About this information

This information is for you if you have, or think you have, premenstrual syndrome (PMS) and want to know more about it. It may also be helpful if you are a partner, relative or friend of someone who is affected by PMS.

A glossary of all medical terms used is available on the RCOG website at: www.rcog.org.uk/en/patients/ medical-terms.

Key points

• PMS is the name given to the physical and emotional symptoms affecting your daily life in the 2 weeks before you have your period. These symptoms usually get better once your period starts.
• You should record your symptoms in a diary over two menstrual cycles in a row to help your healthcare professional make a diagnosis.
• There is a wide range of options to help manage your symptoms and allow you to get on with your daily life.
• Whatever option you choose, continue to keep a diary of your symptoms for at least another 2–3 months, as this can help to see whether a particular treatment is working.

What is PMS?

PMS is the name given to the physical and emotional symptoms affecting your daily life in the 2 weeks before you have your period. These symptoms usually get better once your period starts and often disappear by the end of your period.

Nearly all women have some premenstrual symptoms. Each woman’s symptoms are different, but the most common include:

• mood swings
• feeling depressed, irritable or bad-tempered
• feeling upset, anxious or emotional
• tiredness or having trouble sleeping
• headaches
• changes in appetite and food cravings
• feeling clumsy
• fluid retention and feeling bloated
• changes to skin or hair
• sore or tender breasts.

What are the symptoms?

Common symptoms include pelvic pain and painful, sometimes irregular or heavy periods. It can cause pain during or after sex and can lead to fertility problems. You may also have pain related to your bowels, bladder, lower back or the tops of your legs, and experience long-term fatigue. Some women with endometriosis do not have any symptoms.

Endometriosis can cause pain that occurs in a regular pattern, becoming worse before and during your period. Some women experience pain all the time but for others it may come and go. The pain may get better during pregnancy and sometimes it may disappear without any treatment. For more information, see the RCOG patient information Chronic (long-term) pelvic pain (www.rcog.org.uk/en/patients/patient- leaflets/long-term-pelvic-pain).

What causes endometriosis?

The exact cause of endometriosis is not known but it is hormone dependent. This means that, just like the endometrium which responds to hormonal changes resulting in a period, the endometrial-like tissue located outside the womb also bleeds. This bleeding can cause pain, inflammation and scarring, and can possibly damage your pelvic organs.

Endometriosis may be found:

• on the ovaries, where it can form cysts (often referred to as endometriomas or ‘chocolate cysts’)
• in the peritoneum (the lining of the pelvis and abdomen)
• in or on the fallopian tubes
• on, behind or around the womb
• in the area between the vagina and the rectum.

Symptoms can vary from month to month, although they tend to form a pattern over time.

Between 2 and 4 in 100 women get PMS that is severe enough to prevent them from getting on with their daily lives. A very small number of women get an even more intense form of PMS known as premenstrual dysphoric disorder (PMDD), which is not covered in this information. If you have questions about this, you should discuss it with your healthcare professional and see the Further information section below.

What causes PMS?

The exact cause of PMS is not known. It could be linked to changes in the levels of your hormones and body chemicals.

The levels of your hormones change during your menstrual cycle. Some women are more sensitive to these hormonal changes, which can lead to the symptoms described. Women who use some forms of hormonal contraception are less affected by PMS. PMS has also been linked to a variety of chemical substances in your blood called neurotransmitters, such as serotonin and gamma-aminobutyric acid (GABA).

How do I know I have PMS?

If you are getting symptoms, you should write them down in a diary for at least two menstrual cycles in a row. Your healthcare professional will then review your diary with you to see whether your symptoms fit the pattern of PMS.

If your symptom diary alone is not enough for diagnosis, you may be offered treatment with gonadotrophin- releasing hormone (GnRH) analogues for a period of 3 months. This will temporarily stop your ovaries producing hormones, which may help with your diagnosis.

What are my options?

There is a wide range of options to help you to manage your symptoms and allow you to get on with your daily life. Your healthcare professional will discuss these with you.

Whatever option you choose, you will be advised to continue to keep a diary of your symptoms for at least another 2–3 months, as this can help to see whether a particular treatment is working.

Lifestyle changes

In the first instance, you can take some positive steps to try to improve your symptoms by:

• doing more exercise
• eating a healthy balanced diet – The NHS Choices website at www.nhs.uk/Livewell/healthy- eating/Pages/Healthyeating.aspx can provide more information about a healthy diet
• trying to reduce and manage stress, for example by using meditation, yoga and mindfulness.

Speak with your healthcare professional if you would like further information about ways to change your lifestyle and about treatments that can help.

Psychological support and therapy

Cognitive behavioural therapy (CBT) is known to help PMS symptoms and should be offered to you as a treatment option. This involves discussing your symptoms with a therapist. It can help you learn new ways of managing some of your symptoms to reduce their impact on your daily life.

Complementary therapy

There are several alternative or complementary therapies for PMS. Many women find these helpful, although there is little evidence to show that they are effective.

You should inform your healthcare professional if you are taking any medicine or supplement. This is because some complementary therapies may react with other medicines.

Supplements of calcium, vitamin D, Vitex agnus-castus (a herb known as chasteberry) or Ginkgo biloba may be helpful. Evening primrose oil can reduce breast tenderness.

Medical treatment

The options for treatment include those listed below.

Non-hormonal

• Two types of antidepressant medications have been shown to help PMS symptoms, namely selective serotonin reuptake inhibitors (SSRIs) and serotonin–noradrenaline reuptake inhibitors (SNRIs).
  • Antidepressants should only be prescribed by a healthcare professional. These can be taken on a daily basis for 2 weeks before your period or all the way through your cycle.
  • Side effects may include nausea (feeling sick), insomnia (difficulty sleeping), tiredness and low libido (not being interested in having sex).
  • SSRIs are recommended as one of the first-choice treatments for severe PMS.
  • If you choose to stop taking antidepressants, it is important that you do so gradually so that you do not get withdrawal symptoms, such as headaches. Your healthcare team will advise you.
• If you are planning a pregnancy or if you get pregnant, you should talk to your healthcare professional before stopping any medication.
• Water tablets (diuretics) such as spironolactone may help some women with some physical symptoms of PMS.

Hormonal

Combined oral contraceptive pill Some women find using the combined oral contraceptive pill helps with PMS symptoms. Newer types of contraceptive pills containing a progestogen called drospirenone have been shown to improve PMS symptoms. These are considered as first-choice treatments. You may be advised to take these pills continuously, without a break, for better symptom control.

Estrogen hormone patches or gel

• Using estrogen hormone patches or gel can improve the physical and psychological symptoms of PMS.
• Unless you have had a hysterectomy (removal of your uterus), estrogen hormone patches or gel must be used in combination with a low dose of the hormone progestogen to prevent abnormal thickening of the lining of your womb. Progestogens may be given in the form of tablets (taken for a minimum of 10 days each month), pessaries or a hormone-containing coil.
• Estrogen hormone patches or gel do not work as a contraceptive and so you will still need to use a method of birth control.

Danazol

• Danazol (a synthetic hormone) in low doses can sometimes be used in the second half of your menstrual cycle to reduce breast tenderness. However, your healthcare professional should discuss with you the potential permanent side effects, such as deepening of your voice and enlargement of your clitoris.
• It is important to use contraception while using danazol because it can affect the development of a female baby in the uterus.

SurgerySurgery can treat or remove areas of endometriosis. The surgery recommended will depend on where the endometriosis is and how extensive it is. This may be done when the diagnosis is made or may be offered later. Success rates vary and you may need further surgery. Your gynaecologist will discuss the options with you fully.

Possible operations include:

• laparoscopic surgery – when patches of endometriosis are destroyed or removed
• laparotomy – for more severe cases. This is a major operation that requires a cut in the abdomen so that areas affected with endometriosis can be removed to provide symptom relief. This may involve removing large endometriotic cysts from your ovaries or even removal of your ovaries with or without performing a hysterectomy (removing the womb). You will not be able to have children after a hysterectomy. Longer term pain relief is more likely if your ovaries are removed. However, because of the health risks associated with removal of ovaries, your healthcare professional will discuss this and the possible need for hormone replacement therapy (HRT) with you.

Gonadotrophin-releasing hormone (GnRH) analogues

• GnRH analogues may be recommended if you have severe PMS symptoms and when other treatments have not worked or are not suitable. These may also be used to help reach a diagnosis in some women, as mentioned in the How do I know I have PMS? section above.
• These medicines cause a temporary and reversible menopause, so you will not release eggs and you will not have any periods.
• If you use GnRH analogues for more than 6 months, it may affect your bone strength (osteoporosis). You will be advised to take hormone replacement therapy (HRT) to protect your bones and reduce your menopausal symptoms, such as hot flushes.
• You will be advised to have regular bone density scans to check for osteoporosis if you use this treatment for more than 2 years.
• You should also make sure that you get regular exercise, have a balanced diet and do not smoke.

Surgical treatment

• Your healthcare professional will only suggest surgical treatment if you have severe symptoms and all other treatments have not helped.
• Removal of your uterus along with both ovaries and fallopian tubes can help to improve severe PMS symptoms by making you menopausal.
• If you have surgical treatment for PMS, you may be advised to use HRT to prevent menopausal symptoms. If your uterus and ovaries have been removed, this will be estrogen-only HRT. If you still have your uterus, you will need both estrogen and progestogen. Progestogens protect the lining of your uterus, but may then re-introduce symptoms of PMS. See the RCOG patient information Treatment for symptoms of the menopause, which is available at: www.rcog.org.uk/en/ patients/patient-leaflets/treatment-symptoms-menopause/.
• If you are considering surgical treatment, your healthcare professional will advise you to use GnRH analogues and HRT for 3–6 months before surgery. GnRH analogues have a similar effect on your hormones as having your ovaries removed and will give you an idea of how you may feel after the operation. You may also be able to see whether you will benefit from surgery and whether HRT suits you.
• Surgical treatment such as endometrial ablation or hysterectomy without removal of both ovaries is not recommended for treatment of PMS. See the RCOG patient information Laparoscopic hysterectomy (www.rcog.org.uk/en/patients/patient-leaflets/laparoscopic-hysterectomy), Vaginal hysterectomy (www.rcog.org.uk/en/patients/patient-leaflets/vaginal-hysterectomy), Abdominal hysterectomy (www.rcog.org.uk/en/patients/patient-leaflets/abdominal-hysterectomy) and Endometrial ablation (www.rcog.org.uk/en/patients/patient-leaflets/endometrial-ablation).

At what stage of treatment should I be referred to a gynaecologist?

If simple measures such as combined pills or SSRIs have not worked, your GP will refer you to a specialist. A team of healthcare professionals may be involved in your care, including your GP, a nurse specialist, a dietician, a mental health professional (psychiatrist, clinical psychologist or counsellor) and a gynaecologist. The make-up of the team will depend on the hospital you attend.

Further information and support

PMS is common and many women are affected by its symptoms. Treatment, information and support are available to enable you to manage your symptoms.

National Association for Premenstrual Syndrome (NAPS): www.pms.org.uk

Women’s Health Concern (WHC), the patient arm of the British Menopause Society (BMS): www.womens-health-concern.org

NHS Choices – Premenstrual dysphoric disorder (PMDD): www.nhs.uk/conditions/pre-menstrual- syndrome/symptoms/#premenstrual-dysphoric-disorder-pmdd

Mind – Premenstrual dysphoric disorder (PMDD): www.mind.org.uk/information-support/types-of- mental-health-problems/premenstrual-dysphoric-disorder-pmdd/#

RCOG patient information Treatment for symptoms of the menopause: www.rcog.org.uk/en/patients/patient- leaflets/treatment-symptoms-menopause/

RCOG patient information Laparoscopic hysterectomy: www.rcog.org.uk/en/patients/patient-leaflets/ laparoscopic-hysterectomy

RCOG patient information Vaginal hysterectomy: www.rcog.org.uk/en/patients/patient-leaflets/vaginal- hysterectomy

RCOG patient information Abdominal hysterectomy: www.rcog.org.uk/en/patients/patient-leaflets/ abdominal-hysterectomy

RCOG patient information Endometrial ablation: www.rcog.org.uk/en/patients/patient-leaflets/endometrial- ablation

A full list of useful organisations is available on the RCOG website at: www.rcog.org.uk/en/patients/other- sources-of-help

Sources and acknowledgements

1. This information has been developed by the RCOG Patient Information Committee. It is based on the RCOG Green-top Guideline No. 48, Management of Premenstrual Syndrome. The guideline contains a full list of the sources of evidence we have used. You can find it online at: www.rcog.org.uk/en/guidelines-research-services/ guidelines/gtg48.
2. This information was reviewed before publication by women attending clinics in London, Manchester and Shrewsbury, by the RCOG Women’s Network and by the RCOG Women’s Voices Involvement Panel.