Premenstrual syndrome

Premenstrual Syndrome (PMS)

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Premenstrual Syndrome (PMS)

PMS is also sometimes known as Premenstrual Tension (PMT). One in three women suffers discomforting symptoms in the days before their period. For one in 20 the symptoms are bad enough to more seriously affect their lives.

Most women feel physical or mood changes during the days before menstruation. When these changes affect a woman’s normal life, they are known as premenstrual syndrome (PMS). Premenstrual syndrome can affect menstruating women of all ages and backgrounds. The cause of PMS is unclear. However, the symptoms can be managed in many women.


The American College of Obstetricians and Gynecologists defines the period which occurs approximately five days before menstruation and ends in a few days after menstruation starts and is accompanied by physical and psychological symptoms as premenstrual syndrome (PMS). The late twenties and mid-fifties are the periods when PMS is seen commonly

PMS encompasses a vast array of psychological symptoms such as depression, anxiety, irritability, loss of confidence and mood swings. There are also physical symptoms, typically bloatedness and mastalgia. It is the timing, rather than the types of symptoms, and the degree of impact on daily activity that supports a diagnosis of PMS. The character of symptoms in an individual patient does not influence the diagnosis. In order to differentiate physiological menstrual symptoms from PMS, it must be demonstrated that symptoms cause significant impairment to the individual during the luteal phase of the menstrual cycle.

The Menstrual Cycle

Menstruation is a normal, monthly process. To understand PMS, it helps to know how the menstrual cycle works. This will help you to predict and cope with the symptoms. The average menstrual cycle lasts about 28 days. Normal cycles can range from 21–35 days. During the menstrual cycle, the ovaries produce hormones. These hormones are called estrogen and progesterone. Day 1 of the cycle is the first day of a period.

On about day 5, estrogen causes the lining of the uterus to begin to build up to prepare for a pregnancy.

On about day 14, one of the ovaries releases an egg. This is called ovulation. After ovulation, progesterone levels increase. If the egg is not fertilized by a sperm, the hormone levels decrease. This signals the uterus to shed its lining on about day 28 of the cycle. This shedding, or menstruation, marks the start of a new cycle.


There are more than 100 recognised symptoms linked to PMS, but most women only experience a handful of them. Symptoms can be both psychological (mental) and physical. The most common are:

Psychological PMS Symptoms

• Irritability and mood swings

• Loss of confidence

• Feeling angry

• Feeling upset and emotional

• Depressed mood

• Tearfulness

• Anxiety

• Tiredness

• Poor concentration

• Restlessness

Physical PMS Symptoms

• Weight gain

• Abdominal bloating

• Tender and lumpy breasts

• Swollen ankles

• Headaches

• Backaches

• Skin changes and acne

• Upset stomach

• Insomnia

• Tiredness

• Joint aches

• Dizziness

Behavioural PMS Symptoms

• Food cravings and overeating

• Loss of interest in sex

PMS symptoms usually start up to a week or so before a period is due and disappear when the period starts, or a few days after. Symptoms can vary month to month.

Classification of PMS

Core premenstrual disorders (PMDs) are the most commonly encountered and widely recognised type of PMS. As with all PMDs, symptoms must be severe enough to affect daily functioning or interfere with work, school performance or interpersonal relationships. The symptoms of core PMDs are nonspecific and recur in ovulatory cycles. They must be present during the luteal phase and abate as menstruation begins, which is then followed by a symptom-free week. There is no limit on the type or number of symptoms experienced; however, some individuals will have predominantly psychological, predominantly somatic or a mixture of symptoms.

There are also PMDs that do not meet the criteria for core PMDs. These are called ‘variant’ PMDs and fall into four subtypes.

1. ‘Premenstrual exacerbation of an underlying disorder’, such as diabetes, depression, epilepsy, asthma and migraine. These patients will experience symptoms relevant to their disorder throughout the menstrual cycle.

2. ‘Non-ovulatory PMDs’ occur in the presence of ovarian activity without ovulation. This is poorly understood due to a lack of evidence, but it is thought that follicular activity of the ovary can instigate symptoms.

3. ‘Progestogen-induced PMDs’ are caused by exogenous progestogens present in hormone replacement therapy (HRT) and the combined oral contraceptive (COC) pill. This reintroduces symptoms to women who may be particularly sensitive to progestogens. Although progestogen-only contraceptives may introduce symptoms, as they are noncyclical they are not included within variant PMDs and are considered adverse effects (probably with similar mechanisms) of continuous progestogen therapy

4. ‘PMDs with absent menstruation’ include women who still have a functioning ovarian cycle, but for reasons such as hysterectomy, endometrial ablation or the levonorgestrel-releasing intrauterine system (LNG-IUS) theydo not menstruate.

Who is affected by PMS

Any women of child-bearing age but it is most common in women from their late 20s to their mid-40s. If you have migraine, asthma, epilepsy or cold sores you may also find these conditions become worse before a period


Hormone changes: The cause of premenstrual syndrome is not really known. It is not due to a hormone imbalance or too little of any hormone, as was previously thought. The release of an egg from the ovary each month (ovulation) does appear to trigger symptoms. After ovulation the hormone progesterone is passed in to the bloodstream from the ovaries and it is thought that women with PMS are more sensitive to normal levels of progesterone.


Chemical changes: Chemicals in the brain, such as serotonin, fluctuate during the menstrual cycle. Serotonin contributes to feelings of happiness and regulates mood. It is possible that women with low levels of serotonin are more sensitive to PMS symptoms. Low serotonin levels can also contribute to symptoms of insomnia, tiredness and food cravings.

Weight and exercise: Research undertaken has shown that women are more likely to have PMS symptoms if theyare obese (body mass index over 30) and if they exercise very little.

Stress: Stress can aggravate the symptoms of PMS, although it is not a direct cause

Diet: Too much salty food can contribute to fluid retention and bloating. Fizzy drinks and alcohol can reduce your energy levels and disrupt your mood. Low levels of vitamins and minerals may also worsen PMS symptoms.


There is no laboratory test that can diagnose PMS, although blood and urine tests can rule out other causes. The condition is recognised by noting the type of symptoms and when they occur in relation to the period.

Keeping a diary for a few months will help you to recognize your PMS symptoms and when to expect them – and will also help your GP with diagnosis.

Symptoms of depression, anxiety, perimenopause, chronic fatigue syndrome, irritable bowel syndrome, and thyroid disease are similar to the symptoms of PMS. At  the  same  time,  half  of  women  seeking  treatment  for  PMS  have  at  least  one  of  these conditions. Depression and anxiety most often mimic the psychological symptoms of PMS.  In  this  context,  it  should  be  determined  whether  the  woman’s  mood  disorder  is  related  to  the menstrual cycle. Therefore, women who are thought to be experiencing PMS should be consulted appropriately to rule out these diseases.

The diagnosis of PMS is based on the type of symptoms and the time of emergence in the menstrual cycle. Premenstrual symptoms occur during the period covering the luteal phase of the endometrial cycle and ovulation phase of the ovarian cycle. The severity of symptoms increases just before the start of menstruation, and towards the end of menstruation, all symptoms are resolved. There is an asymptomatic period between the end of menstruation and the beginning of ovulation.

In order to associate the symptoms with PMS, at least one physical and psychological symptom should occur five days before menstruation, these symptoms should end four days after menstruation, they should continue at least three menstrual cycles and should adversely affect daily activities and interpersonal relationships. It is also recommended that the structure of premenstrual symptoms be confirmed by the health worker.

Management of PMS

It  is  recommended  that  PMS  Management  be  carried  out  gradually  by  a  multidisciplinary  team  that  has  adopted  an  integrated holistic approach. At the same time, an individualized management  plan  should  be  applied  because  the  number,  type  and  severity  of  premenstrual  symptoms  vary  from  person  to  person. If PSM is mild to moderate, lifestyle changes and diet  causes  cure  and  if  the  symptoms  start  to  have  an  adverse  impact on daily life pharmacological treatment is recommended.

What You Can Do

Aerobic Exercise: For many women, aerobic exercise lessens PMS symptoms. It may reduce fatigue and depression. Exercise can include brisk walking, running, cycling, or swimming. Try to exercise at least 30 minutes most days of the week. Aerobic exercise also improves health in other ways. For instance, it can promote heart health and help control weight.

Relaxation: Finding ways to relax and reduce stress can help women who have PMS. Your doctor might suggest relaxation therapy to help lessen PMS symptoms. Relaxing activities like yoga or massage also may help. You also should be sure to get enough sleep.

Dietary Changes: Simple changes in your diet may help relieve the symptoms of PMS. Your doctor may suggest a diet rich in fruit, vegetables, and whole grains. Reduce your intake of fat, salt, and sugar. Avoid caffeine and alcohol.


Women with severe PMS may not feel relief with lifestyle or dietary changes alone. If these changes don’t reduce symptoms, your doctor may suggest medications.

Antidepressants, especially SSRIs, can be helpful in treating PMS. These drugs can help lessen mood symptoms. They can be used 2 weeks before the onset of symptoms or throughout the menstrual cycle.

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can help reduce pain. Diuretics (“water pills”) may help reduce fluid buildup. Talk with your doctor before taking NSAIDs or diuretics. Long-term use of NSAIDs can cause stomach bleeding or ulcers. Using NSAIDs and diuretics at the same time may cause kidney problems.

Other options for severe PMS include oral contraceptives (birth control pills) and drugs that prevent ovulation. Birth control pills may lessen physical symptoms. However, they will not likely relieve the mood symptoms of PMS.

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