Premenstrual Syndrome

Premenstrual Syndrome (PMS) or Premenstrual Dysphoric Disorder (PMDD)

A large number of women (30 to 70 per cent) experience premenstrual symptoms even though they do not have Premenstrual Dysphoric Disorder or what most people refer to as PMS (Pre-Menstrual Syndrome). Approximately four to nine per cent experience Premenstrual Dysphoric Disorder.

Premenstrual Dysphoric Disorder (PMDD) is a hormonal brain-biochemistry problem that results in mood and behavioral distress. The symptoms originate from two areas in the brain: the limbic area and up to the cortex. Different chemicals connect the limbic and cortex area of the brain: these are serotonin, dopamine, acetylcholine, and norepinephrine. Any changes in these chemicals affect a woman’s mood and daily functioning.

The limbic area is responsible for memory, appetite, sleep, and strong emotions such as rage, anger, and aggression.
The cortex area affects a person’s judgment, attention, concentration, moods, perceptions, views, and interpretations of what is happening to them and around them.

Premenstrual Symptoms

Physical Symptoms	Behavioural Symptoms	Emotional Symptoms
o headaches, migraines o abdominal cramps o bloating, weight gain o hot flashes o diarrhea, constipation o general malaise, nausea, lack of appetite o skin changes, acne o palpitations o fatigue	o food cravings o decreased interest in activities, work, sex, relationships o wanting to be alone o poor concentration o clumsiness o difficulty making decisions o slower, muddled thinking o increased food intake	o irritability o sadness, depression o tearfulness o anxiety, nervousness o unpleasant, unwanted thoughts o anger, rage, hostility o over-sensitivity, feeling easily overwhelmed o jumpiness

Even though premenstrual women may be quite uncomfortable with headaches, cramps, tender breasts, or other symptoms, this is not PMDD. PMDD is only diagnosed when there are cyclical mood and behavioural changes which affect relationships and day-to-day functioning.

PMDD Symptoms
Women may begin experiencing PMDD Disorder any time during their reproductive years. When you have these symptoms, your brain is unable to maintain its usual chemical balance during the last one to two weeks of your cycle. However, within a day or two of menstruation, the chemical levels in your brain restabilize and your symptoms disappear.

Women who first experience PMDD in their late thirties and early forties often have a history of depression, sometimes related to the postpartum period. Perhaps the symptoms of depression did disappear, but we believe the experience is imprinted in the brain. The brain incorporates the depression experience into its mood and anxiety pathways. When the woman’s hormones change again, the brain's altered chemical pathways form the blueprint for her emotional, physical, and behavioural reactions.

Find out more about our services and resources available in your community. You can also download the patient guide: A Positive Approach: Premenstrual Syndrome and Premenstrual Dysphoric Disorder or order for $10.00 from the C&W Bookstore.

Self-Care for Mild to Moderate PMDD

Reduce stress. Symptoms can worsen when you are under stress so use stress-reduction strategies, such as well-balanced diet, adequate sleep, and regular exercise.

Eat a well-balanced diet. It is essential to have a balanced diet from all food groups (breads and cereals, dairy and dairy products, meats and alternatives, fruits and vegetables) to optimize your brain’s chemical levels. Some additional suggestions are:

Eat according to the Canada Food Guide.
Moderate your intake of sugar and salt.
Eat plenty of grains products, vegetables, and fruit.
Eliminate alcohol that acts as a depressant in the brain.
Reduce or eliminate caffeine and cigarette smoking that can increase anxiety.
Eat plenty of complex carbohydrates, such as potatoes, rice, pasta noodles, cereals, and breads.
Limit the simple carbohydrates, such as white sugar, honey, sweet candies, ice cream, chocolate, regular pop, and juice.
Cook without added fats such as butter and oil.
Avoid diets by eating three smaller meals with some healthy snacks to stop the munchies and to help with premenstrual headaches.
Pass on the salt. Foods high in salt include: cured meats, canned foods, packaged sauces, frozen dinners, cheese, mustard, soy sauce, pickled foods, potato chips and salted nuts. Try flavouring with herbs and spices.
Drink plenty of water to reduce the symptoms of PMS.

Should I take supplements?

Many dietary supplements have been promoted as effective in decreasing PMS symptoms. However, none have been proven to be more than minimally successful. If you are trying different supplements:

Chart your daily symptoms.
Ask the people recommending the supplement for research studies on safety. Do your own investigation. Dial-A-Dietitian may be able to help.
Stop using them if you plan to get pregnant, are pregnant, plan to breast feed, or if your health changes.

What about vitamin B6?

A review of scientific research found twelve controlled trials of vitamin B6 therapy for PMS. Most of the studies failed to show a positive effect beyond the initial two to three months trial. Despite the absence of agreement on its effectiveness, vitamin B6 is routinely suggested for PMS therapy. If you are planning to use B6:

Discuss it with your doctor.
Begin using 50 mg per day every day of the cycle.
If you have side effects such as tingling in the hands or feet, discontinue vitamin B6 and report it to your doctor.
Take B6 with a multivitamin.
Take B6 with food to avoid an upset stomach.

What about Evening Primrose Oil?

Conflicting reports about the effectiveness of Evening Primrose Oil suggests that more research is necessary before it is recommended as an effective treatment for PMS. Based on the limited research it appears:

Evening Primrose Oil is safe as a dietary supplement in the recommended dosage of four grams of Evening Primrose Oil or 400 milligrams of gamma-linolenic acid per day.
The most common reported side effects are diarrhea and headaches.
Some women reported reduced breast tenderness.

Rest and relaxation

Sleep is a priority. The brain biochemistry resets itself during sleep. Two chemicals in particular are important in this process: melatonin and oxytocin. Melatonin is released by the pineal gland in the center of the brain. Melatonin helps you maintain your regular sleep cycle. Oxytocin is a hormone that triggers the let down of breast-milk, promotes the contraction of the uterus during menstruation and in labor, and resets the chemicals in the brain.

Exercise regularly - regular exercise:

Increases the level of endorphins - the body’s mood-enhancing substances
Energizes you and reduces jitteriness
Increases levels of serotonin and dopamine in the brain, therefore helping your brain to regulate itself
Increases your ability to deal with daily stressors
May diminish premenstrual symptoms and depression in some women

Treating severe PMMD

Some women with severe PMDD find that self-care measures are not enough and the physician may recommend medication.

Antidepressants

The latest research indicates that serotonine dysregulation is involved in PMDD. Women with severe PMDD symptoms can be treated with serotonin-reuptake inhibitors or SSRIs, such as Prozac, Zoloft, Luvox, Paxil and Anafranil. The SSRI medications work by increasing the amount of serotonin available to the brain - the SSRIs hold the amount of serotonin in the brain stable even as the woman’s hormones fluctuate.

When serotonin medications cannot be tolerated, a different type of antidepressant called Effexor is an alternative. It enhances serotonin levels and balances the norepinephrine pathways.

Each woman reacts differently to medications. Therefore, women are encouraged to talk to their doctor about the medication and possible side effects.

Some women may need medication only for the last two weeks of their menstrual cycle, while other women may need to take medication daily to alleviate their symptoms. SSRIs will not effect your normal menstrual cycle.

Medications do not stop symptoms immediately. It may take several weeks or months for the proper blood levels to be established so the SSRIs can have the maximum effects.

Hormonal Therapy

Research shows that progesterone had absolutely no effect on PMDD symptoms. For some women who are anxious, irritable, and restless, progesterone may bring some relief.
More research is needed on the use of estrogen for PMDD. However, for most women with PMDD, long term estrogen use is not appropriate because of side effects such as over-stimulation of uterine lining and heavy bleeding.

The ultimate goal is to utilize the appropriate self-care and medication strategies with each woman experiencing PMDD.

Library

PHSA improves the health of British Columbians by seeking province-wide solutions to specialized health care needs in collaboration with BC health authorities and other partners. For more information, visit http://www.phsa.ca

PHSA agencies include: BC Cancer Agency, BC Centre for Disease Control, BC Children’s Hospital and Sunny Hill Health Centre for Children, BC Mental Health & Addiction Services, BC Provincial Renal Agency, BC Transplant, BC Women’s Hospital & Health Centre, and Cardiac Services BC.