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Premenstrual syndrome

Also listed as: PMS

• Signs and Symptoms
• What Causes It?
• Who's Most At Risk?
• What to Expect at Your Provider's Office
• Treatment Options
• Prognosis/Possible Complications
• Following Up
• Supporting Research

Women who have premenstrual syndrome (PMS) experience a variety of physical and emotional symptoms that occur each month from 2 to 14 days before their menstrual cycle. The symptoms usually disappear once the cycle begins. PMS may begin at any age and ends after menopause. Approximately 75% of women experience PMS to some degree, with 20 - 50% finding that symptoms disrupt their daily activities, and 3 - 5% becoming incapacitated.

Signs and Symptoms

PMS is often accompanied by the following signs and symptoms:

• Abnormal bloating and weight gain
• Breast swelling, tenderness
• Mood swings
• Depression and anxiety
• Skin disorders
• Changes in appetite, food cravings
• Changes in interest in sex
• Headaches, backaches, cramps
• Inability to concentrate, loss of interest in usual activities, confusion

What Causes It?

While the exact cause of PMS is unknown, the most popular theories include hormonal changes (estrogen excess or progesterone deficiency), hypoglycemia (low blood sugar), vitamin B ₆ deficiency, abnormal metabolism of prostaglandin (hormone-like substances), excessive fluid retention, and endorphin (a substance in the brain that provides pain relief) withdrawal.

Who's Most At Risk?

Women with a history of the following conditions are at a higher-than-average risk for having PMS.

• Dysmenorrhea (painful menstruation)
• Depressive, mood, anxiety, or bipolar disorders (including a family history of these problems)
• Postpartum depression or psychotic episodes
• High stress

What to Expect at Your Provider's Office

If you are experiencing symptoms associated with PMS, you should see your health care provider. Your health care provider can help make a diagnosis and guide you in determining a treatment or combination of therapies that may work best for you.

You'll need to chart your symptoms and their severity daily for 1 - 2 months. Your provider will take a detailed history of symptoms, do a physical and gynecologic examination to rule out other medical conditions, and conduct a psychosocial evaluation. Certain laboratory and imaging studies may be used, such as a Pap smear, complete blood count, chemistry screen, fasting blood glucose test, and thyroid studies.

Treatment Options

Prevention

Reducing stress, increasing exercise, and making dietary changes around the time of menstruation can prevent PMS symptoms from worsening.

Treatment Plan

Preventive measures and, in some cases, drug therapy, are most often used for treating PMS.

Drug Therapies

Your provider may prescribe the following medications.

• Diuretics, for bloating and water retention
• Analgesics, for headaches and cramps
• Beta-blockers and calcium-channel blockers, to prevent the onset of migraine headaches
• Prostaglandin inhibitors for painful menstruation
• Spironolactone for skin conditions
• Medications that block ovulation
• Bromocriptine for breast soreness
• Anti-anxiety medications
• Antidepressants
• Progesterone, for relief of symptoms

Women who are planning to become pregnant should avoid medications such as prostaglandin inhibitors, diuretics, spironolactone, and danazol.

Surgical and Other Procedures

Women whose symptoms are severe and do not respond to treatment may need to undergo a hysterectomy, including removal of the ovaries, followed by estrogen replacement therapy.

Complementary and Alternative Therapies

A comprehensive treatment plan for PMS may include a range of complementary and alternative therapies.

Nutrition and Supplements

Following these nutritional tips may help reduce symptoms:

• Eliminate all potential food allergens, including dairy, wheat (gluten), soy, corn, preservatives and food additives. Your health care provider may want to test for food sensitivities.
• Eat calcium rich foods, including beans, almonds, and dark green leafy vegetables (such as spinach and kale).
• Eat fewer red meats and more lean meats, cold-water fish, tofu (soy), or beans for protein.
• Use healthy cooking oils, such as olive oil or vegetable oil.
• Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• Avoid coffee and other stimulants, alcohol, and tobacco.
• Drink 6 - 8 glasses of filtered water daily.
• Drink calcium-enriched soy milk, for bone health and symptoms of PMS.
• Exercise moderately at least 30 minutes daily, 5 days a week.

Nutritional deficiencies may be addressed with the following supplements:

• A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-complex vitamins and trace minerals such as magnesium, calcium, zinc and selenium.
• Calcium citrate, 500 - 1,000 mg daily, for bone support and symptoms of PMS.
• Vitamin D, 400 IU daily, for bone support and symptoms of PMS.
• Ipriflavone (soy isoflavones) standardized extract, 200 mg three times a day, for bone loss and symptoms of PMS.
• Progesterone cream, 1/8 - 1/4 teaspoonful (depending upon extract strength) applied topically daily on days 7 - 28 of cycle, for symptoms of PMS. Talk to your doctor. Although available as an over-the-counter product, progesterone cream may interfere with prescription and non-prescription medications, such as oral contraceptives.
• Omega-3 fatty acids, such as fish oils, 1 - 2 capsules or 1 tablespoonful oil daily, to help decrease inflammation. Cold-water fish, such as salmon or halibut, are good sources.
• SAMe (s-adenosyl-L-methionine), 100 - 200 mg before breakfast daily, for mood improvement.
• Melatonin, 2 - 5mg before bed, for sleep regulation.

Herbs

Herbs are generally available as standardized dried extracts (pills, capsules, or tablets), teas, or tinctures or liquid extracts (alcohol extraction, unless otherwise noted). Mix liquid extracts with your favorite beverage. Dose for teas is 1 - 2 heaping teaspoonfuls per cup of water ,steeped for 10 - 15 minutes (roots need longer).

The following herbal remedies may provide relief from symptoms:

• Chaste tree ( Vitex agnus castus ) standardized extract, 400 mg daily before breakfast, for symptoms of PMS.
• Black cohosh ( Actaea racemosa ) standardized extract, 20 - 40 mg two times a day, for symptoms of PMS.
• Evening primrose oil (Oenothera biennis) standardized extract, 500 - 1,000 mg daily, as a source of gamma linolenic acid (GLA), for symptoms of PMS.
• St. John's wort ( Hypericum perforatum ) standardized extract, 300 mg 2 - 3 times per day, for depression associated with PMS. Check with your health care provider if you are taking prescription medications, especially oral contraceptives.
• St. John's wort ( Hypericum perforatum ) (300 mg 2- 3 times per day) for depression associated with PMS. Must be taken consistently throughout the month. Direct sun exposure may cause rashes in some people.
• Kava kava ( Piper methysticum ) standardized extract, 100 - 250 mg 1 - 3 times a day, as needed for symptoms of stress and anxiety associated with PMS. Patients with a history of liver disorders should talk to their doctor about taking this supplement.
• Dandelion ( Taraxacum officinale ) leaf tincture, 5 - 10 mL 2 - 3 times a day, for fluid buildup associated with PMS. You can also prepare teas from the leaf.

Homeopathy

Few studies have examined the effectiveness of specific homeopathic remedies. Professional homeopaths, however, may recommend one or more of the following treatments for PMS based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

A low homeopathic dose, such as 30C, as often as every 15 - 30 minutes, may be used for symptoms of PMS, including bloating, pain, irritability and mood swings.

• Chamomilla -- for intense menstrual pain. This remedy is most appropriate for women who are extremely irritable, angry, and have frequent mood swings.
• Cimicifuga -- for feelings of hysteria, frustration, and being overwhelmed. This remedy is most appropriate for women who have labor-type pains that migrate from one side of the body to the other and may involve the back or even sciatic nerve (the largest nerve in the body; extends from the lower back down through the legs and knees).
• Colocynthis -- for cramps that are relieved by bending forward, abdominal massage, and warmth (such as a heating pad). This remedy is most appropriate for women who are extremely irritable and restless.
• Ignatia -- for emotional symptoms such as grief, panic, and mood swings. This remedy is most appropriate for individuals who feel particularly vulnerable.
• Lachesis -- for women who tend to be annoyed, caustic, talkative, and envious, and whose pain and bloating is worse on the left side. Also for women whose symptoms tend to worsen upon awakening in the morning and with exposure to heat or light pressure. Also for women whose symptoms improve dramatically when menstruation begins.
• Lycopodium -- for bloating with backaches and gas that are the worst during early evening and in warm weather.
• Magnesia phos -- for sharp cramps that are relieved by bending forward, abdominal massage, and warmth (such as a heating pad), but are worsened by cold air.
• Nux vomica -- for individuals who are extremely irritable, confrontational, and feel nauseous.
• Pulsatilla -- for irregular periods with cramps, bloating, or mood swings as the predominant symptoms. An appropriate candidate for Pulsatilla is gentle and yielding but clingy and cries easily. Women who may benefit from pulsatilla may have nausea and water retention that is aggravated by heat.
• Sepia -- for bloating, mood swings, constipation, drowsiness, and irritability.

Acupuncture

Although scientific evidence regarding the use of acupuncture for PMS is lacking, this condition is frequently treated by acupuncturists. Acupuncturists treat people with PMS based on an individualized assessment of the excesses and deficiencies of qi located in various meridians. In the case of PMS, a qi deficiency is usually detected in the liver and spleen meridians. Many treatments include moxibustion (a technique in which the herb mugwort is burned over specific acupuncture points). Qualified practitioners may also recommend herbal treatment or dietary modifications.

Castor Oil Packs

For cramping and pain, dampen a cloth with castor oil and apply to the abdomen. Cover with saran wrap, and then apply a heating pad over this pack. Use for 1 - 3 hours, then remove.

Chiropractic

Some studies suggest that chiropractic spinal manipulation may be effective for women with PMS. Women with PMS have been found to have a higher rate of spine-related problems (such as tenderness and muscle weakness) than those who do not have PMS. In one study, researchers found that women with PMS experience a significant decrease in symptoms after receiving spinal manipulation and soft tissue therapy compared to those who do not receive the chiropractic treatment. The researchers note that these effects may be short-lived and that monthly chiropractic treatment would probably be needed to maintain these positive results.

Prognosis/Possible Complications

Severe PMS can disrupt a woman's life. Psychological and emotional support as well as treatment of the physical symptoms may help.

Following Up

Ongoing follow-up and regular evaluations are necessary.

Supporting Research

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Alexandersen P, Toussaint A, Christiansen C, et al. Ipriflavone in the treatment of postmenopausal osteoporosis: a randomized controlled trial. JAMA 2001;285:1482–8.

Agnusdei D, Bufalino L. Efficacy of ipriflavone in established osteoporosis and long-term safety. Calcif Tissue Int 199:61:S23–7.

Atmaca M, Kumru S, Tezcan E. Fluoxetine versus Vitex agnus castus extract in the treatment of premenstrual dysphoric disorder. Human Psychopharmacol. 2003;18(3):191-5.

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Bertone-Johnson ER, Hankinson SE, Bendich A, et al. Calcium and vitamin D intake and risk of incident premenstrual syndrome. Arch Intern Med. 2005;165(11):1246-52.

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• Review Date: 8/4/2006
• Reviewed By: Ernest B. Hawkins, MS, BSPharm, RPh, Health Education Resources; Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

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