Royal College Issues Guidance On The Management Of Premenstrual Syndrome, UK

Main Category: Women's Health / Gynecology
Article Date: 28 Feb 2008 - 3:00 PDT

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The Royal College of Obstetricians and Gynaecologists (RCOG) has issued guidance on the management of premenstrual syndrome (PMS). The new document Green-top Guideline No.48: Management of Premenstrual Syndrome reviews the diagnosis and management of PMS, including complementary therapies, and is the first guidance to be issued on the topic.

About five percent of women are affected by severe premenstrual symptoms, such as depression, anxiety, irritability, bloating and breast tenderness all to a level where day-to-day activity is significantly inhibited. Yet, the cause and management of PMS remains poorly understood and largely inadequate.

Although a wide range of therapy options exists, there is no consensus on how PMS should be treated and the RCOG hopes that the new guidance will be a useful resource for healthcare professionals.

Mr Nicholas Panay, of Queen Charlottes and Chelsea & Chelsea and Westminster Hospitals and Chairman of National Association for Premenstrual Syndrome (NAPS), who was the lead developer of the guideline with the RCOG Guidelines and Audit Committee, says: "PMS is a multi-faceted condition that has a debilitating effect on the lives of many women. It is our role to ensure that women are receiving the best possible care and most appropriate therapy for their individual cases. We hope that the new guideline will help clinicians tailor their treatment to produce the best outcomes for the women they treat."

Key recommendations in the guideline include:

- Women with severe PMS should ideally receive care from a multi-disciplinary team consisting of a gynaecologist, psychiatrist or psychologist, dietician and counsellor so that the broadest and best range of care is provided

- Clinicians should take an integrated approach to therapy. This may include the use of unlicensed treatments where evidence for effectiveness and safety exists. The guideline also summarises the available data for complementary therapies. While some complementary therapies may be beneficial, it should be remembered that data from clinical studies are limited. Some complementary therapies can also interact detrimentally with conventional medicines, and the referring clinician retains legal responsibility for the patient's well being when they refer them to complementary therapists

- Women with underlying psychopathology as well as PMS should be referred to a psychiatrist

- Prescription of selective serotonin reuptake inhibitors (SSRIs) and selective serotonin and noradrenaline reuptake inhibitors (SNRIs), should be restricted to health professionals with expertise in this area such as specialist gynaecologists, psychiatrists or GPs who have a particular interest in it. Although SSRIs are effective medicines for depression and anxiety and the balance of risks and benefits in adults remains positive, suicide attempts in a small number of young people have been reported following their use, although none were being treated for PMS

- Cycle suppression with some contraceptive pills, estradiol patches and GnRHa (Gonadotrophin releasing hormone analogues) have been shown to be effective interventions

- Surgical approaches have also been shown to be beneficial but should be reserved for extremely severe PMS sufferers where other treatment has failed

Developers of the Guideline recommend more research in the following areas:

- SSRIs/SNRIs: in line with proven effectiveness and safety in adults SSRIs/SNRIs should be considered as one of the first-line pharmaceutical interventions in the management of severe PMS. Newer SSRIs/SNRIs which maximise benefits and minimise side effects should continue to be developed and licensed

- Further data are required from contraceptive pill studies using newer ingredients and alternative regimens e.g. long cycle and continuous use

- Treatment of PMS with Percutaneous estradiol (patches and implant): more long term data are required on the effects on breast and endometrial tissue; no serious short term adverse effects have been demonstrated

- Cognitive behaviour therapy (CBT): studies have shown that when CBT is compared to treatment with fluoxetine (20mg daily) or combined therapy (fluoxetine and CBT) cognitive behaviour therapy was associated with better maintenance of treatment effects. However, CBT can be difficult to access

- Use of progesterone and progestogens in treatment of PMS: studies have shown little benefit of these treatments but larger studies are required

The patient advocacy society NAPS (National Association for Premenstrual Syndrome) can provide additional support for PMS sufferers and can be found at http://www.pms.org.uk.

Royal College of Obstetricians and Gynaecologists