Available evidence regarding the effects of lifestyle changes (exercise and diet) on PMS symptoms is contradictory, complicating evidence-based decision making. Patients and healthcare providers would benefit from an overview of available evidence to support decision making and patient centered care.

Results

1. Exercise

1.1   Suffering of PMS symptoms measured with the Daily Record of Severity of Problems (DRSP)

None of the studies reported on this outcome.

1.2 PMS symptoms

1.2.1 Total PMS symptoms

Total PMS symptoms were not defined as outcome measure, but are reported here since some studies only reported total scores and can thus be included for the outcome measure.

Total PMS symptoms were reported in four studies with data of 134 participants. A variety of measures were used to evaluate PMS symptoms. The pooled standardized mean difference for the change from baseline in total PMS symptoms among participants in the intervention group versus participants in the control group was -1.55 (95% CI -2.92 to -0.19), in favor of the intervention group (figure 1). This difference is considered clinically relevant.

Figure 1. Forest plot of total PMS symptoms among participants with exercise versus participants without exercise intervention.

1.2.2 Physical PMS symptoms

Physical PMS symptoms were reported in four studies with 257 participants. Changes from baseline were measured in various ways. The pooled standardized mean difference for the change in physical PMS symptoms among participants in the exercise group versus participants in the control group was -2.17 (95% CI -3.52 to -0.82), in favor of the intervention group (figure 2). This difference is considered clinically relevant.

Figure 2. Forest plot of physical PMS symptoms among participants with exercise versus participants without exercise intervention.

1.2.3 Psychological PMS symptoms

Data regarding psychological PMS symptoms were extractable from five studies with data of 291 participants. Different measures were used to investigate psychological symptoms. The pooled standardized mean difference for the change in psychological PMS symptoms among participants in the intervention group versus participants in the control group was -1.99 (95% CI -2.71 to -1.27), in favor of the exercise group (figure 3). This difference is considered clinically relevant.

Figure 3. Forest plot of psychological PMS symptoms among participants with exercise versus participants without exercise intervention.

1.3 Quality of life

None of the studies reported on this outcome.

2. Diet

2.1  Suffering of PMS symptoms measured with the Daily Record of Severity of Problems (DRSP)

The DRSP is a valid measure to diagnose and evaluate symptoms related to premenstrual syndrome and premenstrual dysphoric disorder. Each of 24 items need to be rated on a six-point scale every day to determine symptom severity. A higher score reflects more severe symptoms. 

DRSP scores could be extracted from one study covering data of 72 participants (Al Kiyumi 2023). The intervention group had a mean score of 268.55 (SD 13.64) and the control group had a score of 298.23 (SD 13.26). The mean difference for total PMS symptoms among participants after the intervention versus participants after no intervention was -29.68 (95% CI -35.89 to -23.47), in favor of the intervention group. This difference is considered clinically relevant.

2.2 PMS symptoms

2.2.1 Total PMS symptoms

Total PMS symptoms were not defined as outcome measure, but are reported here since some studies only reported total scores and can thus be included for the outcome measure.

Total PMS symptoms were reported in two studies with data of 103 participants. Different measures were used to evaluate PMS symptoms. The pooled standardized mean difference for the change from baseline in total PMS symptoms among participants in the intervention group versus participants in the control group was -1.56 (95% CI -3.91 to 0.80), in favor of the intervention group (figure 4). This difference is not considered clinically relevant.

Figure 4. Forest plot of total PMS symptoms among participants with diet versus participants without diet.

2.2.2 Physical PMS symptoms

None of the studies reported on this outcome.

2.2.3 Psychological PMS symptoms

Data regarding psychological PMS symptoms were extractable from one study with data of 72 participants (Al Kiyumi 2023). This was measured with the Perceived Stress Score, an instrument assessing the perceived stress in the last month. A score ranging from 0 to 56 and a higher score indicates more stress.

The mean score in the intervention group 2 months after intervention was 27.61 (SD 0.67) and in the control group 26.42 (SD 0.671). The mean difference was 1.19 (95% CI 0.88 to 1.50) in favor of the control group. This difference is not considered clinically relevant.

2.3 Quality of life

Yurt 2020 investigated quality of life using the validated 36-Item Short-Form Health Survey (SF-36). In this questionnaire, scores range from 0 to 100 and a higher score corresponds with a better quality of life. The questionnaire has two components: physical health and mental health. Regarding physical health, the mean difference between participants who received a diet intervention and those who did not was 9.90 (95% CI 5.04 to 14.76), favoring diet. This difference is considered clinically relevant. For mental health, the mean difference was 7.00 (95% CI 1.36 to 12.64), favoring diet (figure 5). This difference is considered clinically relevant.

Figure 5. Forest plot of SF-36 scores among participants receiving a diet intervention and participants not receiving an intervention.

A systematic review of the literature was performed to answer the following question: What is the effectiveness of lifestyle interventions (exercise and diet) in the treatment of premenstrual syndrome?

Table 1. PICO

Relevant outcome measures

The guideline panel considered the outcome measure ‘suffering of PMS symptoms measured with the DRSP or with a PMS calendar’ as a critical outcome measure for decision making; and ‘PMS symptoms’ and ‘quality of life’ as important outcome measures for decision making.

The guideline panel defined a 25% difference for dichotomous outcomes (RR< 0.8 or >1.25) and 0.5 SD for continuous outcomes (default boundaries as defined by GRADE) as minimal clinically (patient) important difference.

Search and select (Methods)

The databases Medline (via OVID) and Embase (via Embase.com) were searched with relevant search terms from January 1^st, 2005 until March 7^th, 2024. The detailed search strategy is listed under the tab ‘Literature search strategy’. The systematic literature search resulted in 965 hits. Studies were selected based on the PICO criteria which initially included the use of supplements and stress reduction as interventions as well. Because of the large number of studies, the use of supplements and stress reduction were removed as interventions in the PICO. 79 studies were initially selected based on title and abstract screening of which 19 regarded exercise, exercise program or diet. After reading the full text, 15 of the 19 studies were excluded (see the exclusion table under the tab ‘Evidence tabellen’), and 4 studies were included: 2 regarded exercise (1 review with 6 RCTs and one RCT) and 2 regarded diet (both RCTs).

A large number of studies were excluded during the selection process due to the wide variation in the interventions described. For example, within the category of supplements/dietary interventions, a broad range of approaches was included—ranging from individual vitamins and minerals, flower extracts, supplements of endogenous substances, herbal preparations or herbal teas to comprehensive dietary advice. Similarly, in the studies focused on stress reduction/exercise, the interventions varied greatly as well, including different forms of relaxation therapy, relaxation (muscle relaxation) yoga programs, massage, aromatherapy, meditation/mindfulness, homeopathy and support groups.

Therefore, we chose to include studies in which a specific exercise program or comprehensive dietary recommendation was prescribed to the intervention group and compared to a no intervention or placebo group. Yoga was included if it was part of an exercise program (with active muscle engagement).

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