The Treatment of Premenstrual Symptoms

THE TREATMENT OF PREMENSTRUAL SYMPTOMS Since the first systematic description of the pre menstrual tension syndrome (Frank, 1931), a bewildering array of treatments has been suggested, all of which are based on some underlying notion of aetiology (Steiner and Carroll, 1977). Unfortunately, in this area uncontrolled studies of efficacy are the rule. Such few double-blind, controlled studies as have been performed have been almost invariably negative. One of the earliest causal theories postulated an imbalance in the premenstrual phase between the ovarian steroids oestradiol and progesterone (Israel, 1941). A considerable literature now exists testifying to the therapeutic usefulness of oral contraceptives in premenstrual tension (Mears and Grant, 1962; Moos, 1969a ; Herzberg and Coppen, 1979 ; Silber geld et al, 1971 ; Goldzieher et al, 197! ). A study of over five thousand woman members of the Kaiser Foundation Health Plan (Kutner and Brown, 1972) reported that patients taking combination pills had significantly less severe premenstrual depression than sequential users, a finding often cited in support of the notion that the greater the progestational activity in the premenstrual phase the less the depression. My own study of the prevalence of premenstrual com plaints in women attending their general practitioners found little difference in the proportion of pill-users and non-users complaining of premenstrual symp toms. However, women on the pill complained of significantly fewer symptoms. The oral contraceptive study conducted by the Royal College of Genera! Practitioners (RCGP, 1974) found that the reporting of premenstrual symptoms amongst pill-users was 29 per cent less than in the controls. However, such findings require clarification. Cullberg, in a carefully controlled study (Cullberg, 1972), identified a small group of premenstrual tension patients who were made worse by highly oestrogenic oral contraceptives and better by strongly progestogenic ones. A double-blind con trolled trial showed remarkably little difference between oral contraceptive users and non-users (Morris and Udry, 1972) while in an uncontrolled study (Hood and Bond, 1959), 21 of 25 patients with premenstrual tension were relieved by an oral contraceptive but the improvement was not sustained and was not superior to that obtained by other methods. It has also to be borne in mind that surveys of users and non-users of the pill may reveal a mis leadingly favourable picture of therapeutic efficacy as a consequence of the tendency of patients who tolerate the pill badly or whose premenstrual symptoms are exacerbated by it to discontinue its use and turn to other methods of contraception. Nevertheless, Smith (1975), at the end of a balanced review, concludes that the administration of an oral contraceptive to a patient with premenstrual symptomatology is probably worth trying with one of the following results to be expected : (a) relief of symptoms ; (b) continuation of symptoms but limited to one or two days premenstrually ; (c) intolerance of the oral contraceptive (depressive side-effects); (d) no change. The use of the natural hormone progesterone has been extensively reported and enthusiastically en dorsed(Dalton,1964;1977;1978). In sofarasthere is any underlying theory, it is the assumption, first mooted by Israel (Israel, 1941), that there is in adequate functioning of the corpus luteum with the result that oestrogen is insufficiently opposed by progesterone. A number of recent studies have reported a flattening of the progesterone curve in the luteal phase in premenstrual complainers (Backstrom and Carstensen, 1974; Munday, 1977) but others have failed to confirm this finding (Smith, 1975; O'Brien et al, 1979). The main drawback with the use of progesterone is that it is ineffective when taken by mouth. Injections, in doses ranging from 50 to 100 mg daily, are unpleasant and inconvenient, due to the large amount of oily vehicle necessary, and sup positories and pessaries are expensive and aesthetically distasteful to many, particularly when their use has to be continued for up to two weeks in every month. While theliterature isrichinfavourable reports, few of theseare of adequatelycontrolledtrials. One double-blind, controlled trial of progesterone in jections in 14 carefully documented cases of pre menstrual depression did not find it superior to spironolactone or placebo (Smith, 1975). Nor was any correlation found between plasma levels of progesterone and oestrogenand therapeutic benefit orlackofit.