What are the recommended first-line treatments for managing moderate to severe premenstrual syndrome (PMS) in primary care?

First-line treatments for managing moderate to severe premenstrual syndrome (PMS) in primary care include:

• Offer lifestyle advice such as regular, frequent small balanced meals rich in complex carbohydrates, regular exercise, regular sleep, stress reduction, smoking cessation, and alcohol restriction.
• If pain is predominant, prescribe a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen, naproxen, or mefenamic acid unless contraindicated.
• Consider prescribing a combined oral contraceptive (COC), especially if contraception is also required. COCs containing drospirenone and ethinylestradiol 20 mcg (e.g., Eloine®) have the most evidence for benefit, typically taken in a 28-day cycle with 24 days active pills and 4 days placebo.
• Consider cognitive behavioural therapy (CBT) if psychological intervention is appropriate.
• Consider prescribing a selective serotonin reuptake inhibitor (SSRI) if affective symptoms or premenstrual dysphoric disorder (PMDD) diagnostic criteria are met; SSRIs may be taken continuously or during the luteal phase, with continuous use possibly more effective.

Review treatment effectiveness after 2 months using a validated symptom diary such as the Daily Record of Severity of Problems (DRSP).

If no benefit is observed, assess for other conditions and consider referral to specialist care for further management.

Advise women on the risks, benefits, and off-label status of treatments like SSRIs and COCs for PMS.

Complementary treatments have limited evidence and should be used cautiously with professional advice.

References: NICE CKS