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Premenstrual syndrome: Treatment for PMS

Last Update: June 14, 2017; Next update: 2020.

Some women who have premenstrual syndrome (PMS) have such bad symptoms on the days before their period that they can’t go about their usual activities. But there are various ways to cope with and treat typical symptoms such as pain, breast tenderness and mood swings.

Most women who get PMS don’t have very severe symptoms, and they find ways to cope with them – like getting enough rest and avoiding stress around the time leading up to their period. There is a lot of advice out there about how to deal with PMS, including:

  • getting enough exercise and doing sports,
  • using relaxation techniques and meditating,
  • not smoking,
  • drinking less alcohol and caffeine, and
  • eating less salt.

Most of these lifestyle changes haven’t been looked at in high-quality scientific studies to see how they affect PMS. But that doesn’t mean that they don’t work. Women can try them out and see whether making these changes helps relieve their symptoms. Observing and recording symptoms and attempted "remedies" over the course of several menstrual cycles can help you find out whether the changes have affected the symptoms.

What medications can be used?

Various medications are used for the treatment of PMS. But only very few of them have been approved for this purpose. If a medication is used for the treatment of a medical condition that it hasn't been approved for, it is called “off-label use.” Doctors are obliged to tell you that the use will be off-label, and you might have to pay for it yourself.

Hormonal medications are often used to try to relieve typical PMS-related symptoms. These medications suppress the production of certain hormones made naturally in the body and interfere with the menstrual cycle. Other medications used include antidepressants, diuretics ("water pills"), painkillers and anti-anxiety drugs.

Hormonal contraceptives

The most common way to influence the menstrual cycle using hormones is by taking hormonal contraceptives, such as birth control pills. This treatment is, of course, not suitable for women who would like to become pregnant.

Two studies have provided weak evidence that a contraceptive pill containing two particular hormones – the progestin drospirenone and a low-dose estrogen – can help women with PMS. A comparison of women who took this pill and women who didn't take it revealed the following: Those who took this combination of hormones had fewer symptoms, coped better in everyday life, were more socially active, and were happier in their relationships. But the women also reported side effects, including nausea, breakthrough bleeding (“spotting”) and breast tenderness.

Hormonal contraceptives also increase the risk of blood clotting (deep vein thrombosis). But the general risk of developing thrombosis is low: Depending on the specific product, an estimated 5 to 12 out of 10,000 women who take birth control pills will have deep vein thrombosis within one year, compared to about 2 out of 10,000 women who don't take the pill.

There are a lot of hormonal contraceptives, containing different hormones in different combinations. They are available in the form of pills, coils, patches, vaginal rings and depot injections. There hasn't been enough research to be able to say which of these can help against PMS. Women who would like to use hormonal contraception can talk to their doctor about which type could be most suitable.

Antidepressants

If premenstrual dysphoric disorder (PMDD) is clearly affecting a woman's mental health – leading to things like depression, anxiety and feelings of despair – antidepressants may be an option. A type of antidepressant called SSRIs (selective serotonin reuptake inhibitors) are typically used. These medications increase the concentration of a neurotransmitter (chemical messenger) in the brain called serotonin. It is thought that serotonin influences the way in which women’s bodies react to certain hormones that are released in greater amounts before menstruation.

Scientific research has shown that SSRIs can relieve the psychological symptoms of PMS or PMDD and help women cope better in everyday life. But you have to take SSRIs for at least three months before they start working. They weren't found to be more effective when taken continuously rather than only during the second half of the cycle.

It's important for women who are considering taking antidepressants to know what side effects they could have. SSRIs can cause things like nausea, sleep problems and decreased libido.

Painkillers

Various painkillers are used in the treatment of PMS, including nonsteroidal anti-inflammatory drugs (NSAIDs) such as acetylsalicylic acid (the drug in medications like Aspirin) and ibuprofen. NSAIDs reduce inflammation, relieve pain and block the production of prostaglandin. Many women who frequently have back pain, a headache or abdominal pain before getting their period take these painkillers. NSAIDs can effectively relieve period pain and headaches, and are usually well tolerated. The most common side effects of NSAIDs are stomach problems, nausea, vomiting and drowsiness. If they are taken too much they can also cause headaches.

But there is hardly any research on whether they also help relieve PMS symptoms. Research on NSAIDs in PMS has mainly focused on the drugs naproxen and mefenamic acid.

Diuretics (“water pills”)

Some women who have very swollen and sore breasts use diuretics. Diuretics can cause side effects such as nausea and headaches. Your body can also get used to them: When you stop using them, your body might retain more water than it did before you started using them. So it's important to talk to your doctor about whether diuretics are suitable for you and, if so, use them cautiously. The maximum dose written on the package insert should not be exceeded because your body might lose too much fluid otherwise.

GnRH analogues (agonists)

GnRH (gonadotropin-releasing hormone) is a hormone that regulates the release of what are called gonadotropins. Gonadotropins are sexual hormones that lead to the growth and maturation of egg cells and cause ovulation.

GnRH analogues are used to treat severe PMS in rare cases. These medications really interfere with the balance of hormones in the body, greatly reducing the production of hormones in the ovaries. They often cause things like hot flashes and insomnia. They may also lead to symptoms similar to PMS symptoms, such as a depressive mood. GnRH analogues should not be taken for longer than six months.

When using this treatment for several months, women often also take a low dose of estrogen every day. This approach is called “add-back therapy.” It aims to reduce the estrogen deficiency caused by the GnRH analogues.

There hasn't been enough research to be able to say whether women can benefit from taking GnRH analogues. It isn't possible to become pregnant during treatment with GnRH analogues.

Progesterone

Some women take the hormone progesterone in the days leading up to their period even though it hasn't been approved for the treatment of PMS. The aim is to prevent symptoms that may be caused by low progesterone levels or by progesterone levels falling too rapidly during the second half of the menstrual cycle. But this theory is now considered to be outdated.

Research on the use of progesterone for the treatment of PMS has shown that women who took the hormone did not feel better than those who took just a placebo (dummy tablet). These women were also more likely to have irregular periods.

The only product containing progesterone that has been approved for the treatment of PMS in Germany is a gel for relieving premenstrual breast tenderness. There is not good research on the benefits and harms of this gel, though.

Can herbal products or dietary supplements help?

Some women try to relieve their PMS using herbal products or dietary supplements such as calcium, pyridoxine vitamin B6), magnesium, evening primrose oil, chaste tree extracts (Vitex agnus castus), St. John’s wort, saffron or Ginkgo biloba.

Research has produced weak evidence suggesting that calcium can relieve PMS symptoms when taken at a dose of between 1,000 and 1,200 mg a day. Pyridoxine (vitamin B6) may possibly help when taken at a dose of about 50 to 100 mg per day. Both of these supplements have to be taken continuously throughout the month.

There is also weak evidence suggesting that chaste tree extracts (Vitex agnus castus) are effective in the treatment of PMS symptoms. No clear conclusions can be drawn about the effectiveness of St. John's Wort, saffron or Ginkgo biloba in the treatment of PMS. The studies on magnesium and evening primrose oil produced conflicting results.

What other treatments are there?

It's still not clear whether cognitive behavioral therapy (CBT) can help women cope better with PMS. There aren't enough good-quality studies to be able to answer this question. CBT mainly aims to help people cope better in everyday life by identifying and changing unhelpful thought patterns and behavior. One aim of CBT for PMS could be to learn to deal with it in such a way that the impact in everyday life is reduced to a minimum.

It's also not clear how much women benefit from acupuncture and reflexology massages. There is no evidence that homeopathic medicines like Pulsatilla or Sepia are effective or offer any benefits.

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