Premenstrual syndrome (PMS) is a group of physical, emotional and behavioral symptoms that commonly occur in the two weeks prior to menstruation. It is common among women of childbearing age and symptoms usually recur in a predictable pattern. Some women experience symptoms so severe that they interfere with daily activities. These women have a condition known as premenstrual dysphoric disorder (PMDD), which is diagnosed under specific criteria established by medical authorities. Though the symptoms are similar, PMDD is considered a separate disorder from PMS.

The exact cause of PMS is unknown, although there are several factors that appear to contribute to its occurrence. Some women are particularly sensitive to the normal fluctuations of hormone production during the menstrual cycle, and others react to the changes in serotonin, a brain chemical that affects mood. Women with vitamin deficiencies and those that consume excessive salt, sugar, caffeine or alcohol may also experience PMS symptoms more frequently.

A number of factors have been identified that put women at a greater risk for PMS. Women with a family history of PMS and those with a history of depression or postpartum depression have PMS more frequently.

There are more than 150 symptoms attributed to PMS, but most fall into one of two categories, physical or emotional/behavioral. Some of the most common physical symptoms are abdominal cramps, breast swelling, breast tenderness, fatigue and bloating. Some of the most common emotional/behavioral symptoms are irritability, hostility, aggressive behavior, anxiety and depression.

There are no tools or tests that can be used to conclusively diagnose PMS. Rather, physicians determine whether an underlying medical condition is causing symptoms. If a medical condition cannot be found, then physicians recommend patients keep a menstrual diary to identify the type of symptoms experienced and track when they occur during the menstrual cycle. If symptoms occur in a predictable pattern in the two weeks before menstruation and then cease when menstruation begins, PMS is diagnosed.

PMS is treated in a variety of ways. First, physicians may recommend lifestyle changes such as eating a well-balanced diet, taking vitamins, exercising and reducing stress. Both over-the-counter and prescription medications are used in patients with more severe symptoms.

Because its cause is unknown, there is no known way to prevent PMS. However, making lifestyle changes can help prevent or reduce the severity of symptoms. Because PMS is directly linked to menstruation, the condition stops at menopause (the natural cessation of menstruation).

Premenstrual syndrome (PMS) is a term used to describe a wide range of recurrent symptoms many women experience in the two weeks before menstruation (the luteal phase). Symptoms may be mild or severe. They are physical, emotional or behavioral and usually stop when menstruation begins, or shortly thereafter.

PMS can appear at any time between puberty and menopause. Symptoms usually recur in a predictable pattern, but may worsen with age or stress. PMS often increases during times of hormonal turbulence, such as puberty, after childbirth, after miscarriage or abortion and with changes that may occur with contraception use.

PMS is common among women of childbearing age. Most women experience some of the symptoms associated with PMS at some point in their lives, but not all women have the syndrome. Estimates of the exact percentage of women that have PMS vary widely. According to the National Institutes of Health, an estimated 75 percent of menstruating women experience some form of PMS.

A smaller percentage (less than 10 percent) of women experience symptoms so severe that it disrupts their daily lives. This more severe condition is called premenstrual dysphoric disorder (PMDD). Patients with this disorder are diagnosed under stringent guidelines issued by the American College of Obstetricians and Gynecologists (ACOG).

Although it was first identified in 1931, PMS remains a poorly understood condition because there are differing opinions about its cause, diagnosis and treatment. PMS is a syndrome, meaning that it is a group of related symptoms, but has no known cause. As such, management of PMS focuses on alleviating these symptoms rather than curing their underlying cause.

The exact cause of premenstrual syndrome (PMS) is not known. However, several factors have been identified as possible causes or contributors to its occurrence. They include:

• Hormonal changes. During the second half of the menstrual cycle (the last 14 days of a 28-day cycle), levels of the hormones estrogen and progesterone increase until approximately day 21 and then begin to fall. Tissues throughout the body are sensitive to these changes.
  
  
• Chemical changes. Fluctuations in levels of serotonin, a brain chemical linked to mood states, may be a cause. Insufficient serotonin levels have been linked to depression, and excess levels have been linked to anxiety.
  
  
• Diet. Some PMS symptoms have been linked to deficiencies in calcium and vitamins A, E and B (which helps to produce serotonin). Certain foods and beverages have also been identified as possible contributors to PMS, including:
  
  
• Sodium. Eating salty foods in excess may cause fluid retention and bloating.
  
  
• Alcohol or caffeine. Drinking beverages containing alcohol or caffeine may cause changes in mood or energy level.

Occasionally, some women with severe PMS have undiagnosed depression, though depression alone does not cause all of the symptoms associated with PMS. Stress may aggravate some of the symptoms, but is not a cause of PMS.

A number of factors may put a woman at higher risk for PMS. They include:

• Depression. Women with a history of depression or postpartum depression have a higher incidence of PMS.
  
  
• Heredity. Women with a family history of PMS are more likely to have PMS.
  
  
• Children. Women with more children are more likely to experience more severe symptoms than women with fewer children.
  
  
• Physical activity. Sedentary women are at a higher risk for PMS than those who exercise regularly.

Symptoms of premenstrual syndrome (PMS) vary widely from woman to woman and can range from mild to severe. Although women with PMS can experience abdominal cramps, menstrual cramps (dysmenorrhea) are not considered a PMS symptom because they occur during, not before, menstruation.

There are more than 150 symptoms associated with PMS. Most fall into one of two categories – physical or emotional/behavioral.

The most common physical symptoms include:

• Abdominal cramps, pain or fullness
• Breast swelling and tenderness
• Fatigue
• Bloating or fluid retention
• Headache
• Backache
• Swelling of ankles, feet and hands
• Muscle spasms
• Weight gain
• Acne flare-up
• Nausea
• Constipation or diarrhea
• Food cravings
• Less tolerance for noises and light

The most common emotional/behavioral symptoms include:

• Irritability, hostility or aggressive behavior
• Anxiety or depression
• Difficulty concentrating
• Forgetfulness
• Low self-esteem
• Paranoia
• Changes in sex drive

Severe behavioral or emotional symptoms may indicate premenstrual dysphoric disorder (PMDD).

There are no physical examination findings or laboratory tests specific to the diagnosis of premenstrual syndrome (PMS). However, physicians may take a number of steps to determine whether an underlying medical condition may be causing symptoms. Conditions that may mimic PMS include depression, anxiety disorders, thyroid disorders and perimenopause (the period leading up to menopause). In addition, a number of conditions may worsen before menstruation and mimic the symptoms of PMS. These include migraines, chronic fatigue syndrome and irritable bowel syndrome. If no such condition is found, PMS may be suspected.

To rule out other potential causes of symptoms, the physician will first take a complete medical history, including menstrual history, a list of current symptoms and any medications being taken. The physician will then perform a gynecological examination, including a pelvic examination and a Pap smear (to test for cancerous or precancerous tissue in the cervix). Additional tests will vary according to the type and severity of symptoms.

If a patient does not have an underlying medical condition that explains the presence of symptoms, PMS may be suspected. The physician may recommend the patient keep a menstrual diary to document both physical and emotional/behavioral symptoms over time.

The diary enables patients to identify symptoms and determine when they occur during the menstrual cycle. It is kept over several months to identify patterns in symptoms. If symptoms occur consistently around ovulation and last until the menstruation flow begins, then PMS is usually diagnosed. The presence of the symptoms during the first half of the menstrual cycle, however, often indicates that they are being caused by another condition.

Treatment options for premenstrual syndrome (PMS) vary according to the type and severity of symptoms and how bothersome they are to the patient. Patients are advised to keep a menstrual diary to better understand symptoms so they can be treated more effectively.

If symptoms are mild and do not interfere with daily living, a variety of lifestyle changes are recommended to patients. These may include:

• Nutrition. Making dietary changes can relieve symptoms of PMS or reduce their severity. This includes eating a balanced diet with whole grains, fresh fruits and vegetables, and avoiding excess salt, sugar, caffeine and alcohol, particularly when experiencing PMS symptoms. Some patients benefit from eating six small meals during the day instead of three large ones.
  
  
• Vitamins. Taking a multivitamin every day may help women with PMS.
  
  
• Exercise. Engaging in brisk walking, cycling, swimming or other aerobic activity at least 30 to 60 minutes most days of the week is recommended. Regular daily exercise can help improve overall health and alleviate symptoms. Yoga may be helpful for some patients.
  
  
• Stress reduction. Performing muscle relaxation or deep-breathing exercises may help reduce symptoms such as headaches, anxiety or insomnia. Patients may also benefit from scheduling stressful events for the week after their period.
  
  
• Rest. Getting adequate rest is important. The body may have different sleep requirements at different times during a woman’s menstrual cycle.

If lifestyle changes do not lessen PMS symptoms, then medications are sometimes used. These may include:

• Over-the-counter medications. These may include pain-relievers and anti-inflammatories. There are also some medicines marketed specifically for PMS symptom relief. These usually combine a pain reliever with caffeine, antihistamines and/or diuretics.
  
  
• Diuretics (medications that increase the rate of urine production). These may help minimize bloating and weight gain associated with PMS by eliminating excess fluid in the body tissue.
  
  
• Birth control pills. These may help ease some PMS symptoms by “evening out” hormone levels throughout the menstrual cycle. However, not all women are helped by the use of birth control pills.
  
  In October 2006, the Food and Drug Administration (FDA) approved the use of Yaz, a new type of birth control pill, for the treatment of premenstrual dysphoric disorder (PMDD). The new pill was found to be effective in reducing the physical and emotional symptoms of PMDD in clinical trials.
  
  
• Antidepressants. In severe cases, particularly in women with PMDD, antidepressants may be helpful. One example is selective serotonin reuptake inhibitors (SSRIs), which work by regulating the levels of serotonin (a brain chemical linked to mood). People with depression often have low levels of serotonin.
  
  Although traditionally reserved for more severe cases, SSRIs also may help alleviate symptoms in some women with PMS. When taken in low doses two weeks before menstruation, at the start of PMS symptoms or daily during the menstrual cycle, sertraline (a type of SSRI) can be an effective and well-tolerated treatment for moderate-to-severe PMS, according to a new study.
  
  
• GnRh agonists. May be used in severe cases of PMS to induce anovulation (absence of ovulation) and create a temporary menopausal state. These medications are prescribed only for a short period of time to avoid side effects such as hot flashes and osteoporosis.

There are also vitamin supplements and other products that may help alleviate PMS symptoms. They include:

• Calcium. Taking 1,200 milligrams daily may reduce the physical and psychological symptoms of PMS.
  
  
• Magnesium. Taking 200 milligrams daily may help reduce fluid retention, breast tenderness and bloating in women with PMS.
  
  
• Vitamin B6. Taking 50 to 100 milligrams daily of vitamin B6 and other B vitamins may help some women with PMS symptoms.
  
  
• Vitamin E. Taking 400 international units (IU) daily may ease PMS symptoms by reducing the production of prostaglandins, which are hormone-like substances that cause cramps and breast tenderness.
  
  
• Herbal remedies. Some herbs may be marketed as relieving PMS symptoms, including black cohosh, ginger, red raspberry leaf, dandelion tea, chaste tree berry and evening primrose oil. However, studies have not proven the use of herbs to be effective, and the FDA does not regulate herbs, so their safety and effectiveness have not been proven.
  
  
• Natural progesterone creams. Creams derived from wild yams and soybeans have been marketed as relieving PMS symptoms. Some women experience relief, but their effectiveness has not been proven through scientific studies.

Because the cause of PMS is not known, the condition cannot be prevented. However, many of the lifestyle changes recommended for the treatment of PMS, such as regular exercise, a balanced diet, minimal alcohol and caffeine consumption and adequate rest, may be useful in preventing symptoms from developing or getting worse.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions regarding premenstrual syndrome (PMS):

1. What is causing my PMS?
   
   
2. Can my symptoms be related to an underlying condition instead of PMS?
   
   
3. What factors may worsen my PMS?
   
   
4. What signs and symptoms may indicate the more severe premenstrual dysphoric disorder?
   
   
5. How is PMS diagnosed?
   
   
6. How can I relieve PMS-related symptoms?
   
   
7. Do I need to take prescription medications for my PMS? Are there any side effects with this type of treatment?
   
   
8. How long before I see improvement in my symptoms?
   
   
9. Do I need to make any lifestyle changes to improve my symptoms?
   
   
10. How can I prevent PMS from recurring?