Premenstrual syndrome

Causes

The exact cause of PMS has not been identified. Changes in brain hormone levels may play a role, but this has not been proven. Women with premenstrual syndrome may also respond differently to these hormones.

PMS may be related to social, cultural, biological, and psychological factors.

Up to 3 out of every 4 women experience PMS symptoms during their childbearing years. It occurs more often in women:

• Between their late 20s and late 40s
• Who have at least one child
• With a personal or family history of major depression
• With a history of postpartum depression or an affective mood disorder

The symptoms often get worse in a woman's late 30s and 40s as she approaches the transition to menopause.

Symptoms

PMS refers to a set of symptoms that tend to:

• Start during the second half of the menstrual cycle (14 days or more after the first day of your last menstrual period)
• Go away within 1 - 2 days after a menstrual period starts

The most common physical symptoms include:

• Bloating or feeling gaseous 
• Breast tenderness
• Clumsiness
• Constipation or diarrhea
• Food cravings
• Headache
• Less tolerance for noises and lights

Other symptoms include:

• Confusion, difficulty concentrating, or forgetfulness
• Fatigue and feeling slow or sluggish
• Feelings of sadness or hopelessness
• Feelings of tension, anxiety, or edginess
• Irritable, hostile, or aggressive behavior, with outbursts of anger toward self or others
• Loss of sex drive (may be increased in some women)
• Mood swings
• Poor judgment
• Poor self-image, feelings of guilt, or increased fears
• Sleep problems (sleeping too much or too little)

Exams and Tests

There are no specific signs or lab tests that can diagnose PMS. To rule out other possible causes of symptoms, it is important to have a:

• Complete medical history
• Physical exam (including pelvic exam)

A symptom calendar can help women identify the most troublesome symptoms and confirm the diagnosis of PMS.

Treatment

Keep a daily diary or log for at least 3 months. Record the type of symptoms you have, how severe they are, and how long they last. This symptom diary will help you and your health care provider find the best treatment.

A healthy lifestyle is the first step to managing PMS. For many women, lifestyle approaches are often enough to control symptoms.

• Drink plenty of fluids (water or juice, not soft drinks, alcohol, or other beverages with caffeine) to help reduce bloating, fluid retention, and other symptoms.
• Eat frequent, small meals. Leave no more than 3 hours between snacks, and avoid overeating.
• Eat a balanced diet with extra whole grains, vegetables, and fruit, and less or no salt and sugar.
• Your health care provider may recommend that you take nutritional supplements. Vitamin B6, calcium, and magnesium are commonly used. Tryptophan, which is found in dairy products, may also be helpful.
• Get regular aerobic exercise throughout the month to help reduce the severity of PMS symptoms.
• Try changing your nighttime sleep habits before taking drugs for insomnia.

Aspirin, ibuprofen, and other NSAIDs may be prescribed for headache, backache, menstrual cramping, and breast tenderness.

Birth control pills may decrease or increase PMS symptoms.

In severe cases, medicines to treat depression may be helpful. Antidepressants known as selective serotonin-reuptake inhibitors (SSRIs) are often tried first. You can reduce the need for medicines by using:

• Cognitive behavioral therapy
• Light therapy

Other medicines that may be used include:

• Anti-anxiety drugs for severe anxiety
• Diuretics (may help with severe fluid retention, which causes bloating, breast tenderness, and weight gain)
• Bromocriptine, danazol, and tamoxifen (rarely used for relieving breast pain)

Outlook (Prognosis)

Most women who are treated for PMS symptoms get significant relief.

PMS symptoms may become severe enough to prevent you from functioning normally.

The suicide rate in women with depression is much higher during the second half of the menstrual cycle.

When to Contact a Medical Professional

Call for an appointment with your health care provider if:

• PMS does not go away with self-treatment
• Your symptoms are so severe that they limit your ability to function

Alternative Names

PMS; Premenstrual dysphoric disorder

References

Lentz GM. Primary and secondary dysmenorrhea, premenstrual syndrome, and premenstrual dysphoric disorder: etiology, diagnosis, management. In: Lentz GM, Lobo RA, Gershenson DM, Katz VL, eds. Comprehensive Gynecology. 6th ed. Philadelphia, Pa: Mosby Elsevier; 2012: chap. 36.

Brown I, O'Brien PMS, Marjoribanks I, Wyatt K. Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database Syst Rev. 2009;2:CD001396.

Update Date: 5/31/2012

Updated by: Linda J. Vorvick, MD, Medical Director and Director of Didactic Curriculum, MEDEX Northwest Division of Physician Assistant Studies, Department of Family Medicine, UW Medicine, School of Medicine, University of Washington; and Susan Storck, MD, FACOG, Chief, Eastside Department of Obstetrics and Gynecology, Group Health Cooperative of Puget Sound, Redmond, Washington; Clinical Teaching Faculty, Department of Obstetrics and Gynecology, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.