Premenstrual Syndrome (PMS)

Topic Overview

What is premenstrual syndrome (PMS)?

Most women have tender breasts, bloating, and muscle aches a few days before they start their menstrual periods. These are normal premenstrual symptoms. But when they disrupt your daily life, they are called premenstrual syndrome (PMS). PMS can affect your body, your mood, and how you act in the days leading up to your menstrual period.

Some women first get PMS in their teens or 20s. Others don't get it until their 30s. The symptoms may get worse in your late 30s and 40s, as you approach perimenopause.

What causes PMS?

PMS is tied to hormone changes that happen during your menstrual cycle. Doctors don't fully know why premenstrual symptoms are worse in some women than in others. They do know that for many women, PMS runs in the family.

Not getting enough vitamin B6, calcium, or magnesium in the foods you eat can increase your chances of getting PMS. High stress, a lack of exercise, and too much caffeine can make your symptoms worse.

What are the symptoms?

Common physical signs include:

Bloating.
Swollen and tender breasts.
Lack of energy.
Headaches.
Cramps and low back pain.

It is also common to:

Feel sad, angry, irritable, or anxious.
Be less alert.
Have trouble focusing on tasks.
Withdraw from family and friends.

PMS symptoms may be mild or strong and vary from month to month. When PMS symptoms are severe, the condition is called premenstrual dysphoric disorder (PMDD). But PMDD is rare.

How is PMS diagnosed?

Your doctor will ask questions about your symptoms and do a physical examination. It's important to make sure that your symptoms aren't caused by something else, like thyroid disease.

Your doctor will want you to keep a written record of your symptoms for 2 to 3 months. This is called a menstrual diary. It can help you track when your symptoms start, how bad they are, and how long they last. Your doctor can use this diary to help diagnose PMS.

How is it treated?

A few lifestyle changes will probably help you feel better.

Eat a variety of healthy foods, especially foods rich in calcium. Include whole grains, protein, low-fat dairy, fruits, and vegetables.
Get plenty of exercise.
Cut back on caffeine, alcohol, chocolate, and salt.
For pain, try aspirin, ibuprofen (such as Advil or Motrin), or another anti-inflammatory medicine.

Talk to your doctor if these changes don't provide some relief from your symptoms after a few menstrual cycles. He or she can prescribe medicine for problems such as bloating or for more severe PMS symptoms. For example, selective serotonin reuptake inhibitors (SSRIs) can relieve both physical and emotional symptoms. Low-estrogen birth control pills may help relieve severe PMS or PMDD.

If you are taking medicine for PMS, talk with your doctor about birth control. Some medicines for PMS can cause birth defects if you take them while you are pregnant.

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Menstrual Cycle: Dealing With Cramps

Cause

Premenstrual syndrome (PMS) and the more severe form, premenstrual dysphoric disorder (PMDD), are linked to normal changes in the endocrine system. The endocrine system makes hormones that control the menstrual cycle. The female endocrine system is very complex. Medical experts don't fully understand why normal hormone changes cause PMS in some women and not others.

The one direct cause that is known to affect some women is genetic: Many women with PMS have a close family member with a history of PMS.

Symptoms

Premenstrual symptoms occur between ovulation and the start of menstrual bleeding. More than 150 symptoms have been linked to PMS. They may vary greatly from cycle to cycle and be worse during times of increased stress.

Common physical symptoms

Bloating, weight gain
Fatigue, lack of energy
Headaches
Cramps, aching muscles and joints, low back pain
Breast swelling and tenderness
Food cravings, especially for sweet or salty foods
Sleeping too much or too little
Low sex drive
Constipation or diarrhea

Mood and behaviour symptoms

Sad or depressed mood
Anger, irritability, aggression
Anxiety
Mood swings
Decreased alertness, trouble concentrating
Withdrawal from family and friends

Severe symptoms

Women who have severe premenstrual mood swings, depression, irritability, or anxiety (with or without physical symptoms) are said to have premenstrual dysphoric disorder (PMDD). Symptoms generally go away within the first 3 days of menstrual bleeding. This severe type of PMS isn't common.

Premenstrual worsening of other conditions

Some medical conditions may get worse between ovulation and the first day of menstrual bleeding. The conditions most affected include:

Mental health problems such as depression and anxiety disorders.
Migraines.
Seizure disorders.
Irritable bowel syndrome (IBS).
Asthma.
Myalgic encephalomyelitis/chronic fatigue syndrome.
Allergies.

Are your symptoms really PMS?

What seems like PMS can sometimes be caused by another condition. It's important to know what is causing your symptoms so you can get the right treatment. The best way to learn if your symptoms are PMS is to keep a menstrual diary for 2 or 3 months and then show it to your health professional.

What Happens

Most women first get PMS in their mid-20s, but it becomes more common in women in their 30s. Women in their late 30s and early 40s may have perimenopausal symptoms that are similar to PMS and premenstrual dysphoric disorder (PMDD).

After menopause, when hormones are low and no longer rise and fall each month, women don't have PMS.

What Increases Your Risk

A risk factor is anything that increases your chances of getting sick or having a problem. Risk factors for PMS include:

A family history of PMS.
Age. PMS becomes more common as women age through their 30s, and symptoms sometimes get worse over time.
Anxiety, depression, or other mental health problems. This is a significant risk factor for premenstrual dysphoric disorder (PMDD).
Lack of exercise.
High stress.
A diet low in vitamin B6, calcium, or magnesium.
High caffeine intake.

When should you call your doctor?

Call your doctor if:

PMS symptoms regularly disrupt your life.
You feel out of control because of PMS symptoms.
Home treatments don't help.
Severe PMS symptoms (such as depression, anxiety, irritability, crying, or mood swings) don't end a couple of days after your menstrual period starts.

Who to see

Your family doctor or general practitioner can diagnose and treat PMS.

If you have severe symptoms, you may be referred to a gynecologist to help you make a treatment plan.

If your symptoms are mainly emotional or behavioural, you may be referred to a psychiatrist or psychologist to help you find ways to manage your symptoms.

Examinations and Tests

No single test can diagnose PMS. A diagnosis of PMS or premenstrual dysphoric disorder (PMDD) is usually based on a medical history and information from a two- or three-cycle menstrual diary where you record your symptoms, menstruation days, and ovulation days, if possible.

Treatable thyroid problems sometimes cause symptoms like those of PMS. So you may have a thyroid-stimulating hormone (TSH) blood test to make sure that your thyroid gland is working properly.

It's important for your doctor to rule out other conditions that cause symptoms like those of PMS, so it may take more than one visit to diagnose your symptoms. Diagnosing PMS may be difficult if you have another condition that gets worse during the last 2 weeks of your menstrual cycle.

Treatment Overview

There are ways to reduce your PMS symptoms and their impact on your life. But no single treatment works for all women. You may have to try several to find the right choices for you.

The first step is to try some lifestyle changes, such as limiting caffeine and getting regular exercise. For more information, see Home Treatment.

If you still have moderate to severe symptoms after two or three cycles of home treatment measures, talk to your doctor about further treatment options. These may include taking selective serotonin reuptake inhibitor (SSRI) antidepressants or low-estrogen birth control pills. For more information, see Medications.

A variety of herbs and other complementary treatments may help reduce or relieve PMS. For more information, see Other Treatment.

Surgery to remove the ovaries (oophorectomy) is a rarely used, controversial treatment for the severe form of PMS, premenstrual dysphoric disorder (PMDD). For more information, see Surgery.

Prevention

You can't prevent PMS. But there are things you can do to reduce your chances of having severe symptoms.

Get regular exercise. It helps reduce pain and provide a feeling of well-being.
Eat a variety of healthy foods, especially foods rich in calcium. Include whole grains, protein, low-fat dairy, fruits, and vegetables.
Limit caffeine, alcohol, chocolate, and salt.
Reduce stress by managing your time well, getting enough rest, and learning relaxation techniques.
Quit smoking, if you smoke.

Home Treatment

The first step in learning to manage PMS is to keep a menstrual diary . Write down what kind of symptoms you have, how severe they are, when you have your period, and when you ovulate. This can help you identify patterns in your cycle and plan ahead to better cope with the symptoms.

Next, use some self-care measures for PMS. They focus on practicing healthy habits, managing pain, and reducing stress. When you use these tips, it's best to:

Try one or two at a time, instead of all of them at the same time. This will help you find which measures are most helpful.
Try a measure for two to three menstrual cycles. If it doesn't seem to be helping, try something else.

Practice healthy habits

Get at least 2½ hours of moderate to vigorous exercise each week. Exercise may help relieve tension, pain, and mood-related PMS symptoms.
Eat a variety of healthy foods, especially foods rich in calcium. Include whole grains, protein, low-fat dairy, fruits, and vegetables.
Limit caffeine, alcohol, chocolate, and salt.
Quit smoking, if you smoke.

Manage pain

Use a non-steroidal anti-inflammatory drug (NSAID) such as naproxen or ibuprofen to relieve pain and reduce menstrual bleeding. Try to start taking an NSAID 1 or 2 days before you expect pain to start. NSAIDs work best when taken before and at regular intervals throughout the days you have pain.
Wear a more supportive bra, such as a sports bra, when your breasts are tender.

Menstrual Cycle: Dealing With Cramps

Reduce stress

Try some relaxation techniques, such as breathing exercises, yoga, or massage therapy.
Practice better time management, and get enough sleep.
Create a support system. Join a support group of women who are managing PMS. With your loved ones, plan ways to reduce the demands placed on you when you have PMS.

Medications

If you have moderate to severe premenstrual symptoms even after you've tried home treatment and lifestyle changes, talk to your doctor about using medicine. Be safe with medicines. Read and follow all instructions on the label.

The most commonly used medicines for PMS are:

Non-steroidal anti-inflammatory drugs (NSAIDs) for pain.
Selective serotonin reuptake inhibitors (SSRIs) for mood-related symptoms.
Hormonal birth control, which may help relieve premenstrual dysphoric disorder (PMDD).

Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs such as ibuprofen and naproxen relieve premenstrual pain and cramps and reduce menstrual bleeding. Try to start taking an NSAID 1 or 2 days before you expect pain to start. NSAIDs work best when taken before and at regular intervals throughout the premenstrual pain period.

Selective serotonin reuptake inhibitors (SSRIs)

SSRIs such as citalopram, fluoxetine, and paroxetine may help relieve physical and emotional symptoms of PMS. They are effective either when taken during the premenstrual weeks only or when taken continuously.

Hormonal birth control

A low-estrogen birth control pill such as YAZ or Yasmin may help relieve symptoms of severe PMS or PMDD.
Other types of birth control pills (estrogen-progestin) are widely prescribed for PMS. They may improve bloating, headache, belly pain, and breast tenderness in some women. But other women may have worse symptoms or develop mood problems.
Estrogen alone may offer some benefit for some women. But when estrogen is taken without progestin, it increases the risk of uterine (endometrial) cancer.
Progestin (progesterone) has been used in the past for PMS. But for some women, it may make physical and emotional symptoms worse.

For more information about birth control pills and progestin, see the topic Birth Control.

Diuretics

Spironolactone is a water pill (diuretic). It may reduce bloating and breast tenderness if taken during the premenstrual weeks.
Drospirenone, which is in the certain low-estrogen birth control pills, acts like a diuretic to relieve bloating and breast tenderness. This medicine may also help relieve symptoms of severe PMS or PMDD.

Less commonly used medicines

Propranolol, a beta-blocker medicine, may be used to treat migraines or headaches related to PMS.
Tricyclic antidepressants are not as well studied as SSRIs for PMS. They are generally less favoured because of their possible side effects. But they do improve severe depression and insomnia for some women.
Alprazolam, an anti-anxiety medicine, is only recommended for a few days' use when other treatments have not worked. It can make you sleepy, lose effectiveness over time, and can lead to physical dependence. Long-term use may cause withdrawal or life-threatening symptoms.
Danazol, a synthetic male hormone, can relieve breast pain by decreasing estrogen production. It isn't often prescribed.
Gonadotropin-releasing hormone agonist (GnRH-a) is a last-resort treatment for severe PMDD. This medicine stops the monthly menstrual hormonal cycle and results in a condition similar to menopause.

Side effects

If you are taking medicine for PMS, talk with your doctor about birth control. Some medicines for PMS can cause birth defects if you take them while you are pregnant.
The side effects of some medicines may be just as unpleasant as your PMS symptoms. For example, GnRH-a and danazol have severe side effects. In other cases, the relief from symptoms that a medicine gives may far outweigh its side effects.

Surgery

In the past, some women with premenstrual dysphoric disorder (PMDD), the severe form of PMS, had surgery to remove the ovaries (oophorectomy) and the uterus (hysterectomy). Without ovaries, a woman no longer has a menstrual cycle.

Surgical removal of the ovaries for PMDD is highly controversial and rarely done. It is only considered if a woman meets all of the following criteria:

PMS symptoms are severe and regularly disrupt her quality of life.
She has no future plans to give birth, and she is many years away from natural menopause.
Symptoms improve with the use of medicines that produce a condition similar to menopause (such as danazol or a GnRH-a).
All other treatments have failed.
All or most of the symptoms are directly related to PMDD. Other problems, such as psychological or non-medical problems, do not appear to contribute to the symptoms.

Removing the ovaries leads to early menopause, and the symptoms tend to be more severe than those of natural menopause. Early menopause also increases the risk of osteoporosis, because low estrogen leads to loss of bone density.

Surgery also has risks related to the procedure or anesthesia. For more information, see the topic Hysterectomy.

Other Treatment

Most of the following complementary therapies aren't considered standard treatment for PMS. But you may find that one or more of them helps to relieve some of your symptoms. In general, these treatments are safe and don't cause bothersome side effects.

Before you take any vitamin, herb, or mineral supplement, talk with your doctor or pharmacist. He or she can find out if it might interfere with other medicines you are taking.
Be sure to follow the directions on the label. Don't take more than the maximum dose.
Some natural health products and remedies should be avoided if you are trying to get pregnant.

Complementary therapies commonly used for PMS

Bright light therapy on days when PMS symptoms are present may help relieve mood symptoms.
Calcium and magnesium may help with certain symptoms of PMS.
Vitamin E is used by some women to help with breast tenderness related to PMS.

Complementary therapies sometimes used for PMS

Black cohosh is sometimes used to relieve menopause symptoms, and it might help relieve symptoms of PMS. Health Canada advises that you talk to your doctor before using black cohosh if you have liver problems or if you develop symptoms of liver problems after using black cohosh.^{footnote 1} Symptoms of liver damage can include being more tired than usual, feeling weak, loss of appetite, and yellowing of the skin.
Zinc may help improve PMS-related acne.
Vitex (agnus-castus, or chasteberry) might help relieve irritability, anger, breast tenderness, bloating, cramping, and headaches. But possible side effects include nausea, gastrointestinal upset, and malaise.
Ginkgo biloba may reduce breast tenderness, bloating, and weight gain.
Evening primrose oil ( Oenothera biennis) may offer mild relief of breast tenderness.

References

Citations

Health Canada (2008). Drugs and health products: Black cohosh. Health Canada. http://webprod.hc-sc.gc.ca/nhpid-bdipsn/monoReq.do?id=44. Accessed January 31, 2014.

Other Works Consulted

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Davis AJ, Johnson SR (2000, reaffirmed 2010). Premenstrual syndrome. ACOG Practice Bulletin No. 15, pp. 1–9. Washington, DC: American College of Obstetricians and Gynecologists.

Kwan I, Onwude JL (2015). Premenstrual syndrome. BMJ Clinical Evidence. http://clinicalevidence.bmj.com/x/systematic-review/0806/overview.html. Accessed October 15, 2015.

Reid RL (2008). Premenstrual syndrome. In RS Gibbs et al., eds., Danforth's Obstetrics and Gynecology, 10th ed., pp. 672–681. Philadelphia: Lippincott Williams and Wilkins.

Twogood S, Israel J (2010). Premenstrual syndrome. In Management of Common Problems in Obstetrics and Gynecology, 5th ed., pp. 267–270. Chichester, UK: Wiley-Blackwell.

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Yonkers KA, et al. (2005). Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder. Obstetrics and Gynecology, 106(3): 492–501.

Credits

Current as of: July 17, 2020

Author: Healthwise Staff
Medical Review:
Sarah Marshall MD - Family Medicine
Adam Husney MD - Family Medicine
Kathleen Romito MD - Family Medicine
Martin J. Gabica MD - Family Medicine
E. Gregory Thompson MD - Internal Medicine
Kirtly Jones MD - Obstetrics and Gynecology