What is the premenstrual syndrome (PMS)?

PMS is defined as distressing physical and psychological symptoms, not caused by organic disease, which regularly recur during the same phase of each menstrual cycle, and which significantly regress or disappear during the remainder of the cycle. The symptoms occur in the two weeks leading up to the next period known as the luteal phase of the cycle (Figure 2.3). The severity of premenstrual syndrome may range from that indefinable point that is acceptable to the majority of women to such a degree of debility that for some time each month a woman may fail to function at home, at work or both. There is evidence that suicide and criminal offences occur more frequently premenstrually. PMS and PMT and similarly premenstrual syndrome and premenstrual tension are synonyms.

Some premenstrual symptoms probably occur in 95% of women; only 5% of women have no premenstrual symptoms. Fifty percent of women have mild symptoms and 30% moderate problems. About 5% of women have such PMS symptoms that their lives are disrupted in the two weeks leading up to their periods.

From 2 to 10 percent of women of reproductive age have severe distress and dysfunction caused by premenstrual dysphoric disorder, a severe form of premenstrual syndrome. There has been a suggestion that the hormone profile of women with premenstrual dysphoric disorder is different.

What is the cause of Premenstrual Syndrome (PMS)?

During each menstrual cycle, a woman's body is subjected to cyclical changes in sex hormone levels (Figure 2.3). All women are aware of  premenstrual changes to some degree and, for the majority, these cyclical changes are a normal feature of life. If these physical or psychological changes become excessive and disrupt a woman's life she has premenstrual syndrome or PMS.

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Some premenstrual symptoms probably occur in 95% of women; only 5% of women have no premenstrual symptoms. Fifty percent of women have mild symptoms and 30% moderate problems. About 5% of women have such PMS symptoms that their lives are disrupted in the two weeks leading up to their periods.

How Prevalent is premenstrual syndrome?

Some premenstrual symptoms probably occur in 95% of women; only 5% of women have no premenstrual symptoms. Fifty percent of women have mild symptoms and 30% moderate problems. About 5% of women have such PMS symptoms that their lives are disrupted in the two weeks leading up to their periods.

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How can we tell if I have premenstrual syndrome?

The diagnosis of premenstrual syndrome can only be made from the history (story). There are no symptoms that are exclusively associated with PMS every PMS symptom can occur in other situations and there is no test that can distinguish between those who have PMS and those who do not. Caution is required in making the diagnosis. A chart may help to distinguish whether or not the symptoms are of a cyclical nature or not (Figure 25.1). The symptoms of PMS disappear completely when menstruation stops and they do not recur until ovulation two weeks before the next period.

PMS Premenstrual Syndrome

Some women have underlying psychological problems such as depression or anxiety that become more noticeable in the premenstrual phase (secondary premenstrual syndrome). In these women not all their symptoms disappear after the period. Treatment of PMS in these circumstances may only partially overcome their problems although this may at times be enough to make their lives more tolerable.

How can my premenstrual syndrome be assessed?

Charts are available, which can assist you to record your PMS symptoms. They may help to prove or disprove the relationship between symptoms and the menstrual cycle. These charts can also be helpful in demonstrating whether treatments are providing benefit. Suitable charts are usually available on re quest in reproductive endocrinology clinics. Figure 25.1shows a PMS chart used in my own clinic. This shows example cases to provide a guide for PMS patients and allows for the patients to assess their own symptoms on a severity level from 0 to 3.

PMS Premenstrual Syndrome

Suppression of the menstrual cycle by gonadotrophin releasing analogues (e.g. Goserelin –gonadotrophins) has been described as a means of diagnosing PMS when there is doubt about the diagnosis. The menstrual cycle is suppressed for three cycles so that if symptoms are truly cyclically related they should disappear. The test has been advocated for evaluating the potential benefits of removing the ovaries for patients with possible PMS problems who are coming to hysterectomy . From a practical point of view it is apparent that the “Goserelin test’ will create a temporary menopause-like state; many symptoms (e.g. depression and anxiety) which may be attributable to PMS can also occur with the menopause. This potential difficulty may be overcome by add-back therapy (HRT-Add-Back).

How can cyclical breast pain be treated?

Mastalgia Breast Pain

Figure 25.2

Figure 25.2 is a flowchart outlining the treatment options for cyclical breast pain. Cyclical breast pain may be the only problem or it may be just one of several PMS symptoms. Some treatments are beneficial for cyclical mastalgia. These include:

  • pyridoxine (vitamin B6).
  • bromocriptine (Parlodel).

Prolactin is the hormone particularly responsible for milk production after childbirth. Galactorrhoea (hyperprolactinaemia) tends to occur when prolactin levels are inappropriately elevated (hyperprolactinaemia Q6.10). For more than twenty years, bromocriptine (Parlodel - Novartis) has been the specific antidote for hyperprolactinaemia. It generally proves effective when other measures fail in the relief of cyclical mastalgia even in the absence of hyperprolactinaemia. Newer agents such as cabergoline (Dostinex Pharmacia and Upjohn) are more expensive. They may cause less side effects in some patients.

  • Oil of evening primrose will often prove effective and is readily available without prescription.
  • Danazol at a relatively low dose danazol (200mg daily) during the premenstrual phase of the cycle may improve cyclical breast pain but not other PMS symptoms.
  • GnRH to down-regulate the cyclical hormones may be helpful in severe situations which do not respond to these treatments. Add-back HRT may be required should menopausal symptoms occur (HRT-Add-Back).
  • Fluoxetine (Prozac Lilly) 20mg daily provides a new option for women with severe cyclical mastalgia. There is accumulating evidence that cyclical symptoms, including premenstrual mastalgia, may be related to abnormality in the release of serotonin which is an important neurotransmitter (a chemical released by brain cells to activate other brain cells).

A thirty-four year old lady presented with severe breast pain which had been slowly increasing. She had two children aged six and eight. She was taking no regular medication. A diuretic (encourages increased urine output) provided by her general practitioner had provided only temporary relief. On examination, her breasts were reminiscent of the engorgement encountered by women two or three days after childbirth. Investigations, including prolactin estimations demonstrated no abnormality. Over several years, a variety of treatments including Efamast, diuretics, Parlodel, Danazol, progestogens, and cabergoline individually and in combination have provided at best temporary relief. Down regulation with GnRH analogues and add-back HRT have proven to be effective.

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What treatment is available for PMS (Premenstrual Syndrome)?

Figure 25.3 is a flowchart showing the basic principles and options for treatment.

Figure 25.3

Some women find a discussion of their problem helpful even if it only provides reassurance that the majority of women experience similar symptoms. There have been numerous treatments that have been used to treat PMS. Academics have debated the true benefit of individual medications. It is not really surprising that it is difficult to determine the overall benefit of the various medications as PMS can manifest itself in a wide variety of symptoms occurring in varying severity. Ultimately, what really matters is whether you feel better with a particular therapy. If you only have very minimal problems reassurance alone may be all that is required. At the other extreme, if you have proven severe PMS that has not responded to relatively simple medication, you could benefit from suppression of the cycle by medical or surgical means. The problem for the clinician is that the majority of patients with PMS have moderate symptoms for which reassurance alone may be insufficient and suppression of the menstrual cycle seems excessive.

Ability to cope with the extra burden of premenstrual hormone changes may be enhanced by a variety of non-medical means. Regular exercise may improve your self-esteem and provide you with a feeling of being more healthy. Similarly, relaxation by a variety of means and improving your diet may have a beneficial effect. There is no evidence that special diets for PMS have additional benefit. Theoretically, pyridoxine (Vitamin B6) and magnesium may be beneficial as they are known to play an essential part in the chemistry of the brain: controlled trials (placebo and controlled trials), however, have shown little scientific evidence of clinical benefit. Counselling may assist some individuals to assess their problems in life and make a start on sorting them out.

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What is the place of progesterone and progestogen in the treatment of PMS?

One of the pioneers of PMS diagnosis and treatment has been a strong advocate of progesterone pessaries (Cyclogest - Shire). Research has failed to confirm any evidence of imbalance in progesterone levels between those with and those without PMS. From a theoretical point of view, PMS occurs at the time that the body is producing progesterone so that progesterone deficiency is unlikely to be the problem. Although scientifically controlled studies have never proven its benefit, the fact remains that many women continue to take this form of treatment and they are convinced of its efficacy. Postmenopausal women given oestrogen replacement therapy and cyclical progestogens (Q 28.09) sometimes report recurrence of PMS type symptoms; dydrogesterone (Duphaston - Solvay), medroxyprogesterone acetate (Provera Pharmacia and Upjohn) and progesterone itself seems to have this side-effect less frequently than other progestogens. Duphaston and norethisterone are licensed for use in PMS but scientific control studies tend to show no improvement over placebo (placebo and controlled trials). Progesterone as a vaginal gel (Crinone) introduced on alternate nights became available in 1997 and some find Progest (progesterone replacement therapy) helpful. Depo-Provera used in family planning (Depo-Provera) is administered on a three monthly basis.

A 42 year old lady presented with a history of depression and a suggestion that her problem could be PMS. She had the typical appearance of a severely depressed person. At times she had required hospital admission under the care of a psychiatrist. There was certainly an element of a cyclical increase in her symptoms and at that time it seemed reasonable to offer hormonal treatment on a trial basis. She received dydrogesterone during the second half of the cycle. When she returned a few weeks later she was vivacious and enjoying life to the full. All was well for about a year when she returned quite depressed despite having continued with the dydrogesterone. It turned out that she had recently received an antibiotic for a respiratory infection and this could have altered the absorption of the drug. With increased progestogen the problem resolved and in her case her severe symptoms were effectively controlled by dydrogesterone alone until she reached her menopause. It should be emphasised that this case is unusual. Every person, however, is an individual and although such improvement would not be predictable on the evidence of large studies, in my view the practice of medicine is still an art based on science. Only politicians could believe that medicine is a pure science.

 

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Could suppressing my cycle improve my PMS?

As premenstrual syndrome is a cyclical problem, abolition of the ovarian cycle would seem to be a logical approach. This can be achieved with:-

  • oestrogen and progestogen -
    • danazol

    For women with more severe problems, stronger forms of treatment may be required. Danazol tends to reduce the hormone fluctuations. Danazol 400mg daily will generally suppress the menstrual cycle and can be effective in PMS. Occasionally it may be effective at lower dose levels whilst some patients will need more. Many women tolerate this drug well but others may have side effects including weight gain and an increase in body hair. Danazol can have adverse effect on a fetus so that ade quate contraception is essential.

    • GnRH analogues

    GnRH analogues such as goserelin (Zoladex - Zeneca) or nafarelin (Synarel Searle) will temporarily reduce the sex hormones to menopausal levels. They can only be used for a few months at a time as the prolonged suppression of oestrogens may lead to osteoporosis and arterial disease (Q33.14). In the short-term patients may suffer menopausal type symptoms including hot flushes and vaginal dryness. There is evidence that GnRH analogues will suppress genuine PMS symptoms. Within a few weeks of discontinuation of therapy, the hormone cycle is restored and PMS symptoms return. GnRH analogues may have a part to play:

    • confirming the diagnosis for the clinician as well as other members of the patient's family and her employers.
    • in the treatment of PMS. As previously indicated, GnRH analogues if used alone can only be prescribed for a few months at most. There has been suggestion that they could perhaps be used in combination with HRT. From a theoretical point of view, if the HRT employed was of the continuous combined variety (coronary artery disease) there would be no cycle and no risks associated with prolonged oestrogen insufficiency.
    • as a test prior to hysterectomy if the decision relating to removing the ovaries depends on the possibility of treating PMS type symptoms.
    • surgical removal of the ovaries (usually with hysterectomy)

In some women there may be an insidious change from PMS to menopause problems and in the later 40s HRT may have a part to play. Orally administered HRT is not strong enough to suppress the menstrual cycle. High dose patches or oestradiol implants of 100 mg do suppress the cycle. The problem here is that unless the uterus has been removed, progestogens are imperative to prevent problems with the endometrium (HRT and progestogen). Progestogen must be given for at least 7 days each calendar month to clear the lining of the womb by causing a period. There may be resulting PMS like symptoms when the progestogens are introduced but these symptoms are usually less severe than without treatment. The LNG- containing intrauterine contraceptive device, Mirena, (Mirena-IUS) will deliver ade quate progestogen locally within the uterus to be protective so there is no requirement for a cyclical preparation. Reports of this approach are appearing but further studies are required.

It should be emphasised that although the combined oral contraceptive pill and Mirena-IUS (used in combination therapy in PMS) provide contraception, all other medical treatments are not contraceptive and appropriate precautions should be used.

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Could a diuretic help my PMS?

A diuretic is a drug that increases urinary output. There is no evidence of fluid retention premenstrually, so drugs designed to increase fluid output by increasing the daily urine volume (diuretics) are not to be generally recommended. Some women are convinced that they have fluid retention with evidence of ankle swelling but this is usually a result of a redistribution of body fluid. An occasional mild diuretic may be considered in these circumstances.

Is there a place for anti-depressants in the management of PMS?

Antidepressants and anxiolytic drugs have not been shown to be consistently effective in true PMS. They may have a place in secondary PMS where there are underlying psychological problems which become worse premenstrually.

Abnormality in neurotransmitters (chemicals within the brain) has been demonstrated in PMS. Psychotherapeutic agents, including fluoxetine (Prozac Dista) and paroxetine (Seroxat SmithKline Beecham), that selectively inhibit re-uptake of serotonin are under investigation in the management of PMS. Serotonin is one of these neurotransmitters.

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Is there a place for removing my ovaries in the management of PMS?

Occasionally, if severe problems with premenstrual syndrome persist, hysterectomy with removal of the ovaries may be the only remaining option. It is the removal of your ovaries that will abolish your cyclical symptoms of PMS and you will need oestrogen replacement therapy to prevent menopausal symptoms (HRT-hormone-replacement-therapy). If both ovaries are removed, we gynaecologists will generally recommend that the uterus is also removed. This allows the you to take oestrogen without progestogen. The majority of patients seem to opt for an oestradiol implant (Q 28.6) at the time of surgery but there is no reason why other methods of oestrogen administration (HRT-hormone-replacement-therapy) cannot be used if this is your preference.

Clearly removing the ovaries is only an option if you are absolutely certain that your family is complete. Hysterectomy may be particularly beneficial when there are other problems such as heavy or painful periods. Hysterectomy and removal of the ovaries in younger women for the relief of PMS alone is a drastic option. It should only be considered when the PMS is severely effecting your life. Suppressing the hormone levels by GnRH analogues (8) is a useful test of the likely benefits. There are two other options that should be considered before resorting to the surgical approach in younger women: the Mirena (Mirena) with oestrogen replacement or the long-term suppression of the hormone cycle with GnRH analogues in combination with HRT (8).

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How is PMS treatment monitored?

Initially patients should be seen every 3 or 4 months. Some patients and/or doctors like to use charts to see trends of symptoms (Figure 25.1). When all are happy with the current treatment, less frequent checks are required. A general check up should be performed at least every two years. This should include a blood pressure reading, breast and pelvic examination. These examinations are not performed because of any increased risk, but purely as it is good clinical practice for doctors looking after to provide appropriate reassurance.

PMS Premenstrual Syndrome

For how long should the treatment of my PMS be continued?

When treatment is being taken to correct PMS problems it may be reasonable to stop the medication after a few months and see whether the symptoms are still troublesome. Naturally, the treatment should not be stopped except when it is socially convenient.

Support Groups

Action for ME

PO Box 1302

Wells

Somerset

BA5 1YE

Tel: 01749 670799; 020 7329 2299

British Association for Counselling

1 Regent Place

Rugby

Warwickshire

CV21 2PJ

Tel: 01788 578328 

Migraine Action Association

178A High Road

Byfleet

Surrey

KT14 7ED

Tel: 01932 352468

Myalgic Encephalomyelitis Association

4 Corringham Road

Stanford-le-Hope

Essex

SS17 0HA

Tel: 01375 642466

NAPS (National Association for Premenstrual Syndrome)

2 East Point

High Street

Seal

Kent TN15 0EG

Tel: 01732 760011

Helpline 01731 760012

SAD Association,

P.O. Box 989,

London SW7 2PZ

London Marriage Guidance Council

76A New Cavendish Street,

London W1M 7LB

Tel: 020 7580 1087.

Members of a support group, provide each other with various types of help and information for a particular shared difficulty.

The support may take the form of providing relevant information,

  • relating personal experiences,
  • listening to others' experiences,
  • providing sympathetic understanding and
  • establishing social networks.

A support group may also provide ancillary support, such as serving as a voice for the public or engaging in advocacy.

Support groups maintain interpersonal contact among their members in a variety of ways.

Support groups also maintain contact through printed information rich newsletters, telephone chains, internet forums, and mailing lists.

Support groups offer companionship and information for people coping with diseases or disabilities. Support groups may not be appropriate for everyone, and some find that a support group actually adds to their stress rather than relieving it.

Evaluation of the quality of Web sites is discussed in (internet information). You may find that several general women's health sites may help you (internet information). The following are more specialised relevant Web sites:-

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