Premenstrual syndrome

Definition

Premenstrual syndrome (PMS) refers to symptoms that occur between ovulation and the onset of menstruation . The symptoms include both physical symptoms, such as breast tenderness, back pain , abdominal cramps, headache , and changes in appetite, and psychological symptoms of anxiety , depression, and unrest. Severe forms of this syndrome are referred to as premenstrual dysphoric disorder (PMDD). These symptoms may be related to hormones and emotional disorders.

Description

Approximately 75 percent of all menstruating women experience some symptoms that occur before or during menstruation. PMS encompasses symptoms severe enough to interfere with daily life. About 3 to 7 percent of women experience the more severe PMDD. These symptoms can last four to ten days and can have a substantial impact on a woman's life. The reason some women get severe PMS while others have none was as of 2004, not understood.

Demographics

Not really a characteristic of adolescent girls, PMS symptoms usually begin between ages 20 and 30 years. The disease may run in families and is also more prone to occur in women with a history of psychological problems. Overall however, it is difficult to predict who is most at risk for PMS.

Causes and symptoms

Because PMS is restricted to the second half of a woman's menstrual cycle, after ovulation, it is thought that hormones play a role. During a woman's monthly menstrual cycle, which lasts 24 to 35 days, hormone levels change. The hormone estrogen gradually rises during the first half of a woman's cycle, the preovulatory phase, and falls dramatically at ovulation. After ovulation, the postovulatory phase, progesterone levels gradually increase until menstruation occurs. Both estrogen and progesterone are secreted by the ovaries, which are responsible for producing the eggs. The main role of these hormones is to cause thickening of the lining of the uterus (endometrium). However, estrogen and progesterone also affect other parts of the body, including the brain. In the brain and nervous system, estrogen can affect the levels of neurotransmitters, such as serotonin. Serotonin has long been known to have an effect on emotions, as well as eating behavior. It is thought that when estrogen levels go down during the postovulatory phase of the menstrual cycle, decreases in serotonin levels follow. Whether these changes in estrogen, progesterone, and serotonin are responsible for the emotional aspects of PMS was not, as of 2004, known with certainty. However, most researchers agree that the chemical transmission of signals in the brain and nervous system are in some way related to PMS. This belief is supported by the fact that the times following childbirth and menopause are also associated with both depression and low estrogen levels.

Symptoms for PMS are varied and many, including both physical and emotional aspects that range from mild to severe. The physical symptoms include: bloating, headaches, food cravings, abdominal cramps, headaches, tension, and breast tenderness. Emotional aspects include mood swings, irritability, and depression.

When to call the doctor

A physician or other healthcare provider should be called whenever a woman experiences symptoms of PMS that exceed her ability to cope.

Diagnosis

The best way to diagnose PMS is to review a detailed diary of a woman's symptoms for several months. PMS is diagnosed by the presence of physical, psychological, and behavioral symptoms that are cyclic and occur in association with the premenstrual period of time. PMDD, which is far less common, was officially recognized as a disease in 1987. Its diagnosis depends on the presence of at least five symptoms related to mood that disappear within a few days of menstruation. These symptoms must interfere with normal functions and activities of the individual. The diagnosis of PMDD has caused controversy connected to the concern that it may be used against women, labeling them as being impaired by their menstrual cycles.

Treatment

There are many treatments for PMS and PMDD depending on the symptoms and their severity. For mild cases, treatment includes vitamins , diuretics, and pain relievers. Vitamins E and B6 may decrease breast tenderness and help with fatigue and mood swings in some women. Diuretics work for some women. For more severe cases and for PMDD, treatments available include antidepressant drugs, hormone treatment, or (only in extreme cases) surgery to remove the ovaries. Hormone treatment usually involves oral contraceptives . This treatment, as well as removal of the ovaries, is used to prevent ovulation and the changes in hormones that accompany ovulation. Some studies in the early 2000s, however, indicate that hormone treatment has little effect over placebo.

Antidepressants

The most progress in the treatment of PMS and PMDD has been through the use of antidepressant drugs. The most effective of these are sertraline (Zoloft), fluoxetine (Prozac), and paroxetine (Paxil). They are termed selective serotonin reuptake inhibitors (SSRIs) and act by indirectly increasing the brain serotonin levels, thus stabilizing emotions. Some doctors prescribe antidepressant treatment for PMS throughout the cycle, while others direct women to take the drug only during the latter half of the cycle. Antidepressants should be avoided by women who want to become pregnant. Sertraline appears to significantly improve productivity, social activities, and relationships compared. Side effects of sertraline were found to include nausea , diarrhea , and decreased libido.

There are alternative treatments that can both affect serotonin and hormone responses, as well as affect some of the physical symptoms of PMS.

Vitamins and minerals

Some women find relief with the use of vitamin and mineral supplements. Magnesium can reduce the fluid retention that causes bloating, while calcium may decrease both irritability and bloating. Magnesium and calcium also help relax smooth muscles, and this may reduce cramping. Vitamin E may reduce breast tenderness, nervous tension, fatigue, and insomnia. Vitamin B6 may decrease fluid retention, fatigue, irritability, and mood swings. Vitamin B5 supports the adrenal glands and may help reduce fatigue.

Phytoestrogens and natural progesterone

The Mexican wild yam (Dioscorea villosa ) contains a substance that may be converted to progesterone in the body. Because this substance is readily absorbed through the skin, it can be found as an ingredient in many skin creams. (Some products also have natural progesterone added to them.) Some herbalists believe that these products can have a progesterone-like effect on the body and decrease some of the symptoms of PMS.

The most important way to alter hormone levels may be by eating more phytoestrogens. These plant-derived compounds have an effect similar to estrogen in the body. One of the richest sources of phytoestrogens is soy products, such as tofu. Additionally, many supplements can be found that contain black cohosh (Cimicifugaracemosa ) or dong quai (Angelica sinensis ), which are herbs high in phytoestrogens. Red clover (Trifolium pratense ), alfalfa (Medicago sativa ), licorice (Glycyrrhiza glabra ), hops (Humulus lupulus ), and legumes are also high in phytoestrogens. Increasing the consumption of phytoestrogens is also associated with decreased risks of osteoporosis, cancer , and heart disease.

Antidepressant alternatives

Many antidepressants act by increasing serotonin levels. An alternative means of achieving this result is to eat more carbohydrates. For instance, two cups of cereal or a cup of pasta have enough carbohydrates to effectively increase serotonin levels. An herb known as St. John's wort (Hypericum perforatum ) has stood up to scientific trials as an effective antidepressant. As with the standard antidepressants, however, it must be taken continuously and does not show an effect until used for four to six weeks. There are also herbs, such as skullcap (Scutellaria lateriflora ) and kava (Piper methysticum ), that can relieve the anxiety and irritability that often accompany depression. An advantage of these herbs is that they can be taken when symptoms occur rather than continually. Chaste tree (Vitex agnus-castus ) in addition to helping rebalance estrogen and progesterone in the body, also may relieve the anxiety and depression associated with PMS.

Prognosis

The prognosis for women with both PMS and PMDD is good. Most women who are treated for these disorders do well.

Prevention

Maintaining a good diet, one low in sugars and fats and high in phytoestrogens and complex carbohydrates, may prevent some of the symptoms of PMS. Women should try to exercise three times a week and keep in generally good health. Because PMS is often associated with stress, avoidance of stress or developing better means to deal with stress can be important.

Nutritional concerns

Consuming foods, such as soy products, that are good sources of phytoestrogens may provide relief of PMS symptoms. In general, eating a balanced diet is beneficial.

Parental concerns

Parents should be aware of the symptoms of PMS in their adolescent daughters. The condition is uncommon but can occur in women under the age of 20.

KEY TERMS

Antidepressant drug —A medication prescribed to relieve major depression. Classes of antidepressants include selective serotonin reuptake inhibitors (fluoxetine/Prozac, sertraline/Zoloft), tricyclics (amitriptyline/Elavil), MAOIs (phenelzine/Nardil), and heterocyclics (bupropion/Wellbutrin, trazodone/Desyrel).

Estrogen —Female hormone produced mainly by the ovaries and released by the follicles as they mature. Responsible for female sexual characteristics, estrogen stimulates and triggers a response from at least 300 tissues. After menopause, the production of the hormone gradually stops.

Neurotransmitter —A chemical messenger that transmits an impulse from one nerve cell to the next.

Phytoestrogens —Compounds found in plants that can mimic the effects of estrogen in the body.

Progesterone —The hormone produced by the ovary after ovulation that prepares the uterine lining for a fertilized egg.

Serotonin —A widely distributed neurotransmitter that is found in blood platelets, the lining of the digestive tract, and the brain, and that works in combination with norepinephrine. It causes very powerful contractions of smooth muscle and is associated with mood, attention, emotions, and sleep. Low levels of serotonin are associated with depression.

Resources

BOOKS

Carr, Bruce R., and Karen D. Bradshaw. "Disturbances of Menstruation and Other Common Gynecologic Complaints in Women." In Harrison's Principles of Internal Medicine, 15th ed. Edited by Eugene Braunwald et al. New York: McGraw-Hill, 2001, pp. 295–6.

Jenkins, Renee R. "Menstrual Problems." In Nelson Textbook of Pediatrics, 17th ed. Edited by Richard E. Behrman et al. Philadelphia: Saunders, 2003, pp. 667–70.

Moe, Barbara. PMS (Premenstrual Syndrome). New York: Rosen Publishing Group, 2002.

Premenstrual Syndrome: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. San Diego, CA: Icon Group International, 2004.

Rebar, Robert W., and Gregory E. Erickson. "Menstrual Cycle and Fertility." In Cecil Textbook of Medicine, 22nd ed. Edited by Lee Goldman et al. Philadelphia: Saunders, 2003, pp. 1513–20.

PERIODICALS

Dell, D. L. "Premenstrual Syndrome, Premenstrual Dysphoric Disorder, and Premenstrual Exacerbation of Another Disorder." Clinical Obstetrics and Gynecology 47, no. 3 (2004): 568–75.

Derman, O., et al. "Premenstrual syndrome and associated symptoms in adolescent girls." European Journal of Obstetrics, Gynecology and Reproductive Biology 116, no. 2 (2004): 201–6.

Johnson, S. R., et al. "Premenstrual syndrome, premenstrual dysphoric disorder, and beyond: a clinical primer for practitioners." Obstetrics and Gynecology 104, no. 4 (2004): 845–59.

ORGANIZATIONS

American Society for Reproductive Medicine. 1209 Montgomery Highway, Birmingham, AL 35216–2809. Web site: <www.asrm.com>.

WEB SITES

"Menstruation." National Library of Medicine. Available online at <www.nlm.nih.gov/medlineplus/menstruation.html> (accessed January 8, 2005).

"PMS: What You Can Do to Ease Your Symptoms." American Academy of Family Physicians. Available online at <http://familydoctor.org/x5126.xml> (accessed January 8, 2005).

"Premenstrual Syndrome." Mayo Clinic. Available online at <www.mayoclinic.com/invoke.cfm?id=DS00134> (accessed January 8, 2005).

"Premenstrual Syndrome." The National Women's Health Information Center. Available online at <www.4woman.gov/faq/pms.htm> (accessed January 8, 2005).

"Premenstrual Syndrome." University of Pennsylvania Health System. Available online at <www.obgyn.upenn.edu/pms/pms.html> (accessed January 8, 2005).

L. Fleming Fallon, Jr., MD, DrPH

Premenstrual syndrome

Definition

Premenstrual syndrome (PMS) refers to a compilation of over 150 symptoms that occur between ovulation and the onset of menstruation . The symptoms include both physical symptoms, such as breast tenderness, back pain , abdominal cramps, headache , and changes in appetite; behavioral symptoms such as clumsiness, poor concentration, and sleep problems; as well as psychological symptoms of anxiety, irritability, depression, and unrest. Severe forms of this syndrome are referred to as premenstrual dysphoric disorder (PMDD). These symptoms may be related to hormonal imbalances and emotional disorders.

Description

Between 40-75% of all menstruating women experience symptoms that occur before or during menstruation. PMS encompasses a wide range of symptoms, some as minor as appetite change or others so severe that they may interfere with daily life. Some women experience a beneficial increase in their sexual libido. Only 3-7% of women experience the much more severe premenstrual dysphoric disorder (PMDD). These symptoms can last 4-10 days and can have a substantial impact on a woman.

The reason some women get severe PMS while others have little or none is not understood. PMS symptoms usually begin at puberty and last until menopause . Women more sensitive to hormonal change may experience PMS more than others. Stress is also a huge contributor and the relief of tension often lessens the other symptoms as well. Overall however, it is difficult to predict who is most at risk for PMS.

Causes & symptoms

Because PMS is restricted to the second half of a woman's menstrual cycle, after ovulation, it is thought that hormones play a role. During a woman's monthly menstrual cycle, which lasts from 24-35 days, hormone levels change. The hormone estrogen gradually rises during the first half of a woman's cycle, the pre-ovulatory phase, and falls dramatically at ovulation. After ovulation, the post-ovulatory phase, progesterone levels gradually increase until menstruation occurs. Both estrogen and progesterone are secreted by the ovaries, which are responsible for producing the eggs. The main role of these hormones is to cause thickening of the lining of the uterus (endometrium). However, estrogen and progesterone also affect other parts of the body, including the brain. In the brain and nervous system, estrogen can affect the levels of neurotransmitters, such as serotonin. Serotonin has long been known to have an effect on emotions, as well as eating behavior. It is thought that when estrogen levels go down during the post-ovulatory phase of the menstrual cycle, decreases in serotonin levels follow. Whether these changes in estrogen, progesterone, and serotonin are responsible for the emotional aspects of PMS is not known with certainty. However, most researchers agree that the chemical transmission of signals in the brain and nervous system is in some way related to PMS. This is supported by the fact that the times following childbirth and menopause are also associated with both depression and low estrogen levels.

Nutritional deficiencies, food allergies , and hypoglycemia have been linked with PMS. A diet deficient in essential fatty acids, zinc, magnesium , and vitamin B₆ may affect estrogen and progesterone production and their balance in the body.

Over 150 symptoms for PMS have been identified. These include physical, behavioral, and emotional aspects that range from mild to severe. The physical symptoms include bloating, headaches, food cravings, abdominal cramps, headaches, tension, fatigue, acne , muscle aches, and breast tenderness. Behavioral symptoms may include insomnia, lack of concentration, and clumsiness. Emotional aspects include mood swings, irritability, and depression.

Diagnosis

The best way to diagnose PMS is to review a detailed diary of a woman's symptoms for several months. PMS is diagnosed by the presence of physical, psychological, and behavioral symptoms that are cyclic and occur in association with the premenstrual period of time. PMDD, which is far less common, was officially recognized as a disease in 1987. Its diagnosis depends on the presence of at least five symptoms related to mood that disappear within a few days of menstruation. These symptoms must interfere with normal functions and activities of the individual.

Treatment

There are many treatments for PMS and PMDD depending on the symptoms and their severity. Hypnotherapy , spiritual healing, color therapy, reflexology, Ayurvedic medicine , Chinese herbalism, acupuncture, acupressure, aromatherapy , herbal treatment, Naturopathic treatment, and homeopathy are all therapies that have been used to treat PMS.

Vitamins and minerals

Some women find relief with the use of vitamin and mineral supplements. Magnesium can reduce the fluid retention that causes bloating, while calcium may decrease both irritability and bloating. Magnesium and calcium also help relax smooth muscles, which may reduce cramping. Recent studies indicate that calcium supplements can reduce premenstrual complaints by nearly half. Vitamin E reduces breast tenderness, nervous tension, fatigue, and insomnia. Vitamin B₆ decreases fluid retention, fatigue, irritability, and mood swings. Vitamin B₅ supports the adrenal glands and may help reduce fatigue.

Phytoestrogens and natural progesterone

The Mexican wild yam , Dioscorea villosa, contains a substance that may be converted to progesterone in the body. Because this substance is readily absorbed through the skin, it can be found as an ingredient in many skin creams. (Some products also have natural progesterone added to them.) Some herbalists believe that these products can have a progesterone-like effect on the body and decrease some of the symptoms of PMS.

The most important way to alter hormone levels may be by eating more phytoestrogens. These plant-derived compounds have an effect similar to estrogen in the body. One of the richest sources of phytoestrogens is soy products, such as tofu. Additionally, many supplements can be found that contain black cohosh (Cimicifuga racemosa ) or dong quai (Angelica sinensis ), which are herbs high in phytoestrogens. Red clover (Trifolium pratense ), alfalfa (Medicago sativa ), licorice (Glycyrrhiza glabra ), hops (Humulus lupulus ), and legumes are also high in phytoestrogens. Increasing the consumption of phytoestrogens is also associated with decreased risks of osteoporosis, cancer , and heart disease .

Herbal treatment

Herbal treatment has been used to treat many symptoms of PMS. Herbs to alleviate cramps include angelica root, cramp bark, kava kava , red raspberry, black haw , and rosemary . Black cohosh, peppermint , strawberry leaf, and valerian root have been used to decrease mood swings. Dandelion , couch grass, and hawthorn are effective diuretic herbs used to reduce bloating and swelling. Burdock root and red clover are liver cleansing herbs that can be useful in eliminating excess estrogen from the system. Herbs to balance hormones include blessed thistle , dong quai, false unicorn root, fennel seed, sarsparilla root, and squaw vine. Feverfew may be effective for migraine headaches.

Many herbs may be beneficial as a natural antidepressant. St. John's wort (Hypericum perforatum ) has stood up to scientific trials as an effective antidepressant. As with the standard antidepressants, however, it must be taken continuously and does not show an effect until used for four to six weeks. There are also herbs, such as skullcap (Scutellaria lateriflora ) and kava kava (Piper methysticum ), that can relieve the anxiety and irritability that often accompany depression. An advantage of these herbs is that they can be taken when symptoms occur rather than continually. Chaste-berry tree (Vitex agnus-castus ), in addition to helping rebalance estrogen and progesterone in the body, may also relieve the anxiety and depression associated with PMS.

Aromatherapy

Aromatherapy oils can be a useful adjunct treatment for PMS. Lavender oil reduces headaches, cramps, and painful breasts. Chamomile and sandalwood oils may be used to relieve stress and tension. Premenstrual fatigue may be remedied by geranium, bergamot, and rosemary oils.

Homeopathy

A number of homeopathic remedies may be applied in the treatment of PMS, depending upon the individual's symptoms. Natrum muriaticum may be the appropriate remedy when irritability, lack of self-confidence, depression, anxiety, and headaches are present. Sepia may be given when PMS is accompanied by stress, weepiness, and to calm nerves. Symptoms of indifference, panic attacks, anger, tension, hair loss , sugar cravings, and a reduced sex drive may indicate that Kali carbonicum may be the appropriate remedy.

Allopathic treatment

Allopathic treatments available include over-thecounter anti-inflammatory drugs such as ibuprofen or acetominophen, antidepressant drugs, hormone treatment, or (only in extreme cases) surgery to remove the ovaries. Anti-inflammatory drugs are useful in reducing headaches, muscle aches, and cramping. One recommendation is to begin taking the anti-inflammatory one to two days before the onset of cramps. Doing so will block the cramp-causing hormones, prostaglandins, and may prevent any nausea, vomiting , and diarrhea associated with PMS. Hormone treatment usually involves oral contraceptives. This treatment used to prevent ovulation and the changes in hormones that accompany ovulation. Recent studies, however, indicate that hormone treatment has little effect over placebo.

Antidepressants

Antidepressants prescribed for PMS include sertra-line (Zoloft), fluoxetine (Prozac), and paroxetine (Paxil). They are termed selective serotonin reuptake inhibitors (SSRIs) and act by indirectly increasing the brain serotonin levels, thus stabilizing emotions. Some doctors prescribe antidepressant treatment for PMS throughout the cycle, while others direct patients to take the drug only during the latter half of the cycle. Antidepressants should be avoided by women wanting to become pregnant. Side effects of sertraline were found to include nausea, diarrhea, and decreased libido.

Expected results

The prognosis for women with both PMS and PMDD is good. Most women experience relief from symptoms when treated.

Prevention

Maintaining a good diet, one low in sugars, salt, fats, alcohol, and caffeine , and high in phytoestrogens and complex carbohydrates, may prevent some of the symptoms of PMS. Consumption of more complex carbohydrates may relieve PMS symptoms since carbohydrates drop seratonin levels as they raise insulin levels. For instance, two cups of cereal or a cup of pasta has enough carbohydrate to effectively increase serotonin levels. Carbohydrates also provide steady levels of blood sugar and act to stabilize one's mood. One recommendation is to eat 100 calories of complex carbohydrates every three hours beginning one week before menstruation. Complex carbohydrates include whole wheat bread and pasta, brown rice, and whole grain foods. Caution should be taken due to the fact that a high carbohydrate diet causes water retention, which in turn is a symptom of PMS.

Women should try to exercise three times a week, keep in generally good health, and maintain a positive self image. Because PMS is often associated with stress, avoidance of stress or developing better means to deal with stress can be important. Relaxation techniques, meditation , and yoga practice can aid in stress reduction.

Resources

BOOKS

The Burton Goldberg Group. Alternative Medicine: The Definitive Guide. Fife, WA: Future Medicine Publishing, 1999.

PERIODICALS

Gold, Judith. "Premenstrual Dysphoric Disorder: What's That?" Journal of the American Medical Association 278 (September 24, 1997): 1024-1026.

Hochwald, Lambeth. "Get with the Program. (PMS and Menstrual Care)." Natural Health (January/February 1997): 54-56.

Steiner, M. "Premenstrual Syndromes." Annual Review of Medicine 48 (1997): 447-455.

Jennifer Wurges

Premenstrual Syndrome

Definition

Premenstrual syndrome (PMS) refers to symptoms that occur between ovulation and the onset of menstruation. The symptoms include both physical symptoms, such as breast tenderness, back pain, abdominal cramps, headache, and changes in appetite, as well as psychological symptoms of anxiety, depression, and unrest. Severe forms of this syndrome are referred to as premenstrual dysphoric disorder (PMDD). These symptoms may be related to hormones and emotional disorders.

Description

Approximately 75% of all menstruating women experience some symptoms that occur before or during menstruation. PMS encompasses symptoms severe enough to interfere with daily life. About 3-seven% of women experience the more severe PMDD. These symptoms can last 4-10 days and can have a substantial impact on a woman's life.

The reason some women get severe PMS while others have none is not understood. PMS symptoms usually begin at about age 20-30 years. The disease may run in families and is also more prone to occur in women with a history of psychological problems. Overall however, it is difficult to predict who is most at risk for PMS.

Causes and symptoms

Because PMS is restricted to the second half of a woman's menstrual cycle, after ovulation, it is thought that hormones play a role. During a woman's monthly menstrual cycle, which lasts 24-35 days, hormone levels change. The hormone estrogen gradually rises during the first half of a woman's cycle, the preovulatory phase, and falls dramatically at ovulation. After ovulation, the postovulatory phase, progesterone levels gradually increase until menstruation occurs. Both estrogen and progesterone are secreted by the ovaries, which are responsible for producing the eggs. The main role of these hormones is to cause thickening of the lining of the uterus (endometrium). However, estrogen and progesterone also affect other parts of the body, including the brain. In the brain and nervous system, estrogen can affect the levels of neurotransmitters, such as serotonin. Serotonin has long been known to have an effect on emotions, as well as eating behavior. It is thought that when estrogen levels go down during the postovulatory phase of the menstrual cycle, decreases in serotonin levels follow. Whether these changes in estrogen, progesterone, and serotonin are responsible for the emotional aspects of PMS is not known with certainty. However, most researchers agree that the chemical transmission of signals in the brain and nervous system is in some way related to PMS. This is supported by the fact that the times following childbirth and menopause are also associated with both depression and low estrogen levels.

Symptoms for PMS are varied and many, including both physical and emotional aspects that range from mild to severe. The physical symptoms include: bloating, headaches, food cravings, abdominal cramps, headaches, tension, and breast tenderness. Emotional aspects include mood swings, irritability, and depression.

Diagnosis

The best way to diagnose PMS is to review a detailed diary of a woman's symptoms for several months. PMS is diagnosed by the presence of physical, psychological, and behavioral symptoms that are cyclic and occur in association with the premenstrual period of time. PMDD, which is far less common, was officially recognized as a disease in 1987. Its diagnosis depends on the presence of at least five symptoms related to mood that disappear within a few days of menstruation. These symptoms must interfere with normal functions and activities of the individual. The diagnosis of PMDD has caused controversy in fear that it may be used against women, labeling them as being impaired by their menstrual cycles.

Treatment

There are many treatments for PMS and PMDD depending on the symptoms and their severity. For mild cases, treatment includes vitamins, diuretics, and pain relievers. Vitamins E and B₆ may decrease breast tenderness and help with fatigue and mood swings in some women. Diuretics that remove excess fluid from the body seem to work for some women. For more severe cases and for PMDD, treatments available include antidepressant drugs, hormone treatment, or (only in extreme cases) surgery to remove the ovaries. Hormone treatment usually involves oral contraceptives. This treatment, as well as removal of the ovaries, is used to prevent ovulation and the changes in hormones that accompany ovulation. Recent studies, however, indicate that hormone treatment has little effect over placebo.

Antidepressants

The most progress in the treatment of PMS and PMDD has been through the use of antidepressant drugs. The most effective of these include sertraline (Zoloft), fluoxetine (Prozac), and paroxetine (Paxil). They are termed selective serotonin reuptake inhibitors (SSRIs) and act by indirectly increasing the brain serotonin levels, thus stabilizing emotions. Some doctors prescribe antidepressant treatment for PMS throughout the cycle, while others direct patients to take the drug only during the latter half of the cycle. Antidepressants should be avoided by women wanting to become pregnant. A recent clinical study found that women who took sertraline had a significant improvement in productivity, social activities, and relationships compared with a placebo group. Side effects of sertraline were found to include nausea, diarrhea, and decreased libido.

Alternative treatment

There are alternative treatments that can both affect serotonin and hormone responses, as well as affect some of the physical symptoms of PMS.

Vitamins and minerals

Some women find relief with the use of vitamin and mineral supplements. Magnesium can reduce the fluid retention that causes bloating, while calcium may decrease both irritability and bloating. Magnesium and calcium also help relax smooth muscles and this may reduce cramping. Vitamin E may reduce breast tenderness, nervous tension, fatigue, and insomnia. Vitamin B₆ may decrease fluid retention, fatigue, irritability, and mood swings. Vitamin B₅ supports the adrenal glands and may help reduce fatigue.

Phytoestrogens and Natural Progesterone

The Mexican wild yam (Dioscorea villosa ) contains a substance that may be converted to progester-one in the body. Because this substance is readily absorbed through the skin, it can be found as an ingredient in many skin creams. (Some products also have natural progesterone added to them.) Some herbalists believe that these products can have a progesterone-like effect on the body and decrease some of the symptoms of PMS.

The most important way to alter hormone levels may be by eating more phytoestrogens. These plant-derived compounds have an effect similar to estrogen in the body. One of the richest sources of phytoestrogens is soy products, such as tofu. Additionally, many supplements can be found that contain black cohosh (Cimicifugaracemosa ) or dong quai (Angelica sinensis ), which are herbs high in phytoestrogens. Red clover (Trifolium pratense ), alfalfa (Medicago sativa ), licorice (Glycyrrhiza glabra ), hops (Humulus lupulus ), and legumes are also high in phytoestrogens. Increasing the consumption of phytoestrogens is also associated with decreased risks of osteoporosis, cancer, and heart disease.

Antidepressant Alternatives

Many antidepressants act by increasing serotonin levels. An alternative means of achieving this is to eat more carbohydrates. For instance, two cups of cereal or a cup of pasta have enough carbohydrates to effectively increase serotonin levels. An herb known as St. John's wort (Hypericum perforatum ) has stood up to scientific trials as an effective antidepressant. As with the standard antidepressants, however, it must be taken continuously and does not show an effect until used for 46 weeks. There are also herbs, such as skull-cap (Scutellaria lateriflora ) and kava (Piper methysticum ), that can relieve the anxiety and irritability that often accompany depression. An advantage of these herbs is that they can be taken when symptoms occur rather than continually. Chaste tree (Vitex agnuscastus ) in addition to helping rebalance estrogen and progesterone in the body, also may relieve the anxiety and depression associated with PMS.

Prognosis

The prognosis for women with both PMS and PMDD is good. Most women who are treated for these disorders do well.

Prevention

Maintaining a good diet, one low in sugars and fats and high in phytoestrogens and complex carbohydrates, may prevent some of the symptoms of PMS. Women should try to exercise three times a week, keep in generally good health, and maintain a positive self image. Because PMS is often associated with stress, avoidance of stress or developing better means to deal with stress can be important.

Resources

PERIODICALS

Yonkers, Kimberly A., et al. "Symptomatic Improvement of Premenstrual Dysphoric Disorder with Sertraline Treatment: A Randomized Controlled Trial." Journal of the American Medical Association 278 (September 24, 1997): 983-989.

KEY TERMS

Antidepressant— A drug used to control depression.

Estrogen— A female hormone important in the menstrual cycle.

Neurotransmitter— A chemical messenger used to transmit an impulse from one nerve to the next.

Phytoestrogens— Compounds found in plants that can mimic the effects of estrogen in the body.

Progesterone— A female hormone important in the menstrual cycle.

Serotonin— A neurotransmitter important in regulating mood.

Premenstrual Syndrome

Premenstrual syndrome (PMS) is characterized by emotional and physical symptoms that can be troubling and cause moderate discomfort for women the week or two before the onset of their menstrual cycle. PMS is estimated to affect up to 40 percent of reproductive-aged women. Approximately 5 to 10 percent of these women experience symptoms so severe that it totally impairs their everyday lifestyle . This severe form of PMS is known as premenstrual dysphoric disorder (PMDD). The precise etiology of PMS is still unknown; however, it is increasingly believed that the sensitive equilibrium between female sex steroids (the hormones estrogen and progesterone) and neurotransmitters in the brain is altered in women with PMS.

With a wide range of symptoms, both emotional and physical, the first step in successfully treating PMS is for a woman to recognize the changes in her body and mood. Keeping a close record of symptoms, their severity, and the dates they occur within the menstrual cycle is an important tool. Discussing this with a gynecologist can lead to a very successful treatment plan.

Symptoms

A woman is diagnosed with premenstrual syndrome if she has at least one emotional and one physical symptom during the five days before the onset of her period for three consecutive menstrual cycles . The specific symptom is not as important for diagnosis as is the cyclic fashion in which it appears. Emotional symptoms include minor fatigue , depression , angry outbursts, irritability, anxiety , confusion, social withdrawal, mood swings, and crying spells. Physical symptoms include headaches, bloating, acne, appetite changes and cravings, breast tenderness, and swelling of extremities.

Treatments

Diet.

To help alleviate the symptoms of PMS, many treatments, both traditional and alternative, are being sought by thousands of women daily. According to some experts, the majority of PMS symptoms are a result of hormonal imbalances where there is too much estrogen in the body in comparison with the amount of progesterone. Studies have shown that a number of foods, such as, soy, vegetables and fruit, and nuts and seeds can actually help with hormonal balance. PMS sufferers are advised to increase their intake of fruits, vegetables, whole grains, low-fat dairy products and omega-3 fatty acids (mostly found in seafood and nuts). Eating small, frequent meals at the same time each day can help reduce bloating and fullness.

Several clinical trials have shown that supplementation of calcium and magnesium can play a crucial role in the prevention of PMS. Nine hundred to 1,200 milligrams of calcium per day was found to be effective in reducing food cravings and mood swings, and 200 to 500 milligrams of magnesium reduced bloating and breast tenderness. Studies of vitamin B₆ and vitamin E intake have had varied results. A daily multivitamin-mineral supplement is believed to be beneficial for all PMS sufferers.

Besides additions to the diet, it is suggested that women suffering from PMS should avoid caffeine, in the form of soft drinks, coffee, or chocolate; refined sugars; sodium; and saturated fats. Drinking plenty of water is a complement to cutting back on sodium. The effects of alcohol are usually magnified in premenstrual women, and therefore it is also advised that alcohol consumption be decreased or stopped totally.

Exercise.

Scientific studies have shown that any type of physical exercise can help improve mood, decrease anxiety, and reduce stress reactions. As little as twenty to thirty minutes of aerobic type exercise three to five times a week, such as brisk walking, has shown to decrease some PMS symptoms. Some studies have also shown that doing nonaerobic exercises may also work, but to a smaller degree.

Complementary Medicine.

Based on some preliminary scientific research, the herb chasteberry, also known as vitex agnus-castus, has been shown to relieve several PMS symptoms. According to a clinical trial, reported in January 2001 in a European scientific journal, more than half the women who received 20-milligram chasteberry tablets had a significant improvement in all their symptoms except bloating. Black cohosh and evening primrose oil are other herbs that are gaining popularity, though studies to date are inconclusive.

Some studies have shown that women with PMS who are treated with bright-light therapy can have a substantial improvement in their mood. Bright-light therapy consists of sitting under a bright light of predetermined intensity for thirty minutes for one to two weeks before the onset of a menstrual cycle.

Many other alternative treatments are being explored for relieving PMS symptoms. To date, reflexology, massage therapy, and acupuncture are in the forefront of potential alternative treatments; however, future studies are needed to confirm their overall effectiveness.

Pharmacologic. Since premenstrual symptoms are thought to be related to the changing levels of estrogen and progesterone, these hormones were among the first to be tested as a possible treatment. Although some early research reported positive findings, more recent studies have revealed that progesterone, whether natural of artificial, is not successful in the management of PMS.

A form of pharmacologic treatment that has shown positive results is the suppression of ovulation, which eliminates both the cyclic rhythm of hormone production and eliminating cyclic mood symptoms. The most common medications used for ovulation suppression are gonadotropinreleasing hormone (GnRH) agonists. Currently, the use of GnRH agonists is experimental; however, studies have shown that 75 percent of women treated with GnRH agonists have experienced reductions in tension, depression, mood swings, and breast tenderness.

Evidence from numerous controlled trials has clearly demonstrated that low-dose selective serotonin reuptake inhibitors (SSRIs) also have excellent efficacy with minimal side effects in treating women with severe PMS symptoms. SSRIs are a group of medications primarily used in treating depression and anxiety disorders. These medications have been shown to be best taken during the luteal phase of the menstrual cycle only.

Conclusion

Premenstrual syndrome, and its effect on millions of women, received a lot of attention during the 1990s, and many treatment modalities have emerged. The first step is for a woman to identify her symptoms and seek professional help. Through many available treatments, both traditional and alternative, and lifestyle changes such as diet and exercise, women no longer have to suffer so severely on a monthly basis. Research in this area is still needed, however, and more treatments need to be explored.

see also Cravings; Mood-Food Relationships; Women's Nutritional Issues.

Keri M. Gans

Bibliography

Dell, Diana, and Svec, Carol (2003). The PMDD Phenomenon: Breakthrough Treatments for Premenstrual Dysphoric Disorder (PMDD) and Extreme Premenstrual Syndrome (PMS). New York: McGraw-Hill.

Northrup, Christiane (1998). Women's Bodies, Women's Wisdom. New York: Bantam.

Internet Resources

American College of Obstetricians and Gynecologists. "Dealing with PMS." Spotlight on Women's Health. Available from <http://www.acog.com>

Mayo Clinic. "Premenstrual Syndrome." Available from <http://www.mayclinic.com>

National Association for Premenstrual Syndrome. Available from <http://www.pms.org.uk/>

Nusbaum, Murray, and Schwarz, Richard. "Coping with PMS." American College of Obstetricians and Gynecologists. Available from <http://www.acog.com>

Lichten, Edward M. "Medical Treatment of Premenstrual Syndrome." Available from <http://www.usdoctor.com/pms.htm>

Premenstrual syndrome (PMS)

Symptoms that occur several days before the onset, and sometimes during the first day of, menstruation.

Premenstrual syndrome (PMS) exhibits both physiological and psychological symptoms. The primary physiological symptoms are water retention and bloating, slightly enlarged and tender breasts, and food cravings. Psychological symptoms include irritability and depression . The full range of symptoms that have been attributed to PMS is extremely broad: as many as 150 have been identified. Because the symptoms are so varied from one woman to another (and even within the same woman at different times) it has been very difficult to arrive at a clinical definition of PMS. In addition, researchers disagree over whether PMS consists solely of symptoms that disappear completely at the onset of menstruation or of the premenstrual intensification of symptoms or conditions that are present, although to a lesser degree, during the rest of the month. Most women with premenstrual syndrome typically suffer from more than one symptom during each menstrual cycle.

Although there is no conclusive evidence that PMS is caused by hormone imbalances, some women have been successfully treated by hormonal therapy, which consists of oral contraceptives and monthly injections of progesterone. Recent research has linked premenstrual syndrome to an inadequate number of progesterone receptors or to the failure of those receptors to function properly, suggesting that PMS may be a disorder of progesterone response rather than progesterone deficiency. Other studies have posited a link between PMS and brain opioid (opiate-like) activity, based on alleged similarities between the symptoms of PMS and those of heroin withdrawal. Regular aerobic exercise, which helps stabilize opioid levels in the brain, has been shown to decrease PMS.

The physiological effects of PMS can be reduced through natural means, including stress management, dietary changes, acupressure massage, yoga, regular exercise, and adequate rest. Nutritional supplements, such as vitamins A, E, and B-6 have been shown to aid in the treatment of PMS, as have calcium and magnesium. Some physicians prescribe diuretics to treat water retention or tranquilizers for the treatment of irritability and mood swings. Recent research has suggested that drugs which increase the brain's serotonin levels, such Prozac, may also be helpful in treating PMS.

Although PMS has received much attention from the medical establishment, some women's health experts believe that its severity and significance have been exaggerated, and claim that only a small percentage of women have premenstrual symptoms so disabling that it interferes with work or other aspects of their lives. They also contend that the increased awareness of PMS contributes to a cultural bias that disproportionately attributes a woman's fluctuations in mood to her menstrual cycle, when the moods of both males and females will fluctuate within the course of a month for many reasons—both physiological and environmental—that have nothing to do with menstruation. In a recent investigation into the link between a woman's psychological characteristics and premenstrual syndrome, it was noted that whether or not women report PMS has less to do with the number and severity of their actual symptoms than with their general outlook on life, including levels of self-esteem and the ability to express feelings and manage stress.

Further Reading

Dalton, Katharina. PMS: the Essential Guide to Treatment Options. London, Eng.: Thorsons, 1994.

PMS: It's Not in Your Head. [videorecording] Omaha, NB: Envision Communications, 1993.

premenstrual syndrome (PMS), any of various symptoms experienced by women of childbearing age in the days immediately preceding menstruation . It is most common in women in their twenties and thirties. Some 70%-90% of menstruating women are said to have PMS on a cyclical basis. There are over 150 symptoms associated with the syndrome, including behavioral changes, eating binges, moodiness, irritability, fatigue, fluid retention, breast tenderness, and headaches. Some women have mild symptoms; others have symptoms that interfere with work or home life. A few are completely incapacitated, a condition called premenstrual dysphoric disorder. The symptoms vary from woman to woman, and each woman's symptoms may vary from month to month, making diagnosis difficult.

The exact cause is unknown. Hormonal imbalances, nutritional deficiencies, and neurotransmitter ( serotonin and norepinephrine ) fluctuations are being studied. PMS patients who have had hysterectomies may continue to have symptoms, but the symptoms in all patients disappear with menopause . There is no cure for PMS. In some women, dietary changes and exercise provide some relief through the loss of water weight, the alleviation of stress, and an increase in the production of endorphins . Antidepressants or antianxiety drugs are sometimes prescribed. In severe cases hormones that induce a premature menopause may be administered.

Bibliography: See publications of the National Institute of Child Health and Human Development; S. D. Bender, PMS: A Positive Program to Gain Control (1986) and PMS: Questions & Answers (1989); Boston Women's Health Book Collective, Our Bodies, Ourselves for the New Century (1998).

premenstrual syndrome (PMS) (pree-men-stroo-ăl) n. a group of symptoms experienced in varying degrees by women of reproductive age in the week before menstruation. These include altered mental stability, fatigue, bloating, breast tenderness, and headaches. Treatments include stress management, salt restriction and low-dose diuretics to relieve fluid retention, and analgesia for aches and pains; hormone therapy (progestogens, oral contraceptives, and gonadorelin analogues) may be required.
www.pms.org.uk Website of the National Association for Premenstrual Syndrome

pre·men·stru·al syn·drome (abbr.: PMS) • n. any of a complex of symptoms (including emotional tension and fluid retention) experienced by some women in the days immediately before menstruation.