||Hormonal Treatment of Severe Premenstrual Syndrome
Professor John Studd, DSc,MD,FRCOG
Chelsea Bridge Road
London SW1W 8RH
Premenstrual syndrome is a common and sometimes severe group of cyclical symptoms with distressing physical and psychological symptoms that can seriously effect a woman's well being. These symptoms follow the hormonal changes (whatever they are-probably progesterone) that occur with and following ovulation. Therefore, these cyclical PMS type symptoms do not occur before puberty, after the menopause, during pregnancy, or after hysterectomy and bilateral salpingo oophorectomy. However, the typical cyclical symptoms do remain after a hysterectomy if the ovaries are conserved. Thus, menstruation is not a necessary feature for this condition and it would be more meaningful if the disorder was called the ovarian cycle syndrome (1).
In spite of frequent usage there is no evidence that progesterone is effective for treatment but there is ample evidence that progestogen makes the condition worse. Proven hormonal therapy for this condition is based upon suppression of ovulation. These are:-
1. GnRH treatment over 3-6 months (2). This confirms the diagnosis and removes the symptoms but it is not appropriate for long term therapy without add back oestradiol and progestogen. The progestogen will reproduce the PMS symptoms as these patients are progestogen/progesterone intolerant.
2. Suppression of ovulation by transdermal oestrogens in the dose of 100µg or 200µg of oestradiol patch (3). Such patients also need cyclical progestogen for 7-10 days a month or insertion of a Mirena IUS.
3. Hormonal implants of oestradiol with the addition of testosterone (4) if necessary in the presence of loss of energy, loss of libido and depression. The same protection of the endometrium by progestogen tablets or a Mirena IUS is necessary.
4. Hysterectomy and salpingo oophorectomy with appropriate long term hormonal replacement therapy (5). In those rare patients with bleeding problems or progestogen side effects in spite of the use of a Mirena IUS.
The birth control pill, although it suppresses ovulation, is not usually effective because the progestogen component produces the PMS symptoms for most of the month rather than half of the month.
1. Studd, J., Panay N. (2004) Hormones and Depression in Women.
Climateric. 2004 Dec: 7(4):338-46. Review.
2. Leather A.T., Studd J.W.W., Watson N.R. Holland E.F.N. (1999)
The treatment of severe premenstrual syndrome with goserelin with and without 'add-back' estrogen therapy: a placebo controlled study.
Glynecol Endocrinol 13:48-55
3. Watson N.R., Studd. J.W.W. Savvas M., Garnett T., Baber R.J. (1989).
Treatment of severe pre-menstrual syndrome with oestradiol patches and cyclical oral noresthisterone.
Lancet ii: 730-734.
4. Magos, A.L., Brincat, M., Studd, J.W.W. (1986)
Treatment of the Premenstrual Syndrome by Subcutaneous Oestradiol Implants and Cyclical Oral Noresthisterone: Placebo Controlled Study.
B.M.J. 292, 1629-33.
5. Cronje, WH., Vashisht, A., Studd, JW. (2004) Hysterectomy and bilateral oophorectomy for severe premenstrual syndrome.
Hum. Reprod. 2004 Sep;19 (9) 2152-5
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