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Premenstrual syndrome (PMS) describes a wide range of recurrent symptoms that occur from several days to two weeks before your period. PMS affects up to 75 percent of women in their childbearing years, although only 20 percent to 40 percent have difficulties as a result.
The symptoms of PMS can appear any time between puberty and menopause, but the most common age for it to start to become a problem is during the late 20s to early 30s.
Symptoms of PMS may get worse with age and stress, although the underlying causes are not well understood. Even women who have had hysterectomies can have PMS if at least one functional ovary is left. Women who are vulnerable to depressive illness, panic disorder, other psychiatric disorders or chronic medical conditions may also be susceptible to PMS, although these conditions may occur in women without PMS as well. Heredity may also play a role: if your mother or sister suffers from PMS, you may find you experience it, too.
As many as 150 physical and behavioral symptoms have been assigned to PMS, but the number of PMS symptoms that most women experience is much more limited. The most common symptoms include irritability, bloating, mood swings, anxiety, depressed mood, fatigue, appetite changes, water retention and breast tenderness, among others.
Menstrual cramps, or dysmenorrhea, is not considered a PMS symptom, although many women with PMS also experience menstrual cramps.
PMS appears to be caused by a sensitivity to the rising and falling levels of the hormones estrogen and progesterone, which may influence brain chemicals, including serotonin, a substance that has a strong affect on mood. It's not clear why some women develop PMS or PMDD and others do not, but researchers suspect that some women are more sensitive than others to changes in hormone levels.
Calcium may play a role in PMS, although the reason remains unclear. In one study, women who took 600 mg of calcium twice a day experienced fewer PMS symptoms than women who took a placebo.
Dietary changes and exercise may also help relieve the discomfort of PMS symptoms. When symptoms are severe, serotonergic antidepressant medication may be prescribed. It is thought that increased serotonin reduces PMS symptoms.
One of the most important strategies for coping with premenstrual discomfort is to be aware of any pattern your symptoms follow. The more aware you are of your symptoms—when they start and stop and what works best to relieve them, for example—the better you can develop strategies to recognize and cope with them—whatever they may be.
Premenstrual Dysphoric Disorder
Approximately three to eight percent of women experience premenstrual dysphoric disorder (PMDD), a condition that, like PMS, is associated with the menstrual cycle. The symptoms of PMDD are the same as PMS symptoms, although women with PMDD may experience more dysphoric (depressive) symptoms and more severe symptoms. In fact, to be diagnosed with PMDD, symptoms must be severe enough to disrupt a woman's daily function.
The most important criteria for a PMDD diagnosis are mood symptoms. Physical symptoms may also be present but aren't as critical to the diagnosis. The difference between PMDD and mild PMS is like the difference between a mild tension headache and a migraine, experts say.
Women who have a history of depression are at higher risk for PMDD than other women. Treatment for PMDD includes serotonergic antidepressant medications and a particular brand of birth control pills, called Yaz. Yaz contains drospirenone (a progestin) and ethinyl estradiol (a form of estrogen) and has been shown to be clinically effective at treating the emotional and physical symptoms of PMDD, but should only be used to treat PMDD if you choose to use it for birth control because other forms of treatment for PMDD don't carry the same risks as oral contraceptives. Another form of birth control pill containing drospirenone plus a daily dose of folic acid also is FDA-approved to treat PMDD. It is sold under the brand names Beyaz and Safyral.
Another approach in using birth control pills is to use continuous dosing with no hormone-free interval (for example, Lybrel). This reduced PMS and PMDD symptoms for many women, although findings in multiple studies were not consistent.
Birth control pills containing drospirenone may cause some serious side effects in rare cases, including blood clots in the legs and lungs, so be sure and talk to your health care provider about your risks and benefits. Oral contraceptives are not recommended for women who smoke because of increased cardiovascular risks.
Diagnosis
There is no specific laboratory test to determine if you suffer from PMS, and diagnosis can take some time because symptoms are so varied. But there are certain characteristics that health care professionals consider. To qualify as PMS, symptoms must follow this general pattern:
- • They tend to increase in severity as your cycle progresses.
- • They improve within a few days of your menstrual period starting.
- • They are present for at least two to three consecutive menstrual cycles.
More than 150 physical and behavioral symptoms may be associated with PMS. The most common are irritability and anxiety/tension. Other common symptoms include:
- • Sudden mood swings
- • Depression
- • Headaches
- • Joint and muscle aches
- • Food cravings
- • Fluid retention
- • Forgetfulness
- • Clumsiness
- • Sleep disturbances
- • Breast swelling and tenderness
The timing and severity of these symptoms are key to a PMS diagnosis. An average menstrual cycle spans 21 to 35 days. The follicular phase extends from menses to ovulation, and the luteal phase extends from ovulation to menses. PMS occurs during the luteal phase—approximately the last 14 days of your cycle, usually during the five to seven days before you get your period.
A premenstrual symptom chart or checklist (also called a menstrual cycle diary) is the most common method used to evaluate menstrual cycle symptoms. With this tool, you and your health care professional can track the type and severity of your symptoms, as well as when they occur, to identify a pattern that may indicate PMS.
Follow these simple steps to determine if your symptoms fit the PMS pattern:
- • Track your symptoms using the first day of menstrual flow as Day 1. (Note: Don't be surprised if you do not have any symptoms to record before day 18 or so.)
- • Have a person close to you (your partner, roommate, friend) chart his or her impression of your symptoms, when they occur and their severity.
- • Chart your symptoms for at least three consecutive months to help you and your health care professional identify a pattern that may indicate PMS.
- • Record the date when/if any of the following symptoms occur over two to three consecutive months and note their severity (for example: 1 = mild; 2 = moderate; 3 = severe). Different diaries use different rating systems, with point values to record severity ranging from 1 to 6.
Physical Symptoms
- • Abdominal bloating
- • Breast tenderness
- • Constipation
- • Diarrhea
- • Dizziness
- • Fatigue
- • Headache
- • Swelling of hands/feet
Emotional Symptoms
- • Anger
- • Anxiety
- • Depressed mood
- • Irritability
- • Mood swings
- • Tension
Behavioral Symptoms
- • Crying spells and tearfulness
- • Decreased or increased appetite
- • Difficulty concentrating
- • Difficulty sleeping
- • Forgetfulness
- • Hostility
In addition to suggesting that you keep a menstrual cycle diary, your health care professional likely will ask about your personal and family medical history and will give you a physical exam.
Laboratory tests are not routine but may be obtained to rule out other conditions with similar symptoms, such as low blood sugar (hypoglycemia), mania, depression, thyroid disorders, anemia, endometriosis, allergies, fibroids, dysmenorrhea, lupus, endocrine abnormalities, neurological problems such as brain tumors and heart problems.
Menopause and PMS share some of the same symptoms, so depending on your age and health history, your health care professional may want to make sure that you are indeed ovulating and therefore experiencing PMS, not menopausal symptoms.
To do this, you will probably be asked to use an over-the-counter ovulation testing kit. This is a simple test that you can do at home. The results tell you when ovulation is likely.
If you are approaching menopause (the average age is about 51 for U.S. women, but ranges from 42 to 60 years), blood hormone tests may also be used to confirm if you are menopausal. However, a single blood test is not informative because hormone levels change often.