Premenstrual syndrome (PMS) refers to symptoms that occur between ovulation and the onset of menstruation. The symptoms include both physical symptoms, such as breast tenderness, back pain
, abdominal cramps, headache
, and changes in appetite, as well as psychological symptoms of anxiety
, depression, and unrest. Severe forms of this syndrome are referred to as premenstrual dysphoric disorder
(PMDD). These symptoms may be related to hormones and emotional disorders.
Approximately 75% of all menstruating women experience some symptoms that occur before or during menstruation. PMS encompasses symptoms severe enough to interfere with daily life. About 3-seven% of women experience the more severe PMDD. These symptoms can last 4-10 days and can have a substantial impact on a woman's life.
The reason some women get severe PMS while others have none is not understood. PMS symptoms usually begin at about age 20-30 years. The disease may run in families and is also more prone to occur in women with a history of psychological problems. Overall however, it is difficult to predict who is most at risk for PMS.
Causes and symptoms
Because PMS is restricted to the second half of a woman's menstrual cycle, after ovulation, it is thought that hormones play a role. During a woman's monthly menstrual cycle, which lasts 24-35 days, hormone levels change. The hormone estrogen gradually rises during the first half of a woman's cycle, the preovulatory phase, and falls dramatically at ovulation. After ovulation, the postovulatory phase, progesterone levels gradually increase until menstruation occurs. Both estrogen and progesterone are secreted by the ovaries, which are responsible for producing the eggs. The main role of these hormones is to cause thickening of the lining of the uterus (endometrium). However, estrogen and progesterone also affect other parts of the body, including the brain. In the brain and nervous system, estrogen can affect the levels of neurotransmitters, such as serotonin. Serotonin has long been known to have an effect on emotions, as well as eating behavior. It is thought that when estrogen levels go down during the postovulatory phase of the menstrual cycle, decreases in serotonin levels follow. Whether these changes in estrogen, progesterone, and serotonin are responsible for the emotional aspects of PMS is not known with certainty. However, most researchers agree that the chemical transmission of signals in the brain and nervous system is in some way related to PMS. This is supported by the fact that the times following childbirth
are also associated with both depression and low estrogen levels.
Symptoms for PMS are varied and many, including both physical and emotional aspects that range from mild to severe. The physical symptoms include: bloating, headaches, food cravings, abdominal cramps, headaches, tension, and breast tenderness. Emotional aspects include mood swings, irritability, and depression.
The best way to diagnose PMS is to review a detailed diary of a woman's symptoms for several months. PMS is diagnosed by the presence of physical, psychological, and behavioral symptoms that are cyclic and occur in association with the premenstrual period of time. PMDD, which is far less common, was officially recognized as a disease in 1987. Its diagnosis depends on the presence of at least five symptoms related to mood that disappear within a few days of menstruation. These symptoms must interfere with normal functions and activities of the individual. The diagnosis of PMDD has caused controversy in fear that it may be used against women, labeling them as being impaired by their menstrual cycles.
There are many treatments for PMS and PMDD depending on the symptoms and their severity. For mild cases, treatment includes vitamins
, diuretics, and pain relievers. Vitamins E and B6
may decrease breast tenderness and help with fatigue
and mood swings in some women. Diuretics that remove excess fluid from the body seem to work for some women. For more severe cases and for PMDD, treatments available include antidepressant drugs
, hormone treatment, or (only in extreme cases) surgery to remove the ovaries. Hormone treatment usually involves oral contraceptives
. This treatment, as well as removal of the ovaries, is used to prevent ovulation and the changes in hormones that accompany ovulation. Recent studies, however, indicate that hormone treatment has little effect over placebo.
The most progress in the treatment of PMS and PMDD has been through the use of antidepressant drugs. The most effective of these include sertraline (Zoloft), fluoxetine (Prozac), and paroxetine (Paxil). They are termed selective serotonin reuptake inhibitors
(SSRIs) and act by indirectly increasing the brain serotonin levels, thus stabilizing emotions. Some doctors prescribe antidepressant treatment for PMS throughout the cycle, while others direct patients to take the drug only during the latter half of the cycle. Antidepressants should be avoided by women wanting to become pregnant. A recent clinical study found that women who took sertraline had a significant improvement in productivity, social activities, and relationships compared with a placebo group. Side effects of sertraline were found to include nausea, diarrhea, and decreased libido.
There are alternative treatments that can both affect serotonin and hormone responses, as well as affect some of the physical symptoms of PMS.
Vitamins and minerals
Some women find relief with the use of vitamin and mineral supplements. Magnesium can reduce the fluid retention that causes bloating, while calcium may decrease both irritability and bloating. Magnesium and calcium also help relax smooth muscles and this may reduce cramping. Vitamin E may reduce breast tenderness, nervous tension, fatigue, and insomnia
. Vitamin B6
may decrease fluid retention, fatigue, irritability, and mood swings. Vitamin B5
supports the adrenal glands and may help reduce fatigue.
Phytoestrogens and natural progesterone
The Mexican wild yam (Dioscorea villosa) contains a substance that may be converted to progester-one in the body. Because this substance is readily absorbed through the skin, it can be found as an ingredient in many skin creams. (Some products also have natural progesterone added to them.) Some herbalists believe that these products can have a progesterone-like effect on the body and decrease some of the symptoms of PMS.
The most important way to alter hormone levels may be by eating more phytoestrogens. These plant-derived compounds have an effect similar to estrogen in the body. One of the richest sources of phytoestrogens is soy products, such as tofu. Additionally, many supplements can be found that contain black cohosh (Cimicifugaracemosa
) or dong quai (Angelica sinensis
), which are herbs high in phytoestrogens. Red clover (Trifolium pratense
), alfalfa (Medicago sativa
), licorice (Glycyrrhiza glabra
), hops (Humulus lupulus
), and legumes are also high in phytoestrogens. Increasing the consumption of phytoestrogens is also associated with decreased risks of osteoporosis
, cancer, and heart disease.
Many antidepressants act by increasing serotonin levels. An alternative means of achieving this is to eat more carbohydrates. For instance, two cups of cereal or a cup of pasta have enough carbohydrates to effectively increase serotonin levels. An herb known as St. John's wort (Hypericum perforatum) has stood up to scientific trials as an effective antidepressant. As with the standard antidepressants, however, it must be taken continuously and does not show an effect until used for 46 weeks. There are also herbs, such as skull-cap (Scutellaria lateriflora) and kava (Piper methysticum), that can relieve the anxiety and irritability that often accompany depression. An advantage of these herbs is that they can be taken when symptoms occur rather than continually. Chaste tree (Vitex agnuscastus) in addition to helping rebalance estrogen and progesterone in the body, also may relieve the anxiety and depression associated with PMS.
The prognosis for women with both PMS and PMDD is good. Most women who are treated for these disorders do well.
Maintaining a good diet, one low in sugars and fats and high in phytoestrogens and complex carbohydrates, may prevent some of the symptoms of PMS. Women should try to exercise
three times a week, keep in generally good health, and maintain a positive self image. Because PMS is often associated with stress
, avoidance of stress or developing better means to deal with stress can be important.
Yonkers, Kimberly A., et al. "Symptomatic Improvement of Premenstrual Dysphoric Disorder with Sertraline Treatment: A Randomized Controlled Trial." Journal of the American Medical Association 278 (September 24, 1997): 983-989.
— A female hormone important in the menstrual cycle.
— A chemical messenger used to transmit an impulse from one nerve to the next.
— Compounds found in plants that can mimic the effects of estrogen in the body.
— A female hormone important in the menstrual cycle.
— A neurotransmitter important in regulating mood.
(PMS) the presence of symptoms in the period before menstruation or in the early days of the menstrual period; also called premenstrual tension. Definition and diagnosis depend on the timing and the cyclic nature of symptoms rather than on specific clinical manifestations, which can vary greatly from one patient to another but follow a consistent pattern in the individual from cycle to cycle.
Various psychological and emotional causes of this syndrome have been proposed; only recently has serious attention been paid to it as a physical as well as a psychological phenomenon. Research has shown that onset and increased severity of symptoms often occur when rapid hormonal changes are taking place, e.g., at puberty, after a pregnancy, or when oral contraceptives are discontinued. A transient increase in water retention seems to account for edema, weight gain, bloating, and breast changes. Other etiologic factors may be an estrogen-progesterone imbalance, hypoglycemia, vitamin deficiencies, prostaglandins, and psychogenic disturbances.
Symptoms. Symptoms may begin at the time of ovulation and increase until the menses, or they may appear at ovulation, abate, and then reappear and increase until menses. In some cases they arise only a few days before the onset of menstruation. In true PMS the symptoms cease with the onset of menses or last no more than a few days into the cycle.
Premenstrual syndrome can affect virtually every system of the body and produce behavioral changes that have significant psychosocial impact. Physical symptoms may include headache, vertigo, or paresthesias; common colds, rhinitis, asthma, sinusitis, or sore throat; abdominal bloating, nausea, or food cravings; breast tenderness and engorgement; backache, joint pain, and edema; and others. Psychological or emotional symptoms may include irritability, tiredness with sleep disturbance, mood swings, depression, and altered libido.
Treatment. Successful management of the syndrome is difficult and protocols vary greatly, probably because there is no clear understanding of the causes. Therapies include progesterone therapy, administration of vitamin B6 daily, and curtailment of intake of sodium, methylxanthines (coffee, tea, and chocolate), and nicotine. Additionally, the patient may be advised to restrict the intake of refined sugar, alcohol, and animal fats. Increasing the intake of vegetable oils may be recommended in order to enhance prostaglandin formation.
Patient Care. A major goal of intervention is the promotion of self-care strategies. For example, the patient is encouraged to keep a menstrual calendar to validate cyclic changes and to give her a sense of purposeful management of her life. She may then plan to avoid stressful events during the time symptoms are present. Counseling can help identify sources of stress and effective mechanisms to deal with stressful situations. Sufficient sleep and rest are needed because fatigue tends to exaggerate the symptoms. Moderate exercise can increase the patient's sense of well-being. A nutritious diet is also helpful, especially the inclusion of foods that are natural sources of the B vitamins and magnesium. The intake of sodium, caffeine, and refined sugar should be limited and alcohol and tobacco avoided.
Severe premenstrual symptoms can seriously disrupt vital human relationships, leading to domestic problems including child abuse and other acts of violence. Health care providers will need to be aware of the psychosocial ramifications of premenstrual syndrome and to facilitate positive coping behaviors, make referrals to agencies prepared to deal with these kinds of problems, and provide support and counseling when indicated.
pre·men·stru·al syn·drome (PMS),
in women of reproductive age, a constellation of emotional, behavioral, and physical symptoms that occur in the luteal (premenstrual) phase of the menstrual cycle and subside with the onset of menstruation; characterized by swelling and weight gain due to fluid retention, breast tenderness, irritability, mood swings, anxiety, depression, drowsiness, fatigue, difficulty concentrating, and changes in appetite and libido.
About 80% of menstruating women aged 25-40 experience some symptoms of PMS with at least some menstrual cycles, and 5-10% have severe emotional symptoms associated with impairment in domestic, occupational, or social functioning, identified as premenstrual (or late luteal phase) dysphoric disorder. A specific biologic cause has not been identified. Reported abnormalities in serotonin metabolism have led to the hypothesis that in women with PMS the normal hormonal fluctuations of the menstrual cycle interact with a neurotransmitter dysregulation to trigger mood and anxiety symptoms. Serotonergic antidepressants (for example, citalopram, fluoxetine, paroxetine, and sertraline) or alprazolam often suppress emotional symptoms when administered continuously or cyclically. Calcium supplementation, reducing caffeine and salt intake, regular exercise, and a diet high in complex carbohydrates may help to minimize physical symptoms. In severe cases, suppression of menses with danazol, leuprolide, or nafarelin may be justified.