PMS Premenstrual Syndrome

How can we tell if I have premenstrual syndrome?

The diagnosis of premenstrual syndrome can only be made from the history (story). There are no symptoms that are exclusively associated with PMS every PMS symptom can occur in other situations and there is no test that can distinguish between those who have PMS and those who do not. Caution is required in making the diagnosis. A chart may help to distinguish whether or not the symptoms are of a cyclical nature or not (Figure 25.1). The symptoms of PMS disappear completely when menstruation stops and they do not recur until ovulation two weeks before the next period.

PMS Premenstrual Syndrome

Some women have underlying psychological problems such as depression or anxiety that become more noticeable in the premenstrual phase (secondary premenstrual syndrome). In these women not all their symptoms disappear after the period. Treatment of PMS in these circumstances may only partially overcome their problems although this may at times be enough to make their lives more tolerable.

Suppression of the menstrual cycle by gonadotrophin releasing analogues (e.g. Goserelin �€“gonadotrophins) has been described as a means of diagnosing PMS when there is doubt about the diagnosis. The menstrual cycle is suppressed for three cycles so that if symptoms are truly cyclically related they should disappear. The test has been advocated for evaluating the potential benefits of removing the ovaries for patients with possible PMS problems who are coming to hysterectomy . From a practical point of view it is apparent that the �€œGoserelin test�€™ will create a temporary menopause-like state; many symptoms (e.g. depression and anxiety) which may be attributable to PMS can also occur with the menopause. This potential difficulty may be overcome by add-back therapy (HRT-Add-Back).

How Prevalent is premenstrual syndrome?

Some premenstrual symptoms probably occur in 95% of women; only 5% of women have no premenstrual symptoms. Fifty percent of women have mild symptoms and 30% moderate problems. About 5% of women have such PMS symptoms that their lives are disrupted in the two weeks leading up to their periods.

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How can cyclical breast pain be treated?

Mastalgia Breast Pain

Figure 25.2

Figure 25.2 is a flowchart outlining the treatment options for cyclical breast pain. Cyclical breast pain may be the only problem or it may be just one of several PMS symptoms. Some treatments are beneficial for cyclical mastalgia. These include:

  • pyridoxine (vitamin B6).
  • bromocriptine (Parlodel).

Prolactin is the hormone particularly responsible for milk production after childbirth. Galactorrhoea (hyperprolactinaemia) tends to occur when prolactin levels are inappropriately elevated (hyperprolactinaemia Q6.10). For more than twenty years, bromocriptine (Parlodel – Novartis) has been the specific antidote for hyperprolactinaemia. It generally proves effective when other measures fail in the relief of cyclical mastalgia even in the absence of hyperprolactinaemia. Newer agents such as cabergoline (Dostinex Pharmacia and Upjohn) are more expensive. They may cause less side effects in some patients.

  • Oil of evening primrose will often prove effective and is readily available without prescription.
  • Danazol at a relatively low dose danazol (200mg daily) during the premenstrual phase of the cycle may improve cyclical breast pain but not other PMS symptoms.
  • GnRH to down-regulate the cyclical hormones may be helpful in severe situations which do not respond to these treatments. Add-back HRT may be required should menopausal symptoms occur (HRT-Add-Back).
  • Fluoxetine (Prozac Lilly) 20mg daily provides a new option for women with severe cyclical mastalgia. There is accumulating evidence that cyclical symptoms, including premenstrual mastalgia, may be related to abnormality in the release of serotonin which is an important neurotransmitter (a chemical released by brain cells to activate other brain cells).

A thirty-four year old lady presented with severe breast pain which had been slowly increasing. She had two children aged six and eight. She was taking no regular medication. A diuretic (encourages increased urine output) provided by her general practitioner had provided only temporary relief. On examination, her breasts were reminiscent of the engorgement encountered by women two or three days after childbirth. Investigations, including prolactin estimations demonstrated no abnormality. Over several years, a variety of treatments including Efamast, diuretics, Parlodel, Danazol, progestogens, and cabergoline individually and in combination have provided at best temporary relief. Down regulation with GnRH analogues and add-back HRT have proven to be effective.

There is a paucity of research on the effects of exercise on PMS. Although the American College of Obstetricians and Gynecologists (ACOG) has advised that regular aerobic exercise may help relieve PMS, to make any evidence-based policy recommendations regarding the effectiveness of exercise, more high-quality research is required.0901

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What treatment is available for PMS (Premenstrual Syndrome)?

Figure 25.3 is a flowchart showing the basic principles and options for treatment.

Figure 25.3

Some women find a discussion of their problem helpful even if it only provides reassurance that the majority of women experience similar symptoms. There have been numerous treatments that have been used to treat PMS. Academics have debated the true benefit of individual medications. It is not really surprising that it is difficult to determine the overall benefit of the various medications as PMS can manifest itself in a wide variety of symptoms occurring in varying severity. Ultimately, what really matters is whether you feel better with a particular therapy. If you only have very minimal problems reassurance alone may be all that is required. At the other extreme, if you have proven severe PMS that has not responded to relatively simple medication, you could benefit from suppression of the cycle by medical or surgical means. The problem for the clinician is that the majority of patients with PMS have moderate symptoms for which reassurance alone may be insufficient and suppression of the menstrual cycle seems excessive.

Ability to cope with the extra burden of premenstrual hormone changes may be enhanced by a variety of non-medical means. Regular exercise may improve your self-esteem and provide you with a feeling of being more healthy. Similarly, relaxation by a variety of means and improving your diet may have a beneficial effect. There is no evidence that special diets for PMS have additional benefit. Theoretically, pyridoxine (Vitamin B6) and magnesium may be beneficial as they are known to play an essential part in the chemistry of the brain: controlled trials (placebo and controlled trials), however, have shown little scientific evidence of clinical benefit. Counselling may assist some individuals to assess their problems in life and make a start on sorting them out.


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What is the place of progesterone and progestogen in the treatment of PMS?

One of the pioneers of PMS diagnosis and treatment has been a strong advocate of progesterone pessaries (Cyclogest – Shire). Research has failed to confirm any evidence of imbalance in progesterone levels between those with and those without PMS. From a theoretical point of view, PMS occurs at the time that the body is producing progesterone so that progesterone deficiency is unlikely to be the problem. Although scientifically controlled studies have never proven its benefit, the fact remains that many women continue to take this form of treatment and they are convinced of its efficacy. Postmenopausal women given oestrogen replacement therapy and cyclical progestogens (Q 28.09) sometimes report recurrence of PMS type symptoms; dydrogesterone (Duphaston – Solvay), medroxyprogesterone acetate (Provera Pharmacia and Upjohn) and progesterone itself seems to have this side-effect less frequently than other progestogens. Duphaston and norethisterone are licensed for use in PMS but scientific control studies tend to show no improvement over placebo (placebo and controlled trials). Progesterone as a vaginal gel (Crinone) introduced on alternate nights became available in 1997 and some find Progest (progesterone replacement therapy) helpful. Depo-Provera used in family planning (Depo-Provera) is administered on a three monthly basis.

A 42 year old lady presented with a history of depression and a suggestion that her problem could be PMS. She had the typical appearance of a severely depressed person. At times she had required hospital admission under the care of a psychiatrist. There was certainly an element of a cyclical increase in her symptoms and at that time it seemed reasonable to offer hormonal treatment on a trial basis. She received dydrogesterone during the second half of the cycle. When she returned a few weeks later she was vivacious and enjoying life to the full. All was well for about a year when she returned quite depressed despite having continued with the dydrogesterone. It turned out that she had recently received an antibiotic for a respiratory infection and this could have altered the absorption of the drug. With increased progestogen the problem resolved and in her case her severe symptoms were effectively controlled by dydrogesterone alone until she reached her menopause. It should be emphasised that this case is unusual. Every person, however, is an individual and although such improvement would not be predictable on the evidence of large studies, in my view the practice of medicine is still an art based on science. Only politicians could believe that medicine is a pure science.

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Could suppressing my cycle improve my PMS?

As premenstrual syndrome is a cyclical problem, abolition of the ovarian cycle would seem to be a logical approach. This can be achieved with:-

PMS Premenstrual Syndrome

For how long should the treatment of my PMS be continued?

When treatment is being taken to correct PMS problems it may be reasonable to stop the medication after a few months and see whether the symptoms are still troublesome. Naturally, the treatment should not be stopped except when it is socially convenient.

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Evaluation of the quality of Web sites is discussed in (internet information). You may find that several general women’s health sites may help you (internet information). The following are more specialised relevant Web sites:-