When should I consider referring a patient with PMS for specialist evaluation or treatment?

Consider referring a patient with premenstrual syndrome (PMS) for specialist evaluation or treatment if:

• Primary care management has failed to control symptoms satisfactorily after an initial trial of treatment and lifestyle advice, typically reviewed after 2 months using a validated symptom diary such as the Daily Record of Severity of Problems (DRSP) questionnaire.
• There is no benefit from first-line treatments and other underlying conditions that could explain symptoms (e.g., depression, hypothyroidism, anaemia, irritable bowel syndrome, endometriosis) have been assessed and managed.
• The woman has severe or complex symptoms that require further investigation or consideration of other treatment options not routinely available in primary care, such as transdermal oestrogen, other antidepressants, diuretics, danazol, gonadotrophin-releasing hormone (GnRH) agonists, or surgery.
• Referral should be made to a clinic with a specific interest in PMS or a general gynaecology clinic if a PMS-specific clinic is not available.

Additionally, consider referral for cognitive behavioural therapy (CBT) if psychological intervention is thought to be beneficial, or specialist advice if prescribing SSRIs in people under 18 years.

These recommendations are based on the Royal College of Obstetricians and Gynaecologists (RCOG) guideline and other expert consensus and clinical guidelines.

Summary: Refer if symptoms persist despite primary care treatment and lifestyle measures, no other underlying causes explain symptoms, and more advanced or specialist treatments are needed.

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