Premenstrual Syndrome (PMS)

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

• PMS stands for premenstrual syndrome.
• Premenstrual syndrome is a set of specific physical and psychological features.
• Physical symptoms of PMS include breast tenderness and bloating.
• Psychological symptoms such as mood swings are common in PMS and may include anger and depression.
• PMS occurs in the last half of a woman's menstrual cycle.
• The exact cause of PMS is unknown but is believed to be related to interactions between sex hormones and brain chemicals (neurotransmitters).
• PMS must be distinguished from other disorders that produce similar symptoms. PMS symptoms also must, in some cases, be distinguished from early pregnancy symptoms.
• The only way to distinguish PMS symptoms from those of early pregnancy in the absence of a menstrual period is a pregnancy test.
• A helpful diagnostic tool for PMS is a menstrual diary.
• Natural treatment options and home remedies for PMS include exercise, a healthy lifestyle, and emotional support from family and friends.
• Possible medical treatments to treat cramping and other symptoms of PMS include medications such as diuretics, pain killers, oral contraceptives, drugs that suppress ovarian function, and antidepressants.
• The mood changes surrounding this condition have been described as early as the time of the ancient Greeks. However, it was not until 1931 that this disorder was officially recognized by the medical community. The term "premenstrual syndrome" was coined in 1953.

Premenstrual syndrome (PMS) is a combination of emotional, physical, and psychological disturbances that occur after a woman's ovulation, typically ending with the onset of her 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. The true incidence of PMS has often been overestimated by including all women who experience any physical or emotional symptoms prior to menstruation. It is estimated that 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. About 3% to 8% of women are believed to have the condition.

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.

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 or psychological symptoms of PMS include:

1. Anger 
2. Irritability
3. Anxiety
4. Tension
5. Difficulty concentrating 
6. Depression
7. Crying
8. Social withdrawal
9. Changes in libido (sex drive)
10. Oversensitivity 
11. Exaggerated mood swings
12. The most frequent physical signs and symptoms of PMS include:
13. Fatigue
14. Headache 
15. Bloating (due to fluid retention)
16. Weight gain
17. Musculoskeletal pain
18. Breast tenderness
19. Constipation
20. Diarrhea
21. Acne flare-ups
22. Sleep disturbances with sleeping too much or too little (insomnia)
23. Appetite changes with overeating or food cravings

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).

PMS remains an enigma because of the wide-ranging symptoms and the difficulty in making a firm diagnosis. Several theories have been advanced to explain the cause of PMS. None of these theories have been proven, and specific treatment for PMS still largely lacks a solid scientific basis. Most evidence suggests that PMS results from the alterations in or interactions between the levels of sex hormones and brain chemicals known as neurotransmitters.

PMS does not appear to be specifically associated with any personality factors or specific personality types. Likewise, a number of studies have shown that psychological stress is not related to the severity of PMS.

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 that symptom-free interval after the menstrual flow and prior to 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 health-care 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 prior to 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 benefit.

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 Premesyn 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.
• Pain killers (analgesics): 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 has 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 the mood disturbances related to PMS. Antidepressants appear to work by increasing brain chemical (opioids, serotonin, and others) levels that are affected by the ovarian hormones. These neurotransmitters are important in the control of mood and emotions. The serotonin reuptake inhibitor group of antidepressants seem to be the most effective for symptoms of PMS. Fluoxetine (Prozac) and paroxetine (Paxil) are examples of antidepressant medications from this group that have been found to be 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

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 has 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 the mood disturbances related to PMS. Antidepressants appear to work by increasing brain chemical (opioids, serotonin, and others) levels that are affected by the ovarian hormones. These neurotransmitters are important in the control of mood and emotions. The serotonin reuptake inhibitor group of antidepressants seem to be the most effective for symptoms of PMS. Fluoxetine (Prozac) and paroxetine (Paxil) are examples of antidepressant medications from this group that have been found to be 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 interest 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 first 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.