Premenstrual Syndrome

Premenstrual Syndrome (PMS) is a medical condition characterised by a variety of physical and emotional symptoms felt by women before the onset of menstruation. The symptoms of PMS are cyclic in nature, generally beginning at or after ovulation (release of an egg by the ovaries), and continue until menstruation begins. Typically PMS begins from about 7 to 14 days before menstruation and ending within 24 hours after menstruation has begun.

Research suggests that as many as 75 percent of women of child-bearing age have some degree of PMS. It seriously affects the lives of about 10% of women, often requiring time off from work or school. PMS is most common in women in their 20s and 30s, gradually decreasing and ceasing entirely at menopause.

Causes of Premenstrual Syndrome

Premenstrual syndrome is not due to a single factor. Genetic, environmental, and psychological are important factors in mood disorders as well as hormonal influence. Women have no PMS before puberty, during pregnancy or after menopause – these are times where ovarian hormone cycling has not begun or has ceased.

The principal causes of PMS are not yet established. However, it is most widely accepted that the cyclical endogenous progesterone produced in the luteal phase of the menstrual cycle is responsible for symptoms in women who are unusually sensitive to normal progesterone levels. Indeed, no differences have been demonstrated in progesterone levels between women with and without PMS. Among other effects these hormonal changes may cause the body to retain more sodium and fluid, leading to swelling or bloating.

PMS may also result from nutritional deficiencies (particularly in regard to the vitamins – notably B vitamins – that affect nerve transmission in the brain), and stress (which has been shown to be a factor in the severity of symptoms). There also suggestions that low levels of certain neurotransmitters that affect a woman’s sense of well-being and relaxation, and also stimulate the central nervous system may contribute to the emotional symptoms.

Symptoms

The types of symptoms and the degree of their severity vary markedly. A wide range of symptoms has been described but it is their timing and severity, namely that they significantly disrupt normal functioning, that are most important than the specific character in distinguishing those women with PMS from those with no more than physiological premenstrual symptoms.

The most common physical symptom of PMS is fatigue. Another common symptom is oedema (fluid retention, with bloating or swelling in the abdomen, breasts, fingers and ankles and accompanying weight gain). Other physical symptoms may include headache, cramps, backache, joint and muscle pains, skin lesions (especially acne), constipation or diarrhoea, and a number of related disorders. Typical emotional and psychological symptoms of premenstrual syndrome range from irritability, anxiety, tension, lethargy, and rapid mood swings to hostility, confusion, aggression, and depression.

Premenstrual Dysphoric Disorder (PMDD)

As with all biological parameters, for some women there are extreme premenstrual syndrome symptoms while others have minimal or no symptoms (5 – 10%). A similar number have such extreme symptoms that there is a major impact on their life, that of their family, their interpersonal relationships and normal day to day functioning. This is extreme premenstrual syndrome and is medically termed premenstrual dysphoric disorder (PMDD).

Premenstrual dysphoric disorder (PMDD) affects approximately 3 to 9% of women, involving extreme and predominantly psychological mood changes. Women designated as having PMDD also fulfil criteria for PMS but not necessarily vice versa. While premenstrual dysphoric disorder is closely

related to major depressive disorder, the symptoms of severe depression are cyclical in nature, fluctuating with cycles of ovulation and menstruation. A distinguishing factor in the diagnosis of premenstrual dysphoric disorder is that depression eventually becomes so severe that home, work, and daily life are disrupted.

Diagnosis

There are no objective tests (physical, biochemical or endocrine) to assist in making a diagnosis. Therefore PMS is diagnosed by recording symptoms for several menstrual cycles in a symptoms chart. This is partly because the retrospective reporting of symptoms is inaccurate and because significant numbers of women who report PMS have other underlying problems such as perimenopause, thyroid disorder, migraine, chronic fatigue syndrome, as well as psychiatric disorders such depression, panic disorders and anxiety disorder.

Symptoms that occur in a predictable pattern (starting before menstruation, and then disappearing when it begins) are usual indicators of premenstrual syndrome. A doctor may perform a physical exam, if necessary, to rule out the possibility that symptoms indicate the presence of disease.

Treatment

Treatment of PMS involves finding the remedy or combination of remedies that work for each individual.

Non-Medical Therapies

The majority of women with PMS can be treated simply by general practitioners or by self-help. A lot of unsubstantiated claims have been made for the supplementation of calcium, vitamin E, magnesium, dietary change, vitamin B6, evening primrose oil, exercise, yoga, acupuncture, psychotherapy and many more. There is very little evidence that any of these treatments for PMS are effective with the exception of exercise and cognitive behavioural therapy.

Despite the fact that non-medical treatments are of doubted efficacy, they are generally harmless. They can be tried before resorting to medical therapy as there is no risk, except in severe cases where patients may be delaying therapy. St John’s Wort has been shown to be effective as an antidepressant and could possibly be tried as a self-help measure in PMS though there is no valid evidence (it must not be taken with SSRIs). Also Doctors often recommend vigorous, aerobic exercise because it is thought that exercise stimulates the body’s release of various neurotransmitters, supplementing those that are at low levels.

Medical Therapies

Broadly speaking, treatment of PMS should generally be achievable either by suppressing ovulation and the endocrine cycle either pharmacologically or by surgery or it may be achieved by altering the sensitivity to progesterone by elevating serotonin levels.

Suppression of the ovarian cycle eliminates PMS effectively. This can be achieved by GnRH analogues with add back tibolone. Oestrogen also suppresses ovulation and eliminates PMS without menopausal side effects. Intrauterine progestagen (as levonorgestrel IUS) avoids re-stimulation of premenstrual syndrome at the same time that it protects the endometrium; it reduces periods and provides contraception.

Other medications used to treat PMS include diuretics (to ease fluid retention), oral contraceptives (for hormone control), and anti-anxiety medication, for extreme irritability. SSRIs are the simplest and most effective non-hormonal approach to treatment. Some consider them to be first line medical therapy. Women with premenstrual dysphoric disorder usually require antidepressant medications.

PMS can cause havoc in a woman’s sex life. Because the symptoms include emotional fluctuations as well as physical discomfort, neither the woman nor her partner knows what to expect. Some women find that their energy goes into symptom management, and they become self-absorbed. They tune in to their bodies but tune out their sexual feelings and, many times, their partners too.