Premenstrual syndrome is a common problem which deserves sympathetic attention and appropriate management. Many women find that with support and encouragement they can work out solutions for themselves; and if problems persist, then various medical treatments can be tried. Now that many practices have well woman and family planning clinics, the “best person” to deal with premenstrual syndrome may be any member of the team. It is probably helpful to have someone able and willing to deal with the complex interaction between psychological and physical symptoms, relationship and social difficulties. A purely medical approach will fail to engage the woman in examining her situation on a broad front and may encourage her to pin too much hope on pharmacological solutions for problems that may benefit from adjustments to lifestyle and stress.
Health visitors, counsellors, and nurses as well as general practitioners should be aware of premenstrual syndrome and how it may be affecting their patients. Primary care team members, because of their knowledge of an individual woman and her circumstances, are ideally placed to help her work out whether premenstrual syndrome is the main cause of her distress or whether other factors in her life are actually to blame.
Premenstrual syndrome is a problem that is best dealt with by empowering the woman to do as much as she can to help herself and collaborate positively in evaluating any medical treatments prescribed.
Women coming to the surgery with premenstrual syndrome need time to work out what the problems and solutions are and so a number of appointments may be necessary. The initial consultation should seek to establish a therapeutic relationship, identify the woman’s complaints and begin to prioritize the difficulties.
Assessment starts with the history of the main troublesome symptoms, the timing in the menstrual cycle, the severity, and the impact on the woman and those around her. Ask her why she is seeking help now. There may have been a crisis, an unmanageable extra stressor, or she may have heard about a new treatment that she would like to try. She will not have the definitions of premenstrual syndrome to hand and so may rely on magazine articles, a friend’s suggestion, or a scan of the Internet to prompt her presentation. As many as half of women who present complaining of premenstrual syndrome do not have cyclical symptoms after diary keeping so another label needs to be found, and guidance towards a more useful focus. Unfortunately, many women come already certain of their diagnosis and do not want to contemplate an alternative. This may be because they fear the stigma of depression or relationship difficulties and are not confident about solutions to such issues.
Social and relationship context
Women often feel responsible for the emotional well-being of those around them. They blame themselves when things go wrong and look for internal reasons for social and relationship problems. It may be easier to blame the hormones than confront the misery of an absent partner or wayward children. Some social problems are intractable but can be borne except when further strained by premenstrual symptoms.
Cultural norms, expectations and fears
Many women cannot deal with their own anger and are very upset about irritable outbursts, especially when directed at “innocent victims” such as their small children. A typical example of this might be as follows: a woman is overwhelmed with guilt and depression because of an irritable outburst with partner or children. She is appalled at her behaviour and seeks an explanation that allows her to retain her image of herself as self-controlled and loving and reject the side of herself that becomes angry or demanding because it is not how women should behave, even if the anger is justified. She may describe herself as “Jekyll and Hyde” and does not accept her different reactions as part of normality but instead feels out of control and therefore ill. The most frequent fear is that this represents “madness” and premenstrual syndrome offers a hormonal explanation that avoids this conclusion. Reassurance about her sanity and the role of stress may allow exploration of psychological factors.
The patient may be very familiar with her premenstrual syndrome and better versed in the options for treatment than her professional adviser. She may have already tried a number of strategies and have strong views about the next step. A history of past treatments and the outcomes will enable rational and acceptable choices for the future.
Past medical history
Premenstrual syndrome is a chronic disorder and a history of gynaecological events, previous illnesses, psychological and other will help put premenstrual syndrome in the context of the woman’s previous experience of health and illness.
Daily symptom diary keeping
A clear history of premenstrual syndrome is useful in planning treatment but research has shown that women are rather poor at remembering the detail of fluctuating symptoms and tend to attribute negative symptoms to premenstrual syndrome premenstrually and to external events post-menstrually. Thus a daily symptom diary can provide further information about timing and circumstances that enables better definition and management of the situation. It may indicate a pattern of symptoms that confirms premenstrual syndrome, but if it does not then the woman herself will be the first to speculate on alternative explanations. The chart is also valuable in determining whether advice or treatment is helping and the woman should be encouraged to keep it for several months. Knowing in some detail how she is likely to feel at particular times of the cycle gives the woman some sense of the predictability of her symptoms and allows her to plan for the difficult times. It is very helpful to make allowances for premenstrual syndrome, and many women have benefited from fairly simple rearrangements to their schedules of work and other activities to reduce the stress during premenstrual days.
Education, understanding and support
Talking to her general practitioner, health visitor, or practice nurse may open the door for a woman to talk to others such as her partner, family, friends, or colleagues. This means that problems are brought out into the open rather than the woman feeling isolated or “going round the bend”. A woman can learn more about her body, about normal functions of her female self, and what might be abnormal. Talking to others can also reveal a wealth of remedies and strategies for dealing with premenstrual syndrome. Many women spend their time looking after others and an important part of the strategy to combat premenstrual syndrome is for the woman to look at her needs and to nurture herself.
General health promotion and review of health status
A check on general health is useful. Health promotion is worthwhile for all and the evidence for such advice lies in the broader epidemiological studies on the value of low fat, high fibre diet, exercise and the dangers of smoking and excess alcohol. A person will probably be fitter and able to deal better with stress if eating a balanced “healthy” diet and incorporating some form of exercise and relaxation into her lifestyle.
It is also possible that women are more sensitive to changes in blood sugar levels in the premenstrual days, resulting in feelings of weakness, fatigue, and carbohydrate cravings. Careful attention to diet can help, eating frequent small protein-rich meals, particularly if the woman tends to skip meals or eat sugary snacks. It is well worth looking at caffeine intake, since caffeine can increase levels of anxiety and irritability. Many people drink more tea and coffee than they realize and cutting down or cutting these drinks out completely can be helpful. Alcohol consumption may influence premenstrual syndrome. Many women drink more alcohol in response to premenstrual syndrome but excessive intake can make symptoms worse.
There may be links between smoking and premenstrual symptoms and cutting down or stopping smoking is part of general health advice. Exercise can help many of the physical and emotional symptoms of premenstrual syndrome, including tiredness, anxiety, irritability, and bloating. If breast tenderness is a problem, a well-fitting sports bra may help. Learning simple relaxation techniques or meditation can help too. Isolation and lack of control over life’s demands is known to be stressful. Encouraging fun, time with friends, personal time, and regular sleep can reduce dysphoria and anxiety and give a sense of control.
One of the most distressing symptoms of premenstrual syndrome is aggressive irritability, which women say affects their activities and relationships. Although in our culture women are generally brought up to be more passive and nurturing than men, it is possible that premenstrual syndrome may bring out real anger about real problems in an otherwise easy-going woman. She and those around her may perceive this as irritability and dismiss the underlying problems, which need to be explored. The premenstrual days may not be the best time to tackle problems that are making her angry, but this is not a reason for ignoring them.
This assessment illustrates the importance of taking a holistic approach to premenstrual syndrome and looking at every woman’s circumstances, particularly before embarking on medical treatments. It is important to remind women that good habits of life are best practised in the “good” weeks, as it is much more difficult to start when things are already overwhelming. Books on premenstrual syndrome are available with sections on diet, relaxation and exercise. There is a useful address for women’s health at the end of the chapter. If no women’s health group is run in the surgery, there may be a local group to which women can be referred.