PMS, how serious is it?

The word "PMS" is overused nowadays, as most women of the reproductive age group tend to experience one or few mild emotional or physical symptoms for few days before the onset of their menses (periods). However, these symptoms, despite being infuriating to women, are usually not severe enough to debilitate patients and to negatively affect their interpersonal relations, work schedules and productivity, or to cause a generalized functional impairment. And thus, from a medical perspective, these symptoms, if mild, do not classify as the clinical premenstrual syndrome (PMS).

In contrast, the true PMS is defined as “at least one symptom of economic or social dysfunction that occurs during 5 days before the onset of menses and is present in at least three consecutive menstrual cycles” (as per the American College of Obstetricians and Gynecologists). So, even though most women experience few mild annoying symptoms before the onsets of their periods, yet clinically significant PMS is only seen in 3-8% of women worldwide. These women start having physical as well as affective symptoms (related to mood) occurring repetitively in the second half of their menstrual cycles and often the first few days of menses.

Women usually start experiencing PMS symptoms in their late 20s and throughout their reproductive age (up till the age of menopause). If left untreated, it can be associated with generalized anxiety, depressed mood and a higher risk for mood swings while transitioning into menopause (around the age of 52 in Lebanon) 

What are these symptoms?

Symptoms include abdominal bloating, breast tenderness/pain, headache, low energy, food craving, low sex drive, mood swings, irritability and lower productivity at work among others. Again, you may be experiencing mild mood swings before the onset of your periods, yet this is totally normal, and you may still not satisfy the criteria for the PMS diagnosis. Even among women suffering from PMS, the symptoms severity can differ as around 2% of women experience premenstrual dysphoric disorder (PMDD) which is the most severe form of PMS.  
You should know that there are neither physical signs nor laboratory abnormalities associated with PMS, so the only diagnostic method stems from your "story" and how you relay your symptoms to your doctor. So, know yourself and communicate all of your concerns to your physician.

Also, if you have general mood disturbances, low productivity or depressive episodes that do not coincide with your periods, and if a relationship between your symptoms and your menstrual calendar could not established, then you would not classify as having PMS, and thus an alternative diagnosis should be contemplated (mood disorder outside PMS, hormonal imbalances such as thyroid hormone problem…). Therefore, you should give a detailed menstrual history to your physician by describing the onset of your symptoms with respect to your menstrual diary. An easy user-friendly tool for you to monitor your symptoms in relation to your menstrual cycle is the “Daily Record of Severity of Problems” DRSP  which can be provided by your physician. 

Risk factors for PMS

Genetic factors have been linked to PMS, yet there is still no robust evidence suggesting such a strong association between the two. There are some reports and small studies suggesting the association of PMS with one type of estrogen gene, yet more studies are needed to further elucidate such a potential association.

Other possible risk factors for developing and worsening PMS symptoms are smoking and low education! Also, a history of traumatic event, accident, and higher susceptibility to anxiety are known to be associated with PMS. Here again, any other psychological disorder (depression, generalized anxiety, panic attack disorder…) is an independent risk for developing a more severe form of premenstrual syndrome. Actually, PMS symptoms tend to even worsen in the setting of further external stressors, thus the woman's susceptibility to environmental triggers can aggravate her PMS.

 

Why does it happen?

Well if I have to simplify it, PMS occurs as a result of your sensitivity to cyclic hormonal changes, or an improper response of your body to normal hormonal levels, in addition to alterations in the brain hormones (known as neurotransmitters) that are responsible for most (if not all) of the affective and behavioral changes occurring with PMS. But again, you should be aware that laboratory tests cannot make the diagnosis of PMS which is a clinical one.

Is it serious? "So what if I have few days of low mood and behavioral changes per month"?
Surprisingly, PMS was associated with long term negative ramifications. 

Quality of life

Moderate to severe forms of PMS have been strongly associated with a low quality of life in terms of a lower work productivity and higher work absenteeism. In case your premenstrual symptoms are incapacitating you (at home, at work, with friends…) you should seek medical help as your general quality of life might be negatively impaired on the long run.

 

Suicide risk

Moreover, it is important for you to know that mental health should never be taken lightly. The severe forms of PMS (defined as PMDD) have been associated with a higher percentage of suicidal ideation and attempts. So, it is crucial for you, as a patient, to relay such concerns (if present) to your health care provider. Yes, one can blame hormones and periods for such mood swings, and might say that all women experience such emotional disturbances, but this is not true.
If you are having any thoughts of suicidality (even if you are passively thinking and wishing that you sleep and never wake up because of your severe mood disturbances) you must be referred to a mental health professional. Severe PMS and PMDD can trigger long term debilitating major depression!

 

Is there a treatment?

Before going into the treatments available to alleviate the symptoms of premenstrual syndrome, you should admit that treatment is a must. As I previously have mentioned, if left untreated, PMS and PMDD can cause long term psychological sequelae worsening your quality of life and potentially ending with suicidality. Take your symptoms seriously.

Again, expect your doctor to ask for a detailed menstrual history, because if a temporal link between the symptoms and your cycles could not be established, then PMS cannot be diagnosed and treatment cannot be initiated. So, I would advise you, in order to save time and money, to record your symptoms with respect to your menses for 2-3 months before visiting your clinician, so that a more accurate diagnosis can be made on the spot by your physician.

The goal of treatment is, of course, to alleviate the bothersome symptoms, but more importantly to improve your functionality.

 

Exercise and relaxation techniques

Even though not well studied, we always encourage having a healthy life style in terms of exercise and stress relieving activities. These techniques are specifically helpful if you report mild forms of PMS. The theory behind it is that exercise is known to boost the “happy hormones” level in your body, and thus can alleviate some bothersome mood swings associated with PMS.

 

Herbs and Supplements

Here again, data are limited, but the only herbal extract that was promising in alleviating PMS symptoms (mild forms of PMS) was chasteberry (Vitex Agnus Castus). Studies have shown that Vitex was superior to placebo in the management of mild PMS symptoms. Even though not available on the Lebanese market, Vitex supplements are being recommended with a daily dose of 20-40 mg for mild PMS.

Other supplements including primrose oil, vitamins (B6 and E), calcium and magnesium have been studies, but they were not shown to be superior to placebo and are thus not recommended for the management of even mild forms of premenstrual syndrome. Actually, physicians are against the routine use of high doses of these vitamins if not otherwise indicated.

 

Antidepressants

In patients with moderate to severe PMS/PMDD, lifestyle modifications are still encouraged and advocated, yet their efficacy is questionable. Patients with severe forms of mood swings associated with PMS will most likely need pharmacologic and/or behavioral interventions.
An important question for you to ask yourself, is whether you also want to have a contraceptive method along the treatment of PMS/PMDD or not.

If contraception is not warranted then the first line therapy is an antidepressant. Here is the time for you to acknowledge that there is no shame in being on antidepressants!
There are different types of antidepressants that can be used at doses similar to those used in the setting of major depression (outside PMS). The antidepressants can be taken continuously, at the symptoms-onset, or on a cyclic basis during every second half of your cycle. The regimen used depends on your as well as your physician’s preference.

The efficacy of antidepressant therapy in the management of moderate to severe forms of PMS/PMDD has been well established through robust and validated studies. The effect can be achieved during the next menstrual cycle (it takes up to 3-4 weeks for the medication to kick in), and the dose can be adjusted according to your response or lack of response to the medication. 

The side effects of the most commonly used antidepressants occur in around 15% of patients and include, nausea, headache, difficulty sleeping and low sex drive. Such side effects can be preventable by starting a low dose regimen and then incrementally increasing as needed. In case of intolerance to an antidepressant, your physician can switch you to another.

Should you take the antidepressant forever? Well the duration of use of antidepressants for the management of PMS is not very well established, but the consensus is that women should be on the medication for around 1 year before initiating its discontinuation.

I will not go through the details of the types and doses of antidepressants that can be used as this discussion should be done with your physician.

 

Birth control pills

In case you desire contraception in addition to the management of PMS symptoms, birth control pills (combined estrogen-progesterone pills) become the mainstay for management. Here again the pill can be taken continuously or cyclically (depending on your and your physician’s preferences).

You should be aware that a small yet significant percentage of women experience a worsening of mood disturbances with the initiation of the birth control pill so you should always inform your physician about any positive or negative changes in your mood after the start of any therapy plan.

If response is suboptimal, expect your doctor to add an antidepressant to the pill.

Also, you should be aware that "progesterone only pills" (the pills that only contain progesterone and no estrogen) are not recommended for the management of PMS, as they can worsen your symptoms. So in case you are taking any of these pills inform your physician.

 

Cognitive Behavioral Therapy (CBT)

A fancy name for a short-term, goal-oriented psychotherapy treatment. This has been used for years in the management of psychological symptoms of depression and anxiety yet there are limited data about its use in the management of PMS/PMDD. However, it is still recommended in patients with moderate to severe symptoms with incomplete response to medical management (antidepressants and birth control pills). Such therapies are usually initiated by your psychiatrist or psychotherapist, so expect your primary health care provider/gynecologist to refer you to a health care specialist in case of a partial symptomatic relief. 

 

Other therapies

Acupuncture has limited data for its support as it was never compared to the standard therapies (medications) and thus it is not recommended for the management of moderate to severe PMS/PMDD

Surgery, by removing your ovaries and causing you to go into a surgically induced menopause, is considered as a last resort for severe debilitating cases of PMS/PMDD. This decision is drastic and requires strict conditions before being performed. This discussed is limited to less than 1% of women who satisfy its criteria.

Xanax (alprazolam) and other similar “stress relieving medications” are not recommended to be used in patients with PMS/PMDD as symptoms may get much worse. So be wise in your decisions and never initiate any medication before consulting with your physician.

 

In conclusion, it is quite evident that almost all women experience some mood and physical disturbances around the time of their periods, yet not all of them have severe enough symptoms to negatively impact their daily, social and professional lives. A small percentage of women actually satisfy the criteria for the clinically significant PMS and thus necessitate therapy. 

PMS is a valid syndrome, and its treatment is a must in order to avoid long term negative sequalae and worsening in the quality of life.

Take you mental and physical healths seriously and always report any concerns to your physician

Karam

 

Disclaimer: I do not encourage you to initiate any medication I mention in my articles, before consulting with your physician