Synonyms: PMS, premenstrual tension (PMT), premenstrual dysphoria, late luteal phase dysphoric disorder (LLPDD)

Definition

This is a condition which manifests with 'distressing physical, behavioural and psychological symptoms, in the absence of organic or underlying psychiatric disease, which regularly recurs during the luteal phase of each menstrual (ovarian) cycle and which disappears or significantly regresses by the end of menstruation'.¹
Sometimes the symptom-free period can be as little as a week long, but there must be at least one week without symptoms, in each cycle, for the symptoms to be attributable to this condition.

Premenstrual syndrome (PMS) is characterised by:

• Psychological symptoms: irritability, labile affect, low mood, anxiety and lassitude.
• Physical symptoms: breast tenderness, bloatedness, clumsiness and fluid retention which also occur.²

Aetiology

Research into the causes of premenstrual syndrome (PMS) tends to point to an exaggerated response to circulating hormones, rather than an abnormality in their circulating levels.^3,4,5Other proposed aetiologies include nutritional deficiencies in magnesium and calcium,⁶ relative CNS serotonin deficiency, hypoprolactinaemia, endorphin effects⁷ and excessive levels of nitrous oxide.⁸
Pre-existing conditions such as migraine, mastalgia,⁹ depression,¹⁰ backache, acne and asthma¹¹ can be worsened cyclically. There is often exacerbation of pre-existing psychiatric or psychological problems.⁴
There is ongoing debate as to whether PMS actually constitutes an illness, or is better viewed as a cyclical physiological phenomenon. It severely affects the lives of a proportion of its sufferers, who may seek medical help to overcome its symptoms. The risk of psychological illness appears to be higher amongst women who suffer menstrual problems.¹²

Epidemiology

It is estimated that up to 1.5 million women in the UK experience such severe symptoms that their quality of life and interpersonal relationships are greatly affected. About 35% of these women seek medical help.¹³ It affects around 85% of women to some extent, at some time in their life; about 10% of women suffer marked life-disruption in their mid-20s to mid-40s.^2,3,14

Risk factors

• Obesity
• Smoking¹⁵
• Poor diet
• Lack of exercise⁷

Presentation

Symptoms vary between cycles; they tend to be worse about two weeks prior to menses and improve a few days after starting the period.
The main symptoms leading to a consultation are irritability and inability to cope with domestic or workplace demands.

• Physical symptoms usually lead to a consultation only when mastalgia, dysmenorrhoea or migraine have not responded to self-management.
• Difficult interpersonal relationships with spouse or children may also precipitate a consultation.
• Psychosexual problems, loss of libido and dyspareunia may be reported but usually have to be specifically asked about.

Differential diagnosis

This includes psychological conditions worsened by premenstrual syndrome (PMS).²
There is a need to consider depression, hyperthyroidism and hypomania.

Investigations

• Check BP and pulse rate.
• Consider breast and thyroid examination.
• Are the patient's smears up-to-date? Consider pelvic examination, particularly if bloating is a major problem (this may be ascites due to alternative ovarian pathology), or other reason to suspect physical cause of tummy swelling.

There are no useful tests to confirm the diagnosis.
Consider TFTs/FBC/ESR/U&E if there is reason to suspect an alternative physical cause for symptoms.

Management

General measures

Ask the patient to keep a symptom diary to help with diagnosis and assess effectiveness of interventions.
The most important part of the management is to reassure the patient that you understand her concerns and the disruption that symptoms are causing to her life. Quite often the friction caused by their irritability and volatility alienates the patients from usual sources of support at work and home. As premenstrual syndrome (PMS) can be a long-term problem there are lifestyle changes that may help the patient cope with the symptoms. Reassure that there are many ways to help and it is a matter of finding the best treatment strategy.

• Try regulating carbohydrate intake; complex carbs every 2-3 hrs and avoid excess sugar.⁹
• Reduce saturated fats and caffeine; may improve mastalgia. Good diet may correct any subclinical nutrient deficiencies (e.g. magnesium and calcium) and improve symptoms.
• Vitamin D and calcium supplementation are being investigated as preventative agents.¹⁶
• Reducing salt intake may reduce fluid retention.
• Use a firm, supportive bra day and night.
• Support stockings help aching legs.
• Gentle exercise is effective.¹⁷

Try rescheduling more stressful tasks to the better half of the month. Get the patient to explain PMS to friends and family to improve support. Cognitive behavioural therapy may be useful in motivated patients.¹⁷
Relaxation exercises are helpful as are methods of coping with stress, such as assertiveness and time management training.
Other remedies such as fennel tea and camomile tea may reduce breast tenderness. They act as a good substitute for tea and coffee, which may aggravate irritability further.

Pharmacological

Treatment needs to be tailored to the severity of the PMS. Placebo effect can make a difference in up to 90%.
Try simple analgesia as required for breast tenderness, headaches and period pains. Mefenamic acid and naproxen from day 15 to day 2-3 of the next period are effective, but have adverse effects.

• Pyridoxine is reported to help, but there is little definitive evidence.^17,18
• Calcium supplements may improve tiredness, appetite changes, and depressive symptoms.¹⁹
• Diuretics (especially spironolactone) do improve bloating and swelling but many women with PMS have no objective evidence of fluid retention.
• Selective serotonin reuptake inhibitors (SSRIs) improve symptom scores but there are significant adverse effects and mixed trial results between agents.^17,20,21
• There may be a subset of women who have a primary mood disorder worsened by menstrual factors - late luteal phase dysphoric disorder.¹⁰ Light therapy has been shown to help psychological symptoms in this group.²²
• Combined oral contraceptives are generally reported to improve symptoms and have a physiologically plausible mode of action. There are few good trial data to support their use.¹⁷ Drospirenone plus 20 mg estradiol may help treat premenstrual symptoms in women with PMS.²³ The placebo also had a large effect. Tricycling the pill has been shown to reduce frequency of symptoms.²⁴
• Progesterone should not be used and progestogens are unlikely to help.¹³
• Danazol, bromocriptine for breast symptoms and gonaderelin analogues can be considered if symptoms are severe, but any benefits must be traded off against potential adverse effects.
• Mastalgia may be improved by evening primrose oil and has few adverse effects (however, may - rarely - worsen epilepsy).¹⁷
• Flavonoids (soya is rich in these) may help fluid retention/leg symptoms.^25,26

Surgery

There is no evidence supporting routine use of surgical treatments for PMS. Hysterectomy ± oophorectomy with oestrogen-only HRT should be a last resort and risk:benefit ratio carefully considered. If a severe sufferer is sure that she does not want any more children then it may be an option to consider.

Complications

In young women, consider birth control needs as well as premenstrual syndrome (PMS). Sometimes both can be met using the combined oral contraceptive pill.

Medicolegal notes

• Make a proper assessment before attributing symptoms to PMS, to avoid missing other causes of erratic or dysphoric behaviour.
• PMS has been considered as a mitigating circumstance in some courts for certain minor criminal offences such as shoplifting.

Prognosis

Most women can find effective solutions to their symptoms. A small number continue to be affected severely with worsening symptoms until the menopause.

Document references

1. Management of premenstrual syndrome, Royal College of Obstetricians and Gynaecologists (December 2007)
2. Butcher J; ABC of sexual health: female sexual problems I: loss of desire-what about the fun? BMJ. 1999 Jan 2;318(7175):41-3.
3. Rapkin AJ, Morgan M, Goldman L, et al; Progesterone metabolite allopregnanolone in women with premenstrual syndrome. Obstet Gynecol. 1997 Nov;90(5):709-14. [abstract]
4. Berga SL; Understanding premenstrual syndrome. Lancet. 1998 Feb 14;351(9101):465-6.
5. Norlock FE; Benign breast pain in women: a practical approach to evaluation and treatment. J Am Med Womens Assoc. 2002 Spring;57(2):85-90. [abstract]
6. Thys-Jacobs S, McMahon D, Bilezikian JP; Cyclical Changes in Calcium Metabolism Across the Menstrual Cycle in Women with Premenstrual Dysphoric Disorder (PMDD). J Clin Endocrinol Metab. 2007 May 8;. [abstract]
7. Moreno MA, Giesel AE; Premenstrual Syndrome. eMedicine, May 2006.
8. Levin AM; Pre-menstrual syndrome: a new concept in its pathogenesis and treatment. Med Hypotheses. 2004;62(1):130-2. [abstract]
9. Burt VK, Stein K; Epidemiology of depression throughout the female life cycle. J Clin Psychiatry. 2002;63 Suppl 7:9-15. [abstract]
10. De Ronchi D, Ujkaj M, Boaron F, et al; Symptoms of depression in late luteal phase dysphoric disorder: a variant of mood disorder? J Affect Disord. 2005 Jun;86(2-3):169-74. [abstract]
11. Tan KS; Premenstrual asthma: epidemiology, pathogenesis and treatment. Drugs. 2001;61(14):2079-86. [abstract]
12. Strine TW, Chapman DP, Ahluwalia IB; Menstrual-related problems and psychological distress among women in the United States. J Womens Health (Larchmt). 2005 May;14(4):316-23. [abstract]
13. Wyatt K, Dimmock P, Jones P et al.; Efficacy of progesterone and progestogens in management of premenstrual syndrome: systematic review. BMJ ; 6 October 2001
14. Marvan ML, Cortes-Iniestra S; Women's beliefs about the prevalence of premenstrual syndrome and biases in recall of premenstrual changes. Health Psychol. 2001 Jul;20(4):276-80. [abstract]
15. Masho SW, Adera T, South-Paul J; Obesity as a risk factor for premenstrual syndrome. J Psychosom Obstet Gynaecol. 2005 Mar;26(1):33-9. [abstract]
16. Bertone-Johnson ER, Hankinson SE, Bendich A, et al; Calcium and vitamin D intake and risk of incident premenstrual syndrome. Arch Intern Med. 2005 Jun 13;165(11):1246-52. [abstract]
17. Clinical Evidence. Summary of findings on interventions. ( Log-in required)
18. Kashanian M, Mazinani R, Jalalmanesh S; Pyridoxine (vitamin B6) therapy for premenstrual syndrome. Int J Gynaecol Obstet. 2007 Jan;96(1):43-4. Epub 2006 Dec 21.
19. Ghanbari Z, Haghollahi F, Shariat M, et al; Effects of calcium supplement therapy in women with premenstrual syndrome. Taiwan J Obstet Gynecol. 2009 Jun;48(2):124-9. [abstract]
20. Eriksson E, Andersch B, Ho HP, et al; Diagnosis and treatment of premenstrual dysphoria. J Clin Psychiatry. 2002;63 Suppl 7:16-23. [abstract]
21. Brown J, O' Brien PM, Marjoribanks J, et al; Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD001396. [abstract]
22. Lam RW, Carter D, Misri S, et al; A controlled study of light therapy in women with late luteal phase dysphoric disorder. Psychiatry Res. 1999 Jun 30;86(3):185-92. [abstract]
23. Lopez LM, Kaptein AA, Helmerhorst FM; Oral contraceptives containing drospirenone for premenstrual syndrome. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD006586. [abstract]
24. Coffee AL, Kuehl TJ, Willis S, et al; Oral contraceptives and premenstrual symptoms: comparison of a 21/7 and extended regimen. Am J Obstet Gynecol. 2006 Nov;195(5):1311-9. Epub 2006 Jun 21. [abstract]
25. Christie S, Walker AF, Hicks SM, et al; Flavonoid supplement improves leg health and reduces fluid retention in pre-menopausal women in a double-blind, placebo-controlled study. Phytomedicine. 2004 Jan;11(1):11-7. [abstract]
26. 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 May;93(5):731-9. [abstract]

Internet and further reading

• Premenstrual syndrome, Clinical Knowledge Summaries (December 2009)
• Yonkers KA, O'Brien PM, Eriksson E; Premenstrual syndrome. Lancet. 2008 Apr 5;371(9619):1200-10. [abstract]
• The Premenstrual Syndrome Website

Acknowledgements