Hormonal

Hormonal treatment that suppress ovulation

• combined oral contraceptive (COC)
  • newer COC, in particular those containing the antimineralocorticoid and antiandrogenic progestogen, such as drospirenone may be used as an effective therapy for PMS and can be recommended as one of the first line pharmacological agent
  • evidence suggest that the newer COC should be used continuously rather than cyclically (1)
• oestradiol (patch and implant)
  • percutaneous estradiol combined with cyclical progestogens (to protect the endometrium) has been shown to be effective for the management of physical and psychological symptoms of severe PMS
  • the lowest possible dose of progesterone or progestogen is recommended to minimise progestogenic adverse effects
    • micronised progesterone is theoretically less likely to reintroduce PMS-like symptoms and should therefore be considered as first line for progestogenic opposition rather than progestogens
    • alternatively, a levonorgestrel-containing intrauterine system can be used to administer progesterone directly to the endometrium
  • alternative methods of contraception (barrier or intrauterine) should be given when using oestradiol patch and implant (1)
• danazol
  • although treatment with low dose danazol (200 mg twice daily) is effective in the luteal phase for breast symptoms, it also has potential irreversible virilising effects
  • lipid levels to be monitored if long term treatment planned
  • women should be informed about using contraception while on danazol therapy due to its potential virilising effects on female fetuses
• GnRH agonist analogues
  • usually reserved for women with the most severe symptoms and not recommended routinely unless they are being used to aid diagnosis or treat particularly severe cases where other treatments have failed
  • main complication is induced hypo-oestrogenic state which may be associated with hot flushes, and in the long term, increased risk of osteoporosis and atherosclerosis
    • if used for more than 6 months, add-back hormone therapy should be used (to minimise long term effects of estrogen deficiency).
    • add-back hormone therapy is recommended with combined HRT or tibolone
    • women on long-term treatment should have measurement of BMD (ideally by dual-energy X-ray absorptiometry [DEXA]) every year. Treatment should be stopped if bone density declines significantly (1,2,3,4)

Hormonal treatment that does not suppress ovulation

• progesterone and progestogens
  • there is good evidence to suggest that treating PMS with progesterone or progestogens is not appropriate
  • there is no evidence to support the use of the LNG-IUS 52 mg alone to treat PMS symptoms. Its role should be confined to opposing the action of estrogen therapy on the endometrium

Reference:

• (1) Management of Premenstrual Syndrome: Green-top Guideline No. 48. BJOG. 2017;124(3):e73-e105.
• (2) O'Brien S et al. Diagnosis and management of premenstrual disorders. BMJ. 2011;342:d2994.
• (3) The National Association for Premenstrual Syndrome (NAPS). Guidelines on Premenstrual Syndrome
• (4) Walsh S, Ismaili E, Naheed B, O’Brien S. Diagnosis, pathophysiology and management of premenstrual syndrome. The Obstetrician &Gynaecologist 2015;17:99–104