What role do hormonal treatments play in the management of PMS, and what are the potential side effects?

Role of hormonal treatments in PMS management: Hormonal treatments, particularly combined oral contraceptives (COCs), play a significant role in managing premenstrual syndrome (PMS), especially when symptoms are moderate to severe or when contraception is also desired. COCs containing drospirenone and ethinylestradiol (20 mcg) have the most evidence supporting their use, although this is off-label for PMS alone in the UK. These are typically taken in a 28-day cycle with 24 days of active pills and 4 days of placebo, and continuous use may be more effective but can be limited by breakthrough bleeding ¹. Other new-generation COCs may also be effective, especially if previously tolerated ¹.

Hormonal treatments aim to stabilize hormonal fluctuations that contribute to PMS symptoms, reducing both physical and affective symptoms. Transdermal oestrogen and other hormonal agents may be considered in secondary care for refractory cases ¹.

Potential side effects: The side effects of hormonal treatments include those common to COCs such as nausea, breast tenderness, headache, breakthrough bleeding, and potential increased risk of venous thromboembolism (VTE). Women should be counselled on these risks and benefits before starting treatment ¹. Breakthrough bleeding is a common reason for discontinuation, especially with continuous regimens ¹.

Additionally, selective serotonin reuptake inhibitors (SSRIs) may be prescribed for affective symptoms or premenstrual dysphoric disorder (PMDD), with side effects including nausea, insomnia, fatigue, and reduced libido ¹. Although SSRIs are not hormonal treatments, they are often considered alongside hormonal options in PMS management.

Recent pharmacological research supports the use of drospirenone-containing COCs for PMS symptom relief, aligning with guideline recommendations, and highlights the importance of individualized treatment plans due to variable response rates (Sundström-Poromaa and Comasco, 2023). Emerging studies also explore novel hormonal and non-hormonal agents, but current UK practice prioritizes COCs as first-line hormonal therapy ¹ (Sundström-Poromaa and Comasco, 2023).