sedative and
anaesthetic effects, however at lower levels allopregnanolone
can cause anxiety, negative mood and aggression. The GABA
receptors become less sensitive to allopregnanolone after
exposure to high concentrations, and hence the worsened
symptoms experienced during the luteal phase.9
Serotonergic activity in the brain is also affected by
estrogen and progesterone. Progesterone increases
monoaimine oxidase (MAO), which decreases the
availability of 5-hydroxytryptamine (5-HT), resulting in a
depressed mood. Whereas estrogen increases the degradation
of MAO, thus increasing the availability of free tryptophan in
the brain, which enhances serotonin transport, and therefore
stimulates 5-HT binding sites in the brain, resulting in an
antidepressant effect.10

100

Diagnosis
For an accurate diagnosis of PMS, prospective charting of
symptoms over two menstrual cycles is required. The Daily
Record of Severity of Problems (DRSP) is a well-validated
scale used in the diagnosis of PMS (Box 2).11,12 Prospective
documentation should demonstrate a presence of
symptoms during the luteal phase and resolution of
symptoms during menstruation. If there is a discrepancy
over the symptom pattern, then a third cycle of rating
should be carried out.13
The ISPMD first consensus reviewed the diagnostic criteria
for PMS.1 It highlighted the importance of an accurate
history of symptoms, which should be recorded for a
minimum of 2 months, as stated above. The symptoms
should be present during the premenstrual phase and absent
during the follicular phase, as well accurately recording
symptoms on a symptom chart.
Many patients find conscientious completion of charts
difficult. A new App, PreMentricS is now available (currently
iPhones only [Feb 2015]) which graphically documents
symptoms, provides a diagnosis, and monitors therapy
(Figure 1). It differs from previous charts but has yet to be
scientifically validated.

Patient perspective
One woman had been under the care of psychiatrists,
with regular psychiatric admissions premenstrually. Her
diagnoses included bipolar disorder and borderline
personality disorder but PMS was diagnosed through
prospective charting. The womans symptoms were so
persistent (including progestogen-induced PMS when on
estrogen treatment) that she requested a hysterectomy
with bilateral salpingoophorectomy (BSO) at the age of 28
despite not having children. After much debate she
underwent surgery. Post-surgery and estrogen replacement,
the woman commenced a university degree and remained
symptom-free.
A quotation from another woman highlighted how
debilitating PMS can be to social and family life: GnRH
followed by estrogen and Mirena saved my marriage.

Treatment
Management of PMS is usually performed in a step-wise
manner from non-pharmacological strategies, antidepressant
medications, hormonal strategies, with surgical options being
a last resort.
Women should have their symptoms confirmed by
prospective charting, and only when other underlying
medical and psychiatric conditions have been addressed
should treatment be commenced.

2015 Royal College of Obstetricians and Gynaecologists

Walsh et al.

Box 2. Item content of the Daily Record of Severity of

Problems (DRSP)11
Felt depressed, sad, down, or blue
Felt hopeless
Felt worthless, or guilty
Felt anxious, tense, keyed up or on edge
Had mood swings (e.g., suddenly felt sad or tearful)
Was more sensitive to rejection or my feelings were easily hurt
Felt angry, irritable
Had conicts or problems with people
Had less interest in usual activities (e.g., work, school, friends,
hobbies)
6. Had difculty concentrating
7. Felt lethargic, tired, fatigued, or had a lack of energy
8a. Had increased appetite or over-ate
8b. Had cravings for specic foods
9a. Slept more, took naps, found it hard to get up when intended
9b. Had trouble getting to sleep or staying asleep
10a. Felt overwhelmed or that I could not cope
10b. Felt out of control
11a. Had breast tenderness
11b. Had breast swelling, felt bloated, or had weight gain
11c. Had headache
11d. Had joint or muscle pain
1a.
1b.
1c.
2.
3a.
3b.
4a.
4b.
5.

At work, at school, at home, or in daily routine, at least one of

the problems noted above caused reduction of productivity
or inefciency.
At least one of the problems noted above interfered with
hobbies or social activities (e.g., avoid or do less).
At least one of the problems noted above interfered with
relationships with others.

Women with presumed PMS should initially be

investigated for other conditions such as depression,
anxiety disorders, and hypothyroidism, with referral to the
appropriate medical specialty, and adequate communication

with their general practitioner. There are links between PMS

and sexual abuse, as well as with post-traumatic stress
disorder, and therefore a full history to assess these aspects
should be obtained.14

Non-pharmacological treatment
A course of cognitive behavioural therapy (CBT) to address
relaxation, stress management, and assertiveness training,
has been reported to be effective in mild PMS, with success
being comparable to treatment with fluoxetine.10 Successful
CBT could avoid the need for pharmacotherapy; studies
have shown a more sustained but less rapid improvement
with the use of selective serotonin reuptake
inhibitors (SSRIs).

Complementary therapies
Rigorous research on complementary therapies for the
treatment of PMS is limited, with few well designed
randomised controlled trials. One study on the extract of
the Agnus cactus fruit (Vitex agnus castus) showed
improvement in PMS symptoms in up to 52% of
patients,14 however the trial numbers were small.
Alternative therapies such as exercise, dietary changes and
relaxation may help reduce PMS symptoms, and can improve
general health, but have not been scientifically proven.15,16

Antidepressants
The use of selective SSRIs, particularly fluoxetine 2060 mg,
paroxetine 2030 mg, citalopram 2040 mg and sertraline
50150 mg, has shown a substantial reduction in the
emotional, behavioural and physical symptoms in the
treatment of core PMD. The short onset of action of SSRIs
in women with PMS, means that SSRIs can be taken 14 days

Figure 1. Symptom view and diagnosis of woman with typical (core) premenstrual disorder generated by the PreMentricS App (Permission
Granted by PMS OBrien).

2015 Royal College of Obstetricians and Gynaecologists

101

An overview of the current management of PMS

before menses, as well as continuously.12,14 A meta-analysis

on randomised control trials which involved SSRIs in the
management of PMS, showed the efficacy of SSRIs compared
to placebo.1823Many studies suggest that intermittent SSRI
use is as effective as continuous use in reducing irritability
and other mood symptoms, but less effective in reducing
somatic symptoms. It is important to note that the European
Medicines Agency agrees that SSRIs seem to work in PMS,
and certain SSRIs are approved in parts of the world (for
example USA for PMDD). However neither the use of
intermittent nor continuous SSRI treatments are licensed in
the UK and when they are used they are off-licence.12,2427
Patients should be informed of side effects including
nausea, fatigue, insomnia and sexual dysfunction, and that
side effects are less with intermittent use.6 Unfortunately
PMS symptoms recur following discontinuation of SSRIs.38
There can be significant effects if used during the course of
pregnancy even if this is only the initial stages. Women who
have failed two or more SSRI trials should probably try
hormonal treatment.19
The ISPMD second consensus further supports the use of
SSRIs,10 and within the second consensus it was found that
SSRI use as a first-line treatment was the most important
recommendation in the management of PMS, as well as
highlighting the importance of explaining the side effects
associated with the use of SSRIs. In practice this means that a
diagnosis should be accurately ascertained and a systematic
approach to the management of starting with SSRIs should
be utilised.

Estrogen
Estrogen therapy which inhibits ovulation has been proposed
as a method for management in PMS.28,29 Estrogen is usually
administered as a transdermal patch, or subcutaneous
implant,29 and is an effective agent in the treatment of
PMS. Transdermal patches are more readily available within
the UK, and hence are a frequent choice compared to the
implant. Receiving unopposed estrogen will require
progestogen cover to prevent endometrial hyperplasia,
unless the woman has had a hysterectomy. Progesterone
itself can cause PMS like symptoms, and therefore the lowest
dose possible, for the shortest time is recommended. The side
effects from synthetic progestins can be minimised through
the use of micronised progesterone, which is identical to that
produced by the corpus luteum.30 Alternatively
administration of progesterone directly to the endometrium
using the levonorgestrel-containing intrauterine system may
reduce recurrence of progesterone-induced PMS symptoms
in the long term. A few months after insertion there are
minimal systemic levels of progesterone. Although
excellent endometrial protection is provided, patients
should be advised that initially PMS like symptoms
may occur.12,29

102

Oral contraceptives
Newer oral contraceptives containing drospirenone 3 mg and
ethinyl estradiol 20 micrograms have shown a positive
improvement in PMS symptoms, when hormones were
administered for 24 days, followed by 4 days of inactive pills,
compared to placebo.3234 However, due to the increased risk
of venous thromboembolism, this group of medication is not
suitable for all women. Unfortunately although this
treatment is licensed in the USA for PMS it is not
in the UK.34
No benefit has been found through the use of progesterone
alone additionally the older combined oral contraceptive
pills appear to have no benefit in the treatment of PMS.35,36

Gonadotropin-releasing hormone (GnRH) analogues

Long-acting GnRH analogues suppress ovarian functioning,
reducing the levels of estradiol and progesterone, and
subsequently inhibit the menstrual cycle. Several
randomised
controlled
trials
have
demonstrated
improvement of premenstrual symptoms, with a response
rate to GnRH analogue treatment between 60% and 75%. A
meta-analysis concluded that, compared to placebo,
treatment with GnRH analogues resulted in significant
symptom
relief
in
behavioural
and
physical
PMS symptoms.12,37
Although GnRH analogues seem like a good long-term
option for patients with severe PMS, they induce a hypoestrogenic state and eliminate ovulation.6 In the short term
this results in hot flushes, night sweats, low mood and
insomnia. More importantly, in the long term, risks of this
estrogen deficiency include vaginal atrophy, increased
cardiovascular risk and osteoporosis.6,12 Because of these
long-term risks, treatment without addback therapy should
only be continued for 6 months. If women are receiving
addback therapy on a long-term basis, they should have
assessment of bone mineral density. Although hormone
replacement therapy can be administered to reduce the effects
of estrogen deficiency, this in itself can re-stimulate PMS
like symptoms.
Due to the long-term risks of GnRH analogue use, they
should be reserved for women with the most severe
symptoms, or where other treatments have failed. In those
who fail to respond to GnRH analogues then the diagnosis of
PMS should be questioned.

Hysterectomy and bilateral salpingo-oophorectomy

(BSO)
Surgical options should be considered only as a last resort,
and a trial of GnRH with positive effect is advisable before
deciding to perform BSO and hysterectomy.
Hysterectomy with BSO has a beneficial effect on both
mood and physical symptoms. Oophorectomy alone would
stop PMS symptoms, but hysterectomy is required to ensure

2015 Royal College of Obstetricians and Gynaecologists

Walsh et al.

estrogen replacement post-surgery can be unopposed

without the risk of endometrial hyperplasia, and thus
prevent the PMS side effects associated with progestogens.
Success rates of hysterectomy with BSO are high and longlasting, and now surgical intervention can usually be
performed laparoscopically, it is less invasive than
previously.38,39 It is important to remember that all surgical
procedures carry an anaesthetic risk, as well as the risk of
surgical complications. Surgery undertaken for a mood
disorder is unique to PMS management.
Surgery will render the woman infertile and induces the
menopause. Estrogen replacement therapy should be
commenced post-surgery to prevent the effects of
long-term estrogen deficiency, and should be continued
until the age when menopause naturally occurs.12
Importantly of course is the absence of endometrium, the
estrogen can be administered without the requirement for
protective progestogen

Ongoing assessment
It is important to remember that if a woman has not
responded to more than one pharmacological treatment, they
should be reassessed for potential underlying psychiatric or
medical disorders, therefore highlighting the importance of
regular patient review following initiation of treatment.

Contribution of authorship
SW: extensive literature search around the topic, and
significant contribution to the writing of the main article,
as well as referencing, and creation of several of the CPD
questions. EI: creation of several of the CPD questions,
appraisal of the article content and construction of the
abstract. BN: contribution into the design of the article, with
contribution in to the content and critical appraisal of the
overall article, as well as creation of several CPD questions.
SO: clinical supervisor who came up with the proposed idea
for the paper, with significant input in to the formatting
and content.

Disclosure of interests
None

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2015 Royal College of Obstetricians and Gynaecologists