By Dr Sumayya Ebrahim
Premenstrual Syndrome (PMS), over the years, has been the subject of numerous stand-up comedy routines and the butt of many jokes. One has only to Google “PMS” to find many tongue-in-cheek survival tips for “long suffering husbands”. Many descriptions, all based on symptoms that women experience have been offered. Some of the more humorous ones are:
Prehistoric Monster Syndrome
Psychotic Mood Shift
Perpetual Munching Spree
Pass My Shotgun
Pack My Stuff
Pardon My Sobbing
Pimples May Surface
Plainly Men Suck
However, for women who genuinely suffer from PMS, it is no laughing matter. It can be very frustrating in the workplace or even in inter-personal relationships when true grievances or issues are invalidated by phrases like “Ignore her, she must be PMSing” or “She is in a mood, it must be that time of the month again”.
PMS affects millions of women around the world. Classically it affects women between the years of puberty and menopause. In fact at least 85% of women who menstruate will experience it to a greater or lesser degree. It appears to be linked to the sequence of hormonal events of the normal ovarian or menstrual cycle.
Clear information regarding the cause is not readily available. The range of proposed theories is enormous. An older theory points to deficient progesterone hormone in the second half of the menstrual cycle as opposed to oestrogen. The most recent and plausible explanation revolves around a complex interaction of reproductive hormones like oestrogen and progesterone on brain chemicals and their co-factors (Vitamin B6). The main brain hormones implicated are serotonin and gamma-aminobutyric acid (GABA). Low serotonin levels have been linked to depression, anger, irritability, impulsive behaviour and carbohydrate cravings. GABA is thought to offer protection against anxiety.
It is thought that in PMS suffers that there is an exaggerated physical or emotional response to these fluctuating hormone levels.
Other theories have involved the part of the brain and adrenal gland that controls our responses to stress. This system known as the hypothalamic-pituatary-adrenal system provides cortisol. Low level of cortisol is associated with depression.
Some researchers have demonstrated that a mineral imbalance may result in PMS. They suggest that PMS, in part, represents the clinical manifestation of a calcium deficiency state that is unmasked following the rise of ovarian hormone concentrations during the menstrual cycle.
SO WHAT IS PMS?
PMS is a pattern of symptoms, related to menstruation that can occur month after month. Sometimes the symptoms are mild and sometimes they are severe enough to affect quality of life and relationships. Up to 150 different symptoms have been described. They can be divided into two categories. Some of the more common ones are listed below:
Emotional Symptoms Physical symptoms
Depression Appetite changes (food cravings)
Anxiety Breast tenderness
Crying Spells Weight gain (true)
Social withdrawal Headaches
Poor concentration Swelling of hands and feet
Changes in sexual desire Aches and pains
Lack of inspiration Fatigue
Impulsive behaviour Skin changes
Insomnia/ Hypersomnia (too much sleep) Gastrointestinal symptoms
Loss of confidence Pelvic pain
Loss of judgement Accident prone
Weight increased (perceived) Allergies
Diminished efficiency Asthma
Symptoms can occur in any combination or in any number. Some will be more dominant than others. Premenstrual Dysphoric Disorder (PMDD) is said to be present when the symptoms are so severe that they have a significant impact of a woman’s ability to function socially or at work and may also lead to suicidal thoughts. PMDD is thought to affect between three and eight percent of women of child bearing age.
To diagnose PMS, the pattern of symptoms present usually meets the following criteria:
- Are present in the 14 days before the period, most commonly in the 5 days before, for at least three menstrual cycles in a row.
- Are cyclical.
- End within four days after the period starts.
- At least one week of symptom free days every month or cycle.
- Interfere with some day-to-day activities.
Keeping a diary or record for a period of 2-3 months can aid a doctor or gynaecologist in making a diagnosis and determining the best treatment options. The best way to do this is to use a calendar and on a daily basis chart the following:
- Up to 5 most bothersome symptoms daily.
- Rate them according to severity (1, 2 or 3), 1 being the mildest and 3 the most severe.
- Days that are symptoms free should be left blank.
This helps to determine if the symptoms are cyclical in nature (like in PMS) or constant (e.g. depression). Also, it gives an indication of how treatment can be prioritised accordingly to the most severe symptoms.
Symptoms of other medical conditions may mimic PMS. These are:
- Chronic fatigue syndrome
- Irritable bowel syndrome
- Thyroid disorders
Depression and anxiety are the most common conditions to overlap with PMS. About half of women seeking treatment for PMS have one of these underlying disorders. The major difference between depression/anxiety and PMS is that the symptoms are present all month long. They may however worsen before or during the period. There are also some conditions that may worsen just before menstruation. These are:
- seizure disorders
Simply having information about PMS and its symptoms can help sufferers understand what is happening and in this way reduce anxiety. Awareness of feelings and emotions can help prevent conflict with others. “Talking it through” with others can also be of help. Sharing feelings with family or, where appropriate, with work colleagues could engender more support. It is perhaps better to do this not during the worst symptom days, but later in the cycle when emotional outbursts are less likely.
Regular exercise lessens PMS symptoms. It may reduce fatigue and depression. A good goal would be 30min of exercise at least 3-4 times per week. Regular aerobic exercise like brisk walking, running, cycling and swimming can increase endorphin levels. These are naturally occurring painkillers or opiates of the body. Exercise should be regular, not just during the days of symptoms.
Maintaining regular sleeping habits is also important. Going to bed and waking up at the same time every day, including weekends, may help to lessen moodiness and fatigue.
Finding ways to tackle stress by means of relaxation therapy is also helpful. These include breathing exercises, yoga, meditation and massage. Aromatherapy and reflexology can also help to restore equilibrium.
Simple daily dietary modifications can help tremendously. Eating regularly to keep blood sugar levels constant appears to be the key. This can be achieved by avoiding foods that contain processed sugars (biscuits, sweets, soft drinks or fast foods). Complex carbohydrates which are found in foods made with whole grains like whole wheat bread, pasta and cereals are what is recommended. Other examples are barley, brown rice, beans, and lentils. The sugars found in these foods are released more slowly allowing the body to maintain even blood sugar levels. Maintaining constant blood sugar levels can reduce mood symptoms and food cravings by increasing levels of the “feel good” hormone serotonin.
Calcium and magnesium rich foods like dairy products and green leafy vegetables are also of benefit. Reduce intake of saturated fat and salt. Avoid caffeine and alcohol.
For women who feel that their diets are not adequate in calcium and magnesium, supplementation is required. Daily calcium intake should be approximately 1000mg and magnesium intake no more than 400mg daily. Vitamin B6 or pyridoxine is an important co-factor in the manufacture of the brain chemicals: dopamine, serotonin and tryptophan. Supplementation is recommended only in conjunction with advice and monitoring by a medical care-giver. Doses should be no higher than 100mg daily but in some women may be as low as 10mg to start with. Caution should be exercised with prolonged usage in high dose as it can lead to a condition called peripheral neuropathy. This means losing feelings in arms and legs which may continue even after supplementation is stopped. Vitamin B6 also improves the body’s usage of essential fatty acids. Essential fatty acids like omega 3 and 6 have also been known to reduce symptoms.
This has been used in many forms such as oral medication, creams and vaginal pessaries, to alleviate symptoms. Although there is anecdotal evidence that it brings relief if used in the second half of the menstrual cycle, there is no consistent data in the research literature of it being of any major benefit or disadvantage. Further research is awaited in this area.
This category is usually reserved for women with severe symptoms who have had no relief from all of the above interventions. These are on prescription and should not be self-administered. Drugs that are used are:
- Oral contraceptive pill: this stops ovulation and hence hormonal fluctuations, thereby improving symptoms.
- Diuretics/ Water tablets: only in select severe situations of water retention and bloating.
- Antidepressants and Anti-Anxiety: There are many kinds of these available. SSRI antidepressants (selective serotonin reuptake inhibitors) are prescribed by doctors especially in situations of extreme emotional or mood changes and PMDD. They may have negative side effects which can outweigh their benefit and some people have withdrawal symptoms when trying to come off them.
Usually antidepressants don’t take effect for two to four weeks but with PMS they
seem to work within days and hence can be used effectively either throughout the
cycle or two weeks before the onset of symptoms within the cycle.
- NSAID( Non steroidal anti inflammatories): These are effective for the pain
management of PMS symptoms. With prolonged usage or unsupervised usage
however this medication can lead to gastritis or ulcers.
Finding the right PMS treatment may not be instantaneous. Often it involves trying different options based on individual requirements and symptoms. Starting with general lifestyle measures often brings significant relief. Drug interventions are reserved for women who despite everything else still require more help.