Dr. Krishna Seshadri
Associate Professor and Head: Division of Endocrinology
Sri Ramachandra Deemed University
Consultant : Endocrinology Diabetes and Metabolism
Sri Ramachandra Medical Center

The author can be reached at: krishnagseshadri@gmail.com

Do you experience mood swings, tender breasts, swollen abdomen, food cravings, irritability, fatigue or depression in the days before your period? If you experience some or all of these symptoms then you may have the Premenstrual Syndrome (PMS). For many women the signs and symptoms of PMS are an uncomfortable and unwelcome part of their monthly menstrual cycle. While PMS has over the years been the butt of countless female bashing jokes, it is a very real condition that affects up to 80 percent of menstruating women in varying degrees – and in some women it can be severe enough to interfere with their daily activities, life style and relationships.

The symptoms of PMS are more likely to trouble women in their 20s and 30s, and they tend to recur in a predictable pattern. The physical and emotional changes may be more or less intense with each menstrual cycle.

A list of the common physical and emotional signs and symptoms may be found in box 1. The symptoms occur in the second half of the menstrual cycle (called the luteal phase), and disappear at or within a few days of the onset of menstrual flow. Most women experience only a few of these symptoms.

In a minority, PMS symptoms are so severe they're considered disabling. In these patients, the disturbance markedly interferes with work or school, or with usual social activities and relationships with others (e.g., avoidance of social activities, decreased productivity and efficiency at work). This form of PMS has its own psychiatric designation - premenstrual dysphoric disorder (PMDD). PMDD is a severe form of premenstrual syndrome with symptoms including severe depression, feelings of hopelessness, anger, anxiety, low self-esteem, difficulty concentrating, irritability and tension and requires medical therapy.

The exact cause of PMS is not known. However, several factors have been identified as possible causes or contributors to the occurrence of PMS. Changes in hormone levels appear to be a major influence. Chemical changes in the brain also may be involved. One clue to the cause may be traced to fluctuations of serotonin, a brain chemical (neurotransmitter) that is thought to play a crucial role in mood states, especially depression. Insufficient amounts of serotonin may contribute to other symptoms of PMS, such as fatigue, food cravings and sleep problems.

Occasionally, some women with severe PMS have undiagnosed depression, though depression alone does not cause all of the symptoms associated with PMS. Stress also may aggravate some of the symptoms, but alone isn't a cause.

Some PMS symptoms have been linked to low levels of vitamins and minerals. Eating a lot of salty foods, which may cause fluid retention, and drinking alcohol and coffee, which may cause mood and energy level disturbances, also have been identified as possible contributors to PMS.

There are no unique physical findings or laboratory tests to positively diagnose PMS. To confirm a diagnosis of PMS a doctor must establish that your symptoms are: a) present in the five days before your period for at least three menstrual cycles in a row b) End within four days after your period starts and c) Interfere with some of your normal activities. The best way to help your doctor establish the diagnosis is to keep a record of your signs and symptoms on a calendar or in a diary for at least three menstrual cycles. Note the day, you first noticed the symptoms appear and disappear. Also be sure to mark the day your period started.

Knowing about your symptoms, their triggers and being reassured that they will disappear is the first step in getting a hold on PMS. If your PMS is not so bad that you need medical help you can manage or sometimes reduce the symptoms by making changes in the way you eat, exercise and approach daily life. Try these steps in box 2. Not all of them work for everyone. You will have to figure out the one that works best for you. Maintaining a symptom diary may help you optimize the timing of these life style changes.

Some dietary and non prescription supplements may also help. Taking up to 1200 mg of calcium daily has been shown to reduce some of the physical and psychological symptoms of PMS. Taking calcium also reduces the risk of osteoporosis. Other supplements have not been rigorously tested in clinical trials, but supplements like primrose oil and vitamin E may help some women with breast tenderness. Vitamin A and B6 are NOT recommended. Some women find relief with use of herbal supplements like ginger tea etc. It is important to note that herbal supplements are not rigorously tested by clinical trials and a product label that says herbal or natural is not sufficient guarantee that these are safe. When in doubt, talk to your doctor.

If you've tried managing your PMS with lifestyle changes, but with little or no success, and the symptoms of PMS are seriously affecting your health and daily activities, see your doctor. Your doctor may prescribe one or more medications. The success of medications in relieving symptoms varies from woman to woman. Commonly prescribed medications for PMS include Non steroidal Anti-Inflammatory drugs (NSAID s), diuretics, selective serotonin reuptake inhibitors and hormones that regulate the menstrual cycle. These drugs must be taken under medical supervision only.

It is important to involve your family in the management of PMS. Have a frank discussion with them and let them know what you go through and how you feel. Indicate to them the days that you don’t feel so good. Some women, for instance, place a sad face on the calendar, so that their family knows how they feel. Give yourself space and don't expect to be super wife or super mom all the time. Take care of yourself first, even if it means that others in the family have to take up the load and do the cooking or the dishes on those dishes. It is also a good idea, not to make major decisions on your PMS days. They can wait till you’re back to the normal cheerful YOU.

Common Symptoms of Premenstrual Syndrome

1.Behavioral symptoms: fatigue, sleeplessness, dizziness, changes in sexual interest, food cravings or overeating

2.Psychologic symptoms: irritability, anger, depressed mood, crying and tearfulness, anxiety, tension, mood swings, lack of concentration, confusion, forgetfulness, restlessness, loneliness, decreased self-esteem, tension

3.Physical symptoms: headaches, breast tenderness and swelling, back pain, abdominal pain and bloating, weight gain, swelling of legs, water retention, nausea, muscle and joint pain

Life style changes to control PMS

• Modify your diet
  
  
  • Try eating up to 6 small meals a day instead of 3 larger ones to reduce bloating and the sensation of fullness
    
    
  • Avoid salt for the last few days before your period to reduce bloating and fluid retention.
    
    
  • Choose foods high in complex carbohydrates, such as fruits, vegetables and whole grains.
    
    
  • Reduce coffee intake to feel less tense and irritable and to ease breast soreness.
    
    
  • If you drink alcohol stop. Drinking before your period can make you feel more depressed.
    
    
  • Increase your intake of foods rich in calcium
    
    
  • Take a multivitamin supplement daily
    
    
• Incorporate exercise into your regular routine
  
  
  
  • Engage in brisk walking or other aerobic activity at least 30 to 60 minutes most days of the week. Regular daily exercise can help improve your overall health and alleviate symptoms such as fatigue and a depressed mood.
    
    
• Get plenty of sleep
  
  
  
  • At least eight hours a day. Make sure that you have a consistent sleep and wake schedule during the second half of your cycle.
    
    
• Others
  
  
  
  • Keep to a regular schedule of meals, bedtime and exercise
    
    
  • Practice progressive muscle relaxation or deep- breathing exercises to help reduce headaches, anxiety or trouble sleeping
    
    
  • Try to schedule stressful events for the week after your period
    
    
• Talk with your family
  
  
  • Talking with others about what you are going through can help. Sharing your feelings may help your family to support you more
    
    
  • Indicate to your family the days that you are not feeling great