Premenstrual syndrome (PMS)

Most women feel some discomfort during their period, but it’s not uncommon to also have unpleasant physical and psychological symptoms in the lead up to your period. These symptoms are referred to as premenstrual syndrome (PMS), or premenstrual tension (PMT). While PMS symptoms go away within a few days of getting your period, they tend to return again each month.

It’s thought that up to 80 per cent of women experience at least some symptoms of premenstrual syndrome. PMS is most often a problem for women in their late 20s to early 40s. While most women only have mild symptoms, PMS causes significant distress to some women. Fortunately, there are a variety of treatments and things you can do that can help reduce or relieve PMS symptoms.

Symptoms

A wide variety of symptoms — physical and psychological — can affect women with PMS. Symptoms can start up to 2 weeks before a period (most often 4-10 days beforehand). They improve once the period starts, disappearing altogether within a few days of starting a period. Most women with PMS find that the symptoms come back with each cycle.

Symptoms can include:

  • bloating (abdominal bloating is one of the most common symptoms);
  • tiredness;
  • breast swelling, soreness or discomfort;
  • headaches;
  • sleeping problems, including insomnia;
  • increased appetite (feeling unusually hungry);
  • food cravings;
  • worsening acne;
  • problems with memory and concentration;
  • irritability;
  • anger;
  • mood swings;
  • reduced libido (lowered sex drive);
  • feeling depressed; and
  • feeling anxious.

Less common symptoms include hot flushes, diarrhoea and constipation.

Most women experience just some of these symptoms, which are usually mild. But others have more severe symptoms, and describe a feeling of loss of control and difficulty coping in the lead up to their period.

Women with very severe PMS symptoms that affect their daily lives may be classified as having a condition called premenstrual dysphoric disorder (PMDD). These women have mood symptoms that are severe enough to seriously affect their relationships and their performance at work or school. PMDD is thought to affect about 3-8 per cent of women having regular periods.

Causes and risk factors

The exact cause of premenstrual syndrome is not known. What is known is that PMS does not occur before puberty, after menopause, or during pregnancy, which means women who are not ovulating do not experience it.

PMS is probably related to changes in the levels of sex hormones (oestrogen and progesterone) that happen throughout a woman’s menstrual cycle. These hormone changes are thought to cause fluctuations in the level of serotonin (a neurotransmitter, or chemical messenger) in the brain. Low levels of serotonin cause mood disturbances.

You may have a higher risk of developing PMS if you:

  • have family members who are affected by PMS;
  • have another mood disorder (such as depression);
  • don’t get any exercise;
  • are a smoker; or
  • are overweight.

Being stressed may make your PMS symptoms worse.

Complications of premenstrual syndrome

Having severe PMS or PMDD can have a significant effect on your quality of life. It can put a significant strain on relationships, especially with people you live with. PMS can also affect your performance at work or school, and make you feel like withdrawing from social events and situations.

PMS can also aggravate some other conditions, such as asthma, diabetes, migraines, epilepsy and depression.

When to seek help for PMS

Many women feel like PMS is just a part of life. But PMS is not something that women should have to put up with, especially if it is affecting relationships, social life or work.

You should see your general practitioner (GP) or a doctor at a family planning clinic if you’ve noticed that you don’t feel yourself around the time of your period. Simple lifestyle changes may be all that’s needed to help you feel better. Or if your symptoms are more severe, treatments are available. But don’t suffer in silence.

Tests and diagnosis

There are no tests for PMS - the diagnosis is based on your symptoms and the fact that they are only present during certain times of your menstrual cycle.

Your doctor will ask about your symptoms and when and how often you experience them. The best way to see whether your symptoms relate to your menstrual cycle is to record your symptoms in a diary (or an app on your smartphone) for at least 2 months. You’ll need to note down how you are feeling every day and when you get your period. This can give a reliable indication of exactly what you experienced and when, which helps with diagnosis.

Your doctor may recommend blood tests to rule out other conditions that could be causing your symptoms. They will also want to check that your symptoms are not due to an underlying (and possibly undiagnosed) problem with anxiety or depression.

Treating PMS

There are several treatments available in Australia to help ease the symptoms of PMS. The best treatment for you will depend on your symptoms and how severe they are, as well as your general health.

Lifestyle changes and psychological therapy are usually recommended first. For women with mild symptoms, these measures are often enough. Women with more severe symptoms and those who have not improved with with the initial treatments may need to take medicines to relieve their PMS symptoms. A combination of treatments may be helpful for some women, especially those with a mixture of different symptoms.

Women with severe PMS may be referred to a specialist doctor - a gynaecologist - or another health professional, such as a psychologist, counsellor or dietitian, for further treatment. Those with premenstrual dysphoric disorder (PMDD) may benefit from seeing a psychiatrist.

Lifestyle measures

There are several lifestyle measures that can help improve symptoms of PMS (as well as your overall health).

Diet

Eating a healthy diet is important, as it contains the vitamins and minerals you need and helps keep you in a healthy weight range.

Specific foods and food groups that may help ease the symptoms of PMS include:

  • complex carbohydrates, such as whole grain cereals, vegetables and legumes (e.g. lentils, peas, beans);
  • calcium-rich foods (such as dairy foods, dark green leafy vegetables, tinned salmon with bones and almonds); and
  • foods that are high in B vitamins (such as beans, seeds, eggs, vegetables, milk, meat and fish).

Try to include plenty of the above foods in your diet.

Foods and drinks you should try to limit or avoid if you have PMS include alcohol, caffeine, fatty foods, salt and salty foods. Specifically:

  • cut down on alcohol and caffeine (found in tea, coffee, cola, energy drinks and chocolate) as they can affect your mood;
  • reduce caffeine and fatty foods if sore breasts are a problem for you; and
  • lower your salt intake to help with the bloated feeling caused by fluid retention.

Many women with PMS also find that eating smaller meals more often helps with feelings of bloating.

A dietitian can help you develop a meal plan aimed to reduce some of your PMS symptoms. Your GP should be able to refer you to one that can help.

Physical activity

Getting regular physical activity can help improve several common PMS symptoms, including tiredness, fluid retention, bloating and depressed mood. About 30 minutes of aerobic exercise a day works well for PMS. Choose an activity you enjoy to help you stick at it.

Other lifestyle measures

Other lifestyle adjustments that can help PMS include:

  • de-stressing - try relaxation exercises or techniques, yoga or meditation to help reduce stress;
  • regularly getting enough sleep can improve mood and reduce your stress levels; and
  • quitting smoking if you are a smoker.

Psychological treatment

One type of psychological therapy (talking therapy) that can help PMS is cognitive behavioural therapy (CBT). This therapy, usually offered by psychologists, helps you to identify negative and unhelpful thinking patterns and to develop improved ways of thinking, behaving and responding to challenging situations.

CBT has also been shown to be helpful in treating premenstrual dysphoric disorder (PMDD).

Medicines

If lifestyle and psychological treatments are not effective, your doctor may suggest medicines to treat your PMS. The type of medicine recommended will depend on your symptoms and how severe they are.

Hormonal treatments

The combined oral contraceptive pill (OCP, also called ‘the pill’) may be recommended to help symptoms of bloating and breast pain, and is a good option for women who also want contraception.

The combined OCP, which contains both oestrogen and progestogen (a man-made form of progesterone) suppresses (stops) ovulation. Certain types of OCP are better than others for treating PMS. However, some of the newer types of OCP may have an increased risk of side effects such as blood clots. Your doctor can discuss the risks and benefits of different types of OCP with you.

Specialists sometimes prescribe other hormone treatments for women whose symptoms are severe and not responding to other treatments.

Antidepressants

Certain types of antidepressants - the selective serotonin reuptake inhibitors (SSRIs) - have been found to be effective in relieving both the psychological and physical symptoms of PMS. SSRIs may be taken continuously or only during the 2 weeks before each period. Possible side effects of SSRIs include sleep problems such as insomnia, tiredness, nausea, loss of appetite and diarrhoea.

Other medicines

Spironolactone is a type of diuretic (‘water pill’) that may be helpful for some women with PMS. It may help reduce fluid retention, bloating and breast discomfort, as well as psychological symptoms.

Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen can help relieve breast soreness and headaches associated with PMS.

Vitamins, minerals and herbal preparations

While many complementary medicines have been tried in the treatment of PMS, most have not been proven to be of benefit in clinical trials. However, there is evidence that calcium supplements can help the physical and psychological symptoms of PMS.

Other complementary treatments that may be helpful in PMS include:

  • vitamin B6 (pyridoxine);
  • the fruit extract of Vitex agnus castus (chasteberry);
  • magnesium supplements; and
  • evening primrose oil (for breast symptoms).

Always check with your doctor before taking any medicine, including complementary medicines, as they may have side effects or interact with other medicines that you are taking.

Support and relationships

If you have significant PMS symptoms, you may be aware that you can sometimes be difficult to live with. Treating your symptoms is important. So is educating yourself and those you live with about your condition. By talking through your difficulties and how you are managing them, you can help address any tensions that exist as a result of your PMS. If you have significant relationship problems it may help to see a counsellor.

References

1. Premenstrual syndrome (published March 2014). In: eTG complete. Melbourne: Therapeutic Guidelines Limited; 2017 Nov. https://tgldcdp.tg.org.au (accessed Mar 2018).
2. Mayo Clinic. Premenstrual syndrome (PMS) (updated 16 Dec 2014). https://www.mayoclinic.org/diseases-conditions/premenstrual-syndrome/symptoms-causes/syc-20376780 (accessed Mar 2018).
3. Family Planning NSW. Premenstrual syndrome (updated May 2013). https://www.fpnsw.org.au/health-information/periods/premenstrual-syndrome (accessed Mar 2018).
4. Jean Hailes Foundation for Women’s Health. Premenstrual syndrome (PMS) (last reviewed 9 Dec 2013). https://jeanhailes.org.au/health-a-z/periods/premenstrual-syndrome-pms (accessed Mar 2018).
5. NHS Choices. Premenstrual syndrome (PMS) (updated 17 Dec 2015). https://www.nhs.uk/conditions/pre-menstrual-syndrome/ (accessed Mar 2018).
6. BMJ Best Practice. Patient information from BMJ. Premenstrual syndrome (published 1 Mar 2018). http://bestpractice.bmj.com/patient-leaflets/en-gb/pdf/1290080181371.pdf (accessed Mar 2018).
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