What is PMS?

PMS is a chronic condition experienced by menstruating women which is characterised by distressing physical, behavioural and psychological symptoms that regularly recur during the luteal phase of the  menstrual cycle ( from ovulation to the onset of a period) and that disappear or  significantly diminish by the end of the period (menstruation).

The menstrual cycle normally occurs monthly throughout a woman’s reproductive years as the lining of the womb (uterus) gradually grows in thickness and is shed at the period (menstruation).The average length of the menstrual cycle (from the first day of bleeding to the first of another) is 28 days but this is only an average and can vary greatly between women. Also, an individual woman may find that the length of her menstrual cycle varies from month to month.

What is the difference between PMS and PMDD?

Premenstrual Dysphoric Disorder (PMDD) is the American Psychiatric Association’s definition of one type of severe PMS. The criteria for inclusion using this definition are rather restrictive and only apply to 5-8% of PMS sufferers. Our society recently changed its name to National Association for Premenstrual Syndromes by adding an “s” to reflect the fact that there are a number of variants of Premenstrual Syndrome.

NAPS statement on the definition of PMS

What causes PMS?

The precise causes of PMS have still to be identified but there is compelling evidence that symptoms are directly related to the fluctuation of hormone levels in the monthly cycle. As PMS is absent before puberty (onset of menstruation), in pregnancy and after the menopause there is clear indication that cyclical ovarian activity is an important factor in explaining PMS.

What are the symptoms of PMS?

PMS is characterised by a number of symptoms- over 150 have been identified.

Common psychological and behavioural symptoms are: mood swings, depression, tiredness, fatigue or lethargy, anxiety, feeling out of control, irritability, aggression, anger, sleep disorder, food cravings

Common physical symptoms are: breast tenderness, bloating, weight gain, clumsiness, headaches

No-one experiences all identified symptoms. One symptom may be dominant. Each symptom may vary in severity during a cycle and from one cycle to another. New symptoms may present during a woman’s experience of PMS.

PMS symptoms may be experienced continuously from ovulation to menstruation, for 7 days before, at ovulation for 3-4 days and again just prior to menstruation and in other patterns. Some women do not experience relief from symptoms until the day of the heaviest flow.

How can PMS be diagnosed?

Diagnosis depends entirely  on the timing of symptoms in the menstrual cycle. There are no blood tests that can be taken to confirm PMS and keeping a menstrual chart is the only reliable method of diagnosis. The NAPS menstrual chart , with instructions for using it can be downloaded.

A chart will accurately reflect symptoms and will show the days on which they occur, the days when they are absent, the days of menstruation and the duration of the menstrual cycle.

A chart needs to be kept for at least two cycles, before discussing it with a doctor. It provides both the PMS sufferer and the GP with an evidence base from which to both diagnose and treat PMS.

Can PMS be cured?

There is no known ‘cure’ for PMS except  a hysterectomy as that is the ultimate form of ovulation suppression but with appropriate treatment it can be successfully managed.

Who suffers from PMS?

PMS can occur in any woman during child bearing years. It is estimated that as many as 30% of women can experience moderate to severe PMS, with 5-8% suffering severe PMS/PMDD, this being around 800,000 in the UK.

PMS  appears to begin and increase in severity  at times of marked hormonal change:- in puberty ( even before the first period), starting/stopping the oral contraceptive pill, after pregnancy, with pre-eclampsia, postnatal depression, sterilisation or termination.

PMS is no respecter of persons and has no regard for race or economic status.

It can affect the whole family, not only sufferers but also husbands, partners and children and it can impact adversely too on friends and work colleagues.There will be families where PMS is experienced by successive generations but equally there are PMS sufferers with no family members similarly afflicted. Research on whether PMS is inherited has so far been inconclusive but there may be a genetic cause.

What are the treatments for PMS?

Lifestyle changes: reducing stress, diet, exercise, limiting alcohol and smoking can improve PMS symptoms but they will be insufficient in managing moderate to severe PMS. There is evidence that certain complementary therapies may be of benefit in such cases – Agnus Castus and Magnesium in particular. Medical treatments for moderate to severe PMS fall into two categories – ovulation suppression and SSRis- Selective Serotonin Reuptake inhibitors.

The recommended therapies suppressing  ovulation are :- some combined oral contraceptive pills, oestrogen patches or implants with cyclical progestogen or Mirena. Where these prove not to be successful GnRH analogue therapy can be employed. If severe PMS persists then a Hysterectomy is the ultimate medical treatment.

SSRis in the form of Prozac, Cipramil and Cipralex can be used to treat PMS on the basis that serotonin may be important in causing the condition.

Is there a link between Postnatal depression and PMS?

Premenstrual, postnatal and perimenopausal depression are all hormone related depressive disorders. It is thought that women who suffer with these problems have a vulnerability to hormonal changes. This vulnerability is thought to be due to a genetic cause. Women with postnatal illness often have a family history of PMS, postnatal or perimenopausal depression. They are usually well during pregnancy when hormone levels are stable but develop postnatal depression after delivery as hormone levels fall. As menstruation returns PMS symptoms then recommence or occur for the first time.

How does perimenopause affect PMS?

As women approach the menopause, hormone fluctuations become more exaggerated because the ovaries are not working well and the brain does not control ovarian function as efficiently. In women who are vulnerable to these hormonal changes premenstrual symptoms can commence or deteriorate. The PMS symptoms are often compounded by the start of menopause symptoms such as hot flushes, night sweats and insomnia.

Does PMS decrease with the Menopause?

Premenstrual symptoms will usually cease when women become post menopausal, typically one to two years after the final menstrual period. This is because the hormonal fluctuations which trigger the symptoms become much calmer and eventually settle down completely.

More than 1% of women go through the menopause before the age of 40.  For advice and support in dealing with the associated emotional and health implications visit daisynetwork.org.uk

What is the role of diet in the management of PMS

Quality and quantity of carbohydrates

Cut down on excess sugar and white refined carbohydrates such as pizza and white bread. These carbohydrates cause a rapid release of blood glucose, which may affect mood swings and cravings as well as contributing to weight gain, making your PMS symptoms worse. Carbohydrates that release glucose more slowly are classified as low glycaemic index (GI) carbohydrates. Useful switches include changing white bread for heavy wholegrain rye bread, white rice for basmati rice, potatoes and chips for pulses, beans or sweet potatoes. In addition filling your plate with low glycaemic index vegetables such as salad or greens rather than high GI starches such as potatoes or white rice, is a good way to reduce the glycaemic index of your diet. Eating a little and often can also help keep blood glucose levels stable.

Getting enough of the right nutrients

a) All of us should be eating two portions of oily fish every week for a healthy heart. In addition the essential fats in fish have been shown to improve PMS mood symptoms and pain. Good sources include salmon, mackerel and sardines. The fats in linseeds and pumpkin seeds will give you some of the benefits if you don’t want to eat fish.

b) Green vegetables are an important source of both magnesium, which is often deficient in women with PMS and also folic acid, which is important for hormone balance. In addition we have some data to suggest having a high fibre diet with lots of vegetables can help improve PMS symptoms.

c) B vitamins are important to help the body’s neurotransmitters function properly and diets low in B1 and B2 particularly, are associated with a higher occurrence of PMS; B1 (thiamine) can be found in fortified cereals, legumes and nuts (2/3 servings a day are recommended); B2 (riboflavin) can be found in cow’s/soya milk, red meat, green vegetables (6/7 servings a day); B6 can be found in watercress, cauliflower, cabbage, peppers and bananas and folic acid in green leafy vegetables, fortified cereals and beans.

d) Women whose diet is rich in calcium and vitamin D are less likely to suffer from PMS. Four servings of low-fat dairy products are recommended each day to supply enough of these nutrients. In addition calcium can be found in green vegetables like cabbage, kale and broccoli and vitamin D is made by the skin in response to sunlight.

e) It has been suggested that phytoestrogens such as soy isoflavones in soya foods and lignans in linseeds, may help reduce physical PMS symptoms such as headaches. Our data on this is limited however, women in Asia, who have high levels of phytoestrogens in their diet do have fewer PMS symptoms. Sources include linseeds, soya foods, legumes, fennel, celery, hops, wholegrains and rhubarb.

Alcohol, coffee & salt

Alcohol may contribute to anxiety symptoms and hormone imbalance and is best consumed in moderation. A high caffeine consumption has also been associated with an increased incidence of PMS, may make breast tenderness worse for some women so limit consumption each day. In addition salt encourages water retention so it is important to follow the national guidelines of less than 6mg/d.