What is PMS?
In historical and modern times, many negative connotations regarding menstruation have existed and these may have contributed to some women’s unpleasant expectations of the premenstrual phase. However, Premenstrual Syndrome (PMS) was first noted as a true medical disorder by the American Gynecologist Dr. T. Frank in 1931. The medical community refers to PMS as a condition that is characterized by a constellation of physical and emotional symptoms that have a significant impact on a woman’s day-to-day activities. This is in contrast to the common occurrence of premenstrual symptoms that many women experience. Up to 80% of women experience premenstrual symptoms but only two to five percent actually have PMS. The manifestations of PMS include a set of symptoms that occur during the luteal or premenstrual phase, seven to ten days prior to menstruation. These symptoms must resolve once a woman begins her period. Furthermore, for a woman to have PMS, she must be without symptoms in the follicular or of the menstrual cycle.
The criteria that physicians need to diagnose PMS are as follows: five (or more) of the below symptoms must occur during the luteal phase and be absent after menstruation. Also, at least one symptom must be from Group (A).
• Depressed mood, feelings of hopelessness
• Anxiety, tension
• Sudden and dramatic mood swings
• Anger, irritability
• Decreased interest in usual activities
• Difficulty in concentrating
• Fatigue, lack of energy
• Change of appetite, overeating, food cravings
• Sleep disturbances
• Sense of being overwhelmed
• Physical symptoms such as breast tenderness or swelling, headaches, joint or muscle aches, bloating, and weight gain
In addition, for a positive diagnosis of PMS, it is crucial that these disturbances interfere markedly with work, school, or personal relationships. The cyclic nature of these symptoms cannot be relied upon from memory. A woman must chart them on a daily basis for at least two to three months. Finally, these symptoms cannot be a worsening of a psychiatric disorder such as major depression or anxiety disorder. Only 50 percent of women who visit their physician believing that they have PMS actually meet the above criteria and have the diagnosis of PMS confirmed.
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What are the symptoms of PMS?
Different clusters of symptoms appear in different women but in an individual woman, the symptoms tend to be similar from cycle to cycle. The severity, however, may fluctuate from cycle to cycle. Symptoms usually occur seven to ten days before menstruation and may intensify as menstruation approaches. Symptoms can be mild, moderate, or severe, and may include the following:
Symptoms of women suffering from PMS (those with a star are the most common)
• Mood swings
• Difficulty concentrating
• Changes in libido
• Low self-image
• Social withdrawal
• Crying spells
• Decreased interest in usual activities
• Abdominal bloating
• Breast swelling and tenderness
• Swollen ankles or fingers from fluid retention
• Increased appetite
• Weight gain
• Food cravings
• Upset stomach
• Joint aches
• Muscle spasms
• Increased thirst
• Changes in sleep habits
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If a woman suspects she has PMS, it is imperative to relate the occurrence of the symptoms to the menstrual cycle. However, it is equally important for a woman to evaluate the stresses in her professional and personal life, since these may have a significant impact on how premenstrual symptoms are expressed.
Some women experience very severe PMS. Symptoms of serious psychiatric problems, such as depression or panic attacks, are often most extreme during the premenstrual phase each month and studies have shown that women’s suicide attempts, psychiatric hospital admissions, and violent criminal acts are most likely to occur in the premenstrual days. If a woman feels that she may hurt herself or someone else, she should seek immediate medical attention. Fortunately, this is extremely rare.
There are no specific physical findings or laboratory tests that can diagnose PMS. There is also no symptom that is unique to PMS. The only way to determine whether or not a woman suffers from PMS is for that woman to record the timing and severity of her symptoms — both emotional and physical — throughout the menstrual cycle on a daily basis for two to three months. We have provided an interactive calendar on this site which can be used to chart your cycle. In addition to the symptoms, monitoring basal body temperature and vaginal secretion will contribute useful information to confirm when ovulation occurs. In order to accurately diagnose PMS, your physician will rely upon this charting. It is also useful to gauge your response to therapy.
When working with a doctor to confirm PMS, other disorders must be eliminated, since many symptoms of PMS resemble those of other underlying conditions. Your doctor may want to do a physical examination and a pelvic exam to rule out gynecologic problems. In cases where fatigue is a major symptom, a blood test may be done to rule out anemia, hypothyroidism, and contributors to chronic fatigue syndrome. It is also important to be aware that more serious psychiatric problems may have a cyclic pattern of worsening emotional symptoms in the premenstrual phase. For example, depression is very common in women and often worsens during premenstrual days.
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Possible causes of PMS
PMS has been called everything from a hormonal dysfunction to a mental illness to the feminist issue of the 80s. Although it is known that PMS is associated with ovulation, the true cause remains unknown. It is clear that two components are essential for PMS to occur. The first is the “trigger”, which is clearly identified as ovulation and the resulting, reproductive hormonal changes. The second is the “vulnerability” to the “trigger” that produces the mood changes of PMS. What makes one women “vulnerable” and another not, is unknown. This is the key to identifying the cause of PMS. Many factors have been suggested, but refuted, as contributors to the “vulnerability”, such as a woman’s social and economic status, number of children, diet, amount of exercise, stress level, personality, and characteristics of the menstrual cycle. However, current data supports serotonin, a chemical in the brain, as having an important role in PMS. While no other cause has been nearly as conclusive as serotonin, other possible factors have been investigated and are interesting to consider. Some theories that have been suggested include:
Serotonin is a neurotransmitter. A neurotransmitter is a chemical that is involved in sending messages along nerves in the brain, spinal cord, and throughout the body. Serotonin affects mood. Impaired serotonin activity has been linked to symptoms of depression, anxiety, impulsivity, aggression and increased appetite. Since depression is also a major symptom of PMS, scientists have questioned the role of serotonin in PMS. Abnormal serotonin levels and activities have been found in women suffering from PMS. Furthermore, drugs that enhance serotonin activity, called specific serotonin reuptake inhibitors (SSRI) (e.g., Prozac, Zoloft, Paxil), are effective in the treatment of PMS.
Cyclic fluctuations in reproductive hormones
While it seemed logical to many that the reproductive hormones involved in the menstrual cycle were the cause of PMS, research has proven that there are no differences in estrogen, progesterone, FSH, LH, prolactin, and testosterone levels between women with and without PMS. This only confirms that ovulation acts as the “trigger” but is not in itself the cause. In the past, progesterone supplementation was supported as a treatment for PMS, but has been proven to be ineffective. As discussed in treatments, the only hormonal therapy that works is a regimen that prevents ovulation from occurring.
Abnormal thyroid function
Thyroid disease is common in women. Symptoms of hypothyroidism, or low activity of the thyroid gland, can resemble symptoms of PMS. For this reason, it was thought that the thyroid gland played a role in the cause of PMS. Any woman who suffers from PMS-like symptoms should get her thyroid checked. However, it is clear that the majority of women with PMS have completely normal thyroid function. Thus, supplementation with thyroid hormone in the treatment of PMS is not helpful and may, in fact, be dangerous.
Endorphins are opium-like chemicals manufactured by the body. Opium-like chemicals, including endorphins, are involved in the sensation of euphoria and the perception of pain. Thus, some have proposed that PMS is a state of endorphin deficiency. Endorphin levels in the blood do fluctuate. However, these levels are not felt to reflect the activity of endorphins in the brain. Therefore, there is not enough evidence to support this theory.
Vitamins and minerals
Scientific research has not been able to confirm a difference in the levels of vitamins and minerals between those women with symptoms of PMS and those without. One particular vitamin that has received a great deal of attention is Vitamin B6. Vitamin B6 plays an important role in the synthesis of dopamine, a neurotransmitter that may also be involved in physical and emotional well-being. Thus, Vitamin B6 deficiency has been hypothesized as a cause of PMS. Some researchers have shown improvements in PMS symptoms in women taking vitamin B6 daily, while others have not. However, it is important to limit the amount of vitamin B6 that you take, since neural toxicity has been reported. Therefore, Vitamin B6 supplements should only be taken under the supervision of a doctor.
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Possible PMS treatments
It is both important and interesting to understand the processes by which the scientific community researches diseases and their possible treatments. While many remedies have been introduced and advocated for the treatment of PMS, few have been proven truly beneficial. For the medical community to be convinced of a therapy’s effectiveness, a “double blind placebo controlled study” is conducted. This is a highly regarded method of proving the viability of a particular treatment. In this type of study, one group of subjects receives the medication in question, while another group receives a placebo (an inactive pill). The use of a placebo ensures that the study is “controlled”. “Double blind” means that both the treating physician and the patient are unaware of which therapy they are receiving, thus eliminating any possibility of error. Serotonin agents and agents that block ovulation are the only therapies that have been found to be more effective than placebo. It is interesting that a number of patients do respond to placebo in a positive way. This does not mean that the symptoms are not real. It simply represents the lack of understanding as to how or why the placebo works. Perhaps, the belief that a medication will cure a patient, causes a production of chemicals in the brain that improve symptoms. It may also be that a patient is simply have a positive response to a sympathetic caregiver.
If PMS symptoms are severe and having a substantial impact on your life, it is best to see a doctor. We have provided some information in this section as to treatments that a physician may recommend for very severe PMS symptoms. However, for many women who feel basically healthy, some simple tips may provide considerable relief. While poor diet and a lack of exercise have not been found to be a cause of PMS, keeping physically and emotionally well, through adequate sleep, good nutrition and regular exercise may help relieve some symptoms of PMS. The following tips may help:
A daily diet based on general nutrition guidelines can help in overall well-being as well as PMS control. Eating sweets causes a sudden rise in blood sugar that triggers an insulin response, which results in a subsequent rapid fall in blood sugar levels. Low blood sugar (hypoglycemia) can cause PMS-like symptoms such as irritability and fatigue. To avoid hypoglycemia, eat healthy meals at regular intervals throughout the day and avoid excess sugar. Complex carbohydrates and proteins in healthy foods are digested and absorbed more slowly than refined sugar, insuring a steady, gradual supply of nutrients to the bloodstream. Nutritionists typically advise a diet that consists of 50% carbohydrates, 20% protein and 30% fat. In women with PMS, an attempt to change the diet to a ratio of 60/20/20 is advisable, but can be difficult to accomplish. Avoiding sodium may help control premenstrual fluid retention. Most Americans consume 4,000 to 6,000 mg of salt a day, and if the diet is composed of large amounts of processed foods, salt intake can approach 10,000 mg a day. If fluid retention is a troublesome symptom, restricting salt to 2,000 to 4,000 mg a day is advisable. Use the following basic principles of low-salt nutrition to gradually reduce your salt intake:
• Eliminate table salt (season with herbs, lemon juice or vinegar)
• Don’t add salt in cooking
• Eat fresh rather than processed food
• Read food product labels for sodium amounts
• Change your ordering patterns in restaurants
Exercise not only improves general health but it is believed to stimulate the production of endorphins. Aerobic exercise that increases your heart rate by 50% for 30 minutes, should be done three to five times a week. Benefits include cardiovascular fitness, muscle tone, weight control or reduction, decrease in fluid retention, and increase in self-esteem.
Reducing alcohol and caffeine intake
Alcohol and caffeine may aggravate PMS by affecting a person’s moods. Therefore, by minimizing the amount of alcohol and caffeine that you consume during the premenstrual phase, you may feel better. A rapid withdrawal from caffeine may cause symptoms of lethargy and headache. It is therefore, suggested that you decrease your caffeine intake slowly over time. Also, remember that coffee is not the only source of caffeine. It can also be found in tea, soft drinks, chocolate and some over-the-counter medications.
Most people require about seven hours of sleep each night, but you should get as much rest as feels right for you. Some women find they need extra sleep during the premenstrual week.
Stress may aggravate PMS. It is often impossible to avoid the day-to-day and the unexpected stressors of life. However, relaxation techniques such as meditation, yoga, and exercise can lower your stress level. Learn what is stressful for you, then try to eliminate it as much as possible, especially on premenstrual days. Also, consider making the time to do something enjoyable. This may make you feel better and happier.
Coping with Emotions
One of the most troublesome aspects of PMS is the intensity of the emotional responses during premenstrual days and the inability to control them. No one wants to be depressed and for many people, anger is an uncomfortable emotion even when it is justified. Identifying sources of anger and conflict in your life can help you to find the strength to make changes. When premenstrual symptoms are more emotional than physical, and self-care tips are not effective, a psychotherapist may help. Depending on where you live, there may also be a PMS support group available. Reassurance that others suffer from similar problems can often help.
Vitamin B6 (pyridoxine), 25 - 50 mg twice a day. Vitamin B6 helps the body synthesize catecholamines, a type of neurotransmitter. Therefore, Vitamin B6 may help with central nervous system-related problems such as depression, anxiety, difficulty concentrating, or other emotional problems. Some doctors feel that vitamin B6 helps certain women. However, it is important to avoid excessive doses, which may be toxic. Serious nerve problems have been reported at high doses, and vitamin B6 should be used only under a physician’s supervision.
Vitamin E (alpha-tocopherol), 400 IU twice a day can be helpful with premenstrual breast tenderness. The method by which vitamin E helps alleviate breast complaints is not understood.
Help from Your Doctor
When your own PMS management efforts aren’t working, it may be time to seek help from your doctor. If your doctor is not an expert in the latest developments and research in PMS, he or she may refer you to someone else. This is perfectly acceptable. Furthermore, you may want to consider visiting a psychiatrist. This is not to suggest that PMS is “all in your head”. Rather, many PMS symptoms overlap with those conditions treated by a psychiatrist. Also, many of the medications that are now recommended for PMS sufferers are often prescribed by a psychiatrist. A collaboration between yourself, your physician, and a psychiatrist can be of tremendous value to you. When visiting your doctor, bring along your cycle charts and food logs. Tell the doctor about any medications, over-the-counter drugs, vitamin/mineral supplements, or herbal remedies that you take.
When PMS symptoms are particularly severe, a doctor may recommend one or a combination of the following:
Currently, serotonin agents are the treatment of choice for PMS. Serotonin, as described earlier, has a great deal to do with moods. Specific serotonin reuptake inhibitors (SSRI) (e.g., Prozac, Zoloft, Paxil) have been confirmed in double blind placebo controlled trials as being the most effective treatment of PMS. These drugs may relieve such symptoms as anxiety, impulsivity, aggression, and increased appetite. Serotonin agents, however, are not generally helpful in alleviating the physical premenstrual symptoms.
Prescription diuretics for fluid retention
If limiting salt intake is not effective, diuretics may be helpful in women experiencing significant cyclic fluid retention which can be manifested as weight gain or leg and ankle swelling. Diuretics increase the kidney’s ability to excrete sodium and water in urine, so the amount of fluid surrounding body tissue cells is diminished. Prescription diuretics are powerful drugs that can cause some serious side effects, so they should always be taken under a doctor’s supervision.
Some doctors will try hormone therapy when other treatments have not worked. Progesterone supplementation during the luteal phase is not consistently effective. However, hormone therapy designed to suppress ovulation has some promise. Birth control pills block ovulation, so theoretically, PMS should not exist. However, birth control pills improve PMS symptoms for some women, but others find their symptoms are unchanged or even more severe.
Another form of hormone treatment uses gonadotrophic releasing hormone (GnRH) agonists. GnRH therapy has been used to successfully treat PMS symptoms in very severe cases that have not been helped by other treatments. These agents prevent ovulation by suppressing ovarian function. Thus, estrogen and progesterone levels remain low. Since low estrogen levels are associated with accelerated bone loss and increased cardiovascular disease, long-term therapy with GnRH agonists is not advised. For this reason, this therapy can be combined with supplemental estrogen to minimize these risks. Since GnRH agonists have serious risks, are expensive therapy, and are usually administered by injections or implants, the combination of GnRH and estrogen is reserved for patients with severe symptoms who are not responsive to other forms of therapy.
Tranquilizers, as well as antidepressants that are not specific serotonin reuptake inhibitors (SSRIs), may also relieve some PMS symptoms. The use of tranquilizers should be carefully weighed to ensure that the benefits outweigh the risks since drug dependence (addiction) is a possible risk.
For very bothersome breast swelling or pain, a doctor may suggest bromocriptine. Bromocriptine may relieve premenstrual breast tenderness by decreasing the release of hormones from the pituitary gland. Prolactin is one of many hormones that stimulate breast tissue. Bromocriptine does not relieve other symptoms of PMS. Serious side effects of the drug are rare, but bothersome side effects are common, such as nausea and lightheadedness.
As a last resort, when no other therapies have worked and the PMS symptoms are very severe, a doctor and patient may consider surgery. Oophorectomy, or removal of the ovaries, eliminates PMS. This is radical therapy and should be considered only when nothing else has relieved the symptoms and PMS has had devastating affects on a woman’s personal and professional life. In addition, it is only an option when a woman has completed her child-bearing.
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New Studies Lead to a Better Understanding of PMS
By Dr. Philip Sarrel, M.D.
Even though PMS, or premenstrual syndrome, affects just about all women at some point in their lives, doctors have up until now understood very little about it. But new studies now point to a biological factor — hormones — as the principle cause for PMS.
The ovarian hormones estrogen and progesterone are produced during each menstrual cycle. These hormones circulate in the blood stream, enter cells throughout the body, and have effects on how these cells are able to carry out their daily functions. The brain is made up of millions of cells that are sensitive to the effects of ovarian hormones and the fluctuations in these hormones which occur during the menstrual cycle. For most women, ovarian hormones serve to support basic brain functions including sleep and temperature control, sexual feelings, ability to reason, and moods. For many women, however, brain cell reaction to ovarian hormones can be negative; millions of women experience the monthly occurrence of PMS (premenstrual syndrome) with irritability, anxiety, and sadness during the week to ten days preceding menstruation.
PMS has been the subject of many scientific studies that have helped us to understand how ovarian hormones influence the workings of the brain. Ovarian hormones affect blood flow to the brain; they help sustain and promote the growth of brain cells, and they help control the production and release of brain chemicals (neurotransmitters), which are responsible for many different actions in the brain.
A recent study carried out at the National Institute of Mental Health found that PMS symptoms represent an abnormal response to normal hormone production levels. Women with severe symptoms were compared to women who did not have the syndrome. When the women with severe symptoms were treated with a drug which inhibited their ovaries from producing hormones, the symptoms decreased significantly. These women were also given a placebo, that is, a preparation which had no effects on their ovaries and which did not contain any hormones. When they received the placebo, the symptoms were unaffected. The women with PMS whose symptoms decreased when their ovaries were inhibited were then given the hormone-blocking drug, but this time they had either estrogen or progesterone added. When either of these natural hormones was taken, the women had significant recurrence of their PMS symptoms. The women who did not suffer from PMS showed none of the reactions to the treatments that were seen in the PMS-affected women.
This study seems to clearly identify PMS as a disorder of abnormal sensitivity to normal levels of ovarian hormones. Symptoms such as sadness, anxiety, and irritability, which occur in cycles relating to the time of menstruation, should be regarded as a biological, and not a psychiatric disorder. Although the ovarian-blocking drug cannot be given indefinitely, it could be used for women with the most severe symptoms for at least a short time. Over a longer period, women would suffer from the effects of inadequate levels of ovarian hormones, such as from bone loss and osteoporosis. However, the hormone-blocking drug helps define PMS as a condition caused by hypersensitivity to ovarian hormones.
Hopefully, this new understanding of PMS may lead to new and better treatments.
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