Premenstrual Syndrome (PMS)

Reviewed on 12/14/2021

Facts You Should Know About Premenstrual Syndrome (PMS)

  • Premenstrual syndrome involves a variety of physical, mental, and behavioral symptoms tied to a woman's menstrual cycle.
  • The acronym PMS stands for "premenstrual syndrome."
  • By definition, PMS symptoms and signs occur during the 2 weeks before a woman's period starts, known as the luteal phase of the menstrual cycle.
  • Sometimes the signs and symptoms of early pregnancy are similar to those of PMS (premenstrual syndrome).
  • The signs and symptoms of PMS typically become more intense in the 2-3 days prior to the period and usually resolve after the first day or two of flow.
  • PMS is a complex health concern. A significant portion of menstruating women are believed to suffer from PMS.
  • PMS usually occurs in women in their fourth and fifth decades of life (aged 30-49 years). For a small number of women, it can be severely incapacitating. A woman who has had a hysterectomy (removal of the uterus) may still experience PMS if at least one ovary remains.
  • Because many different processes may contribute to PMS, methods of treatment vary widely and can include medical and alternative approaches. Surgery is a last resort.
  • Some women may have a more severe condition called premenstrual dysphoric disorder (PMDD). PMS and PMDD are not the same. Women with PMDD have more severe symptoms that have a significant impact upon their daily functions. The two may occur together, or a woman may have one and not the other.

When Does Premenstrual Syndrome (PMS) Start?

Premenstrual syndrome occurs during the luteal phase of the menstrual cycle. This phase occurs immediately after an egg is released from the ovary and lasts from day 14 through day 28 of a normal menstrual cycle (day one is the day a woman's period begins).

How Long Does Premenstrual Syndrome (PMS) Last?

The symptoms of premenstrual syndrome usually are gone within 3-4 days of the start of a woman's period.

What Are the Signs and Symptoms of Premenstrual Syndrome (PMS)?

Premenstrual syndrome (PMS): A woman with PMS will have monthly cycles of symptoms in mood, behavior, and/or physical functioning. Though bothersome, these symptoms are usually not severe enough to interrupt a normal lifestyle. Most women who experience PMS symptoms cope with symptoms at home. A few may seek medical care for very severe symptoms. These symptoms affect the following:

Premenstrual dysphoric disorder (PMDD): This is a more severe condition than PMS. It is only diagnosed when symptoms are so bad that they make it hard for a woman to function normally. While the mood symptoms are similar to the mood symptoms of PMS, they are worse and cause more problems. The physical symptoms of PMS may or may not be present.

Like PMS, the symptoms of PMDD start 7-14 days before a woman's period and go away once the period starts. Unlike PMS, PMDD can seriously affect a woman's daily activities. PMDD is diagnosed as a mental health disorder.

A woman may have PMDD if she has five or more of the following symptoms during the premenstrual week and for most cycles during the past year:

  • Depression (feeling despair or hopelessness, not just sadness)
  • Anxiety (keyed up, on edge)
  • Severe mood swings (feeling suddenly sad or extremely sensitive to rejection)
  • Anger or irritability
  • Decreased interest in usual activities (work, school, friends, hobbies)
  • Difficulty concentrating
  • Decreased energy
  • Appetite changes (overeating or cravings for certain foods)
  • Sleep problems (can't sleep or wake up early, or oversleeping)
  • Feeling overwhelmed or out of control
  • Physical symptoms, such as bloating, breast tenderness or headaches
  • If these symptoms do not occur in sync with the menstrual cycle, the woman may have some other medical or mental health condition.
  • The symptoms of PMDD end with menopause, when menstruation stops and the levels of hormones that regulate menstruation no longer rise and fall each month.

What Causes Premenstrual Syndrome (PMS)?

During the luteal phase, hormones from the ovary cause the lining of the uterus to grow thick and spongy. At the same time, an egg is released from the ovary. If the egg meets sperm, it may implant in the lining of the uterus and grow. At this time, the level of a hormone called progesterone increases in the body, while the level of another hormone, estrogen, begins to decrease. The shift from estrogen to progesterone may cause some of the symptoms of PMS.

PMS and PMDD are thought to result from an interaction between the changing sex hormone levels during the luteal phase of the menstrual cycle and neurotransmitters in the brain, particularly the neurotransmitter serotonin, in susceptible women. While hormone levels are generally normal in women with PMS, the individual's response to the hormones and their changing levels may be different or abnormal.

Hormonal cycling affects the level of serotonin, a brain chemical that regulates many functions, including mood and sensitivity to pain. Compared to women who do not have PMS, some women who experience PMS have lower levels of serotonin in their brains prior to their periods. (Low serotonin levels are commonly associated with depression. Popular selective serotonin reuptake inhibitor (SSRI) antidepressant medicines such as fluoxetine [Prozac], sertraline [Zoloft], and paroxetine [Paxil] lift depression by raising levels of serotonin in parts of the brain.)

  • Bloating is a common symptom of PMS. This may occur because of cycling in hormones that affect the kidneys, the organs that control the balance of water and salt in the body. Fluid overload may cause some of the symptoms of PMS, especially swelling and weight gain, and may also aggravate some negative self-perceptions, and thus worsen emotional symptoms at this stage of the menstrual cycle.
  • Hormonal cycling also affects the level of serotonin, a brain chemical that regulates many functions, including mood and sensitivity to pain. Compared to women who do not have PMS, some women who experience PMS have lower levels of serotonin in their brains prior to their periods.

How Can I Tell If It's PMS or If I'm Pregnant?

  • Some symptoms of PMS, particularly breast tenderness, mood changes, bloating and fatigue, can also occur in early pregnancy.
  • Sometimes these PMS symptoms can be confused with symptoms of pregnancy.
  • The only way to tell if you are pregnant, if you have not gotten your menstrual period, is to take a pregnancy test.

When to Seek Medical Care for PMS

If a woman has symptoms of PMS that do not go away within 3-4 days of the start of her period, call a doctor. The woman may have a different medical problem.

When the typical symptoms of PMS become so severe that lifestyle is drastically altered, talk with a doctor.

  • The doctor will evaluate the patient's symptoms for signs of premenstrual dysphoric disorder (PMDD), a mental health concern, which should be diagnosed and treated.
  • Serious signs may also signify other mental or medical problems. Psychiatric diagnoses such as chronic depression, anxiety disorders, and personality disorders may overlap with the diagnosis of PMDD. Medical considerations include hormone imbalances, thyroid problems, electrolyte problems, and low levels of red blood cells. The doctor will want to rule out these more serious medical problems.
  • If the patient has such serious mood changes or behavior changes that she feels she may hurt herself or another person, seek medical care immediately at a hospital's emergency department.

Is There a Test to Diagnose Premenstrual Syndrome (PMS)?

The health care professional will talk with the patient about her symptoms and when they occur each month. Keep track of symptoms, particularly noting when they occur during the menstrual cycle. The health care practitioner may ask the patient to keep accurate records or a diary of symptoms throughout the next month or two. These records give the patient and health care professional a better understanding of the symptoms and how they relate to the patient's menstrual cycle.

  • There are no lab tests that can confirm a diagnosis of PMS.
  • A health care professional may perform various blood tests to rule out other illnesses.
  • Imaging tests may also be ordered to rule out other causes of the symptoms.
  • The health care professional may also ask the patient to see a mental health professional to rule out a mental health disorder or to confirm the diagnosis of PMDD.

What Treatments Are Available for Premenstrual Syndrome (PMS)?

  • Natural and home remedies, medications, and lifestyle changes are used to treat and manage signs and symptoms of PMS and PMDD.
  • The patient and her health care professional may need to try different medications before one is found works for the patient. Medicines may not completely relieve all symptoms, and they are not always necessary. A woman can often make lifestyle changes that help.

What Natural or Home Remedies Treat Premenstrual Syndrome (PMS)?

Certain herbs have been evaluated for use in PMS. Many over-the-counter herbal preparations combine various herbs with certain vitamins to create a PMS formula. Although preliminary reports have been promising, more scientific research is needed to evaluate herbal treatment of PMS, and none have been proven to be of benefit. Furthermore, since botanical or herbal therapies are not regulated, it is difficult to determine the actual dosage and quality of any dietary supplement. Consult a health care professional before using any herbal supplement to treat PMS.

  • Black cohosh: Black cohosh has been shown to positively impact the serotonin pathway and may have a beneficial impact for some women, especially those with vasomotor symptoms (hot flashes). Black cohosh does not affect estrogen levels or function.
  • St. John's wort: This herb may help elevate serotonin levels, possibly helping PMS symptoms. Studies do not agree on its effectiveness. St. John's wort interacts with many medications, and should never be used if a person takes prescription antidepressants.
  • Evening primrose oil: Gamma-linoleic acid (GLA) is the active agent found in evening primrose oil. Much like mefenamic acid, GLA blocks prostaglandin synthesis, resulting in decreased breast tenderness, bloating, and weight gain. The standard dose is 3 grams per day, and it should be started less than one week before the onset of the patient's period. This agent is available without a prescription at health food stores and certain pharmacies. A scientific review of the studies on evening primrose oil showed no proven effect on the symptoms of PMS.
  • Ginkgo biloba: Shown to reduce the symptom of breast pain but not other PMS symptoms.
  • Chasteberry (Vitex; agnus castus fruit extract): Limited studies have shown a benefit for the use of agnus castus fruit extract to help relieve symptoms of PMS. This should not be used in combination with birth control pills.

Natural and home remedies may help reduce many premenstrual symptoms and signs.

Is There a Premenstrual Syndrome (PMS) Diet?

  • Muscle relaxation techniques and massage therapy may help.
  • Dietary restrictions have not shown to be beneficial in treating PMS, but following a healthy nutrition plan is always sound advice. Certain strategies may help with specific symptoms, and some dietary supplements may be of benefit:
    • To lessen bloating and water retention, avoid foods high in salt (sodium), especially in the week before your period.
    • An adequate vitamin and mineral intake may also help with PMS symptoms.
      • Vitamin E: Studies do not agree about how much vitamin E may be helpful, but 300-400 IU per day is a safe dose that may be of benefit.
      • Calcium: Some women get relief taking at least 1,200 mg of calcium per day, through a combination of normal eating and taking supplements.
      • Magnesium: Most studies that have evaluated magnesium have failed to show overall benefit. Some small studies of magnesium supplementation have shown that 200 to 360 mg of magnesium taken up to three times per day may provide some relief. Food sources of magnesium include nuts, legumes, whole grains, dark green vegetables, seafood (oysters), and meats.
      • Vitamin B6: Some studies have shown doses of vitamin B6 up to 100 mg/day may be helpful, but this has not been proved conclusively.

What Medications Treat Premenstrual Syndrome (PMS)?

PMS Treatment

Treatments demonstrated to be effective in PMS include medications that moderate the effects of the neurotransmitter serotonin. The selective serotonin reuptake inhibitor (SSRI) drugs such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) have been shown to be effective in relieving many of the symptoms of PMS and PMDD including mood changes and anxiety. Clinical trials show that SSRIs effectively treat mood symptoms such as depression, anxiety, and anger. Other symptoms of PMS, such as tiredness and decreased sexual drive, may not improve or may worsen on these drugs.

Anti-inflammatory medications such as ibuprofen prevent the body from producing prostaglandins, which have been suggested as a cause of PMS. Reducing the amount of prostaglandins in the body may eliminate many of the inflammatory symptoms of PMS such as menstrual cramps, breast pain, headache, swelling, and other discomforts. Several types of anti-inflammatory agents are used for PMS. Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended initially, and there are several that may be purchased without a prescription.

Common nonsteroidal anti-inflammatory drugs (NSAIDs) used to treat PMS include:

Hormones: Hormones such as nafarelin (Synarel) and leuprolide (Lupron) prevent the release of eggs and menstruation. This treatment eliminates PMS symptoms in more than half of all women receiving it. These hormones are like birth control pills in that they suppress the menstrual cycle, but the cycle returns when they are stopped. Women taking birth control pills with an inert week still bleed every month. Women on this therapy have no periods at all. However, most contraceptive pills and patches can be used in a continuous fashion to reduce or eliminate withdrawal bleeding.

Danazol (Danocrine) is another hormonal agent that blocks the production and the effects of certain female hormones. Danazol is a modified male sex hormone, which was shown to significantly decrease breast pain in clinical studies. It was not effective in treating other symptoms. Danazol may increase certain fat levels in the blood, so it is not recommended if the patient has high cholesterol levels. Because of the profound adverse side effect profile of Danazol, its use continues to decrease.

Benzodiazepines are drugs that decrease anxiety by depressing the central nervous system. Alprazolam (Xanax) is a member of this class. It can be effective in treating the anxiety associated with premenstrual syndrome but may cause drowsiness. Benzodiazepines can be addictive. Diuretics (water pills) are drugs that help the body to shed excess water through the kidneys. These medicines have been used to reduce weight gain, breast swelling, and bloating associated with PMS. Metolazone (Mykrox, Zaroxolyn) and spironolactone (Aldactone) are commonly used diuretics. Research studies have not conclusively shown that diuretics are of benefit in managing PMS.

PMDD Treatment: The same lifestyle changes that sometimes help women with PMS may help relieve the symptoms of PMDD. In most cases, however, PMDD symptoms continue despite such efforts. Studies show that some women with PMDD benefit from treatment with SSRIs, as described previously.

Which Specialties of Doctors Treat Premenstrual Syndrome (PMS)?

PMS can be treated by primary care providers, including pediatricians, internists, and family practitioners as well as gynecologists.

Can I Prevent Premenstrual Syndrome (PMS)?

Lifestyle changes for PMS

  • Perform aerobic exercise (if not daily, then 3-4 times a week, even a brisk walk).
  • Learn and use stress management techniques such as relaxation, deep breathing, meditation, a warm bath, listening to music, or yoga in your day.
  • Limit salt intake (to help reduce fluid retention, bloating, and swelling especially in the feet and hands).
  • Limit caffeine intake (caffeine can make breast tenderness worse and increase headaches).
  • Avoid alcohol (alcohol can often affect a woman differently before her period).
  • Eat small meals and snacks spread throughout the day so you don't go for long periods of time without eating.
  • Vitamin therapy
  • An adequate intake of some vitamins may help prevent some of the symptoms of PMS, although this has not been conclusively established.
  • Vitamin B6 - 100 mg per day maximum (larger doses sometimes cause serious side effects). The patient can also take a B-complex that includes all the B vitamins. Vitamin B6 may take the edge off irritability and reduce fatigue and depression.
  • Vitamin E - 400 IU per day (maximum) may be helpful in reducing breast tenderness.
  • Calcium - 1,000-1,200 mg per day of elemental calcium (the labels on foods and supplements give the amount of elemental calcium they contain) may reduce bloating, body aches, anxiety, or depression.
  • Magnesium - Some small studies of magnesium supplementation have shown that 200 to 360 mg of magnesium taken up to 3 times per day may provide some relief.

Is There a Cure for Premenstrual Syndrome (PMS)?

  • The only definitive cure for PMS is removal of the ovaries, which may have many other complications and unwanted long- and short-term consequences. Most women gain benefit from existing therapies without surgery.
  • If a woman has a severe case of PMS, some doctors will treat them with a variety of medications or with a combination of medicine, diet, and exercise.

What is PMDD? Severe PMS?

  • Premenstrual dysphoric disorder (PMDD) is a particularly severe form of the premenstrual syndrome (PMS).
  • Both PMS and PMDD cause disturbing symptoms during the second half, known as the luteal phase, of a woman's menstrual cycle.
  • PMDD can cause a number of different signs and symptoms, but fatigue, tiredness, mood changes, and bloating are common.
  • The symptoms of PMDD are severe enough to have a significant impact upon the woman's daily activities and functioning.
Reviewed on 12/14/2021
References "Premenstrual syndrome."