Premenstrual syndrome: The monthly demon
Premenstrual syndrome is a complex condition with many emotional and physical features. It is very common and at least 3 out of 4 women report symptoms of PMS. PMS tends to peak in to mid 20’s to 30’s. The symptoms occur in a recurrent pattern, starting a few days before periods and resolving with the onset of periods.
The emotional component of PMS includes tension or anxiety, depressed mood, crying spells, mood swings and irritability or anger, appetite changes and food cravings, trouble falling asleep (insomnia), social withdrawal and poor concentration.
PMS has physical symptoms as well. The most common physical symptoms of PMS include joint or muscle pain, headache, fatigue, weight gain from fluid retention, abdominal bloating, breast tenderness, acne flare-ups and constipation or diarrhoea.
Although the list of symptoms is long, majority of women only have a few of these symptoms. Some women have mild to moderate symptoms which are usually managed by lifestyle measures. However a few women have problems severe enough to incapacitate their life during this time. A sub group of women may have very severe symptoms and they are thought to suffer from a psychiatric disorder called premenstrual dysphoric disorder. PMDD is a severe form of premenstrual syndrome with signs and symptoms including severe depression, feelings of hopelessness, anger, anxiety, low self-esteem, difficulty concentrating, irritability and tension. Although it is not clearly proven, there may a psychiatric basis to PMS in most women.
The causes of PMS are not clearly known, but some factors may contribute to it. The commonly known and studied factors include cyclic changes in hormones, chemical changes in the brain, depression, stress and poor eating habits. The signs and symptoms of PMS disappear with pregnancy and menopause, hence it is postulated that the cyclical hormonal changes during normal ovulation cycle may cause PMS.
It has also been seen that the levels of a chemical called serotonin is reduced in the brain. This leads to mood swings and food cravings. Reduced serotonin is a also a feature in depression, and hence it is postulated that some women may be having underlying depression. Stress is also known to play an important role in the aetiology of PMS.
And finally poor eating habits like junk food and binge eating, coffee, alcohol, high slat foods are all known to worsen symptoms of PMS. Low levels of vitamins and minerals may also be implicated in PMS.
There are no unique physical findings or laboratory tests to positively diagnose premenstrual syndrome. Your doctor may attribute a particular symptom to PMS if it's part of your predictable premenstrual pattern. To help establish a premenstrual pattern, your doctor may have you:
- Keep a diary: Record your signs and symptoms on a calendar or in a diary for at least two menstrual cycles. Note the day that you first notice PMS symptoms, as well as the day they disappear. Also be sure to mark the day your period starts and ends.
- Fill out a questionnaire: On the first day of your period, you fill out a questionnaire. The questions pertain to any PMS symptoms you experienced during the prior two weeks. This tool helps your doctor know whether you might benefit from further evaluation.
The treatment of PMS involves lifestyle measures and medications. Lifestyle measures are initially prescribed and are effective in up to half the women who suffer from PMS.
The following are the lifestyle measures commonly prescribed:
- Eat smaller, more frequent meals to reduce bloating and the sensation of fullness.
- Limit salt and salty foods to reduce bloating and fluid retention.
- Choose foods high in complex carbohydrates, such as fruits, vegetables and whole grains.
- Choose foods rich in calcium. If you can't tolerate dairy products or aren't getting adequate calcium in your diet, you may need a daily calcium supplement.
- Take a daily multivitamin supplement.
- Avoid caffeine and alcohol.
- Get plenty of sleep.
- Practice progressive muscle relaxation or deep-breathing exercises to help reduce headaches, anxiety or trouble sleeping (insomnia).
- Try yoga or massage to relax and relieve stress.
Other than these exercise is a very good way to combat PMS. Exercising 30 min everyday has been shown to reduce the incidence and severity of PMS by more than half. Walking, cycling, swimming, light aerobics and yoga are good forms of exercise for all ages.
But unfortunately in some women all these measure fail and these women may benefit for medications.
The medications commonly used for PMS include:
- Antidepressants like Selective serotonin reuptake inhibitors (SSRIs),are very successful in reducing symptoms such as fatigue, food cravings and sleep problems and are the first line agents for treatment of severe PMS or PMDD. These drugs are generally taken daily. But for some women with PMS, use of antidepressants may be limited to the two weeks before menstruation begins.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) taken before or at the onset of your period, can ease cramping and breast discomfort.
- Diuretics: When exercise and limiting salt intake aren't enough to reduce the weight gain, swelling and bloating of PMS, taking diuretics can reduce water retention and improve symptoms of PMS.
- Oral contraceptives are particularly effective in the management of PMS. They act by stabilising the hormonal changes and reduce the symptoms of PMS in more than 70% women. The progestin drospirenone, which acts similarly to the diuretic spironolactone, has been shown to be even more effective than regular birth control pills are in reducing the physical and emotional symptoms of PMS and PMDD.
- Medroxyprogesterone acetate (Depo-Provera)can be used in severe PMS or PMDD to temporarily stop ovulation thus offering a respite from symptoms. However, Depo-Provera may cause an increase in some of the same signs and symptoms experienced with PMS, such as increased appetite, weight gain, headache and depressed mood.
And finally there are some measures that can be taken by women to help with PMS. Women should aim to consume 1200 mg of calcium every day. This amount can be gained in about 1.2 lit of milk. Women who have lactose intolerance may consume calcium tablets. Vitamin E at a dose of 400 IU/day is effective for treatment of PMS. There are anecdotal reports that evening primrose oil is effective in the symptoms of PMS, however conclusive proof is lacking.