Premenstrual syndrome (PMS)

Premenstrual syndrome (PMS) describes a range of physical and psychological symptoms that can occur in the two weeks before a woman has her period (also known as menstruation).

Most women experience some level of symptoms due to PMS in the two weeks before their period begins. Symptoms generally improve within a day or so of a period starting.

While PMS symptoms are generally relatively mild and manageable, for some women they can be severe to the point where they cause distress and disrupt normal activities.

Signs and symptoms

PMS can have a wide range of symptoms.

Physical symptoms of PMS can include:

• Digestive problems, including constipation and diarrhea;
• Feeling bloated, fluid retention and weight gain;
• Tenderness and swelling of the breasts;
• Joint and muscle pain;
• Acne;
• Headaches and migraines;
• Increased appetite and cravings for food;
• Increased sensitivity to noise, light and touch;
• A lack of energy or fatigue, and;
• Sleeping problems (either difficulty getting to sleep or increased sleepiness).

Psychological symptoms can include:

• Mood swings, particularly feeling close to tears;
• A depressed mood and feelings of hopelessness and being overwhelmed;
• A decreased interest in normal activities;
• Anxiety and tension;
• Anger and irritability that may include increased conflict with others, and;
• Difficulty concentrating.

Causes

A menstrual cycle lasts an average of 28 days, although it can be longer or shorter in different women and vary with each cycle. Control of the menstrual cycle is complex, involving a range of glands and hormones.

In every cycle, about two weeks before the period begins, an egg (ovum) is released from the ovaries. This is called ovulation. Following ovulation, the ovaries release hormones called progesterone and estrogen. These help to prepare and maintain the lining of the uterus so an egg can attach to it if it is fertilized.

If a pregnancy doesn't occur and an egg does not attach, the hormone levels reduce. The uterus sheds its lining and the period begins.

The cause of PMS has not been clearly established. Some research suggests that the changes in levels of female sex hormone levels (such as estrogen and progesterone) are much the same in women who experience significant levels of PMS symptoms and those that don't. It may be that women who experience greater levels of symptoms are more sensitive to changes in hormone levels.

The menstrual cycle. 

Types

Premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) is a severe form of PMS. Around 8% of all women are affected by PMDD.

While the symptoms in PMDD are similar to PMS, they tend to:

• Be more severe;
• Be more psychological than physical, and;
• Cause significant distress and disruption to a woman's lifestyle.

In severe cases of PMDD, some women may experience suicidal thoughts. If you or someone else is in immediate danger of suicide, you can call 911.

Other ways of finding help include:

• Making an appointment with a general practitioner;
• Going to the emergency department of your local hospital;
• Calling a mental health helpline (look under Support Services for numbers), and;
• Calling mental health professionals or counsellors who already provide care for you.

Methods for diagnosis

There is no single test for PMS. Diagnosis is made slightly more complex because:

• Symptoms that occur in PMS can occur in a number of other medical conditions and mental health disorders. These can include thyroid problems (hypothyroidism and hyperthyroidism) and anemia, and;
• Other health conditions can worsen with PMS and may also require treatment. These can include migraine, irritable bowel syndrome and chronic fatigue syndrome.

Your doctor will ask questions about your medical history, your mental health history and your symptoms. You may be asked to keep a diary in which you record your symptoms for a number of months, so that it can be clearly established that your symptoms are worse in the couple of weeks before your period.

Other tests may include:

• Blood tests to identify medical conditions such as anemia and thyroid problems, and;
• A physical examination including a pelvic examination.

Your doctor may refer you to a mental health specialist for assessment.

Types of treatment

Depending on the severity of your symptoms, a number of approaches to treating PMS may be recommended.

Lifestyle changes

If your PMS symptoms are mild, they may be alleviated or managed by a range of lifestyle measures.

Diet

There are a number of dietary changes you can make to help reduce PMS symptoms:

• Bloating can be reduced by eating smaller amounts of food more frequently, rather than large meals;
• Limit foods high in salt that can promote bloating and fluid retention;
• Limit the amount of alcohol and caffeine you consume, because these can affect your mood and energy levels;
• Consume calcium-rich foods because a lack of calcium can make symptoms of PMS worse. Foods high in calcium include dairy foods, leafy green vegetables, fish, nuts and seeds and various foods that are fortified with calcium;
• Limit foods high in sugar and fat, as these can contribute to weight gain, and;
• Consume vegetables, fruits and wholegrain foods that supply nutrients and complex carbohydrates for longer-lasting energy.

Supplements

If you are unable to get sufficient calcium through the foods you consume, your doctor may recommend a calcium supplement.

Pyroxidine (vitamin B6) and magnesium may be of some benefit for some women with PMS. Your doctor can discuss whether supplements are suitable for you.

Physical activity

Regular physical activity can help to reduce stress and improve symptoms of depression and anxiety. Thirty minutes a day of moderately vigorous exercise (such as walking, cycling or swimming) can offer a range of health benefits.

Physical activity can alleviate symptoms of premenstrual syndrome. 

Complementary therapies

A range of complementary therapies may be helpful for some women in reducing stress, which can worsen symptoms of PMS. Examples include meditation and self-hypnosis.

There is evidence that a herb called vitex agnus castus (also known as chasteberry) may be helpful in reducing symptoms of PMS. A range of other dietary supplements have been suggested for relieving PMS, including evening primrose oil, black cohosh and ginkgo biloba. Evidence does not show that these are effective. Herbal supplements can also interact with other medications, so it is important to discuss them with your doctor before you start herbal medications.

Psychological therapies

Psychological therapy is sometimes referred to as 'talking therapy' and describes the process of treating mental health problems by helping people to understand their condition and manage their symptoms.

Therapies such as cognitive behavior therapy may be helpful for women with PMS or PMDD to alleviate anxiety, depression and stress.

Medication

If lifestyle and other measures cannot alleviate the symptoms of PMS effectively, medications may be recommended.

Antidepressants

Antidepressants are the most common medications prescribed for PMS. Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine and sertraline have been found to be effective in treating symptoms of PMS and PMDD. They increase levels of serotonin, a chemical messenger in the brain that helps to elevate mood. SSRIs may be taken every day, or they may be taken only during the two weeks of the menstrual cycle when symptoms occur.

Other antidepressant medications may be recommended if SSRIs are not effective.

Oral contraceptives

Oral contraceptives, such as the Pill, can stop ovulation and improve some symptoms of PMS for some women, although they are not effective for everyone and can also cause side effects that are similar to PMS, such as depression and breast tenderness.

Contraceptive medications are taken every day. They generally have an active version (taken for 21 days) and an inactive version (taken for seven days) so that you have a period.

Oral contraceptives also prevent pregnancy and it is important to take them as recommended by your doctor or they may not be fully effective.

Oral contraceptives can improve some symptoms of PMS. 

Gonadotrophin-releasing hormone (GnRH) analogues

These medications stop ovulation and stop the ovaries from producing estrogen and progesterone. They effectively create an artificial and temporary menopause and can cause menopause-like symptoms such as vaginal dryness and hot flushes.

GnRH analogues are delivered by injections and are generally only recommended if all other treatments are not effective. You may also be recommended hormone replacement therapy (HRT) if you are using these medications on an extended basis.

Prognosis

Most women can manage symptoms of PMS with lifestyle measures. For severe symptoms, medications can help. Symptoms of PMS generally improve after menopause.

Prevention

The lifestyle measures listed above may help to prevent some PMS symptoms.