Millions of women—as many as 80%—develop some degree of premenstrual syndrome (PMS). PMS describes the clusters of seemingly unrelated physical and emotional symptoms that occur in a predictable pattern as women near menstruation each month. Not every woman experiences PMS the same way, of course; it has varying degrees of severity, from mild to incapacitating.
The mildest PMS changes are known as premenstrual moliminal, referring to those symptoms most women experience at or near menstruation, such as bloating and breast tenderness. These women usually don't seek or need treatment. About 20% to 40% of women have additional symptoms and experience moderate PMS. For another 2% to 5%, the symptoms of PMS significantly affect their lives, possibly jeopardizing relationships with friends and family. These women may have premenstrual dysphoric disorder (PMDD).
Well over 150 symptoms of PMS/PMDD have been identified, falling into two categories:
- physical. These symptoms include weight gain or perception of weight gain, fluid retention and bloating, food cravings, appetite changes, and various pains.
- behavioral/psychological. These symptoms include forgetfulness, inability to concentrate, mood swings, and mild to severe depression.
Although the physical symptoms are troubling and disruptive, women are more likely to seek help for the behavioral/psychological changes they experience.
What causes PMS and PMDD?
Although we know a lot about PMS/PMDD, the cause remains elusive. For every study that might identify a cause, another refutes the findings, sending us back to square one.
The latest and most plausible theory proposes a relationship and interaction between neurotransmitters and ovarian hormones. Research supports this theory: Studies have demonstrated positive outcomes when women with PMS or PMDD were treated with a serotonin reuptake inhibiting drug.
How are PMS and PMDD diagnosed?
Diagnosing PMS/PMDD is relatively simple, requiring few costly lab tests. Many of the symptoms are common to all women, but others may vary—which means the diagnostic assessment must be individualized. A history, complete physical examination, and pelvic examination are essential. The history should include a review of medications the woman is currently taking and questions to rule out substance abuse.
Lab assessment—complete blood cell count, blood chemistry, and thyroid profile—and psychological testing may be ordered to rule out other medical and psychological conditions. Hormone profiles are of little value.
The most important tool in making an accurate diagnosis is a symptom diary. At the end of each day for 2 or 3 months, the woman checks off or writes in every symptom she experienced that day, ideally rating the symptoms on a scale of 0 to 4 (with 0 being not present and 4 being severe and unable to function). This will tell you what symptoms the woman has, when they occur in relation to menstruation, and how severe they are. Once treatment begins, the woman should continue keeping her diary so that she and her health care provider can see the progress they've made.
The key to using a symptom diary is to track when symptoms occur during the phases of the menstrual cycle. In true PMS/PMDD, symptoms occur during the luteal phase but not in the follicular phase. Symptoms that occur all month but worsen during the luteal phase usually indicate another physical or emotional problem with superimposed PMS/PMDD. In this case, treatment focuses on both problems for the best results. Symptoms that occur in an erratic pattern with no premenstrual differentiation might suggest that the woman has some medical or psychological problem, but not PMS/PMDD. In that case, an appropriate referral should be made.
How are PMS and PMDD different?
Sometimes, the terms PMS and PMDD are used interchangeably. Although they're similar, they're also different. A careful history will help to differentiate between the two.
Women with PMS and women with PMDD share many of the same symptoms. What differentiates PMDD is a list of 11 groups of symptoms that, according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), are used to make the diagnosis. The list includes:
- feelings of hopelessness and sadness
- persistent irritability
- feeling anxious or tense
- mood swings
- losing interest in daily activities and withdrawing from social situations
- fatigue and lethargy
- feeling overwhelmed
- sleeping too much or not sleeping at all (insomnia)
- inability to concentrate
- food cravings and changes in appetite
- bloating, breast tenderness, headache, or other cyclic physical changes.
According to the DSM-IV, a woman has PMDD if her symptom diary reports five of these symptoms during the luteal phase of her menstrual cycle in 2 months of keeping the diary, with symptoms disappearing between menstruation and ovulation. The woman's symptoms must also be at least 30% more severe in the luteal phase.
A woman with PMS may also have one or all of these symptoms occurring in the same pattern (luteal phase symptoms only). What differentiates the two disorders is the degree of severity: PMDD is severe enough to interrupt daily activities; PMS isn't. Severity is subjective, of course, and some women with mild to moderate PMS may feel that their lives are disrupted just as much as women with PMDD. This shouldn't be discounted when caring for women with PMS.
How are PMS and PMDD treated?
Lifestyle changes—including dietary changes, exercise, vitamin B and calcium supplements, and stress reduction—are the cornerstone of treatment for PMS.
Although research hasn't shown overwhelming value in changing the diet, it does help in some cases. What's more, some of the changes recommended here can help women lose weight, which can decrease their risk of developing heart disease and diabetes, improve self-esteem, and reduce stress.
Limiting sodium intake may improve bloating, breast tenderness, and premenstrual weight gain. Advise women not to use salt when cooking, not to add salt to foods, and to avoid salty snacks and processed foods.
Alcohol and caffeine may be associated with irritation and can contribute to insomnia. They may also worsen symptoms in the premenstrual period, so reducing or avoiding them could help.
Some data indicate that hypoglycemia may contribute to symptoms of fatigue, headaches, food cravings, and mood swings. To counter this, suggest that women eat small, frequent meals that are rich in protein and complex carbohydrates and free from simple carbohydrates. This will even out blood glucose levels, preventing the sharp rise and fall that could contribute to mood swings, inappropriate crying, and food cravings.
Women benefit from exercise regardless of whether they have PMS or PMDD. Exercise reduces fatigue, promotes a sense of well-being, and can reduce stress. In several studies, aerobic exercise helped lower the intensity and number of premenstrual symptoms. Some evidence indicates that exercise can also reduce fluid retention, negative affect, and bloating and can improve problems with concentration, pain, fear, and guilt.
The intensity of exercise isn't as important as the frequency. Gradually increasing the length of time and regularity seems to improve symptoms in all areas.
Some symptoms of PMS/PMDD are thought to be caused by various vitamin or mineral deficiencies, although this theory hasn't been proved convincingly.
A few supplements have some research behind them. Vitamin B6(pyridoxine), for example, is thought to increase cerebral synthesis of several neurotransmitters, including serotonin and dopamine. Studies have used doses of 50 to 500 mg with varying results. Women who decide to take vitamin B6should limit their daily dose to 100 mg; higher doses have been associated with toxicity.
Although the mechanism of action isn't understood, calcium is thought to regulate certain mood disorders associated with PMS. In some studies, calcium helped reduce fluid retention, mood swings, food cravings, and pain. Daily calcium should be 1,000 mg. Some women with PMS may benefit from an additional 100 mg of calcium per day.
Essential fatty acids may raise the body's level of prostaglandin, but study results have been mixed. Some studies have shown good results but had no placebo control group; others with a placebo control group showed no statistical significance. Other double-blind, crossover, placebo-controlled studies demonstrated significant positive results when using evening primrose oil (3 to 4 grams/day). Evening primrose oil contains gamma linoleic acid, which raises prostaglandin levels. Other sources of gamma linoleic acid are grape seed, black currant, and borage oils.
Magnesium's role in treating PMS/PMDD is unclear. What we do know is that magnesium has a hand in metabolizing essential fatty acids and in the activity of vitamin B6. Again, study results have been mixed, with some positive changes seen in fluid retention, mood swings, and some overall scores; anxiety symptoms improved when magnesium was combined with vitamin B6. The recommended daily dose of magnesium is 400 mg.
What about vitamin E? In studies, it has helped improve anxiety, nervous tension, fatigue, depression, headaches, insomnia, and breast tenderness. (Vitamin E, in fact, has been shown to relieve breast tenderness in all phases of the menstrual cycle.) Varying doses of vitamin E were used in published studies, ranging from 150 to 600 international units.
Pharmacologic management options
Nonsteroidal anti-inflammatory drugs (NSAIDs) successfully relieve dysmenorrhea and other PMS symptoms. All NSAIDs seem to work equally, so the clinician can choose the one he or she believes will work best for a particular woman.
Oral contraceptives may be used, but they may worsen symptoms. The aldosterone agonist spironolactone (Aldactone), 25 to 50 mg/day, can relieve bloating and fluid retention. However, salt restriction should be the first recommendation, with diuretics used only if no relief is seen.
The first option for treatment of PMDD is a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine (Sarafem) and sertraline (Zoloft). Recently, Paxil CR was approved for PMDD.
Refer women with psychological issues to the appropriate mental health professional.
Here are a few more considerations for reducing symptoms of PMS and PMDD:
- Counseling, education, and time spent with the patient are probably the most important components of management. The placebo effect is thought to be as high as 40%; most women will improve at least somewhat with these simple interventions.
- Exposure to full-spectrum bright light therapy in the evening has been shown to be markedly reduced PMS/PMDD symptoms.
- Stress relief is a necessary component to any lifestyle change program. Massage, biofeedback, and other relaxation methods may offer considerable relief.
- Herbal remedies and alternative therapies may not have undergone the scrutiny of evidenced-based studies. Women, particularly women with PMDD, should discuss these options with their health care provider before using them.