Pre-Menstrual Syndrome (PMS)

WHAT IS PREMENSTRUAL SYNDROME (PMS)?
PMS is the cyclic appearance of one or more symptoms that occur up to two weeks prior to the menstrual period and resolve with the onset or soon after the onset of the menses. PMS may include a variety of signs and symptoms. Many women experience premenstrual symptoms, but women with PMS have symptoms that interfere with daily functioning.

WHAT ARE THE SYMPTOMS?
The most common symptoms are abdominal bloating, headache, breast tenderness, swelling of the extremities, fatigue, depression, irritability, anger, anxiety, confusion and social withdrawal. About 85% of menstruating women may experience one or more PMS symptoms, but the symptoms may not cause significant disruptions in their daily routines; another 5-11% experience symptoms that significantly interfere with their ability to function at work and home on a daily basis.

WHAT CAUSES PMS?
The cause of PMS has yet to be fully established. Normal ovarian function, rather than hormonal imbalance, appears to be the cyclic trigger. Changes in neurotransmittor levels in the brain are thought to play a role in PMS. A reduction in a neurotransmitter, serotonin, seems to produce symptoms in some women. Differences in the way ovarian steroids, estrogen and progesterone, are metabolized may explain differences in symptoms. A genetic predisposition and cultural expectations may also play a role in this delicate relationship.

HOW IS PMS DIAGNOSED?
A thorough history and exam should be performed. Patients may be asked to maintain a daily, prospective, chart of symptoms for three menstrual cycles. (A sample chart is provided at the end of this handout.) If multiple symptoms are present, the three to five most profound symptoms should be recorded. Weight and basal body temperature charting may be helpful. This chart provides a way to document and measure the symptoms and provides correlation with the menstrual cycle. Before a diagnosis of PMS can be made, there needs to be documentation of the symptoms and their impact on daily activity, and correlation with the menstrual cycle fluctuations. It is also important to first rule out other health problems that may cause similar symptoms.

HOW IS PMS TREATED?
Therapy is individualized for each woman according to symptoms. By keeping a chart of symptoms a woman may be able to identify patterns to the symptoms. Review and discuss the chart with your health care provider. There are many treatment options. Some find physical exercise helpful. Dietary changes that increase complex carbohydrates and protein and decrease saturated fats and refined sugars are recommended. Whole grains and cereals, pasta, legumes, seeds and nuts, vegetables and fruits are helpful in reducing symptoms. Some women find that discontinuing caffeine helps reduce symptoms, but this may need to be done gradually because people who suddenly discontinue caffeine use may suffer from withdrawal symptoms. Reducing alcohol intake also may help modify symptoms.

Over the counter medications can be used to relieve cramps, headache or backache. Vitamin B6 or pyridoxine (50-100mg/day) and calcium (1200mg/day) may reduce some symptoms. Some find relaxation exercises, biofeedback or acupuncture helpful. Counseling may also be helpful in developing a more effective coping style.

Prescription medications such as spironolactone can reduce bloating and edema. Medication such as birth control pills or contraceptive injections may help relieve other symptoms. Several studies have shown that medications that raise the serotonin levels (such as Prozac or Zoloft) have been helpful in relieving severe PMS symptoms.

If you feel that premenstrual symptoms may be causing disruptions in your daily living patterns you are encouraged to discuss these concerns with a health care provider.

Menstrual Diary: Fill in the boxes on the days your symptoms occur. Indicate severity by filling in the boxes as shown:

Circle the dates of your period. MONTH:

References
Lark, S. M., PMS Self Help Book 4th ed., 2001
Cohen, LS et al, Obstetrics and Gynecology, Premenstrual Daily Fluoxetine for PMDD, vol.100 no3 Sept 2002 pgs. 435-444
Kovacs, P. Evaluation and recognition of PMPD. The Clinical Advisor July August 2002 Speroff, L., et al (1999) Clinical Gynecologic Endocrinology and Infertility (6th ed.). Williams & Wilkins
American College of Obstetricians and Gynecologists Web site, search for pre-menstrual syndrome

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