Premenstrual syndrome (PMS)

What is premenstrual syndrome (PMS)?

Premenstrual syndrome (PMS) is a collection of symptoms that many women experience during the several days and sometimes longer before a menstrual period. These symptoms may be physical, psychological and emotional. They disappear soon after the start of menstrual bleeding.

Researchers are not certain what causes PMS. The most popular explanation is that PMS symptoms are related to cyclic changes in:

• female sex hormones
• pituitary hormones
• prostaglandins
• certain brain chemicals (neurotransmitters).

Lifestyle may play a significant role in PMS. PMS symptoms appear to be most troubling in women who:

• smoke
• lead stressful lives
• rarely exercise
• sleep too little
• have a diet high in:
  • caffeine
  • alcohol
  • salt
  • red meat
  • sugary foods.

However, it's not clear whether these factors increase your risk of PMS or if PMS accounts for these differences in lifestyle. For example, it is more likely that PMS causes stress rather than that stress causes PMS.

Medications may exaggerate the symptoms of PMS. Oral contraceptives cause symptoms of PMS in some women. However, in some women, symptoms improve or disappear while using birth control pills.

There is some controversy in the medical community about the difference between premenstrual discomfort and true PMS. Premenstrual discomfort is fairly common among women of childbearing age. It affects about three-quarters of all menstruating women.

However, fewer than one in ten women have symptoms that are severe enough to disrupt their personal relationships or interfere with their work and home responsibilities. Some doctors feel that only women who have such severe symptoms have true PMS.

Other doctors use a less stringent definition for PMS. Their definition includes mild to moderate symptoms.

Premenstrual dysphoric disorder (PMDD) is a severe form of PMS. Women with this disorder have 5 or more PMS symptoms, and they also experience mood swings, anger, irritability, tension and/or anxiety.

Symptoms of PMS

Symptoms of PMS fall into two general categories:

Physical symptoms

• bloating
• breast tenderness
• swelling of feet and ankles
• fluid retention and weight gain
• painful uterine cramps just before and during the first few days of menstruation
• headaches
• food cravings (especially for salty or sweet foods)
• acne breakout
• low energy or fatigue
• palpitations
• dizziness
• backaches or muscle pain.

Psychological and emotional symptoms

• fatigue
• mood swings
• irritability
• depression
• aggressiveness or hostility
• crying spells
• difficulty concentrating
• increased appetite
• forgetfulness
• changes in sexual desire.

The specific symptoms of PMS vary from woman to woman. But the top three complaints are irritability, fatigue, and bloating.

Diagnosing PMS

Your doctor will ask you about:

• your PMS symptoms
• the timing of these symptoms in relation to your menstrual period
• the regularity of symptoms (every month, every other month, etc.).

Your doctor also will ask about the general quality of your life. Questions may include:

• Are you feeling sad, tense, or anxious lately?
• Do you notice mood swings? Fatigue? Difficulty concentrating?
• Are you having difficulties with your spouse, family members, or coworkers?
• Are you so rushed that you sleep poorly and skip meals?
• Do you live a sedentary life with little exercise?
• Do you smoke cigarettes?
• Do you drink alcohol or caffeinated beverages?
• Is your diet high in red meat, salty foods, or sugar?

Next, your doctor will review your medical history. He or she will ask about any medications that you are taking.

Then, your doctor will examine you. He or she will do a pelvic exam with a Pap smear.

No single physical finding can confirm the diagnosis of PMS. But a thorough physical exam can check for other medical problems. These may include hypothyroidism or a tumor of the breast, brain or ovary.

Similarly, no single laboratory test can confirm that you have PMS. But blood tests can rule out medical disorders. These may include hypoglycemia, hypothyroidism or other hormonal problems that may be causing your symptoms.

If there are no physical findings and your laboratory test results are normal, then your doctor may ask you to keep a daily record of your PMS symptoms. You will do this for two or three months. This record will include:

• type of symptoms
• severity of symptoms
• timing of your menstrual periods
• a description of any special stresses that have affected your life.

Once this record is complete, your doctor will review the information. If your symptoms follow a pattern that is consistent with PMS, then this will help to establish the diagnosis.

Generally, premenstrual symptoms must be absent for about two weeks to qualify for the diagnosis of PMS. Symptoms will be absent from shortly after the start of menstruation until the next ovulation.

Expected duration of PMS

PMS can be a long-term condition. In some women, symptoms of PMS flare up before every menstrual period. This pattern continues until menopause. Menopause is the age-related end to menstrual cycles.

In other women, PMS symptoms seem to decrease after age 35.

Preventing PMS

Because doctors are not exactly sure what causes PMS, there is no way to prevent it. However, you may be able to alleviate some PMS symptoms by leading a healthier lifestyle.

Treating PMS

The treatment of PMS depends on:

• the severity and type of symptoms
• how bothersome they are.

For example, your symptoms may be mild. They may not interfere with your daily life or personal relationships. In this case, your doctor may suggest that you try one or more of the following lifestyle changes:

• Exercise regularly, aim for at least 30 minutes most days of the week.
• Do not skip meals. Follow a regular meal schedule to maintain a more stable blood sugar level.
• Eat a balanced diet that is low in refined sugars.
• Try to get a good night's sleep. Avoid staying up all night.
• If you smoke, quit.
• Cut down on caffeine, alcohol, red meat, and salty foods.
• Practice stress reduction techniques. Take a nice long bath. Or, try meditation or biofeedback.

If your symptoms are moderate to severe, your doctor probably will prescribe medications. These medications are aimed at relieving specific symptoms. For example, oral contraceptives, especially those that contain both estrogen and progestin, may minimize the severity of cramps and the length of your period.

Your doctor may suggest that you try an antidepressant medication. This is likely if you have symptoms that interfere with your work or home responsibilities or your personal relationships. These symptoms may include irritability, social withdrawal, angry outbursts or depression.

The most effective antidepressants for relieving PMS are selective serotonin reuptake inhibitors (SSRIs) or a serotonin-norepinephrine reuptake inhibitor (SNRI). Examples include:

• fluoxetine (Prozac, generic versions)
• sertraline (Zoloft, generic versions)
• citalopram (Celexa, generic versions)
• escitalopram (Lexapro, generic versions)
• paroxetine (Paxil, generic versions)
• venlafaxine (Effexor XR, generic versions).

Less commonly, your doctor may prescribe a medication that causes the ovaries to stop producing estrogen, so that ovulation stops. This is usually reserved for very severe symptoms, or when other medications fail. Gonadotropin-releasing hormone (GnRH) agonists, such as leuprolide (Lupron), create a temporary menopausal state. They do this by suppressing hormones that control the production of ovarian hormones and ovulation.

These medications are generally used for short periods of time. They commonly lead to hot flashes and other symptoms of menopause. If therapy needs to continue for more than six months, you will also have to take estrogen to prevent bone loss.

Whether your symptoms are mild or severe, it always helps to have your family's understanding and support while you are being treated for PMS. Your doctor will encourage you to speak frankly with family members about your symptoms and your PMS treatment.

When to call a professional

Call your doctor if your premenstrual symptoms:

• cause you significant distress or discomfort
• make it hard for you to function in daily life
• interfere with your personal relationships.

If you think you are in danger of causing harm to yourself or others, call your doctor for an emergency appointment.

Prognosis

In most women, PMS symptoms begin to subside after age 35. They end at menopause. Women who have PMS or PMDD are at greater risk of developing depression.

Additional info

National Institute of Mental Health
https://www.nimh.nih.gov/

American College of Obstetricians and Gynecologists
https://www.acog.org/

National Women's Health Information Center (NWHIC)
https://www.4woman.org/