Premenstrual syndrome (PMS) refers to a spectrum of cyclical physical, psychological and behavioural symptoms that occur in the luteal phase of the menstrual cycle and resolve with menstruation. Up to 90% of women of reproductive age report experiencing at least one premenstrual symptom, and 20–30% meet diagnostic criteria for PMS. Around 2–5% experience more severe and disabling symptoms consistent with premenstrual dysphoric disorder (PMDD).
Symptoms of PMS
Physical symptoms of PMS include breast tenderness, bloating, headaches, backache, weight gain, acne, and gastrointestinal disturbance. Psychological symptoms include mood changes, irritability, anxiety, feeling out of control, poor concentration, a change in libido, and food cravings. Behavioural symptoms include reduced visuospatial and cognitive abilities and aggression.
Diagnosing PMS
When considering a diagnosis of PMS, it is important to rule out underlying conditions such as mental health conditions, thyroid disorders and perimenopause. Concurrent issues such as anxiety, depression, and domestic violence should be explored.
A diagnosis of PMS is clinical and relies on symptom tracking over two or more cycles and exclusion of any underlying condition. Tools such as the Daily Record of Severity of Problems (DRSP) can aid in tracking symptom timing and severity. PMS should be diagnosed if the symptom diary shows prominence of symptoms during the luteal phase, which resolves with menstruation.
The criteria for PMDD require the presence of at least 5 of 11 cognitive-affective, behavioural, and physical symptoms, which cause significant distress or disablement during the luteal phase.
Managing PMS
Management should be individualised and holistic, beginning with education and reassurance. First-line strategies include lifestyle modifications such as regular aerobic exercise, stress reduction, improved sleep hygiene, and eating regular, balanced meals. Smoking cessation and reducing caffeine and alcohol intake may also help. Although the evidence is limited, some patients report benefits from dietary supplements, such as calcium or vitamin B6, as well as complementary therapies and herbal remedies.
For women with ongoing or moderate-to-severe symptoms, pharmacological treatments may be considered. Combined oral contraceptive pills (COCPs), especially those containing drospirenone, can help regulate hormonal fluctuations and may be used continuously or in extended cycles. If pain is a predominant feature, analgesia such as non-steroidal anti-inflammatory drugs (NSAIDs) can be prescribed.
Selective serotonin reuptake inhibitors (SSRIs), including fluoxetine and sertraline, are effective, particularly for mood-related symptoms. These can be taken continuously or limited to the luteal phase. Cognitive behavioural therapy (CBT) is also beneficial and can be considered in conjunction with pharmacological options.
Patients should be reviewed regularly to assess treatment response. If first-line approaches are unsuccessful, referral to secondary care may be indicated. Second-line therapies include transdermal oestrogen and, in refractory cases, gonadotropin-releasing hormone (GnRH) analogues under specialist supervision.
PMS is a common but often under-recognised condition in primary care. GPs play a key role in identifying symptoms, initiating evidence-based management, and providing compassionate, patient-centred support.
Dr Samantha Miller, MBChB
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References
- The Royal College of Obstetricians and Gynaecologists (2017). Premenstrual Syndrome, Management (Green-top Guideline No. 48). https://doi.org/10.1111/1471-0528.14260
- National Institute for Clinical Excellence (NICE)(2024). Clinical Knowledge Summary (CKS): Premenstrual Syndrome. https://cks.nice.org.uk/topics/premenstrual-syndrome/
- American College of Obstetricians and Gynecologists (2023). Management of Premenstrual Disorders: ACOG Clinical Practice Guideline No.7. https://doi.org/10.1097/aog.0000000000005426
- The American Psychiatric Association (APA)(2022). Diagnostic and Statistical Manual of Mental Disorders (DSM-5). https://dsm.psychiatryonline.org
- British Medical Journal (BMJ) Best Practice (2024). Premenstrual Syndrome and Dysphoric Disorder. https://bestpractice.bmj.com/topics/en-gb/419
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