Premenstrual syndrome (PMS) refers to a varied collection of physical and emotional symptoms during part of 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; medical treatment of PMS is limited to a consistent pattern of emotional and physical symptoms that are of "sufficient severity to interfere with some aspects of life". 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.
Two to ten percent of women have significant premenstrual symptoms that are separate from the normal discomfort associated with menstruation in healthy women.Premenstrual dysphoric disorder (PMDD) consists of symptoms similar to, but more severe than, PMS. Primarily mood-related, PMDD may include physical symptoms as well. 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. 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, lower back pain, abdominal cramps, constipation/diarrhea, swelling or tenderness in the breasts, cyclic acne, and joint or muscle pain, food cravings,  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.
While PMS is linked to the luteal phase, the causes of PMS are not clear, but several factors may be involved. Changes in hormones during the menstrual cycle seem to be an important factor; changing hormone levels affect some women more than others. Chemical changes in the brain, stress, and emotional problems, such as depression, do not seem to cause PMS but they may make it worse. Low levels of vitamins and minerals, high sodium, alcohol, and/or caffeine can exacerbate symptoms such as water retention and bloating. PMS occurs more often in women who are between their late 20s and early 40s; have at least 1 child; have a family history of depression; and have a past medical history of either postpartum depression or a mood disorder.
There is a wide range of estimates of how many women suffer from PMS. The American College of Obstetricians and Gynecologists estimates that at least 85 percent of menstruating women have at least 1 PMS symptom as part of their monthly cycle. Most of these women have fairly mild symptoms that do not need treatment. Others (about 3 to 8 percent) have a more severe form of PMS, called premenstrual dysphoric disorder (PMDD).
Mild PMS is common, and more severe symptoms would qualify as PMDD. PMS is not listed in the DSM-IV, unlike PMDD. To establish a pattern and determine if it is PMDD, 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, predictably recurring, and disruptive to normal functioning. 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).
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. 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.
The National Institute of Mental Health research definition 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.
Many at-home treatments have been offered for PMS, including diet, exercise, or over the counter pills. 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. Non-steroidal anti-inflammatory drugs (NSAIDs; e.g. ibuprofen) have been used to treat pain.
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.
- 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.
- 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. Even without treatment, symptoms tend to decrease in perimenopausal women.
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; newspapers in the 19th century were peppered with remedies to help in the “tyrannous processes” of the menstrual cycle. 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.
The formal medical description of premenstrual syndrome (PMS) and the more severe, related diagnosis of premenstrual dysphoric disorder (PMDD) goes back at least 70 years to a paper presented at the New York Academy of Medicine by Robert T. Frank titled “Hormonal Causes of Premenstrual Tension.” The specific term premenstrual syndrome appears to date from an article published in 1953 by Dalton and Green in the British Medical Journal.1 Since then, PMS has been a continuous presence in our popular culture, occupying a place that is larger than the research attention accorded it as a medical diagnosis.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. 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.
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. The anthropologist Emily Martin argues that PMS is a cultural phenomenon that continues to grow in a positive feedback loop, and thus is a social construction that contributes to learned helplessness or convenient excuse. Tavris says that PMS is blamed as an explanation for rage or sadness. The decision to call PMDD an illness has been criticized as inappropriate medicalization. In both cases, they are referring to the emotional aspects, not the normal physical symptoms that are subjectively present.
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