Professor John Studd, DSc, MD, FRCOG
Chelsea Bridge Road
Pre-menstrual syndrome (sometimes called PMT, Pre-menstrual Tension) is a complex severe disorder that affects many women. Almost all women are aware by some bodily changes that their period is about to come but that is not PMT. About 40% of women have distressing symptoms and about 5% are severely incapacitated by pre-menstrual symptoms.
Typically, women complain of loss of energy, depression, anxiety, irritability, irrational behaviour or loss of libido in the pre-menstrual days. Physical symptoms include headaches, breast discomfort and abdominal bloating. Most women who suffer PMS have a combination of both psychological and physical symptoms.
They usually start at or after ovulation and last for 14 days until the periods appears and then they usually have symptom free days before the next mid cycle.
The ultimate cause of PMS is unknown but it is clearly associated with ovulation and the cyclical changes (whatever they are) of ovarian hormones or their metabolites which produce the cyclical symptoms of PMS. Many treatments, such as oral progesterone, evening primrose oil and vitamin B6 have been used but for the most part, no benefit has been shown in scientific randomised placebo controlled trials. There is certainly a huge placebo respect to this condition and if an unscientific treatment appears to work it should not be discouraged in the individual.
There problem with severe PMS is the severe behavioural and physical problems that can occur lasting for many years. These can break relationships and destroy a career as the woman suffers this Jekyll and Hyde change of personality. She may well have antidepressants or tranquillisers which usually do not help.
Another clue to the hormonal basis of this condition is that women with severe PMS are normally very well during pregnancy and frequently have postnatal depression which is in part due to the sudden change of female hormones after delivery. PMS often becomes worse with age becoming less cyclical and more constant. After about the age of 45 these worsening PMS symptoms blend with the worst part of the climacteric as "menopausal depression" is at its most severe in the 2-3 years before the periods stop. The depression in these perimenopausal women can be very well treated with oestrogens. Transdermal oestrogens are also the best way to treat PMS in younger women.
The logic of this treatment is that oestradiol patches in the dose of 100 or 200 mcgs twice weekly suppress ovulation and the ovarian hormonal changes which cause PMS. 1.2.3. Alternatively, oestradiol implants can be used to suppress ovulation and ablate PMS symptoms.
In women who have problems with loss of energy and libido it is often useful to add testosterone to the oestradiol implant inserting pellets of oestrogen 50mgs (or 75mgs) and testosterone 100mgs. This is most effective as this dose of oestradiol suppresses ovarian activity and the testosterone increases the energy, self-confidence and libido. This treatment has also been pioneered by my research team and published in the appropriate journals. 4.5.
Women with PMS are very sensitive to their own progesterone or to synthetic progestogen. But a woman having continuous oestrogens must have some sort of progestogen to prevent irregular bleeding and excessive growth of the lining of the womb but this oral progestogen, may (not always), produce a slight recurrence of their PMS symptoms. If this happens it may be necessary to change the progestogen, or reduce the dose. Alternatively, a brilliant new device, the Mirena progestogen releasing intra-uterine system enables the lining of the womb to be protected without the woman having to take oral progestogens with their side-effects.
It follows that the most effective treatment for PMS is transdermal oestrogens, either by patches or implants in a dose that usually stops ovulation. It is often advantageous to insert a Mirena coil to prevent bleeding and the cyclical progestational symptoms that oral progestogen produces.
Hysterectomy and bilateral salpingo-oophorectomy may be appropriate for older women. This surgery may seem to be the last resort but it does work and should be followed through with long-term HRT so that the women have no cycles and no symptoms of hormone sufficiency. 6.
JOHN STUDD Professor of Gynaecology
- Watson, N.R., Studd, J.W.W., Riddle, A.F., Savvas, M. (1988) Suppression of ovulation by transdermal oestradiol patches. Br. Med. J., 297, 900-901.
- 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 norethisterone. Lancet ii: 730-734
- Smith, R.N.J., Studd, J.W.W., Zamlera, D., Holland, E.F.N. (1995) A randomised comparison over 8 months of 100mcgs and 200mcgs twice weekly doses of transdermal oestradiol in the treatment of severe premenstrual syndrome. B.J.O.G. 102 475-484
- Magos, A.L., Brincat, M., Studd, J.W.W. (1986) Treatment of the Premenstrual Syndrome by Subcutaneous Oestradiol Implants and Cyclical Oral Norethisterone: Placebo Controlled Study. B.M.J. 292, 1629-33.
- Panay, N., Studd, J.W.W. The psychoterapeutic effect of oestrogens Gynecol Endocrinol 1998, 12:353-365
- Khastgir, G., Studd, J.W.W., Catalan, J. The psychological outcome of hysterectomy. Gynecol Endocrinol 2000 Apr;14(2):132-41