2.  Must use a cycle diary  50 – 60% of patients then discover that their symptoms are not exclusively premenstrual  Also useful in assessing therapy  Cycle to cycle – patient acts as her own control

3.  A physiological condition (75% have it)  Not due to any identified hormone deficiency or excess  (Don’t get trapped into measuring serum everything!)  Best regarded as an abnormal response of brain neurotransmitters to normal cycles  Treat only those whose life is severely affected (3-8%)

4.  Counselling and support  (involve the partner)  Diet  Exercise  Smoking cessation  Decrease caffeine – good for mastalgia  Chinese Herbs  Meditation/?Acupuncture

5.  COC – 85% respond  ≈15% get worse  ?Yasmin better  NSAID when pain is an issue  Vitamin B6 and Evening Primrose Oil  Aldactone  Progesterone (doubtful role)  Danazol  Lithium  SSRIs

6.  Effective (46 trials, 2294 women, RR=0.55, CI 0.68-0.39)  Effective against both physical, functional & behavioural symptoms  Luteal phase use as effective as all cycle use  All SSRIs tested have been found to be effective  Side effects that result in patient withdrawal from treatment are a problem

7.  E2 implant and Mirena  Hysterectomy and E2 implant