Premenstrual Syndrome (PMS)

Premenstrual syndrome (PMS), is a group of symptoms that occurs before the first day of a person's menstrual period. Some people experience mild abdominal cramps for a few hours, while others can experience severe pain and mood swings for up to two weeks before their period starts.

PMS is often diagnosed based on the timing of the symptoms. When the effects are especially burdensome, hormone levels or imaging tests may be needed to determine whether a person has a health condition.

This article discusses the symptoms, causes, diagnosis, and treatment of premenstrual syndrome.

PMS Symptoms

The premenstrual phase is usually a few days before a menstrual period, but it can begin up two weeks before the start of menstruation. For symptoms to be considered part of PMS, they must occur within the two weeks before a period and should not be present the rest of the month. PMS can begin at any age once a person begins having menstrual periods.

There are a number of physical, emotional, and cognitive effects that can occur as part of PMS.

Common symptoms of PMS include:

• Uterine cramps
• Abdominal bloating
• Sore, tender breasts
• Food cravings
• Irritability
• Tearfulness
• Mood swings
• Sadness
• Anxiety
• Angry outbursts
• Headaches or migraines
• Trouble sleeping
• Fatigue
• Change in sexual desire
• Weight gain
• Muscle aches
• Slight swelling of the arms or legs
• Digestive symptoms such as nausea, diarrhea, or constipation
• Exacerbation of digestive disorders, such as inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS)

Many teenagers experience PMS, and each person's symptoms may change as they get older. For example, a person who may be prone to PMS-associated angry outbursts for years might stop experiencing them but could begin having abdominal cramps and weight gain in the days before their period.

Complications of PMS

Some people experience especially distressing effects of PMS that can interfere with relationships, work, and overall well-being.

Serious effects of PMS may include:

• Problems with marriage or relationships
• Difficulty parenting
• Decreased work or school performance
• Loss of interest in socializing
• Suicidal thoughts

If you experience depression with your PMS, you may have a form known as premenstrual dysphoric disorder (PMDD).

What Causes PMS?

The effects of PMS are caused by hormonal changes that occur during the menstrual cycle. Estrogen and progesterone are the main hormones that fluctuate throughout the menstrual cycle. Before a menstrual period, estrogen levels drop, and progesterone levels rise.

There is also a pattern of cyclical physiologic shifts that occur throughout the body in the weeks and days before menstruation, including:

• Metabolic variations
• Alterations in neurotransmitters
• Vascular changes

The neurotransmitters serotonin (associated with mood) and gamma-aminobutyric acid (GABA, associated with rest) are most closely linked with PMS.

All of these physiologic shifts, as well as the hormonal patterns, induce symptoms of PMS.

Some of the hormonal and physiologic patterns of a menstrual cycle and their effects on PMS include:

• Hormone changes cause breast soreness and swelling
• Hormone changes trigger uterine contracting (which causes abdominal/uterine cramping)
• Metabolic variations affect appetite, weight, swelling, and energy levels
• Neurotransmitter alterations affect mood, sleep, digestive symptoms, and can induce migraines
• Vascular changes can affect migraines and may cause swelling of the arms and legs

Experts suggest that the alterations in estrogen and progesterone initiate the other physiologic effects of PMS. While most people have very similar patterns during the menstrual cycle, there are some minor variations—which is why not everyone experiences the same symptoms of PMS.

How Is PMS Diagnosed?

There are several screening tools used in the diagnosis of PMS. Generally, healthcare providers use a medical history or questionnaire to diagnose this condition. There are no blood tests or other diagnostic tests that can verify a diagnosis of PMS.

You probably have PMS if you have symptoms that:

• Happen in the five days before your period for at least three menstrual cycles in a row
• End within four days after your period starts
• Keep you from enjoying or doing some of your normal activities

And symptoms must be unrelated to medications (including hormone replacement), alcohol, or drugs.

You can keep a calendar to help you keep track of the timing of your symptoms.

Menstrual Cycle Calendar

The easiest way to determine if you have PMS is to keep track of your symptoms for two or three months on a standard calendar. A menstrual cycle calendar will help you and your healthcare provider know if you are having cyclical symptoms that correspond with your menstrual cycle.

Take these steps to fill out a menstrual cycle calendar:

1. The first day you begin bleeding, write "Day 1" on your calendar.
2. Note any symptoms you experience on that day and rate each on a scale of 1 to 10.
3. Do this every day for two or three months.

True symptoms of PMS do not begin until after day 13, so any symptoms you experience earlier in your cycle may have another cause. However, you should still include any symptoms you experience on days 1 to 13 on your calendar.

PMDD

PMDD is a severe form of PMS that affects approximately 3% to 8% of people who menstruate. According to the Diagnostic and Statistical Manual of Mental Disorders, to be diagnosed with PMDD a person must experience at least five of the following symptoms during the premenstrual phase of the cycle, and not at other times: 

• Feelings of sadness or hopelessness, or suicidal thoughts
• Severe stress, tension, or anxiety
• Panic attacks
• Inappropriate mood swings and bouts of crying
• Constant irritability or anger that affects other people
• Loss of interest in normal daily activities and relationships
• Inability to concentrate or focus
• Lethargy 
• Binge eating

Differential Diagnosis

You may need a diagnostic evaluation to search for hormonal or uterine problems if you have extreme physical symptoms and/or irregular bleeding. This type of evaluation can include blood tests that examine hormone levels and imaging tests that examine the uterus or ovaries.

If your symptoms do not follow a cyclical pattern, your healthcare provider may consider other conditions such as depression, anxiety, gastrointestinal disease, or thyroid disease.

Treatment for PMS

There are several ways to manage PMS. Some people benefit from using supplements or over-the-counter (OTC) therapies, while others may need prescription medications. Lifestyle approaches can be useful as well.

Whether or not you need treatment depends on the severity of your symptoms and their effect on your life. You can discuss your symptoms with your healthcare provider, who can recommend the best treatment for you.

Treatments for PMS can include:

• OTC pain medication: If you have cramps, headaches, or breast tenderness you may benefit from medications such as Advil (ibuprofen) or Tylenol (acetaminophen).
• Supplements: Some people become deficient in vitamins, such as vitamin C, magnesium, or vitamin B12. Changes in appetite can cause these nutritional deficiencies, and supplements may help with symptoms of PMS, as well as with symptoms of nutritional deficiency.
• Prescription pain medication: If you have severe cramps, migraines, or depression, you may be given a prescription medication to alleviate your symptoms.
• Hormonal therapy: For some, hormone therapy with oral contraceptives, estrogen replacement, or progesterone cream can help reduce the effects of PMS. Keep in mind that hormones can have major effects on fertility and may be contraindicated in those who are at risk of breast, ovarian, or uterine cancer.
• Acupuncture or acupressure: Research suggests that these alternative therapies may reduce some symptoms of PMS for some people.

Lifestyle Adjustments

There are also non-medical approaches you can take to help reduce some of your symptoms. Mild cramps can be relieved by placing an ice pack on the abdomen for a few minutes.

People who have mild mood swings may benefit from talking to a counselor or a trusted friend. Habits such as exercising, writing in a journal, or even just being aware that the mood swings are hormonal can help prevent outbursts that can damage relationships.

Summary

PMS is a group of symptoms that occurs before the first day of a person's menstrual period. Symptoms vary from person to person and can change over time. Hormonal changes are responsible for changes in the body that cause PMS. There are several ways to treat PMS and help relieve symptoms. If you experience PMS, talk with a healthcare provider to determine the best treatment options for you.