PREMENSTRUAL SYNDROME

What is it?
Premenstrual syndrome (PMS) has long been a controversial topic, because years ago it was considered to be a disease without a clear means of diagnosis, no definable cause, and no consistent response to many different treatments. The most prevalent definition of PMS is that it is a collection of several symptoms that occur in the luteal phase of the menstrual cycle, which is the time between ovulation and the beginning of the menstrual period. To have PMS a woman must have a regular ovulatory cycle. By definition then, women who are on birth control pills do not ovulate and do not have PMS; if they suffer from similar problems, those are considered to be a side effect of the pill.

The symptoms of PMS divide easily into those of a physical and those of a mental / emotional nature, and are listed here:

Given this list of symptoms and their premenstrual timing, it can be determined that 75% of women experience PMS to some degree at some point in their lives. Fortunately though, only 5% to 10% of them have their lives severely disrupted by this condition.

What causes PMS?
Although no single underlying cause behind all these symptoms is known to exist, it is clear that there is no hormonal imbalance or abnormality. Every hormone that has ever been checked has shown no difference between those women who complain of PMS and those who do not! The very fact that these women are producing eggs and having periods each month is good evidence that their hormones are entirely normal. It seems overly cruel and sexist to label PMS sufferers as having "messed up, raging hormones".

Current opinion about the cause of PMS symptoms offers different explanations for the physical and mental/emotional problems, and there seems to be good evidence to back up these theories. The physical symptoms are probably caused by a shift of fluid from the bloodstream to the body tissues (which often happens in the luteal phase of the cycle) as well as the direct action of progesterone on smooth muscles such as the bowel to cause it to become more relaxed.

As for the mental/emotional symptoms (which most people think ot when talking about PMS), it has been apparent for many years that they bear a close resemblance to the symptoms of anxiety and depressive disorders. In 1985 this category of premenstrual problems was given the psychiatric designation of "late luteal phase dysphoric disorder". It can be thought of as a mood disorder that cycles with the menstrual period. There are several known chemicals in the brain called neurotransmitters which help regulate the emotional state. The theory regarding this aspect of PMS is that the normal cyclic variation in estrogen and progesterone can, in certain susceptible women, trigger a cyclic decrease in the level of neurotransmitters in the brain, which in turn causes the mood disturbances of PMS. As further evidence of this link, a majority of women with severe premenstrual emotional symptoms will at some time in their lives suffer from an actual episode of clinical depression.

How do I know if I have it?
At least half of all women who present to a medical office with complaints of PMS do not have the disorder, but instead have a different psychiatric or even medical problem. There is no blood test or X-ray to diagnose PMS. The only way to sort it out is through calendar charting (click here for a printable Menstrual Calendar)*. The method is fairly simple. For each day the patient records the date, day of the menstrual cycle (Day 1 being the first day of bleeding), the symptom experienced (the Physical and Mental / Emotional list above is a good guide), and a grading of that symptom on a scale from 0 to 5 (0 = absent, 1 = mild, up to 5 = severe). When two or three cycles of information have been collected, your physician can review the chart and look for patterns that lead to a diagnosis. Of course, in the meantime this does not prevent you from beginning basic treatment measures and looking for improvement.

How is it treated?
At least 95% of women who suffer from PMS will improve on a regimen of diet and exercise alone. These recommendations are summarized below. It is felt that a healthy diet and regular exercise help to decrease the fluid "shift" responsible for many of the physical symptoms and to increase the level of neurotransmitters in the brain which improve the emotional ones.

While we know that hormone levels are not abnormal in PMS sufferers, hormonal treatment has proven very helpful to some patients. It is theorized that the use of these medications to stop ovulation and smooth out or eliminate the normal cyclic variation in estrogen and progesterone (which triggers the neurotransmitter decrease in susceptible women) will prevent the resulting lowering of brain chemical levels and hence prevent PMS. Commonly used medications include birth control pills, Depo-Provera, progesterone, and Aygestin. While some women improve on hormonal therapy, others do not. There is no way to predict a particular patient's response; only a trial of therapy for a few months will tell.

There are a number of medications used for PMS as a whole or targeted to specific symptoms. Various vitamins and minerals, both alone and in special "PMS Formulas", have been popular for years and include calcium, magnesium, B vitamins, and vitamin E. Headache and joint pain usually respond to anti-inflammatory drugs such as Motrin and Aleve. Bloating and swelling are treated with a diuretic ("fluid pill") called spironolactone, and severe cases of breast tenderness with danazol or bromocriptene. The mental/emotional symptoms usually respond to a class of antidepressant drugs which includes Prozac, Paxil, and Zoloft. Whether a patient needs the antidepressant continuously or just in the luteal phase of the cycle can be determined by a short trial.

NON-DRUG MEASURES TO TREAT PMS

Dietary

Eat foods which prevent PMS:
- Complex carbohydrates such as found in potatoes, pasta, and breads
- Whole grains such as wheat, oats, corn, barley, rye, and brown rice
- Legumes such as lentils, green peas, and kidney beans
- Seeds and nuts, especially those that are unsalted and dry roasted or raw
- Lean meats, especially poultry and fish
- Vegetables, especially root vegetables such as carrots, turnips, rutabagas, and green leafy vegetables such as spinach, collards, and mustard greens
- Fresh fruits
- Vegetable oils such as corn, safflower, canola, olive, and sesame

Avoid foods that worsen PMS
- Caffeinated beverages such as coffee, tea, and sodas
- Dairy products such as milk, butter, yogurt, and cheese from cow's milk (cheese from goat's or sheep's milk may be fine)
- Eggs
- Chocolate
- Sugar (honey and maple syrup may be fine)
- Alcohol
- Animal fats and hydrogenated vegetable fats
- Red meats such as beef, pork, and lamb
- Salt and any prepared foods containing a large amount of salt (such as hot dogs and catsup)

Eat small, frequent meals (four to six a day are better than one or two) which are low in fat and high in protein and complex carbohydrates

Lifestyle
Exercise regularly, trying to get in 20 minutes of aerobic exercise a day - walking would be fine!

Avoid fatigue, which only makes PMS symptoms worse.

Plan ahead if possible and avoid any particularly stressful activity during the premenstrual part of the cycle.

Educate your family about your problem and its treatment so that everyone will be more patient and understanding when your symptoms are at their peak.

Learn to relax- this may be as simple as deep breathing, soft music, or a hot bath, or may be a more formal program such as yoga or meditation.

Consider counselling if there are other sources of stress you need help dealing with, such as marital problems or past sexual or physical abuse.

*Menstrual Calendar is in Adobe PDF format. If you don't already have the Adobe Acrobat Reader installed on your system to view and print out PDF files, you will need to download and install this free software on your hard drive .
CLICK HERE TO DOWNLOAD ADOBE ACROBAT READER