Premenstrual syndrome

Most women who have reached the age of menstruating know what premenstrual syndrome (PMS) is, because they will have experienced it to some degree. An unlucky 5–8% have it so badly that it is really distressing, and significantly interferes with their life. It often starts to come on about 6 days before the next period is due, and gradually worsens until bleeding starts. Some women find the worst time is about 2 days before the actual period. As soon as the period starts, most women suddenly feel better, but sometimes the symptoms can linger on.

Symptoms of premenstrual syndrome

Feeling depressed
Feeling anxious and tense, angry and irritable, overwhelmed by everything
Mood swings
No energy, no interest in usual activities
Difficulty concentrating
Overeating (especially chocolate)
Sleeping a lot, or unable to sleep
Breast tenderness, bloating

The cause of premenstrual syndrome

It is obvious that the cause is something to do with hormones, but the exact cause is not yet understood. The levels of progesterone and oestrogen hormones change during the monthly cycle, but researchers cannot decide which is mainly to blame. PMS does not mean that there is anything wrong with your levels of these hormones. More likely, it is something to do with the way your body and brain respond to these changing levels of hormones. Some research has shown that oestrogen and progesterone can affect serotonin in the brain, a chemical that helps to regulate our moods and emotions.

How you can help yourself

Here are some things to try. They may help somewhat, but do not be too disappointed if they fail to cure the problem completely.

Regular physical exercise may lessen premenstrual symptoms.

Agnus castus is made from the fruit of the chasteberry tree, and is a traditional remedy for PMS. You can buy it from health food shops. One research study found it to be helpful in PMS (British Medical Journal 2001;322:134–7).

A special diet is controversial. For your general health it makes sense to eat a diet that is low in fat and sugars, and high in unrefined starchy foods (low glycaemic index) and fruit and fibre. Some people think that this type of diet will help PMS, but scientific evidence is scanty.

Vitamin B6 is commonly suggested, but the jury is still out on whether it is truly beneficial. If you want to try it, don’t take more than 50mg a day, as high doses can be harmful.

Evening primrose oil may help breast symptoms, but will not improve other PMS symptoms.

Try to minimise stress, which is of course easier said than done. Stress at work or relationship difficulties can easily tip anyone over the edge during the premenstrual days, so sort out these problems if you can.

Before you see your doctor

Your doctor will be able to help, but it is a good idea to keep a calendar chart of your symptoms for 2 months beforehand. This will help your doctor to understand the symptoms that are really troubling you, and will also be useful later to decide whether treatments are working.

How your doctor can help

If PMS is affecting you badly, your doctor might suggest medication. These may take several months to make a difference.

Probably the best medications for PMS are the so-called ‘serotonin-uptake inhibitors’ (such as citalopram, escitalopram, fluoxetine, paroxetine, sertraline), or a similar drug called venlafaxine. Usually, these medications are taken from the middle of the monthly cycle until the period starts. They can cause nausea initially, but this usually wears off. Some women notice reduced desire for sex while taking the medication.
Hormone treatments are another possibility. In the past, it was wrongly thought that PMS meant a shortage of progesterone hormone before the period, so there was a fashion for taking extra progesterone at the end of the monthly cycle. In fact there is almost no evidence that this helps (Lancet 2008;371:1200–10). Now, hormone treatments are targeted at preventing ovulation from occurring in the menstrual cycle. Ovulation is the release of the egg from the ovaries at the middle of the monthly cycle; this release triggers the hormone changes that cause PMS in the second half of the cycle. There are various types of hormone treatment to prevent ovulation, and your doctor will be able to choose the method that is best for you.
If you feel bloated, you might think that water retention is occurring, and that a diuretic tablet (which makes you pass more urine) would be the answer. Generally, they do not work; only one diuretic (spironolactone) seems to have any effect.

Written by: Dr Margaret Stearn
Edited by: Dr Margaret Stearn
Last updated: Saturday, February 13th 2010

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