Premenstrual Syndrome
Premenstrual syndrome (PMS) is a group of physical and psychologic symptoms that occur before a menstrual period begins.
Because so many monthly symptoms, such as bad mood, irritability, bloating, and breast tenderness, have been ascribed to PMS, defining and identifying PMS can be difficult. PMS affects 20 to 50% of women. About 5% of women of reproductive age have a severe form of PMS called premenstrual dysphoric disorder.
PMS may occur partly because estrogen and progesterone levels fluctuate during the menstrual cycle. Also, in some women with PMS, progesterone may be broken down differently. Progesterone is usually broken down into two components that have opposite effects on mood. Women with PMS may produce less of the component that tends to reduce anxiety and more of the component that tends to increase anxiety.
Symptoms and Diagnosis
The type and intensity of symptoms vary from woman to woman and from month to month in the same woman. The various physical and psychologic symptoms of PMS can temporarily upset a woman's life.
Symptoms may begin a few hours up to about 14 days before a menstrual period, and they usually disappear completely after the period begins. Women who are approaching menopause may have symptoms that persist through and after the menstrual period. The symptoms of PMS are often followed each month by a painful period (dysmenorrhea), particularly in teenagers.
Other disorders may worsen while PMS symptoms are occurring. Women who have a seizure disorder may have more seizures than usual. Women who have a connective tissue disease, such as lupus or rheumatoid arthritis, may have flare-ups. Respiratory disorders (such as allergies and congestion of the nose and airways) and eye disorders (such as conjunctivitis) may worsen.
In premenstrual dysphoric disorder, premenstrual symptoms are so severe that they interfere with work, social activities, and relationships.
The diagnosis is based on symptoms. To identify it, doctors ask a woman to keep a daily record of her symptoms. This record helps the woman be aware of changes in her body and moods and helps doctors determine what treatment is best. Premenstrual dysphoric disorder cannot be diagnosed until a woman has recorded her symptoms for at least two menstrual cycles. Doctors can distinguish premenstrual syndrome and premenstrual dysphoric disorder from mood disorders, such as depression, because the symptoms disappear soon after the menstrual period begins.
 See the sidebar Symptoms of Premenstrual Syndrome.
Treatment
Treatment involves relieving symptoms. Reducing the intake of salt often reduces fluid retention and relieves bloating. Diuretics (which help the kidneys eliminate salt and water from the body) may be prescribed to help reduce the buildup of fluid. For most women who have mild to moderate symptoms, exercise and stress reduction techniques (meditation or relaxation exercises) help relieve nervousness and agitation. Reducing the consumption of beverages and foods containing caffeine (including chocolate) may also help. Taking calcium supplements (1,000 milligrams a day) lessens the physical and emotional symptoms of PMS. There are claims that other supplements such as magnesium and the B vitamins, especially B6 (pyridoxine), taken daily, lessen symptoms. However, the usefulness of these supplements has not been confirmed. Taking vitamin B6 in high doses may be harmful. Nerve damage has been reported with as little as 200 milligrams a day.
Taking nonsteroidal anti-inflammatory drugs (NSAIDs) (see Section 6, Chapter 78) may help relieve headaches, pain due to abdominal cramps, and joint pain. Taking combination oral contraceptives (birth control pills that contain estrogen and a progestin) reduces pain, breast tenderness, and changes in appetite in some women but worsens these symptoms in a few. Taking oral contraceptives that contain only a progestin does not help.
Women who have more severe symptoms may benefit from taking fluoxetine, paroxetine, or sertraline, which are antidepressants (see Section 7, Chapter 101). They are most effective for reducing irritability, depression, and some of the other psychologic and physical symptoms of PMS. Buspirone or alprazolam (both antianxiety drugs) may reduce irritability and nervousness and help reduce stress. However, taking alprazolam can result in drug dependency. Doctors may ask a woman to continue keeping a record of her symptoms so that they can judge the effectiveness of treatment.
Women who have premenstrual dysphoric disorder may benefit from taking antidepressants. Taking a gonadotropin-releasing hormone (GnRH) agonist (such as leuprolide or goserelin (see Section 22, Chapter 245)), given by injection, plus estrogen, given in a low dose by mouth or patch, may control symptoms. GnRH agonists cause the body to produce less estrogen and progesterone.
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