First the Facts

Most women of reproductive age (with a hormone cycle) experience some degree of premenstrual irritability. 5–8% of women have a much more severe disorder, also related to ovulation and the production of the hormone progesterone. This condition is known as premenstrual dysphoric disorder (PMDD) and at worst it can lead to suicidal thoughts or intention on a monthly basis. The key to diagnosis is the impairment/impact of symptoms and resolution with bleeding. The best time to make the diagnosis is actually just after a period when the disappearance of symptoms is seen.

Treatment with hormones can prevent ovulation or alternatively drugs can be provided which alter the sensitivity of the brain to progesterone or its metabolite allopregnanolone. Your clinician will be able to help you choose the treatment that is most suitable with you.

Symptoms of Premenstrual Syndrome

These can be divided into psychological and physical. Patients can have any number of these and any combination.

Psychological symptoms include:

  • Mood swings
  • Feeling depressed
  • Feeling anxious
  • Irritability/loss of control
  • Aggression
  • No energy or interest in usual activities
  • Difficulty concentrating
  • Cravings
  • Sleep problems – sleeping a lot, or unable to sleep
  • Suicidal ideation/attempts/completion

Physical symptoms include:

  • Breast swelling, tenderness or pain
  • Bloating/swelling
  • Headache/migraine
  • Acne

The Cause of Premenstrual Disorders

Although premenstrual syndrome (PMS)/PMDD is related to cyclical hormonal changes, the exact cause is not yet fully understood. Hormones change during the monthly cycle, and current thinking is that progesterone, or allopregnanolone (the active metabolite of progesterone), is the cause of symptoms post ovulation. PMS/PMDD is not associated with abnormal levels of the hormones; it is most likely due to the way that the brain responds to changing hormone levels in susceptible women.

How Can You Help Yourself?

Record your symptoms prospectively (going forwards) using either a paper version of the daily record of the severity of the problem (DRSP)* or an app like PreMentricS**, developed by experts in the field to help affected women clarify their diagnosis and access the right help.

Hormonal treatments can help, and the right prescription will depend on eligibility following a thorough medical assessment. There are different treatment choices, and these include use of specific hormonal combinations:

A combined pill with low-dose ethinyl oestradiol 20–30 mcg and drospirenone (a progestogen which prevents fluid retention) 3 mg taken continuously; this is Eloine® in the UK.

Sufficient estrogen (oestradiol) to override the cycle can be delivered as a patch, gel or implant.

Some form of progestogen is required in women with a womb, e.g. Mirena (a device containing a progestogen which protects the lining of the womb, keeping it thin and healthy).

Gonadotropin-releasing hormone (GnRH) analogues (Zoladex® or Prostap®) can be injected or provided as an intranasal spray in order to shut down the menstrual cycle. They are best administered 12-weekly to prevent ‘agonist flare’ which is similar to the symptoms associated with PMDD.

These drugs are also sometimes used as a ‘test drive’ to clarify whether symptoms resolve when the hormone cycle is shut down. This is particularly important for the most severely affected women in whom surgery is being considered, as a last resort, when all other treatment options have failed. Surgery involves removal of both ovaries and the womb, and then women can be provided with estrogen-only hormone therapy which is normally well tolerated.

Non-hormonal interventions can help and include:

  • Regular physical exercise and a healthy diet
  • Cognitive behavioural therapy (CBT)
  • Use of antidepressants: Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine or citalopram can help, either taken continuously or from the onset of symptoms (which is likely to coincide with ovulation). These drugs influence serotonin levels and the impact of hormones on specific receptors in the brain.

Before You Seek Medical Help

It is a good idea to keep a record of your symptoms for 2 months using an app like PreMentricS. This will help your clinician to understand the symptoms that you are experiencing and can also help to monitor the effect of treatment.


*Obtainable from the Royal College of Obstetricians and Gynaecologists, UK green top guideline – search ‘RCOG 48’, click on the guideline, and there is a printable page with the chart near the end (PDF).
**Obtainable on App Store and the store for Android.


Written by: Dr Paula Briggs
Last updated: January 2021

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