Premenstrual syndrome

Medical quality assurance by Dr. Albrecht Nonnenmacher, MD at April 5, 2016
StartDiseasesPremenstrual syndrome

Premenstrual syndrome (PMS) symptoms present about 1-2 weeks before menstrual bleeding begins. Eighty-five percent of menstruating women exhibit mild or severe forms of PMS. The symptoms usually ease with menstrual onset.


Definition & Facts

PMS covers a wide range of recurrent or severe premenstrual discomfort. At least 150 varied symptoms have been connected to the disorder. The condition can appear at any age from puberty to menopause, but the average age of onset is during the late 20s to early 30s.

The most severe form of PMS is experienced by approximately 3-8 percent of women. This is premenstrual dysphoric disorder, or PMDD. Symptoms of PMDD can be serious enough to cause illness and disruption of daily routines.

Symptoms & Complaints

PMS may involve a range of emotional and physical symptoms. The emotional impact of PMS can be as debilitating as the physical aspect. Crying spells, angry explosions and social disinterest may cause a strain on important relationships. Changes in appetite and food cravings can lead to unwanted weight gain, which contributes to depression and feelings of losing control.

Physical signs can impact activities of daily living. Headaches are a common symptom, as is muscle pain, contributing to immobility. Fatigue has important consequences for employment expectations. Bloating due to fluid retention is a well-known frustration of PMS.

The most severe form of PMS, premenstrual dysphoric disorder, is so debilitating as to resemble a chronic illness. The severe symptoms of PMDD are similar to PMS, but diagnosis involves at least five chronically reappearing symptoms that occur for seven days before menstrual onset.


Causes of PMS are complex and often relate to cyclical hormonal factors. Mood changes can be directly affected by chemical influences upon serotonin in the brain. Lowered amounts of serotonin may influence appetite fluctuations and fatigue.

Risk factors of PMS include a history of mood disorders, such as depression or bipolar disorder. Stress can be an important contributor to symptoms of PMS, exaggerating discomfort. Obese women suffer PMS more frequently, as obesity contributes strongly to hormonal imbalances of estradiol, a component of the hormone, estrogen.

A sedentary lifestyle is implicated in PMS as are dietary considerations. Caffeine and alcohol are well-known mood disruptors and sabotage energy levels. Drinking caffeinated or carbonated beverages dehydrate the body and contribute to vitamin and mineral depletion. Eating salty foods in excess will encourage water retention and bloating.

Diagnosis & Tests

The diagnostic criteria for determining PMS begins with a general medical history, especially reproductive history. A subjective assessment will be based on a symptom chart provided for the patient using a monthly calendar that pinpoints onset and severity of symptoms for 2-3 menstrual cycles.

When this has been satisfactorily completed, a thorough physical examination will be performed. The exam will include a thyroid examination and breast examination, abdominal examination, and pelvic examination. A history of childbirth will be charted, as PMS symptoms often worsen after childbearing due to neurotransmitters responding abnormally to fluctuating hormones, exacerbated by the stress of motherhood.

Laboratory tests will be ordered to rule out diabetes, anemia, chronic fatigue syndrome, endometriosis, and hypothyroidism, as these diseases may have symptoms similar to PMS. Gestational diabetes will sometimes appear postpartum and be undiagnosed or mismanaged, causing symptoms of being overweight, fluid in the ankles, and tiredness.

A hidden factor contributing to PMS may be thyroid disease, so a test for thyroid function is important. Symptoms of thyroid dysfunction such as fatigue and weight gain, are common PMS symptoms. Irritable bowel syndrome will need to be ruled out, as well as migraine headaches, which may be cyclical.

Anemia can mimic PMS fatigue symptoms, possibly aggravated by the blood loss of menstruation. The influence of perimenopause, a distinct phase in the period leading up to menopause can be a factor in PMS. A complete evaluation of current medications will be performed to rule out side effects.

There is no clinical test that will officially determine PMS. Instead, through process of elimination and evaluation of current health status, a physician may give the diagnosis of premenstrual syndrome.

Treatment & Therapy

Treatment options for PMS will begin with lifestyle changes. Nutrition will be addressed first, especially if a patient is obese. A balanced, healthy diet, including fresh fruits, vegetables and whole grains is suggested, as well as avoidance of salty foods, sugar, caffeine and alcohol while symptomatic. Instead of three large meals per day, some people do better with five or six small meals. A multivitamin every day may help with symptoms.

Regular exercise such as engaging in something fun like cycling or swimming 30-60 minutes per week is beneficial. Yoga may be helpful to some, as it focuses on stretching and deep relaxation, relieving stress, and building strength. The proper amount of rest cannot be overlooked. Sleep requirements may be higher during certain times during the menstrual cycle.

If lifestyle changes have no affect on PMS symptoms, medications will be tried. Over the counter medications like pain relievers and anti-inflammatory drugs can be helpful. Certain medications are marked specifically for PMS. Diuretics may be useful for bloating by eliminating excess fluid through the urine. Birth control pills control hormonal output, and can lessen symptoms by keeping hormones from extreme fluctuation.

In severe cases of PMS, such as premenstrual dysphoric disorder, drugs called gonadotropin-releasing hormone agonists may be used. These drugs induce the absence of ovulation and a temporary menopausal state is created. The drugs are recommended for very short-term use.

Prevention & Prophylaxis

Regular physical activity raises neuroendocrine hormone levels, and other studies suggest that aerobic exercise lowers cortisol levels and therefore stress.

Strength training is known to decrease estrogen and progesterone levels, resulting in fewer PMS symptoms. Endorphin levels are raised with activity as well, contributing to feelings of well-being. Fewer women who are active report severe PMS symptoms.