Premenstrual syndrome

Last updated
Premenstrual syndrome
Specialty Gynecology, psychiatry
Symptoms Fatigue, irritability and other mood changes, tender breasts, abdominal bloating [1]
Complications Premenstrual dysphoric disorder [1] [2]
Usual onset1–2 weeks before menstruation [1]
Duration6 days [2]
CausesUnknown [1]
Risk factors High-salt diet, alcohol, caffeine [1]
Diagnostic method Based on symptoms [3]
TreatmentLifestyle changes, medication [1]
Medication Calcium and vitamin D supplementation, NSAIDs, birth control pills [1] [2]
Frequency~25% of women [2]

Premenstrual syndrome (PMS) is a disruptive set of emotional and physical symptoms that regularly occur in the one to two weeks before the start of each menstrual period. [4] [5] Symptoms resolve around the time menstrual bleeding begins. [4] Symptoms vary, [6] though commonly include one or more physical, emotional, or behavioral symptoms, that resolve with menses. [7] The range of symptoms is wide, and most commonly are breast tenderness, bloating, headache, mood swings, depression, anxiety, anger, and irritability. To be diagnosed as PMS, rather than a normal discomfort of the menstrual cycle, these symptoms must interfere with daily living, during two menstrual cycles of prospective recording. [7] PMS-related symptoms are often present for about six days. [2] An individual's pattern of symptoms may change over time. [2] PMS does not produce symptoms during pregnancy or following menopause. [1]

Contents

Diagnosis requires a consistent pattern of emotional and physical symptoms occurring after ovulation and before menstruation to a degree that interferes with normal life. [3] Emotional symptoms must not be present during the initial part of the menstrual cycle. [3] A daily list of symptoms over a few months may help in diagnosis. [2] Other disorders that cause similar symptoms need to be excluded before a diagnosis is made. [2]

The cause of PMS is unknown, but the underlying mechanism is believed to involve changes in hormone levels during the course of the whole menstrual cycle. [1] Reducing salt, alcohol, caffeine, and stress, along with increasing exercise is typically all that is recommended for the management of mild symptoms. [1] Calcium and vitamin D supplementation may be useful in some. [2] Anti-inflammatory drugs such as ibuprofen or naproxen may help with physical symptoms. [1] In those with more significant symptoms, birth control pills or the diuretic spironolactone may be useful. [1] [2]

Over 90% of women report having some premenstrual symptoms, such as bloating, headaches, and moodiness. [6] Premenstrual symptoms generally do not cause substantial disruption, and qualify as PMS in approximately 20% of pre-menopausal women. [4] Antidepressants of the selective serotonin reuptake inhibitors (SSRI) class may be used to treat the emotional symptoms of PMS. [4]

Premenstrual dysphoric disorder (PMDD) is a more severe condition that has greater psychological symptoms. [2] [1] PMDD affects about 3% of women of child-bearing age. [4]

Signs and symptoms

Any disruptive, cyclical symptom could be a symptom of PMS, and some sources have suggested that the number of claimed symptoms could exceed even 200. [8] However, some symptoms are relatively common in PMS. Common emotional and non-specific symptoms include stress, anxiety, difficulty with sleep, headache, feeling tired, mood swings, increased emotional sensitivity, and changes in interest in sex. [9] Problems with concentration and memory may occur. [1] There may also be depression or anxiety. [1]

Common physical symptoms include bloating, bilateral breast tenderness, and headache. [7]

The exact symptoms and their intensity vary significantly from person to person, and even somewhat from cycle to cycle and over time. [2] Most people with premenstrual syndrome experience only a few of the possible symptoms, in a relatively predictable pattern. [10] Additionally, which symptoms are accepted as evidence of PMS varies by culture. [8] For example, women in China report feeling cold but do not report negative affect as part of PMS, while women in the US report negative affect but not feeling cold as part of PMS. [8]

The exclusion of certain symptoms associated with the menstrual cycle can pose a challenge for researchers. For example, period pain, which is common, is excluded, as it does not usually appear until menstruation, but some experience period pain prior. However, any kind of pain can contribute to stress, difficulty with sleep, fatigue, irritability, and other symptoms that do count towards a PMS diagnosis. [8]

Causes

While PMS is linked to the luteal phase, the causes of PMS are not clear, but several factors may be involved. Changes in hormones during the menstrual cycle seem to be an important factor, with changing hormone levels affecting some more than others. [4] PMS occurs more often in those who are in their late 20s and early 40s, have at least one child, have a family history of depression, and have a past medical history of either postpartum depression or a mood disorder. [11]

Diagnosis

No laboratory tests or unique physical findings exist to verify a PMS diagnosis. However, the three key features are noted: [3]

The National Institute of Mental Health research definition compares the intensity of symptoms from cycle days 5 to 10 to the six-day interval before the onset of the menstrual period. [3] To qualify as PMS, symptom intensity must increase at least 30% in the six days before menstruation. Additionally, this pattern must be documented for at least two consecutive cycles.[ citation needed ] In 2016, the Royal College of Obstetricians and Gynaecologists argued that the definition of PMS should be changed to no longer require the presence of a psychological symptom. [8]

To document a pattern, potentially affected individuals may keep a prospective record of their symptoms on a calendar for at least two menstrual cycles. [8] This will help to establish if the symptoms are limited to the premenstrual time, predictably recurring, and disruptive to normal functioning. A number of standardized instruments have been developed to describe PMS, including the Calendar of Premenstrual syndrome Experiences (COPE), the Prospective Record of the Impact and Severity of Menstruation (PRISM), and the Visual Analogue Scales (VAS). [3]

Additionally, other conditions that may better explain symptoms must be excluded, [3] as a number of pre-existing medical conditions may be made worse at menstruation. [12] This is known as menstrual exacerbation or premenstrual magnification. [13] These conditions may lead individuals who do not have PMS to incorrectly believe they have PMS when they have another underlying disorder, such as anemia, hypothyroidism, eating disorders and substance abuse. [3] A key feature is that these conditions may also be present outside of the luteal phase. Conditions that can be magnified perimenstrually include depression or other affective disorders, migraine, seizure disorders, fatigue, irritable bowel syndrome, asthma, and allergies. [3]

Further, problems with other aspects of the female reproductive system must be excluded, including dysmenorrhea (period pain during menstruation, rather than before it), [8] endometriosis, perimenopause, and adverse effects produced by oral contraceptive pills. [3]

Severe symptoms may qualify as PMDD. [14]

Management

Many treatments have been tried in PMS. [15] Typical recommendations for those with mild symptoms include:

When self-care is not adequate, then medical management may be appropriate. [17]

Management of physical symptoms

Anti-inflammatory drugs such as naproxen may help with some physical symptoms, such as pain. [1]

Spironolactone is effective as a diuretic when water retention cannot be addressed through self-care alone; [15] however, thiazide diuretics are ineffective. [17]

Hormonal medications

In those with more significant symptoms birth control pills may be useful. [3] Hormonal contraception is commonly used; common forms include the combined oral contraceptive pill and the contraceptive patch. [17] This class of medication may cause PMS-related symptoms in some and may reduce physical symptoms in others. [3] They do not relieve emotional symptoms. [3] [17]

Gonadotropin-releasing hormone agonists can be useful in severe forms of PMS but have their own set of significant potential side effects, such as bone loss. [17]

Progesterone support was used for many years – in the 1950s, a deficiency of progesterone was believed to be the cause of PMS [8] – but it does not provide any benefit. [17] [18]

Management of emotional symptoms

Antidepressants

Antidepressants, particularly SSRIs and venlafaxine, are used as the first-line treatment of severe emotional symptoms of PMS, and also in treating PMDD. [17] Those with PMS may be able to take medication only on the days when symptoms are expected to occur, because relief often appears within a few days, rather than the longer timespan expected for depression or other common psychiatric conditions. [17] Additionally, the minimum dose is often lower than for treatment of depression. [17] Although intermittent therapy might be effective and acceptable to some, it might be less effective than continuous regimens for others, especially if they are also experiencing symptoms unrelated to the menstrual cycle. [17] Side effects such as nausea and weakness are however relatively common. [19]

Vitamins, minerals, and alternative medicine

Calcium, magnesium, vitamin E, vitamin B6, chasteberry, and black cohosh may help some. [17] St. John's wort is discouraged because it causes many drug–drug interactions. [17] Although St John's wort may help some with PMS, it is ineffective for PMDD. [15] Evening primrose oil does not help. [17]

Prognosis

PMS is generally a stable diagnosis, with susceptible individuals experiencing the same symptoms at the same intensity near the end of each cycle for years. [20] Treatment for specific symptoms is usually effective. Unsuccessful medical management of severe symptoms frequently indicates misdiagnosis. [17]

Perimenstrual breast pain is associated with fibrocystic breast changes. [21]

Even without treatment, symptoms tend to decrease in perimenopausal women, [22] and induction of menopause through surgical removal of the ovaries is a treatment of last resort. [17] However, those who experience PMS or PMDD are more likely to have significant symptoms associated with menopause, such as hot flashes. [2]

Epidemiology

Over 90% of women report having some premenstrual symptoms, such as bloating, headaches, and moodiness. Mostly the symptoms are mild. [6]

Globally, about 20% of women of reproductive age have PMS that disrupts their everyday lives. [4] Additionally, about 30% of women have mild or moderate symptoms related to their menstrual cycles that do not disrupt their everyday lives. [4]

History

PMS was originally seen as an imagined disease. Women who reported its symptoms were often told it was "all in their head". [23] Woman's reproductive organs were thought to control them. Women were warned not to divert needed energy away from the uterus and ovaries. This view of limited energy very quickly ran up against a reality in 19th-century America that young girls worked extremely long and hard hours in factories; newspapers in the 19th century were peppered with remedies to help in the "tyrannous processes" of the menstrual cycle. In 1873 Edward Clarke published an influential book titled Sex in Education. Clarke came to the conclusion that female operatives suffer less than schoolgirls because they "work their brain less". This suggested that they have stronger bodies and a reproductive "apparatus more normally constructed". Feminists later took opposition to Clarke's argument that women should not leave the private sphere by showing that women could function in the world outside the home in spite of natural body functions. [24] [25]

The first formal description of what is now called PMS as a medical problem, rather than a normal and natural variation, goes back to 1931, in a paper presented at the New York Academy of Medicine by Robert T. Frank titled "Hormonal Causes of Premenstrual Tension". [8] He incorrectly attributed premenstrual symptoms to an excess of the newly discovered sex hormone, estrogen. [8]

The specific name premenstrual syndrome first appeared in the medical literature in 1953. [8] [26] At that time, medical researchers incorrectly thought that PMS was caused by a deficiency in progesterone. [8]

Since at least the 1990s, when PMDD became accepted, the definitions of PMS have focused on psychological symptoms. [8] Throughout the history of PMS, many of the symptoms associated with it have been stereotypical feminine behaviors, such as expressing emotions or "nagging". [8]

Since then, PMS has been a continuous presence in popular culture, occupying a place that is larger than the research attention accorded it as a medical diagnosis. Some have argued that women are partially responsible for the medicalization of PMS. [27] They claim that women are partially responsible for legitimizing this disorder and have thus contributed to the social construction of PMS as an illness. [27] The public debate over PMS and PMDD may have been affected by organizations who had a stake in the outcome including feminists, the American Psychiatric Association, physicians and scientists. [28]

Alternative views

Some supporters of PMS as a social construct believe PMDD and PMS to be unrelated issues: according to them, PMDD is a product of brain chemistry, and PMS is a product of culture, i.e. a culture-bound syndrome. Women are socially conditioned to expect PMS, or to at least know of its existence, and they therefore report their symptoms accordingly. [29] [8] Becoming educated about PMS narrows their interpretation of their experiences by teaching them that certain symptoms are accepted as part of PMS, and that other symptoms are not, even though an accepted symptom might be unrelated to PMS for that woman (who might have a different medical condition), and an excluded symptom might be part of PMS, but not mentioned because they did not think it was relevant. [8] Social psychologist Carol Tavris also says that PMS is blamed as an explanation for rage or sadness. [29]

The identification of PMS as a medical disorder has been criticized as inappropriate medicalization. [8] These critics are concerned that society is pathologizing the menstrual cycle itself, even when the signs and symptoms are non-disruptive. [8]

The view of PMS as primarily a psychological situation, rather than primarily a biologically driven, medical condition dominated by physical symptoms, has also been criticized. [8] This view makes it harder to address psychosocial factors, such as external stress and a lack of social support, that exacerbate premenstrual symptoms. [8] Treating PMS as a psychological situation also makes it difficult to address menstrual exacerbation of other conditions, including catamenial epilepsy, menstrual migraine, and cyclical asthma. [8]

The limitation of PMS to premenstrual symptoms, rather than having a diagnosis that covers all symptoms associated with the menstrual cycle, has also been criticized. [8] Critics of this limitation think that excluding common physical symptoms that appear during the menstrual phase, such as period pain, fatigue, and back pain, is an arbitrary distinction that tends to reinforce the view of PMS as primarily an emotional problem, rather than a biological one. [8] They propose a focus on perimenstrual symptoms instead of strictly pre-menstrual ones. [8]

Research directions

Open research questions related to treatment include how to predict who will respond to SSRIs, which non-drug treatments are effective, and how to manage people who have PMS in addition to other medical conditions. [30]

Researchers are also working towards a single, uniform set of diagnostic criteria and to identify any objective characteristics that could be useful for diagnosis, such as any possible genetic predisposition. [30]

See also

Related Research Articles

<span class="mw-page-title-main">Menstruation</span> Shedding of the uterine lining

Menstruation is the regular discharge of blood and mucosal tissue from the inner lining of the uterus through the vagina. The menstrual cycle is characterized by the rise and fall of hormones. Menstruation is triggered by falling progesterone levels, and is a sign that pregnancy has not occurred.

<span class="mw-page-title-main">Menstrual cycle</span> Natural changes in the human female reproductive system

The menstrual cycle is a series of natural changes in hormone production and the structures of the uterus and ovaries of the female reproductive system that makes pregnancy possible. The ovarian cycle controls the production and release of eggs and the cyclic release of estrogen and progesterone. The uterine cycle governs the preparation and maintenance of the lining of the uterus (womb) to receive an embryo. These cycles are concurrent and coordinated, normally last between 21 and 35 days, with a median length of 28 days. Menarche usually occurs around the age of 12 years; menstrual cycles continue for about 30–45 years.

Amenorrhea or amenorrhoea is the absence of a menstrual period in a female who has reached reproductive age. Physiological states of amenorrhoea are seen, most commonly, during pregnancy and lactation (breastfeeding). Outside the reproductive years, there is absence of menses during childhood and after menopause.

Sexual dysfunction is difficulty experienced by an individual or partners during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal, or orgasm. The World Health Organization defines sexual dysfunction as a "person's inability to participate in a sexual relationship as they would wish". This definition is broad and is subject to many interpretations. A diagnosis of sexual dysfunction under the DSM-5 requires a person to feel extreme distress and interpersonal strain for a minimum of six months. Sexual dysfunction can have a profound impact on an individual's perceived quality of sexual life. The term sexual disorder may not only refer to physical sexual dysfunction, but to paraphilias as well; this is sometimes termed disorder of sexual preference.

<span class="mw-page-title-main">Dysmenorrhea</span> Pain during and sometimes before menstruation

Dysmenorrhea, also known as period pain, painful periods or menstrual cramps, is pain during menstruation. Its usual onset occurs around the time that menstruation begins. Symptoms typically last less than three days. The pain is usually in the pelvis or lower abdomen. Other symptoms may include back pain, diarrhea or nausea.

Premenstrual dysphoric disorder (PMDD) is a mood disorder characterized by emotional, cognitive, and physical symptoms. PMDD causes significant distress or impairment in menstruating women during the luteal phase of the menstrual cycle. The symptoms occur in the luteal phase, improve within a few days after the onset of menses, and are minimal or absent in the week after menses. PMDD has a profound impact on a woman’s quality of life and dramatically increases the risk of suicidal ideation and even suicide attempts. Many women of reproductive age experience discomfort or mild mood changes prior to menstruation. However, 5–8% experience severe premenstrual syndrome causing significant distress or functional impairment. Within this population of reproductive age, some will meet the criteria for PMDD.

Anovulation is when the ovaries do not release an oocyte during a menstrual cycle. Therefore, ovulation does not take place. However, a woman who does not ovulate at each menstrual cycle is not necessarily going through menopause. Chronic anovulation is a common cause of infertility.

<span class="mw-page-title-main">Katharina Dalton</span> Author, chiropodist and gynaecologist

Katharina Daltonnée Kuipers was a British physician and pioneer in the research of premenstrual stress syndrome (PMS), coining the term, treating many women and testifying as an expert witness in influential court cases.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

Premenstrual water retention is the buildup of additional water or fluid in the body. This phenomenon can be seen in various forms like increasing weight gain and swollen belly, legs, or ankles. Water retention is a symptom felt by some women of all backgrounds before their menstruation onset and was listed as one of the most common premenstrual symptoms in addition to cramping and back pain. There is a study that mentions the age effect being potentially linked to the intensity of symptoms, where the maximum symptom intensity was seen around age 35. This symptom, among others, have been connected to premenstrual syndrome (PMS), which is experienced by women days before their menstrual cycle begins. However, water retention itself can cause symptoms similar to those of PMS like body aches, headaches, and nausea. The actual duration of how long symptoms can last varies in length, from a few days to two weeks.

Breast pain is the symptom of discomfort in either one or both breasts. Pain in both breasts is often described as breast tenderness, is usually associated with the menstrual period and is not serious. Pain that involves only one part of a breast is more concerning, particularly if a hard mass or nipple discharge is also present.

<span class="mw-page-title-main">Menstrual disorder</span> Medical condition affecting menstrual cycle

A menstrual disorder is characterized as any abnormal condition with regards to a woman's menstrual cycle. There are many different types of menstrual disorders that vary with signs and symptoms, including pain during menstruation, heavy bleeding, or absence of menstruation. Normal variations can occur in menstrual patterns but generally menstrual disorders can also include periods that come sooner than 21 days apart, more than 3 months apart, or last more than 10 days in duration. Variations of the menstrual cycle are mainly caused by the immaturity of the hypothalamic-pituitary-ovarian (HPO) axis, and early detection and management is required in order to minimize the possibility of complications regarding future reproductive ability.

Psychoneuroendocrinology is the clinical study of hormone fluctuations and their relationship to human behavior. It may be viewed from the perspective of psychiatry, where in certain mood disorders, there are associated neuroendocrine or hormonal changes affecting the brain. It may also be viewed from the perspective of endocrinology, where certain endocrine disorders can be associated with negative health outcomes and psychiatric illness. Brain dysfunctions associated with the hypothalamus-pituitary-adrenal axis HPA axis can affect the endocrine system, which in turn can result in physiological and psychological symptoms. This complex blend of psychiatry, psychology, neurology, biochemistry, and endocrinology is needed to comprehensively understand and treat symptoms related to the brain, endocrine system (hormones), and psychological health..

Ovarian diseases refer to diseases or disorders of the ovary.

Menstrual leave is a type of leave where a person may have the option to take paid or unpaid leave from their employment if they are menstruating and are unable to go to work because of this. Throughout its history, menstrual leave has been associated with controversy and discrimination against men, with very few countries enacting policies. In these countries, menstrual leave is still associated with low uptake. It is seen by some as a criticism of women's work efficiency or as sexism against men. Supporters of menstrual leave policies compare its function to that of maternity leave and view it as a promoter of gender equality.

Women's reproductive health in the United States refers to the set of physical, mental, and social issues related to the health of women in the United States. It includes the rights of women in the United States to adequate sexual health, available contraception methods, and treatment for sexually transmitted diseases. The prevalence of women's health issues in American culture is inspired by second-wave feminism in the United States. As a result of this movement, women of the United States began to question the largely male-dominated health care system and demanded a right to information on issues regarding their physiology and anatomy. The U.S. government has made significant strides to propose solutions, like creating the Women's Health Initiative through the Office of Research on Women's Health in 1991. However, many issues still exist related to the accessibility of reproductive healthcare as well as the stigma and controversy attached to sexual health, contraception, and sexually transmitted diseases.

Menstrual suppression refers to the practice of using hormonal management to stop or reduce menstrual bleeding. In contrast to surgical options for this purpose, such as hysterectomy or endometrial ablation, hormonal methods to manipulate menstruation are reversible.

Menstrual migraine is the term used to describe both true menstrual migraines and menstrually related migraines. About 7%–14% of women have migraines only at the time of menstruation. These are called true menstrual migraines. Most female migraineurs experience migraine attacks throughout the menstruation cycle with an increased number perimenstrually, these are referred to as menstrually related or menstrually triggered migraine.

Sleep problems in women can manifest at various stages of their life cycle. Both subjective and objective data indicate that women are at an increased risk of experiencing different types of sleeping problems during different life stages. Factors such as hormonal changes, aging, psycho-social aspects, physical and psychological conditions, and the presence of sleeping disorders can disrupt women's sleep. Research supports the presence of disturbed sleep during the menstrual cycle, pregnancy, postpartum period, and menopausal transition. The relationship between sleep and women's psychological well-being suggests that the underlying causes of sleep disturbances are often multi-factorial throughout a woman's lifespan.

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References

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  29. 1 2 Carol Tavris, The Mismeasure of Woman (New York: Simon & Schuster, 1992), 142–144.
  30. 1 2 Bieber, Eric J.; Sanfilippo, Joseph S.; Horowitz, Ira R.; Shafi, Mahmood I. (2015-04-23). Clinical Gynecology. Cambridge University Press. pp. 37–41. ISBN   978-1-107-04039-7.
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