Premenstrual syndrome

Premenstrual syndrome, or PMS, is a term that refers to the range of physical and emotional symptoms that some women experience in the lead-up to menstruation. The symptoms resolve once their period begins and there is at least one symptom-free week before the symptoms return.

It is thought that around 40 per cent of menstruating women have PMS, with symptoms ranging from relatively mild to severe.

PMS is a complex condition that involves physical and emotional symptoms. The latest research points to changes in brain chemicals in the time before menstruation. Although the cause isn’t conclusively known, PMS can be managed with various medications and other strategies.

Symptoms
PMS differs from one woman to the next. The wide range of PMS symptoms can include:

Abdominal bloating
Acne
Anxiety
Confusion
Depression, which may include suicidal thoughts
Difficulties in concentration
Digestive upsets, including constipation and diarrhoea
Drop in self-esteem and confidence
Drop in sexual desire, or (occasionally) an increase
Feelings of loneliness and paranoia
Fluid retention
Food cravings
Headache and migraine
Hot flushes or sweats
Increased appetite
Increased sensitivity to sounds, light and touch
Irritability, including angry outbursts
Memory lapses
Mood swings
Sleep changes, including insomnia or excessive sleepiness
Swollen and tender breasts
Weepiness.

Premenstrual dysphoric disorder (PMDD)
About five per cent of menstruating women suffer from seriously debilitating PMS, which is sometimes known as premenstrual dysphoric disorder (PMDD). The symptoms are so severe that an affected woman is unable to live her normal life.

The classification of PMDD is contentious. It is included as a depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), but the health profession is divided over whether PMDD should be classed as a mental disorder. Supporters of the inclusion say that PMDD shares many of the same characteristics of a major depressive disorder. Critics point out that PMDD is biologically driven, and shouldn’t be classed as a mental illness because symptoms resolve once menstruation begins.

PMS and the menstrual cycle
The menstrual cycle is controlled by a complex interplay of hormones.

Eggs (ova) are housed in the ovaries. After menstruation, hormones prompt the ovary to produce five to 20 little cysts called follicles. Each follicle contains an immature egg, even though only one egg usually matures each cycle. The presence of the follicles causes the uterine lining to thicken in preparation for possible pregnancy.

Higher levels of the hormone oestrogen prompt the ovary to release an egg (ovulation) from its follicle. The ruptured follicle changes into a structure known as the corpus luteum, which starts producing the sex hormone progesterone and a small amount of oestrogen. The higher levels of progesterone maintain the thickened uterine lining in case the egg is fertilised.

If pregnancy doesn’t occur, progesterone levels fall and the uterine lining comes away as a period. Typically, PMS occurs after ovulation in the two weeks prior to menstruation. PMS ceases at menopause.

The causes are unknown
The cause of PMS remains unknown, although it is thought that several factors are responsible. Current theories include:

Brain and hormonal interactions – recent research indicates that PMS may be caused by changes in brain chemistry, such as serotonin and its interaction with the hormonal system. These changes occur in the premenstrual time.
Progesterone – it seems logical to assume that progesterone is the catalyst, since PMS occurs when progesterone levels are high and resolves once levels fall at menstruation. However, this link hasn’t been conclusively established. The progesterone theory suggests that the sex hormone interacts with other hormones and brain chemicals to produce the symptoms of PMS.
Endocrine system – some women with PMS have disorders of the endocrine (hormonal) system, such as problems with their thyroid. However, this could just be coincidence, since most women with PMS do not have hormonal disorders.
Diet – dietary deficiencies of some minerals and vitamins are known to produce some of the symptoms of PMS.
Stress – there is evidence to suggest that emotional stress worsens PMS symptoms. Events such as childbirth or discontinuing oral contraceptives, surgery or a stressful event can trigger PMS or worsen PMS symptoms.

Diagnosis methods
There are no specific diagnostic tests for PMS as hormone levels are usually within the normal range. Diagnosis relies on an examination of the patient’s medical history and description of the symptoms. If the symptoms don’t resolve at menstruation, other causes may be suspected.

Medical treatments
There is no cure for PMS. Medical treatment can include:

Hormonal treatments – oral contraceptives can be used to suppress ovulation, which may relieve premenstrual symptoms. There are mixed results. Oestrogen therapy may be considered during the premenstrual time, particularly when hot flushes are occurring. Progesterone therapy has not been shown in research studies to improve symptoms.
Selective serotonin reuptake inhibitors (SSRIs) – this group of medicines are mood stabilisers and antidepressants and can improve PMS symptoms significantly. These medicines increase the brain chemical, serotonin, which appears to fall during the premenstrual phase in women who experience PMS. The simplest SSRI is St. John’s Wort, but the most studied form of SSRI is fluoxetine.
Anti-prostaglandin and anti-inflammatories – medicines such as Nurofen, Naprogesic or Ponstan may help when nausea and pain occur.
Diuretics (fluid pills) – these rarely help, except for genuine fluid retention.
Cognitive behavioural relaxation therapy – uses one or a variety of relaxation techniques to relieve psychological and/or physical symptoms.

Self-help options
PMS responds to self-help. Options include:

Note your symptoms daily in a diary.
Reduce caffeine and alcohol, particularly during the premenstrual phase.
Don’t smoke.
Exercise regularly, especially during the premenstrual phase, as increasing endorphins will reduce symptoms.
Get plenty of rest and good quality sleep.
Reduce stress generally, especially during the premenstrual phase. Communicate with family and friends to reduce your stress at this time.
Try to maintain a good diet, low in sugar and salt.
Consider complementary therapies like vitamins, minerals, acupuncture and herbs, which may help. St. John’s Wort may help mood stabilisation and Evening Primrose Oil capsules may help sore breasts. Always consult your doctor before taking any supplement, including herbal supplements, as they may interact with other medications.

Where to get help

Your doctor
Women’s health clinic
Women’s Health Victoria Information Line Tel. (03) 9662 3742 or 1800 133 321
Family Planning Victoria Tel. (03) 9257 0100

Things to remember

Premenstrual syndrome (PMS) refers to the range of physical and emotional symptoms that some women experience in the lead-up to menstruation.
The symptoms stop once the menstrual period begins, and there is at least one symptom-free week before the symptoms start returning.
PMS responds well to self-care but may need medications to help relieve symptoms.
Related articles:

Fluid retention.
Menstrual cycle.
Menstruation - amenorrhoea.
Menstruation - athletic amenorrhoea.
Menstruation - dysmenorrhoea.
Premenstrual syndrome - treatment options.
Reproductive system.

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Article publication date: 05/11/2003
Last reviewed: 29/03/2007

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