Premenstrual Syndrome

What Is Premenstrual Syndrome (PMS)?

The term premenstrual syndrome (PMS) refers to the physical and emotional symptoms that occur during the one or two weeks before the beginning of menstruation (the time in a woman’s monthly cycle when she bleeds, also known as a woman’s period). Sometimes PMS symptoms last a few days after menstrual bleeding starts.

PMS has been seen since the times of ancient Greece. It has been reported in Eastern (Asian) cultures as well as throughout the Western World. Modern scientific study of PMS has been going on since the early 1930s.

A woman is considered to have PMS when her premenstrual symptoms:

• cause significant discomfort
• interfere with her daily life
• occur primarily during the last two weeks of her menstrual cycle
• cannot be attributed to other conditions

At least 80% of menstruating women have some premenstrual symptoms:

• About 40% of menstruating women have PMS
• About 10% have severe symptoms, a condition called premenstrual dysphoric disorder (PMDD). Nine million women, or approximately five to seven percent of women of childbearing age, have PMDD.

For most women PMS symptoms are mild. In others, the symptoms may be severe and even incapacitating. The severity of a woman’s symptoms has much more to do with her body chemistry than her personality.

PMS can occur at any time after puberty, but more women experience symptoms in their 30s and 40s than in their teenage years. Women who have had more children tend to have more severe symptoms, and women whose mother had PMS are at increased risk. PMS tends to get worse as women age and experience hormonal changes. Women with a history of depression have a greater risk of PMS.

What Are The Symptoms Of Premenstrual Syndrome (PMS)?

The number, type, and severity of symptoms vary among women. They may also be different in the same woman from month to month.

PMS symptoms include:

• Fatigue: This is the most common symptom of PMS. Women with PMS may feel so tired they can barely get through the day. Some women also may have trouble sleeping at night.
• Tension and irritability: A woman with PMS may feel very on edge. Small annoyances seem huge. Often her response is out of proportion to the problem.
• Difficulty concentrating: Many women with PMS find it hard to do things that require concentration, such as balancing a checkbook, following recipes, or making business decisions. They may also be forgetful.
• Anger: During PMS, normal feelings of anger are often exaggerated. A woman may be more argumentative and lash out at those around her.
• Depression: . Sadness and crying easily are common feelings related to PMS. At times the sadness may feel profound and inconsolable.
• Food cravings: Some women crave particular foods, such as sweets or salt. Others find their appetite for almost any food increases.
• Breast tenderness: Many woman experience swelling and soreness around their nipples or breasts.
• Bloating in the abdomen, hands, and legs: Some women with PMS gain weight. Others have fluid shifts to the abdomen, hands, and legs that make them feel uncomfortably swollen or puffy.
• Headaches: Duration and severity of headaches vary from woman to woman, but are common during PMS.

What Causes Premenstrual Syndrome (PMS)?

Experts say that the definitive cause of PMS is not yet known. However, the most likely explanation for PMS is that many women are sensitive to the hormonal shifts that occur in the second half of the menstrual cycle.

What Hormones Cause PMS?

PMS most often occurs in women with normal menstrual cycles. During the normal menstrual cycle, the ovaries make two main hormones, calledestrogen and progesterone. Estrogen is made by the ovaries throughout the entire menstrual cycle. It reaches its highest levels during the second and third weeks and declines during the last week. During the last two weeks of the cycle the ovaries also make progesterone. The last two weeks of the menstrual cycle is called the luteal (secretory) phase.

Both estrogen and progesterone prepare the uterus (womb) to accept a fertilized egg. Both estrogen and progesterone also affect women’s moods.

How Do Hormonal Changes Cause PMS?

The exact cause of PMS is still not known, but researchers believe that PMS symptoms occur because progesterone and estrogen cause changes in brain chemicals called neurotransmitters. The most likely neurotransmitters affected are:

• Serotonin: Women with PMS have fluctuations in serotonin levels. These changes may cause depression and carbohydrate cravings. Serotonin is made by the body from the amino acid tryptophan.
• GABA: GABA stands for gamma-aminobutyric acid. This neurotransmitter is important in feeling calm.
• Endorphins: Endorphins are important in the experience of pain and pleasure. Estrogen and progesterone change endorphin levels.
• Norepinephrine: Norepinephrine and epinephrine are also neurotransmitters that influence mood. In addition, these substances play a role in blood pressure and heart rate.

Could Calcium And Magnesium Imbalances Be Involved?

Some researchers think that certain imbalances in calcium and magnesium levels may trigger PMS symptoms. These two minerals affect nerve cell communication and blood vessel opening and closing. These functions may be involved in PMS symptoms.

Does Stress Cause PMS?

No. PMS is not caused by stress. Women may experience more stress prior to menstruation, and they may handle stress differently during this time, but it is not the cause of PMS. Excessive stress can, however, make PMS symptoms worse.

How Can I Tell If I Have Premenstrual Syndrome (PMS)?

Hormone levels in women with PMS are normal. So, there are no laboratory tests that determine if you have PMS. However, your doctor may do blood tests to determine if you have another problem besides PMS, such as a thyroid condition or early menopause (when menstruation stops, usually associated with aging).

Keeping A Symptoms Calendar

PMS is often incorrectly diagnosed as another physical or emotional problem. The main characteristic that distinguishes PMS is the timing of the symptoms.

So, to diagnose PMS a record of symptoms needs to be kept on a calendar for two to three months. This calendar can help you see patterns in your symptoms. Your doctor will use the calendar along with a health history and physical exam to determine if you have PMS.

Should I Get Treatment For PMS?

PMS is not your fault, and it does not indicate psychological weakness. It is not something to be embarrassed about. Studies have shown that women with PMS are psychologically healthy.

You should consider treatment for PMS if you notice any of the following, especially during the one to two weeks before your period.

• Poor work or school performance: Poor performance at school or at work is often the result of difficulty concentrating, irritability, or fatigue.
• Disturbing physical symptoms: Breast tenderness, bloating, and headaches.
• Problems in your social life: PMS may disturb social relationships. This can include relationships with spouses, friends, lovers, and colleagues.
• Difficulty parenting: Many women with PMS notice their children react to their mood swings and find themselves inappropriately angry at their children’s behavior.
• Suicidal thoughts: Suicidal thoughts are common in women with severe PMS.

What Treatments Work For Premenstrual Syndrome (PMS)?

Many types of treatment are used to relieve symptoms of PMS. Most of them have not been scientifically proven to be effective, although they seem to help many women.

Most researchers and clinicians suggest starting with lifestyle changes, such as diet, exercise, and stress management. Over-the-counter and prescription medicines as well as non-drug treatments like vitamins, minerals, and herbal remedies are also used.

Different treatments are effective for different women. Although you may need to try several before having success, more than 90 percent of women can get at least some relief from their PMS symptoms.

Primary treatment for PMS currently includes:

Non-drug and lifestyle approaches

Medications

Non-drug And Lifestyle Approaches

Many women begin with non-drug treatments, as they tend to have fewer side effects. Non-drug treatments include:

• Changes in diet
• Physical activity
• Stress management
• Nutritional supplements

What changes in diet can help?

Eating a healthy diet is important for general health and may also help relieve PMS symptoms such as bloating, breast tenderness, weight gain, irritability, and headaches.

This includes eating foods high in complex carbohydrates like whole grains and fresh fruits and vegetables, and avoiding saturated fats. It may also help to avoid salt, sugar, caffeine, alcohol, and red meat, and sometimes dairy products. Eating more small meals each day instead of three large meals may reduce food cravings and mood swings.

How can physical activity help?

Most women report that exercise improves their PMS symptoms. It is especially helpful in relieving stress, improving mood, and preventing weight gain.

Try to be physically active for at least 30 minutes on most days of the week throughout your menstrual cycle. Walking or other moderate physical activity may be enough, but some women find they need more vigorous aerobic exercise, such as jogging, biking, swimming, or climbing stairs. If you have not been exercising regularly, talk with your doctor before starting any vigorous exercise program.

What about stress management?

Everyone has events, people, and circumstances in their lives that cause stress. But the way that we handle stressors makes a huge difference in our physical and emotional well-being.

Identifying sources of stress and your reactions to them is the first step in managing stress. Try not to plan stressful activities during the days when your symptoms are worst.

Relaxation techniques, such as meditation, deep breathing, and yoga, help decrease PMS symptoms in some women. Talking with friends or with a counselor may give you ideas on changing negative responses to stress to healthier ones.

What other non-drug treatments can help?

The most common non-drug treatments that help some women with PMS include vitamins, minerals, and herbal remedies. Acupuncture or massage may also help.

• Calcium and magnesium. Calcium and magnesium levels fluctuate during PMS. Some researchers have found that calcium can reduce PMS symptoms by almost half. They now recommend trying calcium before trying prescription medicines. Magnesium supplements seem to help some women with PMS, although this has not been confirmed in any studies.
• Vitamins. Some women report relief of PMS symptoms from taking vitamins, especially vitamins B6 and E, although there is currently no scientific proof. If you try vitamins beyond a daily multivitamin, be careful about the amounts you take. Some vitamins can cause harm in large doses.
• Other dietary supplements. There are a variety of products available that combine different vitamins and minerals for relief of PMS symptoms. PMS Escape is one product that has been shown in a scientific study to help reduce food craving, irritability, depression, and problems concentrating. It contains complex carbohydrates, vitamins, and minerals in a combination that raises levels of the neurotransmitter serotonin.
• Herbal remedies. Although no studies have proven that herbal remedies reduce PMS symptoms, some women have reported relief from using herbs. Evening primrose oil and dong quai have helped some women. A side effect of dong quai is sun sensitivity. Black cohosh may affect estrogen levels, and may help open the blood vessels, which may relieve symptoms. Possible side effects include dizziness and headaches.

What Medicines Can Help Premenstrual Syndrome (PMS)?

There are a number of prescription medicines used to treat PMS, including:

• Birth control pills. These may help relieve the physical symptoms of PMS in some women, but the results are variable. Because birth control pills contain high levels of an estrogen-like hormone and progesterone -like hormone, they actually may cause premenstrual symptoms in some women. Women who experience PMS while on the pill should consider using another method of birth control.
• Progesterone. Many studies have been done using progesterone treatment for PMS. The majority of these studies have concluded that progesterone does not improve PMS symptoms.
• Selective serotonin-reuptake inhibitors (SSRIs). This class of antidepressants affects the availability of the neurotransmitter serotonin. The SSRIs fluoxetine (Prozac) and sertraline (Zoloft)have been shown in scientific studies to help reduce depression, irritability, and anxiety in PMS. Physical symptoms are usually helped too.

  Other SSRIs are also being studied for their effects on PMS. SSRIs can cause the side effects of drowsiness, nausea, and jitteriness in a small percentage of women. Women who begin SSRI therapy must decrease dosages very slowly to avoid possible side effects should they decide to stop the therapy. About 60 percent of women with severe PMS experience significant relief from SSRIs. Many take them throughout their menstrual cycle, but some have success using them just during the premenstrual phase.

• Anti-anxiety medicines. If SSRIs are not helpful, anti-anxiety medicines can be used to relieve anxiety associated with PMS. The one most commonly used is alprazolam (Xanax). It is in the class of medicines called benzodiazepines and works on the neurotransmitter GABA. Because alprazolam can be addictive it must be used cautiously. It should only be used during the few days a month when symptoms are worst. Alprazolam may cause drowsiness and difficulty operating motor vehicles.

  Another anti-anxiety medicine, buspirone (BuSpar), may also help reduce anxiety and depression in PMS. It is not addictive and has less severe side effects than the benzodiazepines.

• GnRH Agonists. Gonadotropin-releasing hormones (GnRH) agonists suppress the hormones that cause ovulation, causing a temporary menopause – like state. They are highly effective in treating PMS, including breast tenderness, irritability, and fatigue.

  However, GnRH agonists can also cause menopausal symptoms, such as hot flashes and vaginal dryness. In addition, long-term use (more than six months) is associated with bone loss (osteoporosis). Small doses of estrogen and progesterone can be given in addition to GnRH agonists to lessen these side effects and allow long-term use.

How Can I Treat Specific Symptoms of PMS?

Many women address their PMS by treating the symptoms that arise. Specific symptoms that are often addressed this way include:

• Headaches
• Cramps
• Mood Changes
• Appetite
• Bloating, Breast Tenderness and Weight Gain

Headaches

Headaches are a common symptom of PMS. Increased tension premenstrually may cause tension headaches. There is also a higher incidence of migraine headaches premenstrually. Specific treatments are available for each of these types of headaches. They includeacetaminophen (such as Tylenol) and aspirin for milder headaches. More serious headaches may require stronger pain medicine or medicines used to decrease the frequency of headache attacks. These require a prescription.

Cramps

Menstrual cramps are disabling to some women. Dysmenorrhea (painful menstrual cramps) is a different condition than PMS but may occur at the same time. The most effective treatment is to beginnonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, before getting your period. Birth control pills are also likely to help with cramps.

Mood Changes

Mood changes, including irritability, depression, and fatigue, may best be relieved by the simple treatment of increasing your physical activity. Scientific studies have shown moderate physical activity to be as effective as medications in improving mental outlook. If physical activity alone does not help enough, talk to your doctor about other treatments.

Appetite

Appetite tends to decrease with vigorous exercise. Finding small ways to indulge without going overboard, and developing non-food ways of comforting yourself, for example taking a warm bath or nap may help. Treatment with SSRIs may also help.

Bloating, Breast Tenderness, And Weight Gain

Being physically active may help to minimize discomfort related to fluid gain.

If your symptoms are very uncomfortable, talk to your doctor about taking a diuretic (medicine that gets rid of extra water in the body).Spironolactone is the prescription diuretic most commonly used for PMS-related bloating.

Living With PMS

PMS is not a psychological problem. However, normal life difficulties, such as work or relationship problems may seem more intense premenstrually. Ask your family and friends for support. Consider joining a PMS support group so that you can share experiences with other women who have similar problems. If your symptoms are creating major problems for you, a counselor or psychotherapist may be able to help you to cope better.

PMS is no longer a mystery. Nor do you have to continue living with difficult symptoms. Treatments are available that can improve the quality of your life. So don’t keep your PMS to yourself. Seek help.

Premenstrual Syndrome: Frequently Asked Questions

Here are some frequently asked questions related to premenstrual syndrome.

Q: Do women with PMS have different hormone levels?

A: No. Women with PMS do not have too little or too much estrogen or progesterone. Hormone levels in women with PMS are normal throughout the cycle, but the effects of the hormones are different depending on the woman.

Q: Can PMS mimic other diseases?

A: Definitely. Women who believe they have PMS may have other conditions, including a thyroid problem, anxiety disorder, panic attacks,diabetes, or even early menopause. The only way to be sure that these conditions are not present is work with your doctor.

Q: Can my PMS be depression?

A: Depression and PMS are different. Nonetheless, some studies have shown that women with PMS may also be genetically predisposed to depression. There is evidence that antidepressants, bright-light treatments, or counseling may help.

Q: Can PMS worsen other medical and psychiatric problems?

A: Yes. Women with a large variety of conditions experience worsening of the symptoms during the one to two weeks before they get their period. These conditions include migraines, diabetes, asthma, allergies, irritable bowel syndrome, seizures, depression, substance abuse, anxiety disorders, and eating disorders.

Q: What about a woman with PMS on the birth control pill?

A: The birth control pill contains high levels of an estrogen-like hormone and a progesterone-like hormone. Taking these hormones may cause premenstrual symptoms. Women who experience PMS while on the pill should consider using another method of birth control. An accurate diagnosis of PMS cannot be made in a woman taking the pill.

Q: Can I have PMS when I am not menstruating?

A: Yes. There are certain times when women of childbearing age can have PMS but are not getting their periods. These include when you are nursing, having erratic periods, while you are going through peri-menopause, or have had a hysterectomy.

Q: Can I get menstrual cramps if I have PMS?

A: Yes. You can have both. However, menstrual cramps usually occur while you have your period, and PMS occurs mainly before your period.

Premenstrual Syndrome: Putting It All Together

Here is a summary of the important facts and information related to premenstrual syndrome.

• Premenstrual syndrome is a term that refers to the physical and emotional symptoms that occur during the one or two weeks before the beginning of menstruation.
• Most women who have menstrual periods experience some premenstrual symptoms. About 40 percent of menstruating women have premenstrual syndrome, and 10 percent have severe symptoms.
• PMS is diagnosed when a woman has symptoms, the symptoms coincide with her menstrual cycle, and symptoms impair her functioning in life, and cannot be attributed to other conditions.
• Charting a calendar of symptoms is one way for a woman to determine if her symptoms relate to her menstrual cycle.
• The older a woman is, the more likely she is to experience PMS. Family histories of PMS, more children, being physically inactive and smoking are all associated with increased severity of symptoms.
• The most likely explanation for PMS is that many women are sensitive to the hormonal shifts that occur in the second half of the menstrual cycle.
• The more a woman understands PMS, the more can be done.
• There are many treatments for PMS that work. A woman will most likely need to try several treatment options before she finds the combination that works for her.
• Lifestyle changes alone, such as diet, physical activity and stress management may help many women with PMS. Other women may also need to take medicine.

Premenstrual Syndrome: Glossary

Here are definitions of medical terms related to premenstrual syndrome.

Aerobic exercise: Exercise in which the body’s need for oxygen is increased. This is usually exercise for a sustained period of time in which the heart rate is mildly elevated.

Diuretic: A medicine that increases the body’s removal of water.

Dysmenorrhea: Pain that occurs in the uterus and lower abdomen during a woman’s period.

Estrogen: The major female hormone produced by the body which influences breast development, enables a mature egg to be released each month, and helps prepare the uterus for pregnancy.

Hormones: Chemicals that travel through the blood stream to deliver messages from one part of the body to another. Hormones are produced in specialized areas, such as the ovaries and thyroid glands, and signal other areas, such as the uterus and brain.

Menopause: The end of having menstrual periods. It occurs in most women between the ages of 45 and 55.

Menstrual: A word referring to the normal monthly cycle of women which results in a period each month. The one to two weeks before the period is called premenstrual.

Menstruation:The normal monthly cycle of women, this results in a period each month.

Neurotransmitters: Natural chemicals that nerve cells, especially in the brain, use to send messages to one another. These chemicals are involved in mood, thought, pain, and pleasure.

Peri-menopause: When the menstral cycle begins to become erratic and less frequent. Usually occurs in women anytime between the ages of 35 and 50.

Progesterone: A hormone made during the last two weeks of the menstrual cycle. It prepares the uterus for implantation of the egg.

Premenstrual Syndrome: Additional Sources Of Information

Here are some reliable sources that can provide more information on premenstrual syndrome.

American College of Obstetricians and Gynecologists 
Phone: 202-638-5577
http://www.acog.com

Information and referral to specialists.

The website for the US Department of Health & Human Services Office of Women’s Health. Provides news, events, and information on a variety of women’s health topics.

National Women’s Health Resource Center 
Phone: 202-537-4015
http://www.healthywomen.org

A nonprofit organization that provides information and resources on all areas of women’s health to consumers and professionals. Services include a newsletter, fact sheets, and database on women’s health information.