From earliest times men have written about women’s changing moods and behaviour and attributed them to their female anatomy and their menstrual cycle. In the twentieth century, Frank (1931) coined the term premenstrual tension. He perceived a link between symptoms in the latter half of the menstrual cycle and the fluctuations of the reproductive hormones. From the 1950s, Dalton has campaigned for the better recognition and treatment of such symptoms and widened the concept, calling it premenstrual syndrome. Since then, premenstrual syndrome has received much publicity, in both the lay and medical press. There is still much debate about the syndrome’s definition, aetiology and treatment, but following considerable research and debate, there is now a better understanding of premenstrual syndrome and a range of ways of managing the problem. It is a complex and fascinating topic that raises many questions about the interactions between hormones and physiological changes and life events and stress. Women today are taking an active and positive role in acquiring knowledge and information about health issues and many women hear about premenstrual syndrome and identify similar symptoms in themselves. With information, patience, and encouragement, women can work out ways to understand and manage their symptoms and this may include seeking medical advice from their general practitioner.

Definition

Many women notice change in their emotional and physical feelings during the menstrual cycle. While for the majority such changes are acceptable, for others they are distressing. These distressing premenstrual changes are now described as “premenstrual syndrome” rather than “premenstrual tension”, in recognition of the variable nature of the symptoms, which may not always include tension. The definition of premenstrual syndrome has been fraught with problems, since the type of symptoms and their severity can vary enormously both between women and between cycles for individual women. There are a number of definitions of premenstrual syndrome available. O’Brien (1990) gives a widely accepted example:

Disorder of non-specific somatic, psychological or behavioural symptoms recurring in the premenstrual phase of the menstrual cycle. Symptoms must resolve completely by the end of menstruation leaving a symptom-free week. The symptoms should be of sufficient severity to produce social, family or occupational disruption. Symptoms must have occurred in at least four of the six previous menstrual cycles.

He does not specify which symptoms, because these can be so variable. More than 150 symptoms have been described, but the commonest include: low mood, irritability, anxiety, tension, clumsiness, poor memory, food craving, sleep disturbance, bloating, breast tenderness, abdominal pain, back ache, weight gain, fatigue.

Some women notice only mood changes, others only physical symptoms, but it is more common for both to be experienced together. There are no specific symptom clusters and individual women tend to report their own unique combination of symptoms. However, most of the women looking for help have a predominance of psychological symptoms because these interfere most with relationships in everyday life.

Recently, a severe premenstrual syndrome with predominantly mood symptoms has been defined in the appendix of the American Psychiatric Association’s Diagnostic and Statistical Manual, called “premenstrual dysphoric disorder”. Operational criteria have been described so that research into this severe condition can be more consistent. Epidemiological data using these criteria reveal a subgroup of women with a disorder that is very like an affective disorder and which may be best treated as one. This has allowed women with the most disabling pattern of premenstrual syndrome symptoms to be researched specifically, with encouraging results for all sufferers. While being yet another medical label for women, this may be helpful with regard to management approaches.

Distressing changes may start up to 14 days before menstruation, although it is more common for the symptoms to last for up to a week, and disappear at or shortly after the start of menstrual bleeding. Many women say that the severity varies from cycle to cycle, depending on general life events and stresses. Until the timing in relation to menstruation is established, premenstrual syndrome can be confused with more general problems such as anxiety or depression, and may be misdiagnosed or mistreated. Hence, the first step in diagnosis is careful and regular symptom recording to establish the nature and timing of the problems. Women should be asked to complete menstrual charts, recording their moods and other symptoms for at least two cycles. Various menstrual diaries are available, or a simple practical alternative is to customize a diary for the individual based on the predominant symptoms.

Some women complain of symptoms that seem to be related to the menstrual cycle but wax and wane at other times in the cycle, e.g. at ovulation. Some definitions allow such variations, e.g. Magos (1990): distressing physical, psychological and behavioural symptoms not caused by organic disease which regularly recur during the same phase of the menstrual cycle and which significantly regress or disappear during the remainder of the cycle.

Again it is crucial to establish the pattern by prospective daily symptom diary kept over several cycles.

Prevalence

It is hard to evaluate how many women experience premenstrual syndrome since the experience of cyclical changes is so common and what makes them distressing and disabling is so subjective. Epidemiological studies indicate that between 75 and 90% of ovulating women experience cyclical changes at least some time in their lives. For many these are in no way a problem. They can indeed be a positive part of their lives and could be regarded as normal “physiological” aspects of the menstrual cycle. Logue and Moos (1988) found that between 5 and 15% of women actually feel better in the premenstrual phase, experiencing increased well-being, energy, and activities before menstruation. About 5 – 10% of women have premenstrual syndrome that is severe and disabling, depending on sample and definition.  This leads to a significant number of consultations for premenstrual syndrome in the surgery. It is likely that what brings a woman to seek medical help is the effect of premenstrual syndrome on her life. Women seek help when symptoms interfere with personal, home, or working life and in particular with relationships with family, children, partner, friend, or colleagues.

Effects of premenstrual syndrome

Premenstrual syndrome is undoubtedly distressing for many women, not only for themselves but also for those around them. Women with small children too young to understand premenstrual syndrome may feel extra stress and be worried about the effect their feelings are having on their children. Cyclical mood changes, particularly if seemingly unpredictable, may be a problem in relationships with a partner, unless premenstrual syndrome is discussed, understood and accepted. Women whose colleagues at work are unsympathetic and dismiss suggestions or complaints on their part as “it’s that time of the month again” will obviously find premenstrual syndrome hard to bear. Women often worry that their performance at work may be impaired before menstruation but studies have shown that this is largely not the case. Many women who suffer with premenstrual syndrome organize their work and home life so that they avoid stressful events premenstrually. Evidence suggests, however, that women who are admitted to psychiatric hospital, attempt suicide, or commit crimes are more likely to be in the luteal phase of their cycle. This is not to say that all premenstrual women are at risk of these events, but women who are likely to require psychiatric admission or commit crimes and who experience premenstrual syndrome, may be more vulnerable in the premenstrual phase. Premenstrual syndrome may well influence women’s sexuality, and there is no doubt that mood changes interact with sexual feelings. A woman who experiences severe premenstrual tiredness or breast tenderness may find this reduces her interest in sexual activities before menstruation, although sexual interest may well increase after menstruation once she feels an improvement in well-being. However, some women feel more sexually interested in the premenstrual phase. Fluctuations in sexual interest may cause worry to a woman and possible problems in relationships unless links to the menstrual cycle are understood. Problems of varying sexual interest linked to premenstrual syndrome may be one reason for consulting the general practitioner.

Who experiences premenstrual syndrome?

There appears to be no distinctive “type” of woman likely to experience premenstrual syndrome, although in general it appears to be more common in women in their thirties and forties and in women who have children. Certain events may be linked to the onset of premenstrual syndrome, such as stopping the oral contraceptive, the birth of a child, or sterilization, which suggests a hormonal connection. premenstrual syndrome can still be experienced following hysterectomy if the ovaries remain. premenstrual syndrome seems to be common across all social classes although it seems that women who seek medical help specifically for premenstrual syndrome are more likely to be in social classes I and II. Therefore, the primary health care team should be alert to the possibility of premenstrual syndrome in women consulting for other problems, such as anxiety or depression. There also appears to be a general link between adverse life events and premenstrual syndrome. Women tend to experience premenstrual syndrome as more of a problem during times of stress, such as when there are problems at home or at work, or during examination times or when moving house. Despite some views that premenstrual syndrome is a complaint of “neurotic” women, there is no consistent relationship between women’s personalities and premenstrual syndrome. There do, however, appear to be links between premenstrual syndrome and general psychological health. Women who are psychiatrically ill may experience more, and more severe, premenstrual psychological symptoms than psychologically healthy women. Women with premenstrual syndrome are more likely to have had a depressive illness in the past and more likely to have had postnatal depression. Recently, interest has focused on premenstrual syndrome in perimenopausal women. During the time leading up to the menopause, premenstrual syndrome can become more severe and blur into the menopause. It is possible that some women are more vulnerable than others to hormonal fluctuations and are therefore at risk of problems with premenstrual syndrome, the menopause, and a mild form of postnatal depression and so require extra support at these times.

Causes of premenstrual syndrome

There has been no shortage of hypotheses to explain premenstrual syndrome. The most plausible include abnormal tissue responses to normal levels of ovarian hormones, abnormalities of serotonin and other neurotransmitters. Endocrinological studies have not shown any convincing abnormalities, particularly none in the luteal phase. Nevertheless, medical suppression of the ovarian cycle with gonadotrophin-releasing hormone or surgical ablation by bilateral oophorectomy has been proven to eliminate premenstrual syndrome. There may be interactions between hormones and neurotransmitters. For example, there may be increased sensitivity to progesterone due to serotonin deficiency. Recent studies showing the efficacy of serotonin reuptake inhibitors have strengthened the evidence for involvement of the serotonin system. To these can be added nutritional theories, including deficiencies of pyridoxine, essential fatty acids, hypoglycaemia and low magnesium or calcium levels. Cultural, psychological, and social theories have also been put forward. Premenstrual syndrome probably results from a combination of physical, psychological, and social factors interacting with life events.

Premenstrual Syndrome: Management

Evaluating the evidence for treatments for premenstrual syndrome

There are many options for the specific treatment of premenstrual syndrome. The evidence for effectiveness varies in both quality and quantity. Much remains unclear. Effective treatment is evidence based if there are controlled trials of a certain quality that indicate the treatment confers benefit compared with placebo or alternative treatment. In premenstrual syndrome a good trial should be double-blind and placebo-controlled, preferably with a crossover design. The trial should establish the presence of premenstrual syndrome in the subjects prior to the trial by the use of prospective daily symptom charts that have been validated for the purpose. There should be at least one cycle prior to randomization of placebo treatment to exclude women who respond to any intervention. The trial should include sufficient cycles to allow for variation in severity that naturally occurs (usually two pretreatment cycles and two or more treatment cycles). Few trials meet these criteria. Variations between samples due to diagnostic differences, sample sources, and outcome measures also add to the difficulty when comparing current information. Nevertheless, some provisional conclusions can be offered to guide management, especially as some treatments are promoted with much fanfare and negative evidence. Other strategies using common sense are cheap and can do no harm and therefore may be tried without concern while researchers pursue further studies to consolidate the evidence.

Non-drug treatments

Psychological approaches

There have been various psychological approaches to the management of premenstrual syndrome, including counselling, psychotherapy, and hypnotherapy, although none has been evaluated in controlled trials. Group therapy or self-help groups allow women to share their experiences and approaches to premenstrual syndrome. Groups for women with premenstrual syndrome, run in the surgery or in a local community centre, can be very valuable for women with premenstrual syndrome and their partners or families. Some women may be helped by a discussion about premenstrual syndrome as part of a series of meetings on women’s health issues where they can obtain information and discuss their problems. Specific premenstrual syndrome groups have been run by general practitioners and psychologists, giving women a chance to air their feelings, try out self-help techniques such as relaxation, and discuss medical treatments.

Cognitive behavioural therapy

This is one of the few psychological treatments that has been evaluated in controlled trials and the evidence is mixed. Three controlled trials have found Cognitive behavioural therapy better than other measures or a waiting list, but two others have found no extra benefit. Variations between the trials are greater than their similarities, so further research is required. Meanwhile, the principles of Cognitive behavioural therapy are useful to promote satisfactory management of this chronic disorder. The rationale for why it may be helpful for premenstrual syndrome is explained below. There are no harmful effects. Such treatment is also likely to improve other areas of poor health and functioning. Cognitive behavioural therapy has been shown to be an effective treatment for many psychological problems, such as anxiety and depression, which are common components of premenstrual syndrome. Cognitive therapy may be particularly suitable for premenstrual syndrome, being brief, time-limited, structured, and collaborative. Therapist and patient work together to help the patient work out solutions to the problems she is facing. It is a common-sense approach that is particularly acceptable to people who are wary of psychological therapy implying that the symptoms are “all in the mind”. The focus of therapy is on the woman’s psychological response to emotional and physical changes and the therapy aims to help the individual to examine patterns of negative thinking and her assumptions about the symptoms and to learn more adaptive and helpful thoughts and behaviours. The cognitive model of premenstrual syndrome proposes that the woman’s cognitive appraisal of the premenstrual changes, in the context of the woman’s circumstances and personal assumptions, determines whether she sees the changes as normal and a manageable part of her life, or distressing. For example, interpreting physiological changes in the luteal phase in a negative way is likely to lead the individual to become more distressed and upset by the symptoms, thereby increasing the woman’s overall level of distress. The symptoms may be magnified by vicious circles of negative thinking, thereby increasing the woman’s anxiety, irritability, or low mood. In particular, the woman may find that physiological changes interfere with her normal coping mechanisms, leading her to predict that she is going to lose control. These thoughts lead the individual to feel tense and anxious, leading to indecision and inability to concentrate. These changes are then interpreted as further evidence that she is losing control and so on in a vicious circle. The rationale for cognitive therapy is that whilst psychological factors do not, in their own right, cause premenstrual distress, psychological factors influence the response to both psychological and physiological symptoms, thereby modifying the degree of distress. For many women, directly targeting the symptoms with physical treatments alone has proved unhelpful; therefore reducing the distress about the symptoms is a more useful strategy. In a small, controlled trial of cognitive therapy for severe premenstrual syndrome in Oxford, the treated group had a significant relief of premenstrual symptoms compared with a waiting list group. The common-sense nature of the approach makes it a valuable addition to the range of treatments for premenstrual syndrome and can be modified for use in primary care.

Premenstrual syndrome: Medical treatments

Premenstrual syndrome: Conclusion

Premenstrual syndrome includes a wide range of physical and emotional changes which vary in severity, duration, and effects on a woman’s life. It is unlikely that there is a single or simple cause, and any consideration of the aetiology of premenstrual syndrome must take into account psychological, physiological, and social factors. Management of premenstrual syndrome is not simple, but it is certainly aided by a greater understanding and acceptance of the problem and the development of a range of approaches and remedies. Women need to devote time to experiment to find an appropriate solution, and may require help from the primary health care team to evaluate how they can help themselves and, if necessary, what medical treatments might be useful. In any individual woman it is essential to determine whether or not she has premenstrual syndrome, what her main problems are, and the circumstances that led her to seek medical help. The first steps are sympathetic discussion of the problems and reorganization of aspects of her life to cope with times of feeling low. Attention to general health and lifestyle is the key to dealing with premenstrual syndrome. Following this, a woman may try a variety of self-help approaches, but may need to call upon the primary care team further to explore the range of effective treatments, both medical and non-medical. If a woman is not helped by any of the approaches available in primary care, even more attention must be paid to correct diagnosis and what is going on in her life more widely. Referral to a specialist premenstrual syndrome clinic may be indicated. Gynaecologists vary in their interest in this topic but, as research is progressing rapidly in this field, it is a great boon for the team and the woman if up-to-date expert advice and treatment are available.

Frequently asked questions

Do I have premenstrual syndrome?

It is likely that you have premenstrual syndrome if you have distressing and disabling symptoms that appear in the premenstrual phase of your menstrual cycle, that are relieved by the onset of menstruation and you have at least a week post-menstrually with few or no symptoms. The pattern should bother you most months, though there can be a lot of variation. No symptoms are specific. It is easy to think that randomly changing symptoms have something to do with hormones even when they do not. There are no tests for it. Instead the doctor relies on you charting your symptoms every day so that the pattern of symptoms is written down for him or her to see. It is usually clear from such a diary whether you have “pure” premenstrual syndrome, premenstrual syndrome on top of background symptoms which are there all month, or that the symptoms vary randomly. Doctors also try to avoid making an illness out of ordinary experiences, so if it does not bother you much it will not be called premenstrual syndrome.

If this isn’t premenstrual syndrome, what is it?

You can usually give the doctor some good ideas yourself. It could be stress at home or work, difficult relationships, or too much to do. You may not be looking after yourself properly and better and more regular meals, sleep, and fun times might be needed. You may be ill and a health check will reveal the problem. It could be that you have got so run down that you are depressed and then everything becomes dreary and difficult to manage. Your doctor will try to help you think about what is wrong.

What works for premenstrual syndrome?

Many things have been tried for premenstrual syndrome. No single treatment is 100% effective, which may explain why so many things have been tried. It seems that actively managing your lifestyle to make it as balanced and healthy as possible can be very helpful. This is not easy for many women and may be why premenstrual syndrome becomes an issue when women have the most demands. It also helps to talk things through and to have a positive attitude. Women report they may benefit from aerobic exercise and extra vitamin B6. Some hormone treatments are known to help, and certain antidepressants, a painkiller called mefenamic acid, and herb extracts. If these don’t help, gynaecologists can also try switching off the cycle (though this is usually only temporarily) and have a few other special hormone treatments to offer. In rare severe cases the womb and ovaries are removed surgically to stop the cycle for good.

How can I help myself?

Careful recording of the symptoms and when they occur is the first step. With this knowledge you can then begin to predict difficult situations and prepare for them better. Here are a few ideas. It may be that you get tired premenstrually. Some early nights may allow you to cope better as the period approaches. Perhaps you generally work through lunch and do not eat until evening. This will probably lead to more stress premenstrually, so book yourself lunch more often. Perhaps you are not doing much exercise. Exercise helps premenstrual syndrome, so plan to walk or cycle more or go to an exercise or dance class. If you need to, think seriously about cutting down on alcohol or cigarettes. Get out and have some fun. Have time to yourself. Meet up with friends. Talking to a friend or counsellor can enable you to see that you have some choice in how you manage your life and offer you vital encouragement to help you break unhelpful habits.

What about hormones?

Hormones ought to be what premenstrual syndrome is all about. Yet there are no measurements of hormones that really give the doctor a good idea of what is happening for sufferers. Changing the balance of the hormones has some effect, but not all hormone supplements are truly effective. Oestrogen patches (the same as hormone replacement therapy, hormone replacement therapy) help many women, but it is not clear whether the combined oral contraceptive pill does or not. For women who need the Pill anyway, a change of type of Pill can improve premenstrual syndrome. It is worth a try. We know from many studies that progesterone suppositories (which used to be a real favourite) are no better than a sugar pill. It is probable that the contraceptive progesterone-only pill does not work very well either. There are other special hormone treatments but they are fairly strong with lots of side effects. These are used by gynaecologists for the desperate sufferer!

What about diet and vitamin supplements?

Lots of diets and supplements have been suggested for premenstrual syndrome. A healthy mixed diet is always sensible but there is no evidence that special foods cure premenstrual syndrome. The research into supplements is still limited but probably vitamin B6 helps (but don’t take too high a dose), evening primrose oil helps breast tenderness, and extract of agnus castus fruit relieves symptoms.

10-Minute consultation

A woman comes to see you complaining of premenstrual syndrome (premenstrual syndrome). She has had it for years. It was less of a problem before her children arrived because she could arrange her life to suit the time of the month, but it has been getting harder to manage in the last few years. This is the first time she has consulted a doctor for it, though she has spoken with friends and tried vitamins and oil of evening primrose. Now she has come because she got so cross with her 12-year-old son when he refused to leave his computer game and come for tea, that she threw his meal in the bin. It was 2 days before her period was due. Now she is mortified that she lost her temper so completely. Her 14-year-old daughter told her to see the doctor.

What issues you should cover

  • Ask about the typical premenstrual symptoms  –  what they are, when they wax and wane, and which are most troublesome. Was this month’s upset different from the usual pattern or simply had a more distressing outcome?
  • Ask about her social situation.
  • Ask about recent events and stressors. Is anything making life, as well as premenstrual syndrome, more difficult now.
  • What does she know about premenstrual syndrome?
  • What has she tried so far? How long did she persist with the strategy? Did it help?
  • Has she any other medical needs? Consider particularly gynaecological complaints that may make premenstrual syndrome worse  –  heavy or irregular periods, painful periods, menopausal symptoms, dyspareunia, etc. Are her contraceptive needs met?
  • Ask about psychological problems  –  does she have general low mood, tearfulness, anxiety, sleep disturbance, appetite change, and lack of enjoyment in life indicative of depressive illness?
  • Ask what does she hope to get from the consultation?
  • Clarify that you agree on a working definition of premenstrual syndrome  –  not specific symptoms but any that occur regularly in the premenstrual phase of the cycle with relief at menstruation and a week post-menstrually with few or no symptoms.

What you should do?

  • Acknowledge the perceived link between the symptoms and the cycle and remind her where appropriate of the possibility that many factors contribute to premenstrual syndrome complaint. Remind her that there are no magic answers but that she can play her part in learning how her body and mind reacts and what strategies improve her well-being.
  • Show her a symptom diary and how to complete it. Stress its importance for understanding her pattern of symptoms and testing the effectiveness of advice and treatment.
  • Outline suitable lifestyle changes if indicated and be sympathetic where these have been difficult to achieve. Note whether there is a general openness or hostility to your explorations of possible self-help. This will indicate whether she is open to trying to help herself or whether she hopes that medical management will fix things.
  • Mention the possible role of her social situation, stressors, and relationships, if this has not already been covered.
  • Mention a few possible treatments which you would consider. If she has already tried various measures, establish which of the remainder would be top of your list.
  • Physical examination is only indicated if symptoms suggest other disorders.
  • Investigations only as indicated, e.g. full blood count if tiredness, prominent dizziness, or excessively heavy periods.
  • Plan to review after 2 months of diary keeping.
  • Offer an opportunity to see the practice nurse (or counsellor) to discuss how diary keeping is going, how she is coping and whether she has been able to utilize any self-help advice. This might occur within a month and gives another opportunity to review general health (e.g. cervical smear) and be reminded of healthy lifestyle issues.

Options for medical treatment

Ideally, medical treatments should come after diary keeping, but many women will simply not manage it so the following treatments remain as therapeutic tests for such women.

  • Over the counter
    • vitamin B6 (50 – 100 mg/day)
    • agnus castus fruit extract
  • Prescription
    • oral contraceptive pill (or a different progestogen if already on it)
    • mefenamic acid (for symptomatic days)
    • oestrogen patches (hormone replacement therapy) plus cyclical oral progestogen (dydrogesterone) unless she has had a hysterectomy. Start at 50 Вµg patches twice weekly and increase over 2 – 4 months as required
    • Selective serotonin re-uptake inhibitors
      • fluoxetine or citalopram 20 mg only in luteal phase
      • fluoxetine or citalopram 20 mg continuously, particularly useful when (1) there is premenstrual exacerbation of underlying depression and anxiety, (2) the symptom pattern is unclear, (3) the patient still insists that a random pattern is premenstrual syndrome, (4) the patient has failed to respond to intermittent doses
  • Specific symptoms
    • pain: naproxen or mefenamic acid
    • breast tenderness: oil of evening primrose
    • bloating: spironolactone
    • headaches: naproxen or mefenamic acid.

 

Share →