152 - Clinical implications

Clinical implications

474 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 3 Premenstrual syndrome Premenstrual syndrome (PMS) is a collection of mood and physical symptoms occurring during the luteal phase of the menstrual cycle. There are several definitions for PMS, which are differentiated by the severity of symptoms required. Premenstrual dysphoric disorder (PMDD), recently added to ICD-­11,1 exists at the more severe end of the diagnostic spectrum (see Craig et al. 20192 for review). Pharmacological management of PMDD The pharmacological management of PMDD can be divided into hormonal and non-­ hormonal treatments (Figure 3.6). Non-­hormonal Guidelines published by the Royal College of Obstetricians and Gynaecologists in the UK3 recommend SSRIs as first-­line treatment. This is supported by a meta-­analysis, which found similar efficacy between different SSRIs.4 Intermittent, luteal phase dosing of SSRIs has been reported to be as effective as continuous prescribing.5 During intermittent dosing, SSRIs appear to directly promote the conversion of progesterone to allopregnanolone (i.e. an allosteric modulator of the GABA-­A receptor).6 Hormonal The combined oral contraceptive pill (COCP) is another first-­line treatment. It can be prescribed cyclically or back ­to back (typically for 3 months) to avoid symptoms associated with hormone withdrawal.7 A 2021 meta-­analysis reported that COCPs improved overall premenstrual symptomatology but not premenstrual depressive symptoms.8 There is no evidence of one COCP being more efficacious than any other. Diagnosis of PMDD/severe PMS Non-hormonal Hormonal Choice of treatment governed by patient preference Psychiatric and hormonal treatments may be used in conjunction SSRI (continuous or intermittent dosing) Combined oral contraceptive (cyclical or continuous prescribing) Transdermal estradiol + progestogenic protection if patient has uterus GnRH analogue ± addback hormonal treatment Treatment of any comorbid psychiatric disorder Figure 3.6  The pharmacological management of premenstrual dysphoric disorder.