Premenstrual Syndrome (PMS)

About 90% of women experience PMS symptoms at one point in their life.

Premenstrual syndrome (PMS) is a combination of emotional, physical, and psychological disturbances that occur after ovulation, typically ending with the onset of menstrual flow. The most common mood-related symptoms are irritability, depression, crying, oversensitivity, and mood swings. The most common physical symptoms are fatigue, bloating, breast tenderness (mastalgia), acne flare-ups, and appetite changes with food cravings.

A more severe form of PMS, known as premenstrual dysphoric disorder (PMDD), also known as late luteal phase dysphoric disorder, occurs in a smaller number of women and leads to significant loss of function because of unusually severe symptoms. The American Psychiatric Association characterizes PMDD as a severe form of PMS in which anger, irritability, and anxiety or tension are especially prominent.

About 90% of women experience premenstrual symptoms at some point in their lifetime, but clinically significant PMS (which is moderate to severe in intensity and affects a woman's functioning) occurs in 20% to 30% of women. It is generally most severe in women in their 4th decade of life. 

A great variety of symptoms have been attributed to PMS. Women can have PMS of varying duration and severity from cycle to cycle. The most frequent mood-related symptoms of PMS include:

1. anger and irritability,
2. anxiety,
3. tension,
4. depression,
5. crying,
6. oversensitivity, and
7. exaggerated mood swings.

The most frequent physical signs and symptoms of PMS include:

1. fatigue,
2. bloating (due to fluid retention),
3. weight gain,
4. breast tenderness,
5. acne,
6. sleep disturbances with sleeping too much or too little (insomnia), and
7. appetite changes with overeating or food cravings.

PMS vs pregnancy symptoms

A great variety of symptoms have been attributed to PMS and some may resemble pregnancy symptoms. Women can have PMS of varying duration and severity from cycle to cycle. The most frequent mood-related or psychological symptoms of PMS include:

• Anger 
• Irritability
• Anxiety
• Tension
• Difficulty concentrating 
• Depression
• Crying
• Social withdrawal
• Changes in libido (sex drive)
• Oversensitivity 
• Exaggerated mood swings
• The most frequent physical signs and symptoms of PMS include:
• Fatigue
• Headache 
• Bloating (due to fluid retention)
• Weight gain
• Musculoskeletal pain
• Breast tenderness
• Constipation
• Diarrhea
• Acne flare-ups
• Sleep disturbances with sleeping too much or too little (insomnia)
• Appetite changes with overeating or food cravings

How long do PMS symptoms and signs last?

The duration of PMS varies among women. Most women experience the symptoms for a few to several days in the week prior to the onset of their menstrual period. Some women may have symptoms for a shorter or longer time period, but symptoms of PMS typically start after ovulation (the mid-point in the monthly menstrual cycle).

The cause of PMS is complicated and not fully understood. More research is needed, but it is believed PMS results from the alterations in or interactions between the levels of sex hormones including progesterone and brain chemicals known as neurotransmitters such as gamma-aminobutyric acid (GABA), serotonin, and catecholamine.

Other possible causes of PMS include:

• Preexisting deficiency in the neurotransmitter serotonin, along with an increased sensitivity to progesterone
• Increased prolactin (a hormone responsible for lactation) or a sensitivity to the effect of prolactin
• Changes in glucose metabolism
• Abnormal hypothalamic–pituitary–adrenal (HPA) axis function
• Insulin resistance
• Electrolyte deficiencies
• Genetic factors
• Stress

PMS does not appear to be specifically associated with any personality factors or specific personality types. 

Some examples of medical conditions that can mimic PMS include:

• Depression
• Cyclic water retention (idiopathic edema)
• Chronic fatigue
• Hypothyroidism
• Irritable bowel syndrome (IBS)

The hallmark of the diagnosis of PMS is the symptom-free interval after the menstrual flow and before the next ovulation. If there is no such interval and the symptoms persist throughout the cycle, then PMS may not be the proper diagnosis. PMS can still be present and aggravate symptoms related to the other conditions, but it cannot be the sole cause of constant or non-cyclic symptoms. Blood or other tests may be ordered to help rule out other potential causes of symptoms.

Another way to help make the diagnosis of PMS is to prescribe drugs that stop all ovarian function. If these medications produce relief of the troublesome symptoms, then PMS is most likely the diagnosis.

The most helpful diagnostic tool is the menstrual diary, which documents physical and emotional symptoms over months. If the changes occur consistently around ovulation (mid-menstrual cycle) and persist until the menstrual flow begins, then PMS is probably the accurate diagnosis. Keeping a menstrual diary not only helps the healthcare professional to make the diagnosis but also promotes a better understanding by the patient of her own body and moods. Once the diagnosis of PMS is made and understood, the patient can better cope with the symptoms.

The diagnosis of PMS can be difficult because many medical and psychological conditions can mimic or worsen symptoms of PMS. There are no blood or laboratory tests to determine if a woman has PMS. When laboratory tests are performed, they are used to exclude other conditions that can mimic PMS.

The treatment of PMS can sometimes be as challenging as making the diagnosis of PMS. Various treatment approaches have been used to treat this condition. Some measures lack a solid scientific basis but seem to help some women. Other treatments with a sound scientific basis may not help all patients.

General management includes a healthy lifestyle including:

• Exercise
• Emotional support during the premenstrual period
• Salt restriction before the menstrual period
• Decreased caffeine intake before menstruation
• Smoking cessation
• Limitation of alcohol intake
• Reduction of refined sugar intake

All of the above have been recommended and may help symptoms in some women. Furthermore, some studies suggest that calcium and magnesium supplements may provide some benefits.

Natural home remedies that can help relieve PMS pain and other symptoms include:

• Meditation: A study on mindfulness showed it helped reduce PMS symptoms
• Yoga: Regular practice may help reduce PMS symptoms and alleviate pain. Pilates, walking, and other gentle exercise is also beneficial.
• Acupuncture: Can be effective when done on certain acupuncture points.
• Good sleep hygiene: PMS can cause insomnia, and good sleep hygiene can help with better sleep.
• Heating pad or warm bath: Helps ease cramping.

Herbal remedies that may help relieve PMS symptoms include:

• Black cohosh: May help relieve some PMS symptoms and reduce menstrual cramp pain.
• Evening primrose oil: May ease some PMS symptoms, particularly breast tenderness (mastalgia).
• Gingko biloba: One study shows a decrease in severity of PMS symptoms in patients who took this herb.
• Calcium: Calcium levels may be low in those with PMS, so supplementation may be beneficial.
• St. John’s wort: May help relieve physical and emotional symptoms of PMS, including irritability, depression, food cravings, and breast tenderness.

Talk to your doctor before taking any herbs or other supplements.

A variety of medications are used to treat the different symptoms of PMS. Medications include diuretics, analgesics, oral contraceptives, antidepressants, and drugs that suppress ovarian function.

• Diuretics: Diuretics are medications that increase the rate of urine production, thereby eliminating excess fluid from the body tissues. Several nonprescription menstrual products (including Diurex PMS, Lurline PMS, Midol PMS, Pamprin Multisymptom, and Premsyn PMS) contain diuretics, and either caffeine or pamabrom. Spironolactone (Aldactone) is a prescription diuretic that has been widely used to treat premenstrual swelling of the hands, feet, and face. Unfortunately, it has not been effective in all patients.
• Analgesics (pain killers): These are commonly given for menstrual cramps, headaches, and pelvic discomfort. The most effective group of analgesics appear to be the nonsteroidal anti-inflammatory drugs (NSAIDs). Examples include ibuprofen (Advil, Motrin), naproxen (Aleve, Anaprox), and mefenamic acid (Ponstel).
• Benzodiazepines: The benzodiazepine alprazolam (Xanax) has been shown in some studies to relieve the depressive symptoms of PMS or PMDD. However, this drug is not considered a first-line treatment for these conditions because of its addictive potential.
• Oral contraceptive pills (OCPs): OCPs are sometimes prescribed to even out ovarian hormone fluctuations. While older studies failed to provide evidence that oral contraceptive pills can consistently provide relief for symptoms of PMS, the newer birth control pills, with their improved hormonal formulations, seem to be more beneficial for many women. Oral contraceptive pills containing the progestin drospirenone have been approved by the FDA for the treatment of PMS and premenstrual dysphoric disorder (PMDD).
• Ovarian suppressors: Drugs like danazol (Danocrine) have been prescribed to suppress ovarian hormone production. Unfortunately, Danocrine cannot be used over long periods because of side effects.
•  Gonadotropin-releasing hormone (GnRH): Complete suppression of ovarian function by a group of drugs called gonadotropin-releasing hormone (GnRH) analogs have been found to help some women with PMS. These GnRH analogs are not given over the long term (more than six months) because of their potential for adverse effects on bone density causing an increased risk of bone thinning (osteoporosis). In some cases, these drugs may be prescribed along with hormone supplementation.
• Antidepressants: These are widely used in treating mood disturbances related to PMS. Antidepressants appear to work by increasing brain chemical (opioids, serotonin, and others) levels that are affected by ovarian hormones. These neurotransmitters are important in the control of mood and emotions. The serotonin reuptake inhibitor group of antidepressants seems to be the most effective for symptoms of PMS. Fluoxetine (Prozac) and paroxetine (Paxil) are examples of antidepressant medications from this group that are effective in treating the mood changes associated with PMS.

It is important to know that these drugs, although useful in treating mood disturbances in some women, are not necessarily effective in treating the physical symptoms. Often, it is a combination of diet, medications, and exercise that is needed to afford the maximum improvement from the many symptoms of PMS.

Evidence suggests that exercise can help relieve some of the symptoms of PMS in adolescents and young women. Physical activity improves general health and helps relieve nervous tension and anxiety. Exercise is believed to release endorphins. Endorphins contribute to euphoric feelings such as the "runner's high" experienced after prolonged exercise. Endorphins are chemical messengers for nerves (neurotransmitters) that affect mood, perception of pain, memory retention, and learning.

"Low-impact" aerobic exercises are less stressful on the joints and avoid the muscle and joint pounding of more "high-impact" exercises like jogging and jumping rope. Benefits of exercise for PMS pain and other symptoms include:

• Cardiovascular fitness
• Muscle tone
• Weight loss or control
• Decreases fluid retention
• Increases self-esteem
• Aerobic exercise strengthens the heart and improves overall fitness by increasing the body's ability to use oxygen.
• Swimming
• Walking
• Dancing

• Widespread recognition of PMS has attracted a broad range of research interests in the treatment and management of the symptoms of PMS.
• Although there is no "cure" for PMS at this time, there are many options for managing its signs and symptoms.
• The priority is an accurate diagnosis.
• Other medical or psychological conditions should be identified and treated.
• Proper diet, exercise, and lifestyle changes can improve overall health and thereby lead to the reduction of symptoms.
• If these measures are not effective, over-the-counter or prescription medications may be indicated.
• Most women can control their PMS symptoms successfully and continue to lead healthy and productive lives.