Premenstrual syndrome (PMS)

Disease/Disorder

Also known as: Menstrually related mood disorder (MRMD), premenstrual tension, late luteal phase disorder (LLPD), premenstrual dysphoric disorder (PMDD)

Anatomy or system affected: Breasts, psychic-emotional system, reproductive system

Definition: A disorder characterized by the cyclic recurrence of physical and behavioral symptoms during the days between ovulation and the first few days of menstruation.

Key terms:

endorphins: hormones, found mainly in the brain, that bind to opiate receptors, reducing the sensation of pain and affecting emotions

luteal phase: the second half of the menstrual cycle after ovulation; during this phase, the corpus luteum secretes progesterone

menses: the monthly flow of blood and cellular debris from the uterus that begins at puberty in women

premenstrual dysphoric disorder (PMDD): a severe form of premenstrual syndrome characterized by affective symptoms causing significant disturbances in relationships or social adaptation

progesterone: a hormone produced in the ovary that prepares and maintains the uterus for pregnancy

serotonin: a neurotransmitter involved in sleep, depression, and memory

Information on Premenstrual Syndrome (PMS)

Causes: Unknown; possibly depletion of neurotransmitters resulting from hormonal changes and sensitivities

Symptoms: Physical (fatigue, headache, breast tenderness and swelling, back and abdominal pain, muscle and joint pain, weight gain, water retention, acne, nausea, palpitations); behavioral (insomnia, dizziness, changes in sex drive, cravings for salty or sweet food, increased appetite); psychological (irritability, anger, depression, anxiety, mood swings, lack of concentration, confusion, forgetfulness, restlessness, decreased self-esteem)

Duration: Often chronic with acute episodes

Treatments: Patient education; exercise; adequate sleep; stress avoidance; dietary changes (increased complex carbohydrates, decreased sodium and caffeine); vitamin E supplements; calcium carbonate supplements; diuretics (spironolactone); antianxiety medications (benzodiazepines); selective serotonin reuptake inhibitors; hormonal therapy (Gonadotropin-releasing hormone agonists, oral contraceptives); Non-steroidal anti-inflammatory drugs (NSAIDs)

Causes and Symptoms

Several causes of premenstrual syndrome (PMS) have been proposed. Changes in hormone levels during the luteal phase of the menstrual cycle, when the ovaries are making progesterone, may deplete neurotransmitters such as enkephalins and endorphins, which are responsible for a sense of well-being; gamma-aminobutyric acid (GABA), which aids in relaxation; and serotonin, which stimulates the central nervous system. The disorder may be more likely to occur in women who have enhanced sensitivity to progesterone, a disposition related to serotonin deficiency. PMS may be related to excess prostaglandin, a hormone-like substance that may affect blood pressure and metabolism and smooth muscle activity. Some evidence suggests that women with PMS have lower blood levels of allopregnanolone, a by-product of progesterone that plays a role in mood.

Up to 85 percent of women experience mild to moderate forms of PMS. Another 5 percent of women have symptoms so severe that they interfere with daily activity and may be diagnosed with premenstrual dysphoric disorder (PMDD). In some women, symptoms of PMS increase with age, perhaps because serotonin levels are altered with changes in estrogen levels.

PMS symptoms can be subdivided into physical, behavioral, and psychological. Physical symptoms include fatigue; headache; breast tenderness and swelling; back and abdominal pain; acne; heart palpitations; bloating; weight gain; nausea; muscle and joint pain; water retention; swelling of ankles, feet, and hands; and decreased tolerance to noise or light. Behavioral symptoms include fatigue, insomnia, dizziness, changes in sex drive, cravings for salty or sweet food, and increased appetite. Psychological symptoms include irritability, anger, depressed mood, crying, anxiety, tension, mood swings, and lack of concentration, confusion, forgetfulness, restlessness, loneliness, decreased self-esteem, and tension. The symptoms of depression, anxiety disorders, perimenopause, and thyroid dysfunction are similar to PMS. A distinguishing feature of PMS is its cyclic occurrence.

Researchers at the University of California, San Diego suggests the following criteria for diagnosing premenstrual syndrome: At least one psychological (affective) and physical (somatic) symptom occurs during the five to seven days before menses in each of the previous three cycles, and symptoms are relieved during days four through thirteen of the menstrual cycle. The National Institute of Mental Health and the American Psychiatric Association give similar diagnostic criteria. Blood tests are not necessary for the diagnosis of PMS. Laboratory studies such as a blood count or thyroid function tests may be recommended to screen for other medical conditions that cause fatigue, such as anemia and thyroid disease.

Treatment and Therapy

Treatment for premenstrual syndrome can be divided into three categories: nonpharmacologic therapy, dietary supplementation, and pharmacologic therapy. Nonpharmacologic therapies include patient education, supportive therapy, and behavioral interventions. Women who receive educational materials about PMS may gain an increased sense of control and relief of symptoms. Supportive therapies include relaxation and cognitive-behavioral therapy. A therapist may also be able to teach coping methods. Behavioral interventions include keeping a daily symptom diary. Each day for three months, a woman records in a diary and ranks any health complaints on a scale of “none at all” to “extreme.” The PMS pattern is an increase in symptoms during the fourteen days before menstruation and then a decrease in symptoms within one hour to a few days after bleeding begins. In addition to keeping the diary, exercising thirty minutes a day (to stimulate the release of enkephalins and endorphins and to reduce swelling through sweat), sleeping six to eight hours every night, avoiding stress, and making dietary changes may help symptoms. Increasing the intake of complex carbohydrates (fruits, vegetables, and whole grains) may relieve mood-related symptoms by boosting the level of tryptophan, a precursor of serotonin. Lowering sodium intake can reduce bloating, fluid retention, and swelling. Restricting caffeine consumption may reduce irritability and insomnia.

Vitamin E supplements may reduce breast pain. Vitamin E as a dietary supplement is also a potentially beneficial antioxidant and poses minimal risk. Calcium carbonate supplementation may also improve PMS symptoms.

Nonprescription drugs, such as diuretics for bloating and analgesics for pain, may diminish the symptoms of PMS. Prescription treatments for PMS include antianxiety medication such as the benzodiazepines, which mimic the effects of GABA to relieve irritability but are highly addictive; selective serotonin reuptake inhibitors (SSRIs), which increase serotonin levels; hormone treatments such as gonadotropin-releasing hormone (GnRH) agonists and birth control pills that stop the production of estrogen and progesterone; spironolactone, a diuretic that relieves breast tenderness and fluid retention; and nonsteroidal anti-inflammatory drugs (NSAIDs), or prostaglandin inhibitors, for pain such as headache.

Some treatments that have no proven benefit in relieving the symptoms of PMS include: Progesterone, antidepressant drugs such as Tricyclic Antidepressants (TCA), Monoamine Oxidase Inhibitors (MAOI), lithium, and popular dietary supplements such as evening primrose oil, essential free fatty acids, and ginkgo biloba.

Perspective and Prospects

Hysteria (literally, “wandering womb”) was described in Egypt in about 1900 BCE as an abnormality of the uterus caused by its “migration” to different parts of the body, resulting in various symptoms, such as headache and swollen feet. The term “premenstrual tension” was first used by mental health professionals in the 1930s.

Research on PMS gained momentum in the 1980s. Whereas only one article on PMS appeared in 1964, 425 articles were published on the topic between 1988 and 1989. What had once been considered a pseudocondition, with PMS as a catchall phrase for up to 150 symptoms occurring before menstruation, was recognized as a medical disorder. Research has focused on biomedical and psychosocial causes and treatments.

Bibliography

Bloch, Miki, et al. "Premenstrual Syndrome: Evidence for Symptom Stability Across Cycles." American Journal of Psychiatry. (2014). Print.

Bonnice, Sherry. Premenstrual Disorders. Broomall: MC Mason Crest, 2014. Print.

Dalton, Katharina, and Wendy Holton. Once a Month: Understanding and Treating PMS. 6th ed. Alameda: Hunter House, 2000. Print.

Dickerson, Lori M., J. Mazyck, and Melissa H. Hunter. “Premenstrual Syndrome.” American Family Physician 67.8 (2003): 1743–52.

Hahn, Linaya. PMS: Solving the Puzzle-Sixteen Causes of PMS and What to Do About It. Evanston: Chicago Spectrum, 1995. Print.

Richards, Misty, et al. "Premenstrual Symptoms and Perimenopausal Depression." American Journal of Psychiatry (2014). Print.

Taylor, Diana, and Stacey Colino. Taking Back the Month: A Personalized Solution for Managing PMS and Enhancing Your Health. New York: Perigee, 2002. Print.

Vliet, Elizabeth Lee. Screaming to Be Heard: Hormonal Connections Women Suspect and Doctors Still Ignore. New York: M. Evans, 2001. Print.