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.

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: http://www.asrm.com.

WEB SITES

"Menstruation." National Library of Medicine. Available online at http://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 http://www.mayoclinic.com/invoke.cfm?id=DS00134 (accessed January 8, 2005).

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

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

L. Fleming Fallon, Jr., MD, DrPH