Family doctor

Overview

• PMS affects up to 80 percent of women but only about five percent are severely debilitated by it.
• It was officially recognised by the medical community in 1931.
• PMS is believed to be the result of sex hormone changes or alterations of chemicals in the brain after ovulation but there is no evidence to prove this.
• PMS can lead to severe depression if left untreated, and suicidal tendencies in rare cases.
• It can be treated with dietary changes, counselling, exercise, prescription or non-prescription medicines.

What is it?

Premenstrual syndrome (PMS) was first recognised by the medical community in 1931 but there have been descriptions of the disorder since ancient Greece.

For PMS to be diagnosed as a medical problem, the symptoms must interfere with a woman's social life and work.

A variation of PMS, known as premenstrual dysphoric syndrome, is characterised by severe symptoms which have a negative impact on a woman's lifestyle and functioning. In worst cases it can lead to suicidal tendencies.

Up to 80 percent of women will experience some symptoms of PMS. However, only five to 10 percent are thought to be severely affected. PMS can lead to serious depression if left untreated.

Several theories are suggested to explain PMS, however none of these have been proven. Studies of medical treatment for PMS also show inconsistent results.

One theory suggests reduction in sex hormones following ovulation is responsible for PMS. Another links changes in neurotransmitters in the brain such as serotonin and tryptophan (responsible for mood and emotion) to the disorder. A third theory suggests the brain chemicals, opioid peptides, which affect people's moods, fluctuate in response to the hormones produced by the ovaries.

PMS symtoms which begin the late 30s and early 40s may be linked to a reduction in male hormones in women. Androgen levels fall in women with age, so that by the time they are in their 40s, the level of testosterone is about half the level of women in their 20s.

What are the symptoms?

The syndrome is a combination of psychological, emotional and physical changes around the time of ovulation (mid-cycle) which continue until the start of menstruation.

Symptoms may start anytime after ovulation which is around day 14 of the menstrual cycle. In most cases the symptoms end at the start of menstruation, but in some instances they continue until the end of the period.

Women usually experience mood swings, are easily aggravated, and may seem depressed, tense, and oversensitive.

Emotional symptoms include:

• Anger
• Aggression
• Crying
• Memory problems
• Insomnia
• Nervousness
• Lack of concentration
• Withdrawal

Physical changes involve bloating (fluid retention), tiredness, breast tenderness, acne and food cravings.

Other physical symptoms include:

• Constipation
• Diarrhoea
• Dizziness
• Headache
• Migraine
• Muscle aches
• Hot flushes
• Heart palpitations
• Weight gain

It should be noted that the above symptoms may be associated with many different medical conditions and are not specific to PMS.

How is PMS diagnosed?

PMS is normally diagnosed by excluding other medical conditions, including menopause in middle-aged women. A thorough patient history and physical examination is able to rule out most other possible medical conditions.

A diary is often used to document the symptoms of PMS throughout the menstrual cycle. For PMS to be diagnosed there must be a 30 percent increase in symptoms following ovulation (two weeks before menstruation) and a marked improvement after the start of the woman's period.

A diary helps to distinguish PMS from other disorders such as depression, irritable bowel syndrome, or hypothyroidism (under active thyroid) which may be present throughout a woman's menstrual cycle.

If there is no symptom-free interval following the onset of menstruation, then it is likely another medical condition is responsible for the symptoms.

The diary is normally used over a two to three month period, rating symptoms according to a simple scale at the same time each day.

A diagnosis of PMS is made when the following factors are observed:

• No other conditions can explain the symptoms
• The diary of symptoms shows a marked increase in severity over at least two menstrual cycles
• A symptom-free interval of at least a week is experienced during each cycle
• The woman's work and lifestyle are impacted by the syndrome

What can be done to help?

Treatment can involve dietary changes, exercise, counselling, non-prescriptions medicines such as vitamins, or prescription drugs such as nonsteroidal anti-inflammatories or diuretics.

Diet:

Avoiding some foods before your period may be helpful. Things to avoid include:

• Salt
• Caffeine
• Smoking
• Alcohol
• Animal fats
• Dairy products

Exercise:

Exercise can help to relieve the tension and anxiety associated with PMS. It also appears to release endorphins responsible for a "natural high".

Try to do 30 minutes of exercise five times a week. Regular exercise is the key to limiting the effects of PMS.

Non-prescription alternatives:

The following vitamins, minerals, and interventions may be useful for women with mild PMS:

• Magnesium
• Zinc
• Calcium
• Evening Primrose Oil
• Vitamin A
• Vitamin E
• Vitamin B6
• Acupuncture
• Reflexology

A dose of 50 mg of vitamin B6 once or twice a day is sometimes recommended to help relieve symptoms of PMS.

St John's Wort is not considered to be an effective treatment for PMS because it can induce mania and blood pressure changes.

Prescription medicines:

Several medicines can be trialed in the treatment of PMS. These include pain killers, diuretics, hormone treatments, antidepressants, and oral contraceptives. What suits one women may not suit another and several treatments may need to be tried before a successful drug is found.

Pain killers - The most effective pain killers are thought to be nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen and mefenamic acid.

Diuretics - These are used to increase the rate of urine production and thereby reduce the level of fluid retention (bloating). They may have effects and their use is generally not advisable.

Oral contraceptives - These are sometimes prescribed to relieve PMS. However, only about 25 percent of women treated find them beneficial. Fifty percent do not notice any difference and some women complain of worse symptoms, particularly those with a history of depression. Oral contraceptive pills should be used in the treatment of PMS with caution.

Hormone therapy - Gonadotropin-releasing hormone agonists (GnRH), danazol and estradiol are sometimes should to relieve PMS over the short-term. Their long-term use is not advised because long-term side effects are not known. They also reduce bone density.

Antidepressants - These work by increasing the brain chemicals affected by ovulation, and serotonin reuptake inhibitors (i.e. Prozac) are increasingly used to treat irritability and depression related to PMS. Studies are looking at whether these drugs can be used in the premenstrual phase alone. The recommended starting dose is lower for PMS than in the treatment of depression. These drugs are not effective at reducing any physical symptoms of PMS such as bloating.

Fluoxetine (Prozac) has so far been shown to be effective at 20mg, with a 52 percent improvement compared to placebo. Some doctors prescribe it from day 15 to 28 of the cycle.

Sedatives - Benzodiazepines have been used in women with anxiety linked to PMS. However, there is no evidence that these drugs are effective in the management of the condition, and they carry a risk of addiction.

In general, medication should be trialed over two to three menstrual cycles to see if there is any improvement. Studies estimate that medication begins to work from between two and four months.

Treatment recommendations continue to change with new research findings. Currently serotonin reuptake inhibitors (SSRIs) are recommended if there are significant psychological problems. NSAIDs are used if the symptoms mainly involve physical signs such as breast tenderness and bloating, and if dietary changes, vitamins and exercise have not relieved symptoms after two or three months.

Getting help

Speak to your family doctor if you are experiencing problems with PMS. Your doctor will be able to help establish a diagnosis and recommend appropriate treatment.