Premenstrual Syndrome (PMS)

RCOG Green-top Guideline No. 48 Management of Premenstrual Syndrome. Last reviewed: May 2023. NICE CKS Premenstrual syndrome. Last revised: Sep 2024.

Disclaimer

This article draws on recommendations from both the NICE CKS and the RCOG Green-top Guideline No. 48.

Please note that the two sources do not fully align — the RCOG guideline provides more detailed and advanced management pathway, while NICE CKS offers a concise, primary care–focused approach.

For clarity and exam relevance, this article involves simplification and redundancy to suit educational purposes.

Guidelines

Prospective daily symptom diary for 2-3 cycles
  • Daily Record of Severity of Problems (DRSP) is a validated questionnaire
  • RCOG recommends against retrospective reporting of symptoms 

Diagnose PMS if symptom diary shows:
  • Prominence of symptoms during the luteal phase, and
  • Resolves with the onset of menses, and
  • Followed by symptom-free week

Refer to secondary care if completed symptom diary alone is inconclusive.

Definitive test: GnRH agonist ovarian suppression test for 3 months
  • Resolution of symptoms after ovarian suppression is diagnostic of PMS

  • Regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates
  • Regular exercise
  • Regular sleep
  • Stress reduction
  • Smoking and alcohol cessation (if applicable)
 

Advise that there is limited evidence to support the use of complementary treatments and dietary supplements (including reflexology, St John's wort, calcium and vitamin D, ginkgo biloba, evening primrose oil, vitamin B6, and magnesium)

1st line:
  • NSAIDs as required
  • COCPCombined oral contraceptive pill
    • Drospirenone + ethinylestradiol is most effective
    • Continuous dosing is more effective

Options in severe PMS:
  • SSRISelective serotonin reuptake inhibitor (esp. if there are affective symptoms)
  • CBTCognitive behavioural therapy
 

RCOG recommends the following:
  • 2nd line
    • Transdermal oestradiol patches + micronised progesterone
    • LNG-IUS
  • 3rd line: GnRH analogues + HRT
  • 4th line: surgical treatment (bilateral salpingo-oophorectomy +/- hysterectomy) +/- HRT
Author: Adams Lau
Reviewer:
Last edited: 11/07/25