Premenstrual syndrome (PMS) can cause various symptoms before periods. In some women the symptoms can badly affect their quality of life at that time. Various treatment options are available.
What is the premenstrual syndrome?
PMS is a condition in women where certain symptoms occur each month before a period. PMS is sometimes called premenstrual tension (PMT) or premenstrual disorder (PMD).
What are the symptoms of premenstrual syndrome?
Many different symptoms have been reported. The most common are listed below. You may have just one or two symptoms, or have several:
- Mental (psychological) symptoms include: tension, irritability, tiredness, feelings of aggression or anger, low mood, anxiety, loss of confidence, and feeling emotional. You may have a change in your sleep pattern, in sexual feelings and in appetite. Relationships may become strained because of these symptoms.
- Physical symptoms include: breast swelling and/or pain, tummy (abdominal) bloating, swelling of the feet or hands, weight gain and an increase in headaches. If you have epilepsy, asthma, migraine or cold sores, you may find that these conditions become worse before a period.
Who gets premenstrual syndrome?
PMS most commonly affects women aged 30-40 years. However, it can affect you at any age, even if you are less than 20 years old. Most women can tell that a period is due by the way they feel both physically and mentally. For most, the symptoms are mild and not troublesome.
About one woman in twenty has PMS where the symptoms become bad enough to disrupt normal functioning and quality of life. Day-to-day life and performance at work can be affected. It may cause tension with family and friends.
How is premenstrual syndrome diagnosed?
There is no test for PMS. The diagnosis of PMS is based on your symptoms.
Sometimes it is difficult to tell if your symptoms are due to PMS, or if they are due to other conditions such as anxiety or depression. Your doctor may ask you to keep a diary of symptoms over a couple of months. It is when the symptoms occur that indicates PMS, not just their nature or type.
If you have PMS you may have:
- Symptoms that start sometime after ovulation (when you release an egg from an ovary each month), which occurs about two weeks before the start of a period. Typically, symptoms occur during the five days before a period. However, some women have symptoms for two weeks or so leading up to a period. Typically, symptoms gradually become worse as the period approaches.
- Symptoms that go within three to four days after your period starts.
Symptoms that occur all the time are not due to PMS.
What causes premenstrual syndrome?
The cause is not known. It is not due to a hormone imbalance, or due to too much or too little of any hormone (as was previously thought). However, the release an egg from an ovary each month (ovulation) appears to trigger symptoms. It is thought that women with PMS are more sensitive to the normal level of progesterone. This hormone is passed into the bloodstream from the ovaries after you ovulate.
One effect of over-sensitivity to progesterone seems to reduce the level of a brain chemical (neurotransmitter) called serotonin. This may lead to symptoms, and may explain why medicines that increase the level of this brain chemical work in PMS.
What can I do to help?
The following may help:
- Read about it. It may help you to understand what is happening. This may relieve some of the anxiety about symptoms. It may be useful to keep a chart or diary. Note the days you feel irritable, low, or anxious, or have any other symptom that you feel may be part of PMS. See how long symptoms last before a period. Then it may be worth noting in a diary when your periods are due. As you can predict when your PMS symptoms are likely to occur, you can expect them and be ready for them. For example, it may be possible to avoid doing important things on the days when symptoms are expected.
- Talk about it with your family, friends or partner. It may help them to understand how you are feeling. It may be best to do this after your period when symptoms have eased.
- Exercise. Some women who exercise regularly say they have less of a problem with PMS. Try doing some regular exercise several times a week.
- Food and drink. Some people claim that various diets help to ease PMS. However, there is little evidence from research trials that this is true. Reducing the amount of sugar and refined carbohydrates you eat before your period may help your symptoms.
- Reduce caffeine and alcohol intake. Some women find that alcohol or caffeine (found in tea, coffee, cola, etc) makes their symptoms worse. So, it may be worth a trial of not having alcohol or caffeine prior to periods to see if this helps.
What are the treatment options for premenstrual syndrome?
Many treatments for PMS have been tried over the years. There are very few that have been proven to work. Treatments for PMS may take a while to work fully. If you start a treatment, try it for several months before deciding if it is helping or not.
It can be difficult to remember how things were several months ago. If you keep a diary of symptoms, it will help you to decide if you are better with treatment than you were before. Treatments may not cure symptoms completely. However, the symptoms often become a lot easier or less frequent with treatment.
Not treating is an option
Understanding the problem, knowing when the symptoms are coming and planning a coping strategy are all that is required for many women. Some women find the self-help measures listed above and such things as avoiding stress or doing relaxation exercises prior to a period can help.
Treatments that you can buy without needing a prescription
Various products are sold for the treatment of PMS, including calcium, magnesium and vitamin B6 (pyridoxine). There is very little evidence to support the use of them.
Simple painkillers such as ibuprofen or paracetamol may help with breast tenderness.
Selective serotonin reuptake inhibitors (SSRIs)
An SSRI medicine (for example, fluoxetine) is commonly prescribed to treat more severe PMS. These medicines were developed to treat depression. However, they have also been found to ease the symptoms of PMS, even if you are not depressed. They work by increasing the level of serotonin in the brain (see above in 'What causes premenstrual syndrome?'). You have a good chance that symptoms of PMS will become much less if you take an SSRI.
Research suggests that taking an SSRI for just half of the cycle (the second half of the monthly cycle) is just as effective as taking an SSRI all of the time. Side-effects occur in some women, although most women have no problems taking an SSRI. There are various types and brands.
The combined oral contraceptive (COC) pill
In theory, preventing ovulation should help PMS. This is because ovulation, and the release of progesterone into the bloodstream after ovulation, seems to trigger symptoms of PMS. The COC pill (known as 'the pill') works as a contraceptive by preventing ovulation.
However, pills do not always help with PMS, as they contain progestogen hormones (with a similar action to progesterone). A newer type of pill called Yasmin® contains a progestogen called drospirenone which may not have the downside of other progestogens. However, it is not clear from the research whether or not it is any better than other pills. If you have PMS and require contraception then the pill may be a possible option to use for both effects. If you take the pill, your doctor may advise you to reduce the pill-free week to only four days, or to run three packets together without having a break.
Oestrogen given via a patch or gel has been shown to improve symptoms by suppressing egg production. Oestrogen tablets are not effective though. However, you will also need to take progestogens if you have not had a hysterectomy. These can be taken as tablets or an intrauterine system (IUS) can be inserted. The doses of oestrogen in a patch are much lower than in the COC pill, so the patch is not a method of contraception, but the IUS is.
Other methods of suppressing ovulation include gonadotrophin-releasing hormone analogues. They are usually given by injection and with hormone replacement therapy (HRT) to protect your womb (uterus). Surgery to remove both ovaries also prevents ovulation and is likely to cure PMS, although is a drastic option. Because of this, it is only done in the most severe cases where nothing else has helped.
Cognitive behavioural therapy (CBT)
CBT is a talking treatment (psychological treatment), during which, ways to find more adaptive ways of coping with premenstrual symptoms are explored. This has been shown to be effective for some women.
Further reading and references
Heavy menstrual bleeding - assessment and management; NICE Clinical Guideline (August 2016)
Management of Premenstrual Syndrome; Royal College of Obstetricians and Gynaecologists (2016)
Nevatte T, O'Brien PM, Backstrom T, et al; ISPMD consensus on the management of premenstrual disorders. Arch Womens Ment Health. 2013 Aug16(4):279-91. doi: 10.1007/s00737-013-0346-y. Epub 2013 Apr 27.
Amenorrhoea; NICE CKS, July 2014 (UK access only)
Dysmenorrhoea; NICE CKS, May 2014 (UK access only)
Menorrhagia; NICE CKS, June 2017 (UK access only)
Fibroids; NICE CKS, June 2017 (UK access only)
Singh SS, Belland L; Contemporary management of uterine fibroids: focus on emerging medical treatments. Curr Med Res Opin. 2015 Jan31(1):1-12. doi: 10.1185/03007995.2014.982246. Epub 2014 Nov 12.
Orozco LJ, Tristan M, Vreugdenhil MM, et al; Hysterectomy versus hysterectomy plus oophorectomy for premenopausal women. Cochrane Database Syst Rev. 2014 Jul 28(7):CD005638.
Brito LG, Pouwels NS, Einarsson JI; Sexual function after hysterectomy and myomectomy. Surg Technol Int. 2014 Nov25:191-3.
Hi,My last two periods have been completely brown. The blood is dry and there are some thick blood clots. I’ve been on the birth control pill for 12 years and I’m super concerned that it’s a hormone...jenny 43933
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