Premenstrual syndrome (PMS or PMT)
Written by Dr Philip Owen, consultant obstetrician and gynaecologist
What is premenstrual syndrome?
PMS or PMT?
The terms premenstrual syndrome (PMS) and premenstrual tension (PMT) are interchangeable.
Around 90 per cent of menstruating women get advance warning of an approaching period because of physical and/or psychological changes in the days before their period begins.
For most women the symptoms are mild, but a small proportion finds their symptoms so severe they dread this time of the month.
The terms ‘mild’ and ‘severe’ in respect of PMS are arbitrary, but relate to the extent of disruption to your home and work life that's attributable to the monthly cycle.
About a third of women say PMS significantly affects their life, with 5 to 10 per cent classifying their PMS as severe.
Symptoms of PMS
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For some women, the days before the start of their period can be awful.
There are more than 100 recognised symptoms that may be due to PMS. Fortunately, most women experience only a handful of problems. The most common symptoms are listed below.
Psychological
o Irritability.
o Mood swings.
o Losing your temper easily.
o Loss of confidence.
o Crying for no particular reason.
o Aggression.
o Poor concentration.
o Tiredness.
Physical
o Breast tenderness.
o Abdominal swelling or bloating.
o Weight gain.
o Swollen ankles.
o Headaches and possibly migraine.
None of these symptoms is exclusive to PMS. They can be caused by other conditions such as depression, stress, thyroid gland problems (under- or over-activity) and anaemia.
How do I know if I have PMS?
PMDD
Premenstrual dysphoric disorder (PMDD) is a mood disorder that occurs during the menstrual cycle.
The symptoms are similar to PMS, but are severe enough to impair or prevent quality of life.
PMDD is a depressive disorder.
While blood tests and urine tests are helpful in making sure there isn't another cause for PMS symptoms, there is no test that can diagnose PMS.
Instead, diagnosis is based upon the type of symptoms and when they occur. The symptoms of PMS have a fairly consistent relationship with the start and finish of a period, which is an essential clue to the diagnosis.
However, it is possible to have more than one problem at the same time, so care needs to be taken by doctors not to ‘blame the hormones’ too quickly.
Most women with PMS notice a gradual worsening of their symptoms during the week running up to their period, with a rapid or gradual disappearance of symptoms when their period starts.
But sometimes symptoms can persist during your period or even for a couple of days after it has finished.
To help doctors diagnose PMS, it helps to keep a diary of your symptoms and their severity over a few consecutive months.
A cyclical pattern should be apparent, and a diagnosis of PMS is usually only made if there are 10 consecutive symptom-free days each month.
What causes PMS?
Hormone levels
Measuring hormone levels is of no help in understanding PMS because there are no differences between women who get PMS and those who don't.
It is not exactly known what causes PMS. Common sense indicates it must somehow be linked to the fluctuating levels of female hormones experienced after ovulation. But the subtleties of why some women are more affected than others are not understood.
Normal fluctuations in hormone levels are responsible for some of the symptoms most commonly associated with the monthly cycle, such as bloating, breast tenderness or headaches.
Women who suffer from PMS may possibly have a lower than normal level of a certain chemical in their brain (serotonin), which may explain some of the non-physical symptoms such as irritability, depression and mood swings.
PMS is not caused by any underlying abnormality with the pelvic organs.
When should I seek treatment?
Recognising your symptoms are due to PMS is an important first step.
For the majority of women, the symptoms are a minor inconvenience you can recognise, anticipate and deal with yourself.
Who do I talk to?
A visit to your GP is usually the first step if you are suffering with PMS.
You could ask for a double appointment to give more time for discussion.
Or your GP may prefer to have a quick word at first, then ask you to come back and discuss things in depth.
The Family Planning Clinic and Well-Woman Clinic are other sources of help.
You may seek reassurance from your doctor, but do not necessarily need or want treatment. The value of such a discussion can be high and result in significant improvement in your symptoms.
For a minority of women, PMS is serious enough to affect work, daily life and relationships. If this sounds like you, you should see your GP to discuss your problems, possibly with a view to some treatment.
Women with severe symptoms who have not responded to simple treatments might wish to see a specialist. This usually means a gynaecologist, but a psychiatrist with a particular interest in treating severe PMS can sometimes be more appropriate.
What treatments are available?
The placebo effect
Part of the reason few PMS treatments provide long-term relief is the so-called 'placebo effect'.
A placebo is a treatment that is ineffective (eg a dummy tablet) but has the psychological effect of making you feel better.
To demonstrate a treatment is better than a placebo requires careful scientific study.
Not all PMS treatments have been subjected to evaluation in this way.
There are many treatments for PMS, most of which have some short-term benefit. However, few provide relief for longer than a few months.
Treatment will depend upon the nature of the symptoms and their severity.
For many women, simple changes to diet and lifestyle, reducing alcohol and caffeine intake and cutting down on cigarettes will make the monthly symptoms more bearable. Your GP can give you guidance in this.
A suitable diet sheet is available via the National Association for Premenstrual Syndrome (NAPS) at www.pms.org.uk.
Non-hormonal treatments
Vitamin B6
This is also known as pyridoxine. It is commonly recommended for mood swings and irritability.
There is some scientific support for its use for mild symptoms, but you need to be careful not to take too high a dose. It is advisable to consult your doctor before starting treatment.
Evening primrose oil (EPO)
Capsules of EPO can be helpful in alleviating premenstrual breast pain in some women. However, the evidence in favour of its effect is slight and it has been withdrawn from NHS prescription for this reason.
Bromocriptine and cabergoline
Bromocriptine (eg Parlodel) and cabergoline (Dostinex) reduce the output from the brain of a hormone called prolactin. Prolactin is the hormone that stimulates the breasts to produce milk.
These drugs may be useful if premenstrual breast pain is a major symptom, but their long-term use should be avoided.
Diuretics (water tablets)
Diuretics (water tablets) may give relief from ankle swelling. They will not relieve abdominal bloating, which is not caused by fluid retention but by relaxation and distension of the muscle in the wall of the bowel.
Diuretics need to be prescribed by a doctor and should only be taken for a few days each month in the lowest of doses.
Antidepressants
There is much enthusiasm for the use of a class of antidepressants called SSRIs (eg Prozac) in the treatment of severe PMS where the symptoms are mostly depression, mood swings, irritability, etc.
The results of treatment are often dramatic and are supported by scientific studies. Side effects can sometimes be a problem. Discussion with a GP or specialist is essential before starting treatment.
Hormonal preparations
Progestogens
A group of hormones taken for 10 to 14 days before the beginning of the period. Progestogens are widely prescribed and have relatively few side effects.
It was once thought that PMS was due to a lack of progestogen in the bloodstream, but it is now recognised this isn't the case.
Some women do gain short-term relief of mild symptoms with progestogens. Most scientific studies do not support their use.
Combined oral contraceptive (COC) pill
There is no good evidence that the Pill works in PMS, but it is often prescribed, especially if contraception is required. Some women find the COC gives them PMS because of the hormones contained in the pill.
There is some initial evidence to suggest the combined Pill called Yasmin, which contains a novel progestogen, may be of some benefit to women with PMS. However, more data is needed.
Danazol
Danazol (eg Danol) is a synthetic hormone based on the male hormone testosterone. Its use in PMS is supported by scientific studies.
It has a number of side effects, such as encouraging the growth of body hair and other masculinising effects, which means it is only suitable for use in low doses and will not be tolerated by all women.
Pregnancy must be avoided while taking this medication.
Oestrogen patches and implants
Extra oestrogen (one of the female hormones) via patches or implants can suppress ovulation and reduce the naturally occurring hormone fluctuations.
There is some evidence to support its use in PMS. Usually patches and implants will only be used on the advice of a gynaecologist.
Mirena intra-uterine system (IUS)
Mirena is in fact a contraceptive device, which is placed inside the uterus (womb). It releases a small dose of progestogen hormone into the body.
Most women experience a reduction in the heaviness and duration of their periods and some say it improves their PMS. It may be combined with an oestrogen patch or implant.
Treatments for severe PMS
Medicines
Drugs known as LHRH analogues or GnRH analogues (such as Zoladex, Prostap and Synarel) are potent medicines used by gynaecologists for a number of conditions.
They temporarily ‘switch off’ a woman's ovaries, which usually gives relief from PMS within two months. They are only suitable for short-term use up to six months.
LHRH analogues may be used to confirm the diagnosis of PMS and to help guide you and your gynaecologist towards considering surgery. They are used only in severe and difficult-to-treat PMS.
One of the potential disadvantages of using these particular drugs is they cause flushings and sweats due to the drop in oestrogen output from the ovaries (like that which occurs in the menopause).
They also accelerate the natural rate of bone loss and can therefore increase your chances of developing osteoporosis (fragile bones).
To counter this, they are usually combined with a drug called tibolone (Livial) that mimics HRT. Doctors call this ‘add-back’ treatment.
Surgery
Hysterectomy & PMS
Removing the womb only (hysterectomy) may not improve PMS.
This is because you can still get PMS if one or both ovaries are still present and functional.
For a small minority of women, surgical removal of the ovaries is the only measure that will allow them to continue a normal existence, free of PMS.
This is a major and still controversial step to be considered carefully by you, your GP and gynaecologist.
Once the ovaries are removed, you must be prepared to take hormone replacement therapy (HRT) until at least the age of 50.
Because it is such a drastic step, the use of LHRH analogues are usually used first - effectively non-surgical ways of putting the ovaries out of action. If this treatment works well, there is more chance surgery will be effective.
Many gynaecologists will not operate for PMS alone, but will do so if there are additional problems, such as uncontrolled heavy menstrual bleeding, for which surgery is going to help.
Last updated 02.06.2005
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