Suppression of the ovarian cycle eliminates PMS effectively. This can be achieved by GnRH analogues with add back tibolone. The scope for long-term therapy is, however, limited. Oestrogen also suppresses ovulation and eliminates PMS without menopausal side effects. Intrauterine progestagen (as levonorgestrel IUS) avoids re-stimulation of premenstrual syndrome at the same time that it protects the endometrium; it reduces periods and provides contraception.
SSRIs are the simplest and most effective non-hormonal approach to treatment. Some consider them to be first line medical therapy. Some patients consider this form of therapy to be stigmatized.
St John's Wort has been shown to be effective as an antidepressant and could possibly be tried as a self-help measure in PMS though there is no valid evidence (it must not be taken with SSRIs).
Cognitive behavioural therapy is effective but access to clinical psychologists is extremely limited in the United Kingdom.
Non-medical treatments are of doubted efficacy but usually are harmless. They can be tried before resorting to medical therapy as there is no risk, except in severe cases where patients may be delaying therapy.
Correct diagnosis is all important and those patients without a symptom-free week probably have a continuous underlying psychological problem. They should be referred back to the general practitioner or, in severe cases, referred on to a psychiatrist.
The majority of patients can be treated simply by general practitioners or by self-help (NAPS www.pms.org.uk).
Only the most severe patients with clear-cut PMS requiring medical or surgical intervention should be referred for secondary care management. Those with complex psychological problems ought to be assessed by the psychiatrist. Gynaecologists, preferably those with an interest and expertise in the problem, should only be asked to manage PMS patients when symptoms are severe enough to justify endocrine or surgical intervention.
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