PMS: What is the place of progesterone and progestogens in the treatment of PMS?

One of the pioneers of PMS diagnosis and treatment has been a strong advocate of progesterone pessaries (Cyclogest - Shire). Research has failed to confirm any evidence of imbalance in progesterone levels between those with and those without PMS. From a theoretical point of view, PMS occurs at the time that the body is producing progesterone so that progesterone deficiency is unlikely to be the problem. Although scientifically controlled studies have never proven its benefit, the fact remains that many women continue to take this form of treatment and they are convinced of its efficacy. Postmenopausal women given oestrogen replacement therapy and cyclical progestogens (Q 28.09) sometimes report recurrence of PMS type symptoms; dydrogesterone (Duphaston - Solvay), medroxyprogesterone acetate (Provera Pharmacia and Upjohn) and progesterone itself seems to have this side-effect less frequently than other progestogens. Duphaston and norethisterone are licensed for use in PMS but scientific control studies tend to show no improvement over placebo (placebo & controlled trials). Progesterone as a vaginal gel (Crinone) introduced on alternate nights became available in 1997 and some find Progest (progesterone replacment therapy) helpful. Depo-Provera used in family planning (Depo-Provera) is administered on a three monthly basis.

A 42 year old lady presented with a history of depression and a suggestion that her problem could be PMS. She had the typical appearance of a severely depressed person. At times she had required hospital admission under the care of a psychiatrist. There was certainly an element of a cyclical increase in her symptoms and at that time it seemed reasonable to offer hormonal treatment on a trial basis. She received dydrogesterone during the second half of the cycle. When she returned a few weeks later she was vivacious and enjoying life to the full. All was well for about a year when she returned quite depressed despite having continued with the dydrogesterone. It turned out that she had recently received an antibiotic for a respiratory infection and this could have altered the absorption of the drug. With increased progestogen the problem resolved and in her case her severe symptoms were effectively controlled by dydrogesterone alone until she reached her menopause. It should be emphasised that this case is unusual. Every person, however, is an individual and although such improvement would not be predictable on the evidence of large studies, in my view the practice of medicine is still an art based on science. Only politicians could believe that medicine is a pure science.

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