The information provided by Advanced Healthcare for Women and E. Daniel Biggerstaff, III, M.D. is for informational purposes only. As each woman is unique, do not rely on this information for diagnosis and treatment. We cannot guarantee the accuracy of the content and advise that you see a qualified Health Care Professional for individual needs and care.

PMS or premenstrual syndrome is a condition in which a group of symptoms occurs at the same time with each menstrual cycle. These symptoms are most frequently seen during the week prior to the menses but may be present two weeks prior to the menses, during the menstrual cycle, or even after the menstrual flow stops. Symptoms that may be seen with PMS include:

• Depression
• Mood swings
• Anxiety
• Anger or irritability
• Decreased interest in usual activities
• Difficulty concentrating
• Lack of energy and easy fatigability
• Overeating or specific food cravings
• Excessive sleep or insomnia
• Feeling of being overwhelmed or out of control
• Physical symptoms including breast tenderness and swelling, headaches, bloating, weight gain, or muscle or joint pain.

The most severe form of PMS is termed PMDD or Premenstrual Dysphoric Disorder. By definition, a patient with PMDD has at least five of the above symptoms and at least one of the first four listed above. The condition markedly interferes with normal activity and is not merely worsening of symptoms of another condition such as true depression or panic disorder. Of course it is possible to have a depressive disorder in addition to PMDD.

PMS or PMDD is differentiated from other conditions by the facts that:

1. the symptoms recur monthly at the same time in relation to the menses, and
2. there is a period of time, most commonly just after the menstrual flow stops, when the patient is relatively symptom free. Some patients have only a few days each month when they have no symptoms.

Some of the conditions that should be excluded before a diagnosis of PMS or PMDD is made include:

• major depressive disorder
• dysthymic disorder
• panic disorder
• personality disorder
• hypothyroidism
• and collagen vascular disease such as systemic lupus erythematosus

A menstrual calendar can be helpful to both the patient and the physician in diagnosing PMS and PMDD. For two consecutive months, write down the symptoms and their severity each day. Please bring this information with you at your doctor’s visit.

The causes of PMS/PMDD are still under scientific investigation. We know the cyclic changes in female hormones are responsible for the symptoms of PMS/PMDD but do not completely understand how this occurs. Many researchers note that women with PMS have a blunted response to serotonin. One of the actions of serotonin is as a neurotransmitter in the brain. A neurotransmitter is responsible for carrying the electrical impulse from one nerve as it connects to another nerve. Many women with PMS/PMDD respond well to SSRI’s (selective serotonin reuptake inhibitors) such as fluoxetine (Prozac® or Sarafem®). But, some women do not respond to these medications, suggesting that serotonin is only part of the story.

Treatment should begin with lifestyle changes including:

regular aerobic exercise

dietary changes including restriction of salt, sugar, alcohol, and caffeine

adequate sleep

stress management

avoid nicotine and street drugs

Aerobic exercise provides many health benefits in addition to reduction of heart disease and weight control. Regular aerobic exercise causes the production of endorphins in the brain. Endorphins are chemically related to morphine and result in a sense of well-being. Aerobic exercise also aids in reducing the production of excessive cortisol in situations of acute or chronic stress. High levels of cortisol decrease uptake of glucose by the brain – the brain needs glucose to function properly.

Dietary changes begin with limiting salt, caffeine, sugar and alcohol intake. Fatty foods should be limited also. Some of these include doughnuts, french fries, peanut butter, potato chips, salad dressings, margarine, and cooking oils. Some women also respond well to reduction of meat, eggs, poultry, and fish during the premenstrual time of their cycle. On the positive side, you should increase the intake of vegetables such as broccoli, carrots, brussel sprouts, and sweet potatoes. Fruits such as apples, oranges, blueberries, and raspberries should also be included in your diet. Beans, peas, and lentils in addition to whole grains such as brown rice, oatmeal and whole wheat bread should round off your dietary considerations.

Adequate sleep and stress management are important in any healthy lifestyle plan. In today’s fast-paced environment, many women find they do not have enough hours in the day to get done what they need to do. Making sure you get sleep and taking time for yourself can have a major impact on the way you feel and are able to function. If you are "stressed out," the symptoms of PMS/PMDD are likely to be much worse.

Vitamins, minerals, and herbs are used by some women to reduce the effects of PMS/PMDD. Patients should check with their physician before taking supplements because of potential interaction with other medications.

vitamin B₆ – cofactor for production of serotonin and melatonin and may increase production of neurotransmitters – may help depression – usual dosage 50-200mg/d

vitamin E – may bind to estrogen receptor sites and help alleviate breast tenderness – usual dosage 200 IU twice a day – avoid excessive intake which may impede the bloods ability to clot

calcium – may help reduce water retention, mood swings, and difficulty concentrating – usual dosage 1,200 mg/d – some research suggests it may be taken in combination with magnesium to alleviate symptoms

omega-3 fatty acids (flaxseed, black currant, grapeseed, or evening primrose oils) – help increase levels of anti-inflammatory prostaglandin E₁ which can help reduce premenstrual and menstrual cramping – may also reduce breast tenderness, bloating, and irritability

chaste tree berry – may reduce prolactin and follicle-stimulating hormone levels and increase luteinizing hormone levels and help balance the production of estrogen and progesterone during the second half of the menstrual cycle – alleviate physical symptoms

ginkgo biloba – improves circulation in small vessels and reduces breast tenderness and water retention – can cause irritability and insomnia

St. John’s Wort – raises serotonin levels – used for depression

licorice root – contains corticosteroid-like hormones – may help relieve physical symptoms

dandelion leaf – is a diuretic – used for bloating

valerian root – used for anxiety and may help sleep

phytoestrogens (plant-derived estrogens) – found in soy products and many legumes – claimed to help balance estrogen – may help reduce physical symptoms

Occasionally patients will respond to oral contraceptive, but many patients have problems with water retention and worsening of PMS/PMDD symptoms on the birth control pill. Other anti-depressants and anti-anxiety agents have been used to treat the symptoms. GnRH agonists have been used to treat PMDD by shutting down ovarian function. These drugs are expensive and may have major side effects. If there are other medical indications for hysterectomy with removal of uterus, tubes and ovaries, the symptoms of PMS/PMDD will be alleviated.