Premenstrual Syndrome
Premenstrual Syndrome
Definition
Premenstrual syndrome, or PMS, is a constellation of physical, behavioral, and mood symptoms that some women experience during the luteal phase of their menstrual cycle, which spans roughly the 7 to 10 days before the start of menses.
Description
In their reproductive years, women normally have fluctuations of various hormones over the course of the menstrual cycle. An average menstrual cycle lasts about 28 days, although a normal cycle can range from 21 to 35 days. Many hormones are released into the blood during the menstrual cycle, including estrogen and progesterone. Fluctuations in hormone levels cause changes in the ovaries and the uterus. On around day 14 of a 28-day cycle, an egg is released from the ovaries, in a process called ovulation. After ovulation, the luteal phase of the menstrual cycle begins. The luteal phase lasts about 14 days in a normal 28-day menstrual cycle. If the egg is not fertilized by a sperm, the lining of the uterus is shed in the process called menstruation. The onset of menstruation, or menses, marks the end of the luteal phase. The characteristic features of PMS are physical and emotional symptoms that start in the luteal phase and disappear soon after the onset of menses.
The cluster of symptoms associated with premenstrual syndrome was first described in the scientific literature in 1931, by R.T. Frank, the chief of obstetrics and gynecology at New York’sMt. Sinai Hospital. The term “premenstrual syndrome” was coined in 1953, in an article written by the English physician Katharina Dalton, who believed that PMS was due to a deficiency of the hormone progesterone.
PMS occurs in the middle of a symptom continuum that ranges from premenstrual molimina, or the normal signs heralding the onset of menses, to severe distress and dysfunction. The large majority of women between the ages of menarche and menopause experience physical, emotional, and/or behavioral changes during the time period before the start of menses, but many of them do not find these changes troubling. Women who experience severe symptoms are considered to have premenstrual dysphoric disorder, or PMDD, which was formerly called late luteal phase dysphoric disorder. The Diagnostic and Statistical Manual of Mental Disorders , fourth edition (DSM-IV), describes PMDD as a condition that warrants further study before being granted the status of a specific disorder, but PMDD is used as a diagnostic category. For a woman to be diagnosed as having PMDD, she must have at least 5 of 11 symptoms, which include sadness, tension, mood swings, irritability, reduced interest in usual activities, difficulty concentrating, fatigue , appetite and sleep changes, a sense of being overwhelmed, and physical symptoms such as bloating or pain. At least one of the symptoms must be a mood symptom, and symptoms have to be present for most days during the luteal period for most months in the past year. Symptoms must remit shortly after the onset of menses.
Women who experience symptoms that are troubling enough to affect relationships, work, or family life but whose symptoms do not meet the criteria for PMDD are considered to have PMS. PMS is not listed as a psychiatric disorder in the DSM-IV. According to the tenth edition of the International Statistical Classification of Diseases and Related Health Problems, ICD-10, a diagnosis of PMS can be made even if only one distressing symptom is present. The American College of Obstetricians and Gynecologists guidelines for diagnosing PMS require at least one symptom to be present in the five days preceding the menses for three consecutive menstrual cycles.
Some people criticize the characterization of PMS as a disorder. They point out that PMS is not well defined and that many women experience PMS symptoms. They fear that making PMS into a disorder stigmatizes women in general and makes women subject to negative portrayals in popular culture. Women are described as PMSing, aggressive, hostile, and crazy, and are the frequent targets of jokes about the effects of the menstrual cycle. The idea that women are strongly influenced by their menstrual cycles can have an impact on their professional lives, even though there is little evidence that PMS impairs task performance. Some people even suggest that the promotion of PMS as a disorder is attributable to a profit motive. They claim that the concept of PMS exists partly because it is financially beneficial for hospitals and clinics to provide treatments for PMS, even though many of these treatments are ineffective or unproved.
Others advocate defining PMS as a disorder. They argue that PMS is a significant burden for many women, and that women with PMS are relieved to have the condition recognized as a real problem, rather than have it be dismissed as the product of an overactive imagination.
Demographics
As many as 80% of women report that they experience some change in mood, behavior, and physical
sensations or functioning in the time period before the onset of menses, although most women do not find these changes troubling. PMDD affects about 5% to 8% of women between puberty and menopause. About 10% to 40% of all menstruating women have PMS, which means that they experience symptoms that are marked enough to impair relationships, work, or family life but do not have symptoms that are severe enough to warrant a diagnosis of PMDD. Although many researchers list these and similar estimates of the prevalence of PMS, others point out that such estimates may be inaccurate because PMS is not a well-defined condition, and because prevalence estimates are usually derived from women’s retrospective reports. Retrospective reports are often flawed because of memory distortions. For example, it is possible that some women who experience symptoms throughout the menstrual cycle misremember them as occurring only in the period prior to menstruation.
PMS can begin at any age after menarche or at the time of the first menstrual period. PMS occurs most often in women who ovulate, but women who do not ovulate may also experience it. For example, it may occur in women around the time of menopause, when women sometimes have menstrual periods, even when they do not ovulate. According to the National Women’s Health Information Center, PMS is most common in women who are between their late 20s and early 40s, have at least one child, have a family history of depression, and have suffered from depression in the past. Some scientists have suggested that PMS is more likely to occur in women who eat large amounts of chocolate, or women who drink heavily. Women with PMS typically seek medical help for the condition in their 30s.
Symptoms
Symptom type can vary from menstrual cycle to cycle, as can symptom severity. The PMS symptoms most commonly reported by women are bloating, irritability, and difficulty sleeping. Other symptoms include breast discomfort, headaches, swelling of hands or feet, back pain, joint or muscle aches, fatigue, lapses in memory, decreased interest in sex, angry outbursts, restlessness, difficulty concentrating, confusion, depression, anxiety, social withdrawal, and cravings for sweet or salty foods and caffeine.
Causes
The causes of PMS are unclear. Scientists have put forward many theories to explain the etiology of PMS, including low levels of the hormone progesterone, changes in the ratio of the hormone estrogen to progesterone, increases in the activity of the adrenal gland, too much of the hormone prolactin, decreased endorphins, and too little prostaglandin, among others. Research does not provide consistent support for any of these theories.
However, most scientists do agree that abnormal levels of the neurotransmitter serotonin, or abnormal bodily responses to serotonin, may be involved in PMS. The fluctuations of hormones during the menstrual cycle may have an effect on serotonin function, but the details of the mechanisms involved are still unclear. Evidence for the involvement of serotonin in PMS comes from the fact that PMS and PMDD have many symptoms in common with disorders such as depression, which involve abnormalities related to serotonin levels. Also, many women with PMDD and PMS find that symptoms are alleviated when they take selective serotonin reuptake inhibitors (SSRIs ), which are antidepressant drugs that increase the levels of serotonin available to nerve cells.
Because there are many different kinds of PMS symptoms and many different etiological theories with partial support, some researchers speculate that there may be more than one form and multiple causes of PMS
Diagnosis
There are no laboratory tests for diagnosing PMS, because the cause of the condition is unknown. A diagnosis of PMS is typically made only after a woman has kept a record of daily symptoms over the course of the menstrual cycle for at least three months. This allows women to determine whether their symptoms occur only during the luteal phase of the cycle or at other times as well.
A diagnosis of PMDD is given only after ruling out the possibility of a premenstrual increase in the symptoms of another disorder. Some women with general medical conditions such as seizure disorders, endocrine dysfunctions, cancer, systemic lupus eryth-ematosus, anemia, endometriosis, and some kinds of infections may experience higher levels of negative mood and fatigue during the premenstrual period. Some women with psychological disorders, such as depression, anxiety disorders, bulimia nervosa, substance use problems, and personality disorders, may also experience exacerbations of their symptoms during the premenstrual period. These women, however, experience symptoms throughout the menstrual cycle, unlike women with PMS, who only experience symptoms during the luteal phase.
Treatment and prevention
Treatments for PMS include lifestyle changes, drug therapy, nutritional supplements, and herbal remedies.
Lifestyle changes
Changes in lifestyle, rather than drug therapy, are recommended for women who experience mild PMS. For many women, regular exercise alleviates PMS symptoms. One theory suggests that a decrease in endorphin levels in the late luteal phase may result in premenstrual symptoms. Exercise causes endorphins to be released, which may help to alleviate the depressive symptoms that some women with PMS experience. Twenty to thirty minutes of aerobic exercise at least three days a week are recommended.
Because stress can exacerbate PMS, taking steps to reduce work and family stress, especially in the premenstrual period, can be helpful. Women who experience PMS may find it helpful to avoid scheduling stressful activities on days when they expect to have symptoms. Dealing with issues at work and within relationships that produce conflict may also be helpful, because achieving a sense of control can reduce stress.
Although some researchers point out that there is no evidence that dietary changes can alleviate PMS, others recommend keeping dietary salt levels low to prevent fluid retention and bloating, and reducing caffeine intake to alleviate breast discomfort and reduce jitteriness.
Drug therapy
The main pharmacological agents used to treat PMS are SSRIs, anti-anxiety medications, drugs that induce chemical menopause, hormones, and oral contraceptives.
The U.S. Food and Drug Administration (FDA) has approved the use of the SSRIs fluoxetine and sertraline for the treatment of PMDD. Although the FDA has not approved these drugs for PMS, reports indicate that they are helpful for treating PMS. The dose that is prescribed for PMDD and PMS is typically smaller than that used to treat depression. SSRIs typically take two to four weeks before they begin to have an effect on the symptoms of depression, but they alleviate the symptoms of PMS and PMDD in a much shorter time, usually in one or two days. For depression, intermittent dosing with SSRIs is not usually effective, but for PMS and PMDD SSRIs are effective when taken daily only during the luteal phase of the menstrual cycle.
Studies show that SSRIs are not effective for about 40% of women with PMDD. These results may indicate that hormones and neurotransmitters other than serotonin are also implicated in PMDD.
Some practitioners report that alprazolam is effective for alleviating the anxiety that some women with PMS experience. Alprazolam is a benzodiazepine drug that is sold under the brand name Xanax. Other reports indicate that alprazolam is not an effective treatment for negative premenstrual mood symptoms and that it can also impair task performance. In addition, the use of alprazolam can lead to addiction .
Chemically inducing menopause is an effective way of eliminating PMS and PMDD, but because this treatment has many side effects, it is only used as a last resort. Drugs such as leuprolide, which is sold under the brand name Lupron, are used to induce chemical menopause. Leuprolide is similar to a gona-dotropin-releasing hormone, a hormone naturally released by the brain . Leuprolide reduces estrogen production by the ovaries. Because low estrogen can lead to problems such as thinning of bones, estrogen is sometimes administered to women who take drugs like Lupron, to reduce side effects such as osteoporosis and hot flashes. However, estrogen add-back therapy is very expensive and may result in the return of PMS symptoms.
In the 1950s, the English physician Katharina Dalton treated many women with PMS by giving them supplements of the hormone progesterone. She reported that progesterone was effective in alleviating symptoms in these women. More recent research in the United States has not confirmed Dalton’s results. Despite this, gynecologists still sometimes prescribe progesterone for PMS, because some women report benefits. Natural progesterone, or synthetic progesterone in the form of drugs such as Provera, may be used. Progesterone injections can be given in the form of Depo-Provera, which is a contraceptive. A dose of injected Depo-Provera lasts for three months. It prevents women from getting periods. The drug has a sedative effect on some women and so alleviates premenstrual anxiety. The drug can, however, have negative side effects, including bleeding or spotting, depression, and weight gain.
Some women with PMS find that symptoms are alleviated when they take a low-dose birth control pill, although, for unknown reasons, other women actually have worsening of symptoms when they use oral contraceptives. In October 2006, the FDA approved the
use of the birth control pill YAZ for treating PMDD. YAZ contains a synthetic form of progesterone called drospirenone and estrogen in the form of ethinyl estra-diol. Reports indicate that YAZ alleviates both physical and emotional symptoms of PMS.
Nutritional supplements and herbal remedies
Some health practitioners suggest using nutritional and herbal supplements, selected to treat the primary symptoms experienced, although their effectiveness in alleviating PMS is controversial. Some nutritional supplements and herbs can be toxic or may interact with medications. There are varying dosage recommendations for many of these supplements in the scientific literature. For these reasons, women should consult with their physicians before using such substances.
For fluid retention problems, diuretic therapy with 25 mg of spironolactone twice a day is sometimes recommended. Spironolactone is sold under the trade name Aldactone. Other reports indicate that a spironolactone supplement of 100 mg per day improves both the physical and mood symptoms of PMS. Using a calcium supplement of 1,200–1,500 mg daily also appears to reduce PMS symptoms in some women. Some practitioners recommend using vitamin B6 supplements of 50–100 mg daily, but others recommend a higher dose. Vitamin B6 is a natural diuretic and may help to reduce bloating. Furthermore, vitamin B6 appears to suppress the action of prolactin, which is a hormone that may be involved in PMS. Vitamin B6 may also play a role in the metabolism of serotonin, which appears to be involved in PMS. A Vitamin E supplement of about 400–600 units a day is sometimes suggested for helping to alleviate breast discomfort. Daily supplements of magnesium appear to reduce symptoms related to fluid retention such as weight gain, breast tenderness, swelling of hands and feet, and abdominal bloating. Dose recommendations vary from 200–600 mg daily.
Although the effectiveness of herbal remedies is even more controversial than that of nutritional supplements, women sometimes use them. Some practitioners report that women who use evening primrose oil find that it occasionally alleviates PMS symptoms, although others report that studies have not demonstrated its effectiveness. Evening primrose is a plant that has a fatty acid essential to the body, called gamma-linoleic acid. Some researchers have speculated that gamma-linoleic acid may help PMS symptoms by raising the levels of prostaglandin in the body. Other oils that contain gamma-linoleic acid are borage oil, black currant oil, and rapeseed oil. Many other types of herbal supplements are described as having
KEY TERMS
Adrenal gland —A gland that produces many different hormones, including estrogen, progesterone, and stress hormones.
Anemia —A condition in which red blood cells do not supply enough oxygen to body tissues.
Benzodiazepine —A class of anti-anxiety drugs.
Bulimia nervosa —An eating disorder in which binge-eating is followed by inappropriate and often dangerous efforts to control body weight.
Contraceptive —A method that prevents conception and pregnancy.
Endocrine dysfunction —A problem relating to inadequate or excessive production of hormones.
Endometriosis —A condition in which the tissue that is normally present in the lining of the uterus grows elsewhere in the body.
Endorphin —A neurotransmitter that acts like a natural opiate, relieving pain and producing euphoria.
Gonadotropin-releasing hormone —A hormone produced by the brain that stimulates the pituitary gland to release hormones that trigger ovulation.
Luteal phase —The period of time between ovulation and menstruation.
Menarche —The first menstrual period.
Menopause —The cessation of menstrual periods.
Neurotransmitter —A chemical that sends signals from one nerve cell to another.
Osteoporosis —The thinning of bone and loss of bone density.
Personality disorder —A chronic pattern of behaving and relating to others that causes significant distress and impairs functioning.
Premenstrual molimina —The normal signs that indicate that menses will soon occur.
Prostaglandin —A chemical produced in the body, which is involved in many functions, including blood pressure regulation and inflammation.
Systemic lupus erythematosis —A chronic, inflammatory autoimmune disorder.
the potential to relieve PMS symptoms, although there is conflicting information in the scientific literature about their efficacy. These herbal supplements include chaste tree berry, ginkgo biloba, and St. John’s wort.
Prognosis
Women who have PMS typically experience symptoms throughout their reproductive years, except during pregnancy. In some women, PMS can become more severe around the time of menopause, in the perimenopausal time period. PMS generally remits after menopause.
Resources
BOOKS
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text rev. Washington D.C.: American Psychiatric Association, 2000.
Minkin, Mary Jane, and Carol V. Wright. The Yale Guide to Women’s Reproductive Health From Menarche to Menopause. New Haven, CT: Yale University Press, 2003.
Ratcliff, Kathryn Strother. Women and Health: Power, Technology, Inequality and Conflict in a Gendered World. Boston: Allyn and Bacon, 2002.
Speroff, Leon, and Marc A. Fritz,. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia: Lippincott Williams and Wilkins, 2005.
PERIODICALS
Clayton, A. H., A. E. Keller, C. Leslie, and W. Evans. “Exploratory Study of Premenstrual Symptoms and Serotonin Variability.” Archives of Women’s Mental Health 9.1 (Jan. 2006): 51–57.
Dell, Diana L. “What’s new in PMS? (premenstrual syndrome)” Patient Care for the Nurse Practitioner Apr. 2005.
Hudson, Tori. “Premenstrual Syndrome: A Review of
Herbal and Nutritional Supplements.” Townsend Letter for Doctors and Patients 270 (2006): 126–31.
Mishell, Daniel R. “Premenstrual Disorders: Epidemiology and Disease Burden.” American Journal of Managed Care 11 (2005): S473–79.
Rapkin, Andrea J. “New Treatment Approaches for Premenstrual Disorders.” American Journal of Managed Care 11 (2005): S480–91.
Strine, Tara W., Daniel P. Chapman, and Indu B. Ahluwa-lia. “Menstrual-Related Problems and Psychological Distress among Women in the United States.” Journal of Women’s Health 14.4 (2005): 316–23.
Yonkers, Kimberly A. “Management Strategies for PMS/PMDD.” Journal of Family Practice 53.9 (2004): SS15–20.
WEB SITES
“FDA Approves New Indication for YAZ to Treat Emotional and Physical Symptoms of Premenstrual Dys-phoric Disorder (PMDD).” Berlex. Oct. 5, 2006. http://www.berlex.com/html/press/articles/10052006.html
“Gynecologic Problems: Premenstrual Syndrome.” The American College of Obstetricians and Gynecologists.http://www.acog.org/publications/patient_education/bp057.cfm
ORGANIZATIONS
American College of Obstetricians and Gynecologists (ACOG), 409 Twelfth Street SW, P.O. Box 96920, Washington, DC 20090-6920. Telephone: (800) 762-2264 http://www.acog.org
The Hormone Foundation, 8401 Connecticut Avenue, Suite 900, Chevy Chase, MD 20815-5817. Telephone: (800) 467-6663 http://www.hormone.org
National Women’s Health Information Center, U.S. Department of Health and Human Services, Office on Women’s Health, 8270 Willow Oaks Corporate Drive, Fairfax, VA 22031. Telephone: (800) 994-9662 http://www.4woman.gov
National Institute of Mental Health, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. Telephone: (866) 615-NIMH (6464) http://www.nimh.nih.gov
Ruvanee Pietersz Vilhauer, PhD