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|Patient UK||Premenstrual syndrome|
Premenstrual syndrome (PMS), also called premenstrual tension (PMT) is a collection of emotional symptoms, with or without physical symptoms, related to a woman's menstrual cycle. While most women of child-bearing age (up to 85%) report having experienced physical symptoms related to normal ovulatory function, such as bloating or breast tenderness, medical definitions of PMS are limited to a consistent pattern of emotional and physical symptoms occurring only during the luteal phase of the menstrual cycle that are of "sufficient severity to interfere with some aspects of life". In particular, emotional symptoms must be present consistently to diagnose PMS. The specific emotional and physical symptoms attributable to PMS vary from woman to woman, but each individual woman's pattern of symptoms is predictable, occurs consistently during the ten days prior to the start of the menstrual period, and vanishes either shortly before or shortly after the start of menstrual flow.
Culturally, the abbreviation "PMS" is widely understood in English-speaking countries to refer to difficulties associated with the menstrual period, and the abbreviation is used frequently even in casual and colloquial settings, without regard to medical rigor. In these contexts, the syndrome is rarely referred to without abbreviation, and the connotations of the reference are frequently more broad than the clinical definition.
Premenstrual dysphoric disorder (PMDD) consists of symptoms similar to, but more severe than, PMS, and while primarily mood-related, may include physical symptoms such as bloating. PMDD is classified as a repeating transitory cyclic disorder with similarities to unipolar depression, and several antidepressants have been approved as therapy.
Signs and symptoms
More than 200 different symptoms have been associated with PMS, but the three most prominent symptoms are: irritability, tension, and dysphoria (unhappiness). Common emotional and non-specific symptoms include stress, anxiety, difficulty in falling asleep (insomnia), headache, fatigue, mood swings, increased emotional sensitivity, and changes in libido. Physical symptoms associated with the menstrual cycle include bloating, abdominal cramps, constipation, swelling or tenderness in the breasts, cyclic acne, and joint or muscle pain.
The exact symptoms and their intensity vary significantly from woman to woman, and even somewhat from cycle to cycle. Most women with premenstrual syndrome experience only a few of the possible symptoms, in a relatively predictable pattern. For example, one woman with PMS may be anxious and tense for three or four days before her menstrual period begins, and this will happen with only small variations each cycle, such as being somewhat more tense (or less tense) than in previous cycles.
Women with PMS do not experience completely different symptoms each cycle, such as anxiety with one cycle, depression the next, anger in the following cycle, and so forth. Each woman with PMS has her own personal pattern of symptoms. While one woman might be anxious and tense, another woman might experience PMS as causing her to be depressed and tearful for two days each cycle, and another woman might find that she is easily irritated by problems that she normally considers minor. Each woman's pattern, although different from what other women with PMS experience, will be relatively predictable and stable for the woman who experiences it.
Under typical definitions, symptoms must be present at some point during the ten days immediately before the onset of the menstural period, and must not be present for at least one week prior to ovulation. Although the intensity of symptoms may vary somewhat, most definitions require that the woman's unique combination of symptoms be present in multiple, consecutive cycles.
The exact causes of PMS are not fully understood. While PMS is linked to the luteal phase, measurements of sex hormone levels are within normal levels. In twin studies, the concordance of PMS is twice as high in monozygotic twins as in dizygotic twins, suggesting the possibility of some genetic component. Current thinking suspects that central-nervous-system neurotransmitter interactions with sex hormones are affected. It is thought to be linked to activity of serotonin (a neurotransmitter) in the brain. Recent studies in rats indicate that levels of glutamate, an excitory neurotransmitter, spikes prior to menstruation in the cortex and hippocampus. High glutamate levels have been tied to mood disorders in several studies.
Preliminary studies suggest that up to 40% of women with symptoms of PMS have a significant decline in their circulating serum levels of beta-endorphin. Beta endorphin is a naturally occurring opioid neurotransmitter which has an affinity for the same receptor that is accessed by heroin and other opiates. Some researchers have noted similarities in symptom presentation between PMS symptoms and opiate withdrawal symptoms.
A variety of evolutionary rationales for the syndrome have been offered, though these nearly always fail to account for any physiological role. One suggestion is that, including that it is an epiphenomenon due to the selective advantage accruing to other phases of the hormonal cycle, that it leads to "intensification of male ardour during the next onset of fertility", and that it prompts females to reject infertile males (who cause PMS due to not impregnating the female). "... an infertile male/potentially fertile female partnership would tend to break down, thus allowing a new pair-bond to be formed. The greater the degree of premenstrual hostility of the female, the sooner a fertile mating could ensue." Any theory would have to account for the persistence of PMS over substantial evolutionary time, as it appears to afflict baboons as well.
- High caffeine intake
- Stress may precipitate condition
- Increasing age
- History of depression
- Family history
- Dietary factors (Low levels of certain vitamins and minerals, particularly magnesium, Vitamin B-6, manganese, zinc,vitamin E and also Vitamin D)
There may be a genetic aspect to the probability of having premenstrual syndrome: it has been shown that the likelihood of both identical twins suffering from PMS is higher than with fraternal twins. This means that if one twin has PMS, then the other twin is more likely than average to have PMS, pointing to a genetic component.
There is no laboratory test or unique physical findings to verify the diagnosis of PMS. The three key features are:
- The woman's chief complaint is one or more of the emotional symptoms associated with PMS (most typically irritability, tension, or unhappiness).
- Symptoms appear predictably during the luteal (premenstrual) phase, reduce or disappear predictably shortly before or during menstruation, and remain absent during the follicular (pre-ovulatory) phase of the menstrual cycle.
- The symptoms must be severe enough to disrupt or interfere with the woman's everyday life.
To establish a pattern, a woman's physician may ask her to keep a prospective record of her symptoms on a calendar for at least two menstrual cycles. This will help to establish if the symptoms are, indeed, limited to the premenstrual time and are predictably recurring. A number of standardized instruments have been developed to describe PMS, including the Calendar of Premenstrual syndrome Experiences (COPE), the Prospective Record of the Impact and Severity of Menstruation (PRISM), and the Visual Analogue Scales (VAS).
In addition, other conditions that may better explain symptoms must be excluded. A number of medical conditions are subject to exacerbation at menstruation, a process called menstrual magnification. These conditions may lead the woman to believe that she has PMS, when the underlying disorder may be some other problem, such as anemia, hypothyroidism, eating disorders and substance abuse. A key feature is that these conditions may also be present outside of the luteal phase. Conditions that can be magnified perimenstrually include depression or other affective disorders, migraine, seizure disorders, fatigue, irritable bowel syndrome, asthma, and allergies. Also, problems with other aspects of the female reproductive system must be excluded, including dysmenorrhea (pain during the menstrual period, rather than before it), endometriosis, perimenopause, and adverse effects produced by oral contraceptive pills.
Although there is no universal agreement about what qualifies as PMS, two definitions are commonly used in research programs:
- The National Institute of Mental Health research compares the intensity of symptoms from cycle days 5 to 10 to the six-day interval before the onset of the menstrual period. To qualify as PMS, symptom intensity must increase at least 30% in the six days before menstruation. Additionally, this pattern must be documented for at least two consecutive cycles.
- The definition formulated at the University of California at San Diego requires both affective (emotional) and somatic (physical) symptoms during the five days before menstruation in each of three consecutive cycles, and must not be present during the pre-ovulatory part of the cycle (days 4 through 13). For this definition, affective symptoms include symptoms like depression, angry outbursts, irritability, anxiety, confusion, and social withdrawal. Somatic symptoms include symptoms like breast tenderness, abdominal bloating, headache, and swelling of hands and feet.
Many treatments have been suggested for PMS, including diet or lifestyle changes, and other supportive means. Medical interventions are primarily concerned with hormonal intervention and use of selective serotonin reuptake inhibitors (SSRIs).
- Due to similarities in the symptoms of PMS and hypocalcemia, calcium supplementation has been studied as a potential treatment. Several studies indicate that taking dietary supplements of 1000 mg/d relieves nearly all symptoms in most women compared to placebo.
- Various vitamins have been proposed to improve symptoms with mixed results. vitamin E (400 IU/d) has shown some effectiveness. A number of other treatments have been suggested, although research on these treatments is inconclusive so far: Vitamin B6, magnesium, manganese and tryptophan.
- Chasteberry has been used by women for thousands of years to ease symptoms related to menstrual problems. While the effectiveness of this is unclear for PMS, it is suggested to be effective at treating cyclic breast tenderness.
- DL phenylalanine can reduce or prevent symptoms of PMS in some women. It is only effective when the PMS is associated with an abrupt decline in circulating serum beta-endorphin levels.
- Some evidence suggests that daily treatment with St. Johns wort (Hypericum perforatum) may improve the most common physical and emotional symptoms associated with PMS, though this herb is more often prescribed for depression alone and may be unrelated to PMS.
- Supportive therapy includes evaluation, reassurance, and informational counseling, and is an important part of therapy in an attempt to help the woman regain control over her life. In addition, aerobic exercise has been found in some studies to be helpful. Some PMS symptoms may be relieved by leading a healthy lifestyle: Reduction of caffeine, sugar, and sodium intake and increase of fiber, and adequate rest and sleep.
- SSRIs like fluoxetine, sertraline can be used to treat severe PMS. Women with PMS may be able to take medication only on the days when symptoms are expected to occur. Although intermittent therapy might be more acceptable to some women, this might be less effective than continuous regimens. Side effect such as nausea and weakness are however relatively common.
- Non-steroidal anti-inflammatory drugs (NSAIDs; e.g. ibuprofen) have been used to treat pain.
- Clonidine has been reported to successfully treat a significant number of women whose PMS symptoms coincide with a steep decline in serum beta-endorphin on a monthly basis.
- Hormonal intervention may take many forms:
- Hormonal contraception is commonly used; common forms include the combined oral contraceptive pill and the contraceptive patch. This class of medication may cause PMS-related symptoms in some women, and may reduce physical symptoms in other women. They do not relieve emotional symptoms.
- Progesterone support has been used for many years but evidence of its efficacy is inadequate.
- Gonadotropin-releasing hormone agonists can be useful in severe forms of PMS but have their own set of significant potential side effects.
- Diuretics have been used to handle water retention. Spironolactone has been shown in some studies to be useful.
PMS is generally a stable diagnosis, with susceptible women experiencing the same symptoms at the same intensity near the end of each cycle for years.
Treatment for specific symptoms is usually effective at controlling the symptoms. Even without treatment, symptoms tend to decrease in perimenopausal women, and disappear at menopause.
Women who have PMS have an increased risk for clinical depression.
The number of women who experience PMS depends on the definition used. The World Health Organization estimates that 199 million women have premenstrual syndrome as of 2010 (5.8% of the female population). While 80% of menstruating women have experienced at least one symptom that could be attributed to PMS, estimates of prevalence range from as low as 3% to as high as 30%.
Mood symptoms such as emotional lability are both more consistent and more disabling than somatic symptoms such as bloating. A woman who experiences mood symptoms is likely to experience these symptoms consistently and predictably, whereas physical symptoms may come and go.
Many researchers started study the Premenstrual Syndrome of women in the 19th century. The first person to name and describe the premenstrual syndrome was Robert T. Frank. Interest in PMS began to increase after it was used as a criminal defense in Britain during the early 1980s.
PMS was originally seen as an imagined disease. Women who reported its symptoms were often told it was "all in their head". Woman’s reproductive organs were thought to have complete control over them. Women were warned not to divert needed energy away from the uterus and ovaries. This view of limited energy ran very quickly up against a reality in 19th century America that young girls worked extremely long and hard hours in factories. This contradiction was resolved in many ways by “detailing the weakness, degeneration and disease suffered by female clerks and operatives who strive to emulate the males by unremitting labor”. This disregarded the very poor health conditions of the workers. Advertisements were starting to get rid of the Victorian era thought of the female uterine economy and the woman’s place being in the private sphere. Newspapers in the 19th century were peppered with remedies to help in the “tyrannous processes” of the menstrual cycle.
Sally Shuttleworth conducted a study on two new papers, The Leeds Intelligencer and The Leeds Mercury, from which examples of popular advertising are drawn. The sample is between 1830 and 1855. Both papers cover local and national news; advertise the material and the sexual body that undermines the generalized notions of the Victorian era. Graphic sexual details and venereal-disease remedies were included in the papers. As the publicity heated up on the topic, it became clear that the real ground for dispute was not indecency but the professional territory, prestige, and material gains. Soon doctors stop putting their names in advertisements.
An early 1837 advertisement for “Lady Huntingdon’s female pills” proclaims that they have rescued many young women from an “early grave”. Advertisements for PMS curing pills were very common in the 19th century. Another advertisement for the “Croskell’s female corrective pills” were meant to cure women of menstruation. The constant refrain throughout the advertisements of this period was that of female vulnerability and the side effects of menstrual obstruction.
These advertisements made PMS and menstruation seem like bodily defects, thus making female reproductive systems and bodies were seen as dysfunctional. These advertisements made it difficult for women to keep working the long and rigorous hours they had to in factories. The relationship between woman’s capacity to work and menstruation was a central issue during the 19th century. A focus shift from menstruation to PMS also occurred later in the 19th century, but the main issue still being addressed was whether or not women were fit to work out side of the home
In 1873 Edward Clarke published an influential book titled “Sex in Education”. Clarke came to a conclusion that female operatives suffer less than schoolgirls because they “work their brain less”. This suggested that they have stronger bodies and a stronger reproductive “apparatus more normally constructed”. Feminists later took opposition to Clarke’s argument that women should not leave the private sphere by showing how woman could function in the world outside the home in spite of their bodily functions.
One of the dissenters from Clarke’s opinions was Mary Putnam Jacob, who wrote “The Question of Rest for Women During Menstruation” in 1877. Her piece showed that “women do work better, and with much greater safety to health when their work is frequently intermitted; but those intermittent breaks should be at short intervals and lasting a short time, not at long intervals and lasting longer. Finally that they are required at all times, and have no special reference to the period of the menstrual flow”. Also given the type of work men would probably also work better if they had frequent shorter breaks.
In order for a condition to be accepted as a disease by society, many different parts of society must agree on it. Women have contributed to the rise of interest in PMS and society's acceptance of it as an illness. It is argued that women are partially responsible for the medicalization of PMS. By legitimizing this disorder, women have contributed to the social construction of PMS as an illness. It has also been suggested that the public debate over PMS and PMDD was impacted by organizations who had a stake in the outcome including feminists, the APA, physicians and scientists.
The study of PMS symptoms is not a new development. Debates about the definition and validity of this syndrome have a long history. As stated above, growing public attention was given to PMS starting in the 1980s. Up until this point, there was little research done surrounding PMS and it was not seen as a social problem. By the 1980s, however, viewing PMS in a social context had begun to take place.
Some medical professionals and other people believe that PMS might be a socially constructed disorder rather than a physical illness. The anthropologist Emily Martin argues that PMS is a cultural phenomenon that continues to grow in a positive feedback loop. Also, the studies on PMS will either tell women that PMS is detrimental to their work capabilities depending on whether the need for women in the work force is strong (historically during wartime when men were away) or if women are being relegated to home life (when men return from war and once again desire work). At the time that women were being forced back into the home after WWI, the symptoms of PMS and menstruation were considered more debilitating than during WWII, when it was not a “liability after all.”  In general, wartime triggers studies that diminish the impacts of PMS in women's lives, whereas inter-wartime studies promote the idea of PMS being a large, monthly obstacle in women's lives.
In women with PMDD—which supporters of the medical model of PMS say is a severe form of PMS, and critics say is unrelated—studies have shown a correlation between self-reported emotional distress and levels of a serotonin precursor as measured by positron emission tomography (PET). PMDD also has a consistent treatment record with SSRIs, when compared with placebos. The decision to call PMDD an illness has been criticized as inappropriate medicalization.
Most supporters of PMS as a social construct believe PMDD and PMS to be unrelated issues: according to them, PMDD is a product of brain chemistry, and PMS is a product of a hypochondriatic culture. Most studies on PMS and PMDD rely solely on self-reporting. According to sociologist Carol Tavris, Western women are socially conditioned to expect PMS or to at least know of its existence, and they therefore report their symptoms accordingly.
Another view holds that PMS is too frequently or wrongly diagnosed in many cases. A variety of problems, such as chronic depression, infections, and outbursts of frustration can be mis-diagnosed as PMS if they happen to coincide with the premenstrual period. Tavris says that PMS is blamed as an explanation for rage or sadness.
The use of multiple SSRIs to treat PMS has caused some controversy. The makers of Prozac began marketing the generic form, fluoxetine, under the name Sarafem to treat PMS. This coincided with their loss of patent on Prozac, which has led to one suggestion that their motives are not completely benign. An oral contraceptive named drospirenone (Yaz) was approved to treat PMDD. The marketing of Yaz centers on this aspect of the drug.
Many of the following studying people have different views on the women with Premenstrual Syndrome. Edward Clarke wrote an influential book, Sex in Education (1873) saying that women should stay home because of their uncontrollable behaviors when they have Premenstrual Syndrome. Thomas Buckley mentions that in his article too, "a menstruating woman should isolate herself because this is the time when she is at the height of her powers. Thus, the time should not be wasted in mundane tasks and social distractions, nor should one's concentration be broken by concerns with the opposite sex." Michelle Harrison, after studying premenstrual women, said that, "Women who are premenstrual often have a need for time alone, time to themselves, and yet few women actually have that time in their lives.
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