PMS (premenstrual syndrome) affects many women around the world. It is the name given to a wide range of symptoms that occur around the time of a period and then generally disappear toward the end of the period. Although in many cases it can be mild and easy to deal with, sometimes PMS can be severe enough to affect every day life, this occurs in about 5 to 10 percent of women.

It is difficult to pin-point exactly how common PMS is because it can affect women in different ways and to varying degrees. It may occur during the week running up to their period, or as soon as the period begins and can continue until ovulation (egg release).

For many women the beginning of a period is anticipated by a pattern of changes in their body. These changes can be anything from breast tenderness to changes in mood. Many people find this alteration unproblematic, but for some these changes can be extremely disruptive and unpleasant.

Women who suffer with the most extreme form of PMS are described as having PMDD or “premenstrual dysphoric disorder”. This is the most intense form of the syndrome and it can really affect women’s lives. It can be incapacitating, limiting normal function, sometimes leading to severe depression and therefore it can be a potentially life ruining condition. However, such severity is rare and only around 3 to 8 percent of women have symptoms that are this severe.

Background information on Menstruation

Periods are the monthly shedding of the lining of the womb (menstruation). They start during puberty (usually between the ages of 10 -16) and continue until the menopause (average age 52). Monthly changes in hormones cause the lining of the womb to build up and then shed (bleed), following ovulation (the menstrual cycle).

The normal menstrual cycle lasts for 28 days, but this can vary between 24 and 35 days. During the menstrual cycle a “period” occurs when the lining of the womb is shed, causing bleeding (menstruation). This normally lasts between 2 and 7 days, although 5 days is the average. The cycle itself begins on the first day of menstrual bleeding. Every woman will have a different menstrual cycle and bleeding will vary in regularity, duration, heaviness and pain. In order to expel all of the lining, the uterus contracts and can cause some women severe discomfort.

Causes and risk factors

The exact cause of PMS has yet to be discovered. It is generally believed however that it is an exaggerated response to the shift in hormones (oestrogen and progesterone) which occurs in a normal menstrual cycle.

PMS is more prevalent in women between 30 and 50 and can worsen in the lead up to the menopause. Many find that it is a condition that runs in families and a mother who suffers badly is more likely to have a daughter who also has the condition.

Symptoms

Symptoms can vary from month to month and women can experience completely different symptoms. Nearly 95 percent of pre-menopausal women suffer from at least one or more of the symptoms which can be split into behavioural and physical.

Behavioural Symptoms

Behavioural symptoms can vary dramatically between each individual and can worsen due to other factors, such as stress or circumstances.

Symptoms can include:

• Irritability, short- temper and a feeling of being flustered.
• Anxiety.
• Clumsiness.
• Depression, feeling sad or emotional.
• Insomnia (not sleeping).
• Lethargy (very tired).
• Lowered self-esteem.
• Crying bouts.
• Mood swings.
• Social isolation- wanting to be alone.
• Aggression.
• Lack of concentration.

Physical Symptoms

• Fluid retention and a bloated sensation.
• Constipation/ diarrhoea.
• Nausea.
• Muscle pains.
• Abdominal swelling.
• Swollen fingers and ankles.
• Change in appetite, food cravings, weight gain.
• Migraines.
• Sore or tender breasts.
• Change in hair and skin condition.

Diagnosis

There is no specific test that can diagnose PMS. Some women are able to deal with the symptoms themselves and might not need to see the doctor unless they are worried. If the symptoms are affecting general life or the symptoms are very severe, the first step is to see the GP and discuss them, after this the GP may refer to a specialist in the area, either a gynaecologist or a psychologist with a PMS specialty.

If you are having symptoms it is a good idea to keep a mood diary to show your GP or specialist, this will help them understand the symptoms and pick out a possible pattern.

Treatments

Treatments depend on the severity of the symptoms. For women with mild symptoms there are some simple but effective things which can be tried.

For more in depth treatment information see our expert interview, where treatments are discussed further. Things which may help include:

• Understanding and reassurance from friend’s family and doctor.
• Discussing all domestic and personal factors which may be a cause of additional stress.
• Relaxation techniques.
• Exercise.
• Avoid caffeine and alcohol; these can affect mood and energy.
• Eat a balanced diet, which is rich in vitamins and minerals and aim to eat at least five portions of fresh fruit and vegetables a day.

Some complementary therapies have been shown to be beneficial (see our expert interview).

If considering alternative therapies, women need to be aware that they are not medically recommended. Licensing can be variable and some can have adverse interactions with medications or damaging effects. Always ask for advice from your doctor.

For women with more severe symptoms all of the above can still be helpful, but additional treatment may be needed. There is no single treatment that works for everyone and all have benefits versus possible side effects, they include:

• Counselling or psychotherapy- this can help women come to terms with the condition and learning coping mechanisms.

• Contraception- oral contraceptives, such as the combined pill can regulate hormonal balance and reduce symptoms. New lower dose pills are being developed, with shorter breaks between packets.

• Cycle suppression (stopping ovulation) - with oestrogen patches/gel or with monthly injections.

• Anti-depressants- these do not need to be taken all the time, they can be taken at a specific part of the cycle and may help.

• (GnRH) analogues- these are drugs which temporarily ‘shut down’ the ovaries. They cause menopausal symptoms and can have the side effects and risks associated with the menopause. HRT (hormone replacement therapy) can then be used to help with these symptoms.

• Surgery- removal of the womb (hysterectomy) and also the ovaries would be required to stop PMS. This is very rarely an option as it will end fertility and trigger the menopause, which has its own risks and undesirable symptoms. This is only advised in the most severe circumstances and after lengthy discussions.

Cat’s story- about the most severe form of PMS called PMDD premenstrual dysphoric disorder. Unfortunately treatments that are often successful did not work for Cat, but she has come through this, she has learnt her cycle and found ways to deal with it.

      "I have suffered with PMDD since I was 13, but I was only diagnosed at 27. For over 10 years I had been diagnosed as depressed and in and out of community mental health departments. After stopping the Pill and having a baby age 21, my hormones went crazy and I suffered pre and post natal depression. In the years that followed I began noticing a pattern to my moods and depression. At times, I thought I really was severely mentally ill. I always had PMS, but I realised that my worst times happened when I was due on my period. My PMS was so severe that it had begun to take over my life, wreck relationships, ruin jobs, studying and cause me so much emotional pain that I often found myself considering suicide. I would become housebound, no social life or friends and fearful of ever making an appointment because I could never guarantee how I would be feeling.

It was only my persistence and researching that made me realise I did in fact have a mood disorder and not straight depression. I researched 'mood disorders' instead of depression and discovered PMDD – Premenstrual Dysphoric Disorder. I read the only book available at that time, and began to chart my moods using a chart from the book. I found a GP willing to listen, took in printed information and my charts and got the correct diagnosis of Premenstrual Dysphoric Disorder. Coming to terms with what that meant took many years, and sometimes I still struggle.

PMS is one thing, many women suffer with moodiness, anger, irritability at pre-menstruation, but my PMDD threatened to destroy everything. As a mother I felt I wasn't well enough to look after my children, I have been unable to work and feel really separated from the rest of the world. My PMDD is not once a month, it is twice a month, leaving on average 10 - 14 days of feeling like me, and the rest is spent coping with symptoms. It is very difficult to find people to talk to who understand when it is so rare, and when menstrual problems are seen as something to joke about or ridicule. I have often dealt with comments like 'pull yourself together' and 'get a grip', and people denying that PMDD exists.

I am now 34 and have tried every medication offered to me. I have discovered that I am very sensitive to any type of hormone, and cannot tolerate the Pill or IUD. I spent a total of around 5 years on anti-depressants, which never really worked for me. They took the edge off, but didn't stop the extreme lows and outbursts. I have seen psychiatrists and gynaecologists. At one point, I went through hormone treatment to stop all my hormones and put me into a chemical menopause. This is often a route that works for PMDD sufferers, and some go on to have a hysterectomy. Unfortunately, this option did not work for me.

I have found that counselling has helped, along with mind techniques such as CBT (cognitive behavioural therapy), NLP and meditation. Finding support is essential. Being able to talk through the irrational thoughts can usually avert disaster. Keeping busy is also a good way to keep the mind focused, so I draw, create, paint, write and cook lots!

   I am now medication free for the first time in my life. I have had to learn my cycle and I now plan things around it. I avoid busy social situations when I know it will be too much for me. Eating healthily, regular exercise and avoiding stress has also helped improve my symptoms. Making sure I continue to communicate with loved ones and work through problems, finding strength to leave the house even when I don't want to and being open and outspoken about my disorder all contribute to life feeling easier and less stressful and traumatic".

         

If you would like to tell us your story so we can help and inform other women; there is more information available HERE

PMS: Text Version

This interview was recorded in December, 2009.

Hello. Today we are joined by Dr. Nick Panay to discuss PMS, a condition which many women will be all too familiar with.

Nick, Can I start by asking you to explain some of the symptoms of PMS?

There can be psychological symptoms, physical symptoms, and behavioural symptoms. The most distressing symptoms are the psychological ones. They can often lead to mood disturbances, and at worst can lead to the break down of relationships.

What causes these symptoms?

It’s the fluctuation of hormone levels in the menstrual cycle that causes the symptoms. It seems that there may be some genetic differences between women that are vulnerable to these fluctuations and those that aren’t.

Does contraception help?

Contraception can help but it has to be the right sort of contraceptive. There are some female friendly oral contraceptives which are now coming on to the market, which I believe used in the appropriate way can benefit symptoms immensely.

Could you explain further into what kinds of contraceptive can help PMS?

Yes there are some new combined oral contraceptives, so modern versions of the pill, where the hormone free interval has been shortened. So typically there would be a seven day hormone free interval with the pill, some of the new pill preparations have a four or even two day hormone free interval. What that means is that there is much less likely to be a resurgence of cycle related symptoms during the hormone free interval. The other thing that has changed is that the type of hormones that are used in the pill cause less side effects. The old-fashioned types of pill used to give PMS type side effects, and that limited the effectiveness of treatment. Nowadays there are much more female friendly types of progesterone, as well as oestrogen in the pill, and this can avoid the side effects and let the benefits come through.

What is the difference between PMS and PMDD?

PMDD is the severest form of PMS and it’s the American Psychiatric Associations definition for severe PMS.

Can PMS symptoms be inherited from your mother?

Yes there is often a family history, up to fifty percent of cases actually can have inheritance either from a mother or they may have a sister that is affected by the condition.

Can diet help with the symptoms of PMS?

I think that diet is vitally important, and what I tell my patients is that they should have a well-balanced diet, particularly the low-glycemic index diet - so brown cereals, brown rice, other pulses and that sort of thing are particularly helpful to maintain blood sugar levels that are constant, and prevent the triggering of symptoms.

What measures can we take to alleviate these symptoms?

Yes, lifestyle changes are very important as a first line measure. Often women are given evening primrose oil, but that is only particularly good for breast tenderness. If there are other excesses in ones life; for instance alcohol, chocolate – which is great when you have it but can lead to rebound symptoms, smoking or caffeine. These can all exacerbate the symptoms, so it is important to try and moderate those, and then if there are symptoms that persist, it is important to go and see the doctor sooner rather than later.

Do complementary therapies help?

There are some complementary therapies which have been shown in trials to be beneficial. The ones that have the most evidence base are Agnus Castus which is the fruit of the Chaste berry tree, red clover isoflavones which are basically plant oestrogens, and vitamin D and calcium. We completed a small trial in a programme called The Truth About Food, where we gave oily fish and milk to our sufferers and found that they had a 30% improvement in their symptoms.

How important is it to research further into problems like PMS, and what kind of research is currently taking place at the moment?

PMS is a very poorly understood condition, there is some very interesting work going on at the moment at Harvard University in the States, looking at the genetics of the condition. We need to try and understand why some women are pre-disposed to it and others aren’t, and through this work I believe we will finally find a marker for PMS. Because at the moment all we know is that some women are vulnerable and some aren’t, and it is very difficult to predict who that’s going to be. The other area of research which is vitally important, is finding treatments which are evidence based for both effectiveness and safety.

One of the other treatments that are often prescribed for PMS is antidepressants can you explain more about this?

Yes, anti-depressants in PMS are often regarded as being a bit of a ‘no - no’ by women because by taking them they feel they are being labelled as a psychiatric case. In fact the use of anti-depressants in PMS is different to that used in depression and anxiety. They can be used in just the second half of the cycle for 14 out of the 28 days. So that means there isn’t a dependence on them, so they can be stopped just as easily as they are started. There is even some evidence now that you can used anti-depressants just at the time that the symptoms occur, and that might only be for four or five days, and they can be equally effective, to when their use is continuous.

Can I ask when PMS is most likely to affect a woman and can it develop further as she ages?

Yes, young women often have mild PMS type symptoms which don’t really affect their quality of life, or their relationships. But unfortunately as women get into their 30s and early 40s PMS symptoms can increase in severity, particularly the psychiatric type symptoms. The reason that happens is that hormone fluctuations tend to become more violent if you like, as the woman starts to approach the peri-menopause – the menopause transition. There are other times in a woman’s life where these sort of symptoms can occur, post-natally you will have heard of the blues; post-natal blues, post-natal depression and again that is because of fluctuating hormone levels. These fluctuating levels are what we think triggers the symptoms.

Can I ask how pregnancy would affect PMS?

Yes often you will hear from a woman that the last time she actually felt well, was when she was pregnant, particularly in the second half of pregnancy, and that is because hormone levels are stable at that stage, relatively high. Some actually feel quite euphoric because of very high oestrogen levels which stimulate neurotransmitters in the brain like serotonin. Unfortunately post-natally that high can be replaced by a low, as hormone levels start to fall. So if you have somebody who you know is predisposed to PMS, it is important to watch them carefully after they have had the baby so they don’t suffer post-natal depression. We can treat post-natal depression with hormonal support.

If you suffer with PMS throughout your adult life, will somebody’s menopause be worse?

Unfortunately women that are pre-disposed to premenstrual fluctuations in hormone levels that trigger symptoms are potentially subject to a worse menopause. So they can suffer more with hot flushes and sweats, and also mood related symptoms. So again around the peri-menopause the menopause transition, it is important to watch individuals such as that and give them appropriate support if they develop these symptoms.

Is surgery ever something that would be prescribed for PMS?

Surgery is actually the most effective treatment for PMS because removal of the ovaries, removes the hormone fluctuations that trigger the symptoms. Unfortunately of course it is a major operation and it can lead to other problems like menopause symptoms. We actually only end up doing hysterectomies in one or two women a year with severe PMS, and these are the women that have the severest symptoms, that haven’t been settled down by other treatments. But in those women that we do hysterectomy for, they actually have a very good outcome as long as we give them adequate hormone replacement therapy; because there is no point in replacing PMS symptoms with menopause symptoms.

Can I ask you if there are any support groups you know of for sufferers of PMS?

I’m very glad you asked me that question, because I am actually chairman for the National Association for Premenstrual Syndrome. This organisation provides support for PMS sufferers; it has a blog where PMS sufferers can compare notes on their symptoms and what treatments they have found effective, I would very much recommend any sufferer to visit our website. www.pms.org.uk

Brilliant, thanks so much for joining us today it’s been a pleasure talking to you.

Pleasure.

Some common myths addressed by Specialist Consultant Nick Panay.

It is all in your head....
Many people are reluctant to accept the severity to which some women are affected by PMS, what could you say in response to this?

PMS is a genuine condition, which causes a chemical reaction in the body. It is very real and can be very distressing to those suffering. It is important that people take on board the seriousness of the condition.

My doctors will not recognise I have PMS

It is very important that a symptom diary is kept for at least two months as this will demonstrate the cyclicity of the symptoms and in particular, the improvement after menstruation

The diary on the NAPS website www.pms.org.uk can be either filled in online or downloaded

Nothing can be done about PMS, you just have to wait until it’s gone

There are many strategies which can help to relieve symptoms including, lifestyle, complementary, gynaecological and psychological. The NAPS website www.pms.org.uk can provide more detailed information about the many ways of improving PMS symptoms.

Click here to go to Research Success Stories

• The Royal College of Obstetricians and Gynaecologists website has a wide range of information and guidelines on many women’s health topics. This can be found at: http://www.rcog.org.uk/womens-health/patient-information
   
• NHS Choices website also has a range of health information. This can be found at: http://www.nhs.uk/Pages/HomePage.aspx