Most women experience some degree of Premenstrual Syndrome (PMS), a group of symptoms linked to the menstrual cycle. These symptoms, which occur in the week or two weeks before menstruation, include fatigue, abdominal bloating, irritability, breast pain, migraine headaches, acne, and many more.
“There are at least 120 different symptoms associated with PMS and they vary widely. I have been a nurse for 35 years and I’ve learned that PMS is not the same for all women,” said Patricia Mehring, RN, MSN, WHNP, Women’s Health Nurse Practitioner at the Froedtert & The Medical College of Wisconsin Obstetrics and Gynecology Clinic.
Just because a woman experiences one symptom with her menstrual period during her twenties, for example, it does not necessarily follow that she will have that same problem in her thirties, Mehring said. “PMS is not the same for all women, and not the same at all points in a woman’s life. It can change as we age.”
Estimates indicate that up to 85% of all actively menstruating women experience some premenstrual symptoms. “Forty to forty-five percent of women have symptoms that are significant enough to interfere with their daily lives, but most women are on the low end of the spectrum, getting some symptoms that make them believe their period is coming,” noted Mehring. “The symptoms can range from mild to severe,” she added.
Those who experience severe PMS symptoms may have premenstrual dysphoric disorder (PMDD). The main symptoms of PMDD, which can be disabling, include feelings of sadness or despair, tension, anxiety, and panic attacks, among others. “This group represents maybe 5% of all women with PMS,” Mehring said.
More Awareness, More Options
There are still some questions surrounding PMS, but in general, the heightened level of awareness about the disorder has made it easier for women to get help, Mehring stressed. “PMS was finally recognized as a legitimate problem by the medical community in the 1980s. Until then, women were often told that their suffering was ‘all in their heads.’ A lot of what women needed was validation of the fact that they had a real illness. Now they are more likely to discuss it with their health care practitioner.”
Sometimes women who are suffering from PMS don’t even realize they are exhibiting symptoms. “It is family members who recognize it,” Ms. Mehring said. “I have had mothers bring in their daughters because they have seen cyclic recurrence of certain behaviors. Husbands will point out behavior changes to their wives, too,” she said.
What’s Behind PMS?
Even now, the causes of PMS still are not completely understood. “Hormone level fluctuations during the menstrual cycle are the basis for the condition, but how these changes in the female sex hormones (estrogen and progesterone) lead to the varied symptoms is still unclear,” Mehring said.
While stress and emotional problems don’t seem to cause PMS, they can make it worse. “Men’s hormone levels are pretty steady during their lives, but for women, hormone levels are much more dynamic. There are at least 20 different theories that try to explain why PMS occurs,” Mehring explained. As more people recognize the symptoms of PMS, there are greater attempts on the part of the medical community to try to define what constitutes the condition.
No Magic Pill
Determining whether a woman has PMS is a process, Ms. Mehring explained. “There is no test you can take. When a woman comes in with symptoms that she thinks are PMS, the first thing we do is try to determine if there is any pattern or cyclic recurrence of symptoms prior to her menstrual cycle. Women often want a magic pill to make it better, but there isn’t a single answer for all women,” she said. “In order to demonstrate that someone truly has PMS, we ask them to prospectively chart their symptoms in a diary for a minimum of two or three cycles.”
Charting can help rule out other causes for the symptoms a woman is having, Mehring said. In PMS, the symptoms must be restricted to the second two weeks of a woman’s cycle. “Charting helps some women come to grips with the fact that although they might feel bad premenstrually, they are actually experiencing an exaggeration of an existing problem like depression, which is there at other times in the cycle as well,” she stressed.
Although there is no one-size-fits-all treatment for PMS, a variety of remedies work for different women. “Most women have a combination of emotional and physical symptoms,” Mehring said. She pointed out three general approaches to treatment :
- Lifestyle changes in areas such as diet and exercise
- Hormonal alterations by use of oral contraceptives or other alternatives
- Symptom-based pharmacologic treatments including antidepressants and diuretics
The first step in general PMS relief often consists of non-medical strategies to reduce symptoms. “Most practitioners focus first on preventive strategies like lifestyle changes,” Ms. Mehring said. “Diet is one of the big things we look at. The very foods that women tend to crave will almost always contribute to PMS symptoms. If you are irritable, you don’t need further stimulation from caffeine or chocolate. If you are bloated, you should avoid salt. I recommend a hypoglycemic diet with frequent small meals including protein and avoidance of refined sugars during the premenstrual period,” she said.
Over-the-counter pain relievers such as aspirin and ibuprofen can alleviate cramps. Vitamin supplements such as calcium, magnesium, and vitamin E have been shown to be helpful in reducing bloating and breast tenderness. “There is a fair amount in the literature about these supplements,” Mehring said.
Many herbal or natural products are advertised as helpful for relieving PMS symptoms, such as black cohosh, ginger, chaste tree berry and others. However, these claims typically have not been proven and the US Food and Drug Administration does not regulate these products for safety or effectiveness.
“As studies have looked at various theories regarding PMS and why some women have such strong symptoms, they have discovered that there is actually some change in the body’s ability to release or respond to serotonin [a neurotransmitter in the brain that affects emotions, behavior and thought]. Using serotonin reuptake inhibitors such as Prozac or Zoloft does tend to even things out,” Mehring said. These often can be used at a lower dose than what is required to treat depression.
“The big question is whether the individual needs to be on something all month long. Some studies have shown success in managing premenstrual symptoms using SSRIs sporadically, especially Prozac because it has a long half-life, but questions still remain,” said Mehring.
Because fluctuating hormone levels are behind PMS at least in part, some clinicians support the idea of hormone therapy to manipulate and suppress ovulatory cycle changes, Mehring said. “The rising and falling of progesterone seems to be the trigger. Therefore, if you give oral contraceptives to stop the trigger, hopefully you can knock out the symptoms.”
Along those lines, some of the newer oral contraceptives that inhibit a monthly period are useful in treating the symptoms of PMS. “Some of these pills allow for only four periods a year,” Mehring noted. “There is no medical reason why a woman must have a period every month.”
Besides the conventional treatments, some women with PMS report relief by using relaxation techniques and massage. “If you find something that works for you, stay with it,” Mehring said. “No one treatment has been effective for all women. The best we can do is look at the symptoms and try to tailor our recommendations.”