Disclaimer

Choice of Guidelines

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 a 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

Investigation and Diagnosis

Primary Care (1st line)

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.

Secondary Care

Definitive test: GnRH agonist ovarian suppression test for 3 months

• Resolution of symptoms after ovarian suppression is diagnostic of PMS

Management

Lifestyle Advice

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

Pharmacological Management

1st line:

• NSAIDs as required
• COCP
  • Drospirenone + ethinylestradiol is most effective
  • Continuous dosing is more effective

Options in severe PMS:

• SSRI (esp. if there are affective symptoms)
• CBT

Secondary Care Options 

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

References

Original Guideline