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Premenstrual Syndrome (Pms)

Definition

  • Premenstrual syndrome (PMS) denotes a collection of recurring physical and emotional symptoms at the latter part of the menstrual cycle that are severe enough to interfere with some parts of normal functioning. PMS affects women of childbearing age.

Prevalence

  • Most women experience mild symptoms before menstruation.
  • The prevalence of PMS has been estimated to be as high as 20-30% and the prevalence of severe PMS 5-10%.
  • A part of patients who suffer from severe, especially psychological, symptoms fulfill the criteria for PMDD (premenstrual dysphoric disorder), which are stricter than the criteria for PMS.
  • Symptoms are at their worst in women aged 30-40 years, but they may occur before the age of 20. Symptoms start to improve at the onset of menopause.

Aetiology

  • PMS is triggered by ovarian function, but the precise aetiology remains undefined.
  • The changes in hormone levels associated with normal ovarian function cause an aberrant response in the central nervous system and elsewhere in the body.
  • Central nervous system neurotransmitters, including serotonin and GABA, play a role in the development of the PMS symptoms.

Symptoms

  • Emotional: irritability, depression, mood swings, outbursts of anger, confusion, concentration difficulties, tiredness, insomnia, changes in appetite, social withdrawal
  • Physical: breast tenderness, headache, swelling of the limbs and abdomen, various types of aches and pains

Diagnosis

  • Diagnosis is based on the patient's history.
  • The patient should have at least one emotional and one physical symptom during five days before menstruation.
  • Symptoms should disappear within three to four days after the start of menstruation and return no earlier than on day 13 of the menstrual cycle.
  • The symptoms should recur during follow-up on two consecutive cycles; however, an isolated cycle may be free of symptoms.
  • A symptom diary kept by the patient during two consecutive menstrual cycles is the most reliable way to assess the symptoms and their timing in relation to the menstrual cycle.
  • Symptoms interfere with normal life.
  • Symptoms are not caused by another state or illness, or by use of alcohol, pharmaceuticals or illicit drugs.
  • A gynaecological examination and palpation of the breasts should be carried out. Laboratory tests are of no benefit but may be useful in differential diagnosis.

Differential diagnosis

Treatment

  • An explanation of the syndrome, and its relation to normal hormonal functioning, is often the only treatment needed.
  • Avoidance of coffee, alcohol and stress, and increasing the amount of exercise, may lessen the symptoms, as do calcium either alone or combined with vitamin D, magnesium or vitamin B6 Vitamin B-6 for Premenstrual Syndrome, or, of herbs, the chaste tree (Vitex agnus-castus).
  • Selective serotonin re-uptake inhibitors have proved to be effective Serotonin Reuptake Inhibitors for Premenstrual Syndrome either administered continuously or cyclically, starting midway through the cycle until the start of menstruation. A dose smaller than that used in the treatment of depression is usually sufficient (e.g. fluoxetine 20 mg/day or citalopram 10-30 mg/day).
  • Combined oral contraceptives prevent ovulation and may lessen the symptoms in some patients Combined Oral Contraceptives for Premenstrual Syndrome. However, combined oral contraceptives may actually induce PMS symptoms in some previously asymptomatic women.
    • Regimes of combined oral contraceptives containing drospirenone have been noted to relieve severe symptoms of PMS. These regimes include a 4-day, rather than the usual 7-day, hormone-free interval Oral Contraceptives Containing Drospirenone for Premenstrual Syndrome. An extended regimen of oral contraceptives, i.e. using 3 to 6 packs continuously without a break, may provide better relief than the conventional regime.
  • A levonorgestrel-releasing intra-uterine device may help some patients.
  • A small dose of a diuretic for a few days may be prescribed for severe oedema (e.g. spironolactone 25-50 mg/day).
  • In special cases, gonadotrophin-releasing hormone agonists (GnRHa) may sometimes be considered. They depress ovarian functioning and result in a postmenopausal hormonal state thus reducing PMS symptoms. Any subsequent menopausal symptoms, and the risk of osteoporosis, may be lessened by adding oestrogen/progestogen to the treatment regime (hormonal add-back therapy).

References

  • Mortola JF. Premenstrual syndrome--pathophysiologic considerations. N Engl J Med 1998 Jan 22;338(4):256-7. [PubMed]
  • Campagne DM, Campagne G. The premenstrual syndrome revisited. Eur J Obstet Gynecol Reprod Biol 2007 Jan;130(1):4-17. [PubMed]
  • The American College of Obstetricians and Gynecologists. ACOG practice bulletin, Number 15, April 2000
  • Wyatt K, Dimmock P, Jones P, Obhrai M, O'Brien S. Efficacy of progesterone and progestogens in management of premenstrual syndrome: systematic review. BMJ 2001 Oct 6;323(7316):776-80. [PubMed]
  • Coffee AL, Kuehl TJ, Willis S, Sulak PJ. Oral contraceptives and premenstrual symptoms: comparison of a 21/7 and extended regimen. Am J Obstet Gynecol 2006 Nov;195(5):1311-9. [PubMed]
  • Wyatt KM, Dimmock PW, Ismail KM, Jones PW, O'Brien PM. The effectiveness of GnRHa with and without 'add-back' therapy in treating premenstrual syndrome: a meta analysis. BJOG 2004 Jun;111(6):585-93. [PubMed]
  • Borenstein JE, Dean BB, Yonkers KA, Endicott J. Using the daily record of severity of problems as a screening instrument for premenstrual syndrome. Obstet Gynecol 2007 May;109(5):1068-75. [PubMed]
  • O'Brien S, Rapkin A, Dennerstein L et al. Diagnosis and management of premenstrual disorders. BMJ 2011;342():d2994. [PubMed]
  • Shehata NA. Calcium versus oral contraceptive pills containing drospirenone for the treatment of mild to moderate premenstrual syndrome: a double blind randomized placebo controlled trial. Eur J Obstet Gynecol Reprod Biol 2016;198():100-4. [PubMed]
  • Appleton SM. Premenstrual Syndrome: Evidence-based Evaluation and Treatment. Clin Obstet Gynecol 2018;61(1):52-61. [PubMed]