Premenstrual syndrome

Signs and Symptoms

Symptoms of PMS include:

• Bloating and weight gain
• Breast swelling, tenderness
• Mood swings
• Depression and anxiety
• Skin problems
• Changes in appetite, food cravings
• Changes in interest in sex
• Headaches, backaches, and cramps
• Not being able to concentrate, loss of interest in usual activities, and confusion
• Fatigue
• Irritability

What Causes It?

While the exact cause of PMS is unknown, the most popular theories include hormonal changes (too much estrogen or not enough progesterone), low levels of vitamin B6 or other nutrients, abnormal metabolism of hormone-like substances called prostaglandins, and low levels of the brain chemical serotonin that affects mood.

Who is Most At Risk?

Women with a history of the following conditions are at a higher than average risk for having PMS.

• Earlier onset of first menstrual period
• Family history of PMS
• Dysmenorrhea (painful menstruation)
• Depressive mood, anxiety, or bipolar disorders (including a family history of these problems)
• Postpartum depression or psychotic episodes
• High stress
• High alcohol and caffeine intake
• High body mass index

What to Expect at Your Provider's Office

If you have symptoms associated with PMS, see your health care provider. Your provider can help make a diagnosis and find a treatment or combination of therapies that may work best for you.

You will need to chart your symptoms and their severity daily for 1 to 2 months. Your provider will take a detailed history of symptoms, do a physical and gynecologic examination to rule out other medical conditions, and perform a psychosocial evaluation. Laboratory and imaging studies may be used to rule out other conditions.

Treatment Options

Prevention

Reducing stress, increasing exercise, and making dietary changes around the time of menstruation may prevent PMS symptoms from worsening. Supplementing the diet with certain vitamins and minerals, including calcium, vitamin B6, vitamin D, Omega-3 fatty acids, and others, may also help. Several studies show that women who exercise report less breast tenderness, fluid retention, personal stress, anxiety, and depression than those who do not exercise.

Treatment Plan

Preventive measures and, in some cases, drug therapy, are most often used for treating PMS.

Drug Therapies

Your provider may prescribe the following medications:

• Diuretics, for bloating and water retention
• Nonsteroidal anti-inflammatory drugs (NSAIDs), for headaches and cramps, including ibuprofen (Advil, Motrin) and naproxen (Aleve)
• Antidepressants
• Birth control pills, to stop ovulation and stabilize hormone levels
• Medroxyprogesterone acetate (Depo-Provera), to treat severe PMS (Depo-Provera halts ovulation temporarily, but may also trigger an increase in some PMS symptoms, such as increased appetite, weight gain, and depression)

Complementary and Alternative Therapies

A comprehensive treatment plan for PMS may include a range of complementary and alternative therapies (CAM). Work with an experienced provider and always inform every member of your health care team about any CAM therapies you are considering adding to your regimen.

These nutritional tips may help reduce symptoms:

• Eliminate all potential food allergens, including dairy, wheat (gluten), soy, corn, preservatives, and food additives. Your health care provider may want to test for food sensitivities.
• Eat calcium-rich foods, including beans, almonds, and dark green leafy vegetables (such as spinach and kale).
• Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy), or beans for protein.
• Use healthy cooking oils, such as olive oil or coconut oil.
• Reduce or eliminate trans fatty acids, found in commercially-baked goods, such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• Avoid coffee and other stimulants, alcohol, and tobacco.
• Reduce the amount of salt in foods to lessen fluid retention.
• Drink 6 to 8 glasses of filtered water daily.
• Drink calcium-enriched soy milk, for bone health and symptoms of PMS.
• Exercise moderately at least 30 minutes daily, 5 days a week. Studies suggest that women who exercise regularly are less likely to have symptoms of PMS.

These supplements may also help:

• A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-complex vitamins and trace minerals such as magnesium, calcium, zinc, and selenium.
• Calcium citrate, 500 to 1,000 mg daily, and vitamin D, 400 IU daily. Several studies suggest that calcium may reduce PMS symptoms. Calcium and vitamin D are also good for your bones.
• Magnesium, 400 mg daily. Studies suggest magnesium may help reduce breast tenderness, bloating, migraine, and fluid retention. High doses of magnesium can lower blood pressure and cause loose stools.
• Vitamin B6, 100 mg per day. The evidence is not overwhelming, but a few studies suggest vitamin B6 may help some women reduce symptoms of PMS. Vitamin B6 can be harmful at high doses, so ask your doctor before taking it.
• Progesterone cream, 1/8 to 1/4 tsp. (depending upon extract strength) applied topically daily on days 7 to 28 of cycle, for symptoms of PMS. DO NOT use this cream, or any hormone supplement, without first talking to your doctor. Although available as an over the counter product, progesterone cream may interfere with prescription and nonprescription medications, such as oral contraceptives. If you have a hormone-sensitive condition, such as endometriosis or breast cancer, you should consult with a specialist before taking progesterone.
• Omega-3 fatty acids, such as fish oils, 1 to 2 capsules, or 1 tbsp. of oil daily, to help reduce inflammation. Fish oils may increase the risk of bleeding. If you take blood-thinning medication such as warfarin (Coumadin) or aspirin, talk to your doctor before taking fish oil.

Herbs are generally available as standardized dried extracts (pills, capsules, or tablets), teas, or tinctures or liquid extracts (alcohol extraction, unless otherwise noted). Mix liquid extracts with your favorite beverage. Dose for teas is 1 to 2 heaping tsp. per cup of water, steeped for 10 to 15 minutes (roots need longer).

The following herbal remedies may provide relief from symptoms:

• Chaste tree (Vitex agnus castus) standardized extract, 400 mg daily before breakfast. Several studies suggest chaste tree or chasteberry may help reduce symptoms of PMS, including headache, irritable mood, and breast tenderness, however at least one study found it did not help reduce bloating. Vitex may interfere with some medications, including birth control pills, antipsychotics, and estrogen supplements for use with in-vitro fertilization (IVF) treatments, for example. If you have a hormone-sensitive condition, such as endometriosis or breast cancer, or if you have a history of Parkinson disease or mental illness, talk to your doctor before taking chaste tree.
• Black cohosh (Actaea racemosa) standardized extract, 20 to 40 mg, 2 times a day, is sometimes suggested for a number of women's health conditions, including PMS. Scientific evidence that it helps reduce PMS symptoms is lacking. Black cohosh may interact with a number of medications. Ask your doctor before taking black cohosh if you have a history of hormone-related conditions, such as breast, uterine, or ovarian cancer or endometriosis; or if you have a history of liver or kidney disease.
• Evening primrose oil (Oenothera biennis) standardized extract, 500 to 1,000 mg daily, as a source of gamma linolenic acid (GLA), for symptoms of PMS. Evening primrose oil may increase the risk of bleeding and the risk of seizures in epople with a history of seizures or schizophrenia. If you take blood-thinning medications, such as warfarin (Coumadin) or aspirin, ask your doctor before taking evening primrose oil.
• St. John's wort (Hypericum perforatum) standardized extract, 300 mg, 2 to 3 times per day, for depression associated with PMS. St. John's wort interacts with a number of other medications and herbs. Check with your health care provider if you are taking prescription medications, especially birth control pills. St. John's wort must be taken consistently throughout the month for best results. Direct sun exposure may cause rashes in some people.
• Dandelion (Taraxacum officinale) leaf tincture, 5 to 10 mL, 2 to 3 times a day, for fluid retention associated with PMS. You can also prepare teas from the leaf. Dandelion can interact with a number of medications, including lithium and some antibiotics. Dandelion can also cause an allergic reaction in persons allergic to ragweed.

Few studies have examined the effectiveness of specific homeopathic remedies. Professional homeopaths, however, may recommend one or more of the following treatments for PMS based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type, includes your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

A low homeopathic dose, such as 30C, as often as every 15 to 30 minutes, may be used for symptoms of PMS, including bloating, pain, irritability, and mood swings.

• Chamomilla, for intense menstrual pain. This remedy is most appropriate for women who are extremely irritable, angry, and have frequent mood swings.
• Cimicifuga, for feelings of hysteria, frustration, and being overwhelmed. This remedy is most appropriate for women who have labor type pains that migrate from one side of the body to the other and may involve the back or even sciatic nerve (the largest nerve in the body; extends from the lower back down through the legs and knees).
• Colocynthis, for cramps that are relieved by bending forward, abdominal massage, and warmth (such as a heating pad). This remedy is most appropriate for women who are extremely irritable and restless.
• Ignatia, for emotional symptoms, such as grief, panic, and mood swings. This remedy is most appropriate for individuals who feel particularly vulnerable.
• Lachesis, for women who tend to be annoyed, caustic, talkative, and envious, and whose pain and bloating is worse on the left side. Also for women whose symptoms tend to worsen upon awakening in the morning, and with exposure to heat or light pressure. Also for women whose symptoms improve dramatically when menstruation begins.
• Lycopodium, for bloating with backaches and gas that worsen during early evening and in warm weather.
• Magnesia phos, for sharp cramps that are relieved by bending forward, abdominal massage, and warmth (such as a heating pad), but are worsened by cold air.
• Nux vomica, for individuals who are extremely irritable, confrontational, and feel nauseous.
• Pulsatilla, for irregular periods with cramps, bloating, or mood swings as the predominant symptoms. An appropriate candidate for pulsatilla is gentle and yielding but clingy and cries easily. Women who may benefit from pulsatilla may have nausea and water retention that is aggravated by heat.
• Sepia, for bloating, mood swings, constipation, drowsiness, and irritability.

Acupuncturists treat people with PMS based on an individualized assessment of the excesses and deficiencies of qi located in various meridians. In the case of PMS, a qi deficiency is usually detected in the liver and spleen meridians. Many treatments include moxibustion (a technique in which the herb mugwort is burned over specific acupuncture points). Qualified practitioners may also recommend herbal treatment or changes to the diet. Although sceintific evidence for the use of acupuncture for PMS is lacking, acupuncturists often treat PMS.

Castor Oil Packs

For cramping and pain, dampen a cloth with castor oil and apply to the abdomen. Cover with saran wrap, and then apply a heating pad over this pack. Use for 1 to 3 hours, then remove.

Massage, yoga, guided imagery, and bright light therapy may also help relieve PMS symptoms

Some studies suggest that chiropractic spinal manipulation may help women with PMS. Women with PMS have been found to have a higher rate of spine-related problems, such as tenderness and muscle weakness, than those who do not have PMS. In one study, researchers found that women with PMS reported fewer symptoms after receiving spinal manipulation and soft tissue therapy compared to those who did not get chiropractic treatment. The researchers note that these effects may not last long and that monthly chiropractic treatment may be necessary to maintain these results.

Prognosis/Possible Complications

Severe PMS can disrupt a woman's life. Women who have PMS may also be at higher risk of developing depression after having a baby. Psychological and emotional support, as well as treatment of the physical symptoms may help.

Following Up

You may need to see your doctor on a regular basis to treat PMS.

Supporting Research

Alexandersen P, Toussaint A, Christiansen C, et al. Ipriflavone in the treatment of postmenopausal osteoporosis: a randomized controlled trial. JAMA. 2001;285:1482-8.

Ambrosini A, Di Lorenzo C, Coppola G, Pierelli F. Use of Vitex agnus-castus in migrainous women with premenstrual syndrome: an open-label clinical observation. Acta Neurol Belg. 2013;113(1):25-9.

Atmaca M, Kumru S, Tezcan E. Fluoxetine versus Vitex agnus castus extract in the treatment of premenstrual dysphoric disorder. Human Psychopharmacol. 2003;18(3):191-5.

Bayles B, Usatine R. Evening primrose oil. Am Fam Physician. 2009 Dec 15;80(12):1405-8.

Berger D, Schaffner W, Schrader E, Meier B, Brattstrom A. Efficacy of Vitex agnus castus L. extract Ze 440 in patients with pre-menstrual syndrome (PMS). Arch Gynecol Obstet. 2000;264(3):150-3.

Bertone-Johnson ER, Hankinson SE, Bendich A, et al. Calcium and vitamin D intake and risk of incident premenstrual syndrome. Arch Intern Med. 2005;165(11):1246-52.

Biggs WS, Demuth RH. Premenstrual syndrome and premenstrual dysphoric disorder. Amer Fam Physician. 2011;84(8):918-24.

Bryant M, Cassidy A, Hill C, et al. Effect of consumption of soy isoflavones on behavioural, somatic and affective symptoms in women with premenstrual syndrome. Br J Nutr. 2005;93(5):731-9.

Canning S, Waterman M, Orsi N, Ayres J, Simpson N, Dye L. The efficacy of Hypericum perforatum (St John's wort) for the treatment of premenstrual syndrome: a randomized, double-blind, placebo-controlled trial. CNS Drugs. 2010 Mar 1;24(3):207-25.

Chocano-Bedoya PO, Manson JE, Hankinson SE, et al. Intake of selected minerals and risk of premenstrual syndrome. Am J Epidemiol. 2013;177(10):1118-27.

Ernst E. Herbal remedies for anxiety - a systematic review of controlled clinical trials. Phytomedicine. 2006;13(3):205-8.

Girman A, Lee R, Kligler B. An integrative medicine approach to premenstrual syndrome. Am J Obstet Gynecol. 2003;188(5 Suppl):S56-65.

Jahanfar S. The heritability of premenstrual syndrome. Twin Res Hum Genet. 2011;14(5):433-6.

Johnson TL, Fahey JW. Black cohosh: Coming full circle? J Ethnopharmacol. 2012;141(3):775-9.

Kim SY, Park HJ, Lee H, Lee H. Acupuncture for premenstrual syndrome: a systematic review and meta-analysis of randomised controlled trials. BJOG. 2011;118(8):899-915.

Lentz. Comprehensive Gynecology. 6th ed. St. Louis, MO: Elsevier Mosby; 2012.

Lopez LM, Kaptein AA, Helmerhorst FM. Oral contraceptives containing drospirenone for premenstrual syndrome. Cochrane Database Syst Rev. 2012;2:CD006586.

Lydeking-Olsen E. Beck-Jensen JE, Setchell KD, Holm-Jensen T. Soymilk or progesterone for prevention of bone loss--a 2 year randomized, placebo-controlled trial. Eur J Nutr. 2004;43(4):246-57.

Ma L, Lin S, Chen R, Zhang Y, Chen F, Wang X. Evaluating therapeutic effect in symptoms of moderate-to-severe premenstrual syndrome with Vitex agnus castus (BNO 1095) in Chinese women. Aust N Z J Obstet Gynaecol. 2010 Apr;50(2):189-93.

Marjoribanks J, Brown J, O'Brien PM, Wyatt K. Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database Syst Rev. 2013;6:CD001396.

North American Menopause Society. Treatment of menopause-associated vasomotor symptoms: position statement of The North American Menopause Society. Menopause. 2004;11(1):11-33.

Pearlstein T. Psychotropic medications and other non-hormonal treatments for premenstrual disorders. Menopause Int . 2012;18(2):60-4.

Rakel: Integrative Medicine. 3rd. ed. Philadelphia, PA: Elsevier Saunders; 2012:53.

Sohrabi N, Kashanian M, Ghafoori SS, Malakouti SK. Evaluation of the effect of omega-3 fatty acids in the treatment of premenstural syndrome: "a pilot trial". Complement Ther Med. 2013;21(3):141-6.

Sylven SM, Ekselius L, Sundstrom-Poromaa I, Skalkidou A. Premenstrual syndrome and dysphoric disorder as risk factors for postpartum depression. Acta Obstet Gynecol Scand. 2013;92(2):178-84.

Teixeira AL, Oliveira EC, Dias MR. Relationship between the level of physical activity and premenstrual syndrome incidence. Rev Bras Ginecol Obstet. 2013;35(5):210-4.

Whelan AM, Jurgens TM, Naylor H. Herbs, vitamins and minerals in the treatment of premenstrual syndrome: a systematic review. Can J Clin Pharmacol. 2009 Fall;16(3):e407-29.

Wuttke W, Gorkow C, Seidlova-Wuttke D. Effects of black cohosh (Cimicifuga racemosa) on bone turnover, vaginal mucosa, and various blood parameters in postmenopausal women: a double-blind, placebo-controlled, and conjugated estrogens-controlled study. Menopause. 2006;13(2):185-96.

Wuttke W, Jarry H, Christoffel V, Spengler B, Seidlove-Wuttke D. Chaste tree (Vitex agnus-castus) -- pharmacology and clinical indications. Phytomedicine. 2003;10(4):348-57.

Yonkers KA, Pearlstein TB, Gotman N. A pilot study to compare fluoxetine, calcium, and placebo in the treatment of premenstrual syndrome. J Clin Psychopharmacol. 2013;33(5):614-20.

Zamani M, Neghab N, Torabian S. Therapeutic effect of Vitex agnus castus in patients with premenstrual syndrome. Acta Med Iran. 2012;50(2):101-6.