Pre Menstrual Syndrome – Causes, Symptoms, Diagnosis & Risk Factors

Overview

Pre menstrual syndrome (PMS) is a condition in women that starts five to eleven days before menstruation and lasts until after menstruation. It is a combination of physical, emotional, psychological and mood disturbances that usually end with the onset of menstrual flow. The mood-related symptoms that commonly occur are depression, oversensitivity, crying, irritability, and mood swings. The physical symptoms are fatigue, bloating, breast tenderness (mastalgia), acne, and appetite changes associated with the craving for food. Premenstrual dysphoric disorder (PMDD) or late luteal phase dysphoric disorder, is a more severe form of PMS, known to occur in some women and leads to significant loss of function. Unusually severe symptoms like irritability, anger, anxiety or tension are particularly prominent.
About 90% of women at some point in their lifetime have premenstrual symptoms. It is estimated that 20% to 30% of women have clinically significant PMS, i.e., moderate to severe in intensity affecting the woman’s functioning. A more severe form of PMS occurs in the 4th decade of life and 3% to 8% of women are known to have this condition.
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Causes

The exact cause of premenstrual syndrome (PMS) is not known. A combination of many factors contributes to the symptoms.

• Hormone Changes: The menstrual cycle has two phases: (1) proliferative phase or follicular and (2) secretory phase or the luteal phase. During the menstrual cycle, the levels of hormones like progesterone and estrogen rise and fall. These hormone changes are believed to be the biggest causative factor for many of the symptoms of PMS. During the luteal phase, the hormones which are released from the ovary make the lining of the uterus to become thick and spongy. At the same time, an egg is released from the ovary. At this time, the level of a hormone called progesterone increases in the body, while the level of another hormone, estrogen, begins to decrease. Due to hormonal fluctuations i.e. the shift from estrogen to progesterone during the luteal phase, the symptoms of PMS occur. PMS and PMDD are due to an interaction between the varying sex hormone levels during the secretory or the luteal phase of the menstrual cycle.
• Chemical Changes in the Brain: The changes in hormone levels during the menstrual cycle cause the changes in the levels of a chemical in the brain, known as serotonin. Serotonin is known to help regulate your mood and make you feel happier. This change in hormone levels leads to the reduction in the level of serotonin causing the mood changes connected with PMS. In some women with PMS, the antidepressant medication known as selective serotonin reuptake inhibitors (SSRIs) are known to increase serotonin levels.
• Lifestyle Factors: The lifestyle factors are known to increase the risk of PMS are
• Weight and exercise: Obese people are more prone to PMS compared to the normal individuals and exercise help for balancing the hormonal levels in the body.
• Stress: Stress is not a direct cause of PMS. The symptoms of PMS are aggravated by stress.
• Diet: Eating too little of some foods and too much of others can also aggravate the symptoms of PMS. For example, too salty food can cause bloating. Caffeinated drinks and Alcohol are known to disrupt the mood and energy levels of the body. PMS symptoms get worse due to low levels of minerals and vitamins.

Symptoms

Premenstrual syndrome (PMS) vary every month and from person to person. There are many different symptoms of PMS. The PMS symptoms may be similar or vary every month in intensity. Slightly different symptoms occur every few months. For every woman, the symptoms are different. The symptoms of PMS may happen in the menstrual cycle each month at the same time. It can happen two weeks before menstruation begins. Symptoms start to improve as the period is about to start and disappear once the period begins.
Some of the symptoms of PMS, such as depression, weight gain, fatigue are similar to symptoms of thyroid disorders. This can help to rule out a thyroid disorder as a cause of the symptoms.

Symptoms of PMS

Physical Symptoms:

• Feeling of bloating
• Discomfort and pain in the abdomen
• Backache
• Headaches
• Breast pain
• Joint and muscle pain
• Trouble in sleeping (insomnia)
• Nausea
• Weight gain (up to 1kg)
• Long-term or (chronic) illnesses like migraines  or asthma usually get worse

Psychological and Behavioral Symptoms:

• Mood swings
• Feeling upset or emotional
• Social withdrawal
• Feeling irritable or angry
• Crying
• Anxiety
• Difficulty concentrating
• Confusion and forgetfulness
• Clumsiness
• Restlessness
• Tiredness
• Decreased self-esteem
• Loss of interest in sex
• Appetite changes or food cravings

Premenstrual Dysphoric Disorder (PMDD)

Many women with PMS have severe symptoms. Some symptoms are severe enough to prevent them living their usual lives. This type of PMS the result is more intense and is known as premenstrual dysphoric disorder (PMDD). The symptoms of PMDD are similar to those of PMS, but are more blown up and has more physical symptoms than psychological symptoms

Symptoms can include:

• Feelings of hopelessness
• Persistent sadness or depression
• Extreme anger and anxiety
• Decreased interest in usual activities
• Sleeping much more or less than usual
• Very low self-esteem
• Extreme tension and irritability

Woman with PMDD may usually have suicidal thoughts. Depression is a common symptom of PMDD. PMDD is very difficult to deal with as it has a negative effect on the daily relationships and life.
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Risk Factors

• Age: PMS is associated with ovulatory menstrual cycles. So PMS starts after menarche and continue as ovulation ends i.e at menopause. The PMS is mostly seen between the mid-20s to late-30s.
• Stress: Higher levels of stress have been shown as risk factors for PMS.
• Obesity: Body mass index ≥30 is a risk factor for developing PMS.
• Overall Health: Women with other health problems are more likely to have PMS. The presence of any medical or psychological problem is a risk-factor for PMS.
• Depression and Anxiety has also has been shown to increase the risk of PMS

Diagnosis

The diagnosis is done based on more than one recurrent symptom like mood swings and physical pain that is severe enough to cause impairment and is absent between menses and ovulation. The doctor will rule out other causes like anemia, thyroid disease, endometriosis, irritable bowel syndrome (IBS), chronic fatigue syndrome, connective tissue or rheumatologic disorder.

• History of depression or mood disorders in the family can result in PMS or another condition.
• Some conditions, such as IBS, hypothyroidism, and pregnancy, have symptoms similar to PMS.
• Thyroid hormone test to ensure that your thyroid gland is working properly, a pregnancy test, and possibly a pelvic exam to check for any gynecological problems would be required.
• The person is asked to keep a diary to determine the symptoms. A calendar is used to keep track of the symptoms and menstruation every month. If the symptoms start around the same time every month, PMS is a likely cause.

Treatment

Treatment for premenstrual syndrome (PMS) helps to manage the symptoms that interfere with the daily life.
In mild to moderate types of PMS, changes are done to diet and lifestyle before medical treatment.

Lifestyle changes

• Diet changes help to maintain a balanced and healthy diet to manage symptoms of PMS
• Eating more frequently and smaller meals prevent bloating.
• Salty foods should be avoided to limit fluid retention and bloating.
• Drink a lot of water to prevent dehydration. Being dehydrated leads to tiredness and headaches .
• The complex carbohydrates like fruit, vegetables and whole grains should be included in the diet.
• Calcium-rich foods like milk and cheese and are taken to improve the psychological and physical symptoms of PMS. Calcium-fortified soya can be used as an alternative to dairy products.
• Eat plenty of vegetables and fruits that are rich in vitamins and minerals at least five times a day
• Avoid  alcohol and caffeine  to change the energy and  mood  levels

Smoking

• Quit smoking to reduce the symptoms of mild PMS.

Exercise

• Every week at least 150 minutes of moderate-intensity of aerobic activity like swimming, walking, and cycling is done.
• Overall health, depression, tiredness can be improved by exercises.
• Stretching and breathing exercises like pilates and yoga helps to reduce stress levels and to sleep better.

Complementary Treatments

• Alternative non-prescribed treatments and supplements can treat PMS. Some women may find these helpful for easing their symptoms.
• Supplements of vitamin D, calcium, agnus cactus and magnesium is used to reduce the symptoms of PMS.
• Always ask the doctor before taking any supplements, as taking them alongside certain medications or in excessive amounts can be harmful.
• If you decide to take a complementary treatment, take one at a time so you know it works for you. Go back to your GP if your symptoms don’t change after three months, as they may recommend another treatment.

Psychological Therapy

• Psychological symptoms require mental health treatment.
• Cognitive behavioral therapy helps to develop new ways of managing some of the symptoms.

Medical Treatment

If PMS symptoms are a severe or premenstrual dysphoric disorder (PMDD) is diagnosed with medical treatment can be used.
Medical treatments for PMS are:

• Painkillers
• Combined oral contraceptive pill
• Oestrogen-only patches and implants
• Selective serotonin reuptake inhibitors (ssris)
• Gonadotrophin-releasing hormone (gnrh) analogues

Painkillers

The painkiller medications like non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol help relieve the painful PMS symptoms like

• Stomach cramps
• Joint pain and muscle pain
• Headaches

Oral contraceptive pills

• The combined contraceptive pill helps to improve the symptoms of PMS by preventing ovulation (where an egg is released from the ovary). Contraceptive pills which have hormone progestogen, is effective for treating PMS symptoms and also improve symptoms of PMDD. The side effects of contraceptive pills include depressed mood or breast pain.

Oestrogen-only patches and implants

• Oestrogen-only patches and implants like combined contraceptive pills, prevent ovulation and improve symptoms of PMS. Side effects of oestrogen patch and progestogen are itching, skin irritation, and soreness.

Selective serotonin reuptake inhibitors (SSRIs)

• Selective serotonin reuptake inhibitors (SSRIs) are the most effective treatment in severe PMDD or PMS.
• SSRIs like sertraline and fluoxetine are the antidepressants.

Gonadotrophin-releasing hormone (GnRH) analogues

• Gonadotrophin-releasing hormone (GnRH) analogues are synthetic hormones stop the periods by blocking the production of oestrogen and progesterone by creating temporary menopause. They are taken as an injection.

FAQs

How long before your period does one have PMS?

The average duration of a menstrual cycle is 28 days. Ovulation occurs on the 14 of the cycle. Menstruation, or bleeding, occurs on day 28 of the cycle. PMS symptoms can begin around day 14 and last until seven days after the start of menstruation.

Who can develop premenstrual dysphoric disorder?

Any woman may have PMDD, the following but women with a family history of PMDD or PMS have a higher risk.  Women with a family history or personal history of depression, other mood disorders or postpartum depression also have a similar risk.

What is the difference between premenstrual syndrome and premenstrual dysphoric disorder?

Premenstrual dysphoric disorder (PMDD) is a severe, form of premenstrual syndrome (PMS). Although PMDD and PMS have both emotional and physical symptoms, PMDD leads to extreme mood shifts that disrupt the work and damage relationships.
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