What are Pre-Menstrual Syndrome and Premenstrual Dysphoric Disorder?

Most regularly ovulating women experience some physical and mood symptoms during the premenstrual phase. Medically significant premenstrual syndrome (PMS) is apparent, when at least one moderate to severe physical and psychological symptom occurs during the premenstrual phase. [1].

There seems to be three main elements to the problem of PMS

  • The Brain – Some women have a mood centre that is very sensitive to their cycle.
  • The ovarian cycle – an ovulatory cycle is required for PMS. Thus women feel good when pregnant or breast-feeding.
  • The “Black Box” – this represents everything else. Any stressful event will greatly aggravate PMS.

Diagnosis of Pre-menstrual Disorder and Premenstrual Dysphoric Disorder

The criteria for PMS have been clearly stated by the American College of Obstetrics and Gynaecology as follows [1]:

1. The woman reports more than one of the following mood and physical symptoms during the five days before menses, over at least 3 menstrual cycles:

Mood Symptom

Physical Symptom

Depression

Breast tenderness

Angry outbursts

Abdominal bloating

Irritability

Headache

Anxiety

Swelling of hands / feet

Confusion

Social withdrawal

2. Symptoms should be relieved within 4 days of onset of menses, without recurrence until at least day 13 of the cycle (Day 1 of the cycle is the first day of menstrual bleeding.)

Premenstrual dysphoric disorder (PMDD) is a more severe form of PMS. In this condition, the focus is on psychological symptoms. Premenstrual symptoms typically worsen after the mid-30s and some women date their problems to a bout of postnatal depression.

Below is a list of some of the non-controversial aspects of PMS [2]:

  • The symptoms are present in regularly ovulating women.
  • The symptoms do not occur in women who are not ovulating (e.g. prepubertal girls, during pregnancy or after menopause).
  • Medicines that increased synaptic serotonin in the brain are immediately effective therapies for PMS.
  • Pre-existing mood disorders are usually aggravated by the menstrual cycle. In other words, women who already suffer from depression or anxiety often find that their symptoms worsen in the pre-menstrual phase.
  • Women who suffer from mood disorders, including PMS often find that progestins such as Provera® make their symptoms worse.

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 How are PMS and PMDD treated?

Natural Therapies

Some natural therapies that scientific studies have shown are better than a placebo (dummy tablet):

  • Vitamin B6 in doses up to 100 mg daily (e.g. Bioglan® 100mg one daily). Very high doses of B6 can cause nerve damage, especially in the hands and feet.
  • Elemental Calcium up to 1,200mg per day and Elemental Magnesium up to 400mg daily. ActiCal®, Active Calcium or Active Calcium Plus (USANA) in a dose of two chewable tablets morning and night would cover both calcium and magnesium requirements. “Elemental” is a key word here. Some products may state that they contain 500mg Calcium ascorbate, but when you read the fine print, it usually states that this is equivalent to 100mg elemental calcium. Higher doses of magnesium can have a laxative effect. High dose calcium can cause constipation.
  • Evening Primrose oil 3000 mg daily. More helpful for cyclical breast pain than for mood swings.
  • Premular®  is an extract of the berries from the chaste tree (also called Agnus castus), made by Flordis.

Lifestyle changes

Many women find that the following lifestyle changes can really help improve their PMS:

  •  Vigorous exercise
  • A diet low in salt and high in fruit and vegetables
  • Relaxation therapies such as meditation

Drug therapies

Progesterone

Progesterone is often recommended for PMS, but clinical trials have failed to show any benefit over placebo. Synthetic progestins (e.g. Provera®, Primolut®) can make PMS worse and should be avoided. The older contraceptive pills such as Nordette® and Triphasil® usually make the symptoms of PMS worse. Some women find that the modern pills such as Yaz® can help. Oestrogen patches can also help PMS and may be combined with a Mirena® device which will protect the uterus from cancerous changes and reduce period bleeding by around 90%. The Mirena® device contains a progestin but the blood levels are 100-1,000 times lower than tablets and so unpleasant mood side-effects are far less common.

Serotonin Re-uptake Inhibitors (SSRI)

The most tested and clinically proven drugs for severe PMS and PMDD are the modern antidepressants called “SSRIs”. When used for depression, they take 2 to 4 weeks to work. However, when used to treat PMS they only take 2 days to work. Thus if a woman has significant PMS symptoms from days 21-28 of her cycle, then she needs only to take the drugs from days 19 and stop it when she starts a period. The most tested SSRI for PMS is Prozac® (Lovan). The main side effects are headaches and nausea which tend to occur with the first 2-3 doses and then rapidly improve with time.

Surgical treatments

Hysterectomy does not improve PMS. It is the ovarian cycle that triggers the mood centre of the brain and so if the ovaries are left behind, then the PMS will continue after the hysterectomy. However, if a woman with severe PMS is going to have a hysterectomy, then consideration should be given to removing the ovaries and giving back some natural oestrogen (as an implant, patch or gel) to prevent menopausal symptoms.

References:

  • [1] ACOG Practice Bulletin 2000; 15:1-9.
  • [2] Rapkin A, Mikacich J. Premenstrual syndrome: gynaecology or psychiatry? Reproductive Medicine Review, 2001; 9: (3), 223-239

More Information:

If you’d like more information you can view health information fact sheets on our Health Information page, such as:

  • Herbal Medicines
  • Reproductive Services

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