As premenstrual syndrome is a cyclical problem, abolition of the ovarian cycle would seem to be a logical approach. This can be achieved with:-

  • oestrogen and progestogen -

either by a combined oral contraceptive pill taken without an interval. The combined oral contraceptive pill suppresses ovulation and provides one option for the treatment of PMS. It may be a first option if the patient is also seeking contraception. Surprisingly, some women with no history of PMS develop this problems when they start a combined pill. There is no medical reason why the pill needs to be taken on a cyclical basis and on occasion taking the pill on a continuous basis may prove effective for PMS problems. By taking two or three pill packets "back-to-back" some of these problems may be reduced but periods will only occur every two or three months.

  • danazol

For women with more severe problems, stronger forms of treatment may be required. Danazol tends to reduce the hormone fluctuations. Danazol 400mg daily will generally suppress the menstrual cycle and can be effective in PMS. Occasionally it may be effective at lower dose levels whilst some patients will need more. Many women tolerate this drug well but others may have side effects including weight gain and an increase in body hair. Danazol can have adverse effect on a fetus so that adequate contraception is essential.

  • GnRH analogues

GnRH analogues such as goserelin (Zoladex - Zeneca) or nafarelin (Synarel Searle) will temporarily reduce the sex hormones to menopausal levels. They can only be used for a few months at a time as the prolonged suppression of oestrogens may lead to osteoporosis and arterial disease (Q33.14). In the short-term patients may suffer menopausal type symptoms including hot flushes and vaginal dryness. There is evidence that GnRH analogues will suppress genuine PMS symptoms. Within a few weeks of discontinuation of therapy, the hormone cycle is restored and PMS symptoms return. GnRH analogues may have a part to play:

  • confirming the diagnosis for the clinician as well as other members of the patient's family and her employers.
  • in the treatment of PMS. As previously indicated, GnRH analogues if used alone can only be prescribed for a few months at most. There has been suggestion that they could perhaps be used in combination with HRT. From a theoretical point of view, if the HRT employed was of the continuous combined variety (coronary artery disease) there would be no cycle and no risks associated with prolonged oestrogen insufficiency.
  • as a test prior to hysterectomy if the decision relating to removing the ovaries depends on the possibility of treating PMS type symptoms.
  • surgical removal of the ovaries (usually with hysterectomy)

In some women there may be an insidious change from PMS to menopause problems and in the later 40s HRT may have a part to play. Orally administered HRT is not strong enough to suppress the menstrual cycle. High dose patches or oestradiol implants of 100 mg do suppress the cycle. The problem here is that unless the uterus has been removed, progestogens are imperative to prevent problems with the endometrium (HRT and progestogen). Progestogen must be given for at least 7 days each calendar month to clear the lining of the womb by causing a period. There may be resulting PMS like symptoms when the progestogens are introduced but these symptoms are usually less severe than without treatment. The LNG- containing intrauterine contraceptive device, Mirena, (Mirena-IUS) will deliver adequate progestogen locally within the uterus to be protective so there is no requirement for a cyclical preparation. Reports of this approach are appearing but further studies are required.

It should be emphasised that although the combined oral contraceptive pill and Mirena-IUS (used in combination therapy in PMS) provide contraception, all other medical treatments are not contraceptive and appropriate precautions should be used.

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This is the personal website of David A Viniker MD FRCOG, retired Consultant Obstetrician and Gynaecologist - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.
I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.

I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.

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