Premenstrual syndrome
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Premenstrual syndrome (PMS) is a disruptive set of emotional and physical symptoms that regularly occur in the one to two weeks before the start of each menstrual period.<ref name=":1" /><ref name=":2" /> Symptoms resolve around the time menstrual bleeding begins.<ref name=":1" /> Symptoms vary,<ref name="Women2021">Template:Cite web</ref> though commonly include one or more physical, emotional, or behavioral symptoms, that resolve with menses.<ref name="Tiranini">Template:Cite journal</ref> The range of symptoms is wide, and most commonly are breast tenderness, bloating, headache, mood swings, depression, anxiety, anger, and irritability. To be diagnosed as PMS, rather than a normal discomfort of the menstrual cycle, these symptoms must interfere with daily living, during two menstrual cycles of prospective recording.<ref name="Tiranini"/> PMS-related symptoms are often present for about six days.<ref name="AFP2011">Template:Cite journal</ref> An individual's pattern of symptoms may change over time.<ref name=AFP2011/> PMS does not produce symptoms during pregnancy or following menopause.<ref name="Women2014">Template:Cite web</ref>
Diagnosis requires a consistent pattern of emotional and physical symptoms occurring after ovulation and before menstruation to a degree that interferes with normal life.<ref name=AFP2003/> Emotional symptoms must not be present during the initial part of the menstrual cycle.<ref name=AFP2003>Template:Cite journal</ref> A daily list of symptoms over a few months may help in diagnosis.<ref name=AFP2011/> Other disorders that cause similar symptoms need to be excluded before a diagnosis is made.<ref name=AFP2011/>
The cause of PMS is unknown, but the underlying mechanism is believed to involve changes in hormone levels during the course of the whole menstrual cycle.<ref name=Women2014/> Reducing salt, alcohol, caffeine, and stress, along with increasing exercise is typically all that is recommended for the management of mild symptoms.<ref name=Women2014/> Calcium and vitamin D supplementation may be useful in some.<ref name=AFP2011/> Anti-inflammatory drugs such as ibuprofen or naproxen may help with physical symptoms.<ref name=Women2014/> In those with more significant symptoms, birth control pills or the diuretic spironolactone may be useful.<ref name=Women2014/><ref name=AFP2011/>
Over 90% of women report having some premenstrual symptoms, such as bloating, headaches, and moodiness.<ref name="Women2021"/> Premenstrual symptoms generally do not cause substantial disruption, and only qualify as PMS in approximately 20% of pre-menopausal women.<ref name=":1">Template:Citation </ref> Antidepressants of the selective serotonin reuptake inhibitors (SSRI) class may be used to treat the emotional symptoms of PMS.<ref name=":1" />
Premenstrual dysphoric disorder (PMDD) is a more severe condition that has greater psychological symptoms.<ref name=AFP2011/><ref name=Women2014/> PMDD affects about 3% of women of child-bearing age.<ref name=":1" />
Signs and symptoms
Any disruptive, cyclical symptom could be a symptom of PMS, and some sources have suggested that the number of claimed symptoms could exceed even 200.<ref name=":3">Template:Citation</ref> However, some symptoms are relatively common in PMS. Common emotional and non-specific symptoms include stress, anxiety, difficulty with sleep, headache, feeling tired, mood swings, increased emotional sensitivity, and changes in interest in sex.<ref name="Merck">Template:Cite web</ref> Problems with concentration and memory may occur.<ref name="Women2014"/> There may also be depression or anxiety.<ref name="Women2014" />
Common physical symptoms include bloating, bilateral breast tenderness, and headache.<ref name="Tiranini"/>
The exact symptoms and their intensity vary significantly from person to person, and even somewhat from cycle to cycle and over time.<ref name=AFP2011/> Most people with premenstrual syndrome experience only a few of the possible symptoms, in a relatively predictable pattern.<ref name="Mayo"/> Additionally, which symptoms are accepted as evidence of PMS varies by culture.<ref name=":3" /> For example, women in China report feeling cold but do not report negative affect as part of PMS, while women in the US report negative affect but not feeling cold as part of PMS.<ref name=":3" />
The exclusion of certain symptoms associated with the menstrual cycle can pose a challenge for researchers. For example, period pain, which is common, is excluded, as it does not usually appear until menstruation, but some experience period pain prior. However, any kind of pain can contribute to stress, difficulty with sleep, fatigue, irritability, and other symptoms that do count towards a PMS diagnosis.<ref name=":3" />
Causes
While PMS is linked to the luteal phase, the causes of PMS are not clear, but several factors may be involved. Changes in hormones during the menstrual cycle seem to be an important factor, with changing hormone levels affecting some more than others.<ref name=":1" /> PMS occurs more often in those who are in their late 20s and early 40s, have at least one child, have a family history of depression, and have a past medical history of either postpartum depression or a mood disorder.<ref>Template:Cite book</ref>
Diagnosis
No laboratory tests or unique physical findings exist to verify a PMS diagnosis. However, the three key features are noted:<ref name=AFP2003/>
- The chief complaint is one or more of the emotional symptoms associated with PMS. Irritability, tension, or unhappiness are typical emotional symptoms.
- Symptoms appear predictably during the luteal (premenstrual) phase, reduce or disappear predictably shortly before or during menstruation, and remain absent during the follicular (pre-ovulatory) phase.
- The symptoms must be severe enough to cause distress or interfere with everyday life.<ref name=":1" /><ref name=":2">Template:Citation</ref> Mild or occasional symptoms, which are extremely common, do not necessarily qualify as PMS.<ref name=":2" />
The National Institute of Mental Health research definition compares the intensity of symptoms from cycle days 5 to 10 to the six-day interval before the onset of the menstrual period.<ref name="AFP2003" /> To qualify as PMS, symptom intensity must increase at least 30% in the six days before menstruation. Additionally, this pattern must be documented for at least two consecutive cycles.<ref name="Tiranini" /> In 2016, the Royal College of Obstetricians and Gynaecologists argued that the definition of PMS should be changed to no longer require the presence of a psychological symptom.<ref name=":3" />
To document a pattern, potentially affected individuals may keep a prospective record of their symptoms on a calendar for at least two menstrual cycles.<ref name=":3" /> This will help to establish if the symptoms are limited to the premenstrual time, predictably recurring, and disruptive to normal functioning. A number of standardized instruments have been developed to describe PMS, including the Calendar of Premenstrual syndrome Experiences (COPE), the Prospective Record of the Impact and Severity of Menstruation (PRISM), and the Visual Analogue Scales (VAS).<ref name="AFP2003" />
Additionally, other conditions that may better explain symptoms must be excluded,<ref name="AFP2003" /> as a number of pre-existing medical conditions may be made worse at menstruation.<ref name="Merck2022">Template:Cite web</ref> This is known as menstrual exacerbation or premenstrual magnification.<ref name="cambridge">Template:Cite journal</ref> These conditions may lead individuals who do not have PMS to incorrectly believe they have PMS when they have another underlying disorder, such as anemia, hypothyroidism, eating disorders and substance abuse.<ref name="AFP2003" /> A key feature is that these conditions may also be present outside of the luteal phase. Conditions that can be magnified perimenstrually include depression or other affective disorders, migraine, seizure disorders, fatigue, irritable bowel syndrome, asthma, and allergies.<ref name="AFP2003" />
Further, problems with other aspects of the female reproductive system must be excluded, including dysmenorrhea (period pain during menstruation, rather than before it),<ref name=":3" /> endometriosis, perimenopause, and adverse effects produced by oral contraceptive pills.<ref name="AFP2003" />
Severe symptoms may qualify as PMDD.<ref name="NIH2020">Template:Cite web</ref>
Management
Many treatments have been tried in PMS.<ref name=":6">Template:Cite book</ref> Typical recommendations for those with mild symptoms include:
- reducing salt and caffeine intake,<ref name=":4">Template:Cite web</ref>
- not drinking alcohol,<ref name=":6" />
- reducing stress, e.g., by scheduling fewer activities during the week before menstruation,<ref name=":6" /><ref name=":5">Template:Cite book</ref>
- learning what to expect with PMS,<ref name=":5" />
- increasing exercise,<ref name=":5" /> and
- improving sleep.<ref name="Women2014" /><ref name=":5" />
When self-care is not adequate, then medical management may be appropriate.<ref name=":5" />
Management of physical symptoms
Anti-inflammatory drugs such as naproxen may help with some physical symptoms, such as pain.<ref name="Women2014" />
Spironolactone is effective as a diuretic when water retention cannot be addressed through self-care alone;<ref name=":6" /> however, thiazide diuretics are ineffective.<ref name=":5" />
Hormonal medications
In those with more significant symptoms birth control pills may be useful.<ref name="AFP2003" /> Hormonal contraception is commonly used; common forms include the combined oral contraceptive pill and the contraceptive patch.<ref name=":5" /> This class of medication may cause PMS-related symptoms in some and may reduce physical symptoms in others.<ref name="AFP2003" /> They do not relieve emotional symptoms.<ref name="AFP2003" /><ref name=":5" />
Gonadotropin-releasing hormone agonists can be useful in severe forms of PMS but have their own set of significant potential side effects, such as bone loss.<ref name=":5" />
Progesterone support was used for many years – in the 1950s, a deficiency of progesterone was believed to be the cause of PMS<ref name=":3" /> – but it does not provide any benefit.<ref name=":5" /><ref>Template:Cite journal</ref>
Management of emotional symptoms
Antidepressants
Antidepressants, particularly SSRIs and venlafaxine, are used as the first-line treatment of severe emotional symptoms of PMS, and also in treating PMDD.<ref name=":5" /> Those with PMS may be able to take medication only on the days when symptoms are expected to occur, because relief often appears within a few days, rather than the longer timespan expected for depression or other common psychiatric conditions.<ref name=":5" /> Additionally, the minimum dose is often lower than for treatment of depression.<ref name=":5" /> Although intermittent therapy might be effective and acceptable to some, it might be less effective than continuous regimens for others, especially if they are also experiencing symptoms unrelated to the menstrual cycle.<ref name=":5" /> Side effects such as nausea and weakness are however relatively common.<ref name="Mar2013">Template:Cite journal</ref>
Vitamins, minerals, and alternative medicine
Calcium, magnesium, vitamin E, vitamin B6, chasteberry, and black cohosh may help some.<ref name=":5" /> St. John's wort is discouraged because it causes many drug–drug interactions.<ref name=":5" /> Although St John's wort may help some with PMS, it is ineffective for PMDD.<ref name=":6" /> Evening primrose oil does not help.<ref name=":5" />
Prognosis
PMS is generally a stable diagnosis, with susceptible individuals experiencing the same symptoms at the same intensity near the end of each cycle for years.<ref name="pmid10584765"/> Treatment for specific symptoms is usually effective. Unsuccessful medical management of severe symptoms frequently indicates misdiagnosis.<ref name=":5" />
Perimenstrual breast pain is associated with fibrocystic breast changes.<ref>Template:Cite book</ref>
Even without treatment, symptoms tend to decrease in perimenopausal women,<ref name="titleLifeWatch - Womens Health - Womens Reproductive Health: PMS" /> and induction of menopause through surgical removal of the ovaries is a treatment of last resort.<ref name=":5" /> However, those who experience PMS or PMDD are more likely to have significant symptoms associated with menopause, such as hot flashes.<ref name="AFP2011" />
Epidemiology
Over 90% of women report having some premenstrual symptoms, such as bloating, headaches, and moodiness. Mostly the symptoms are mild.<ref name="Women2021"/>
Globally, about 20% of women of reproductive age have PMS that disrupts their everyday lives.<ref name=":1" /> Additionally, about 30% of women have mild or moderate symptoms related to their menstrual cycles that do not disrupt their everyday lives.<ref name=":1" />
History
PMS was originally seen as an imagined disease. Women who reported its symptoms were often told it was "all in their head".<ref name=brennerclinic>Template:Cite news</ref> Woman's reproductive organs were thought to control them. Women were warned not to divert needed energy away from the uterus and ovaries. This view of limited energy very quickly ran up against a reality in 19th-century America that young girls worked extremely long and hard hours in factories; newspapers in the 19th century were peppered with remedies to help in the "tyrannous processes" of the menstrual cycle. In 1873 Edward Clarke published an influential book titled Sex in Education. Clarke came to the conclusion that female operatives suffer less than schoolgirls because they "work their brain less". This suggested that they have stronger bodies and a reproductive "apparatus more normally constructed". Feminists later took opposition to Clarke's argument that women should not leave the private sphere by showing that women could function in the world outside the home in spite of natural body functions.<ref>Template:Cite book</ref><ref>Tsang, T.L. (2015) 'Article 1: "A fair chance for the girls": discourse on women's health and higher education in late nineteenth century America', American Educational History Journal, 42(1-2), 137+, available: https://link.gale.com/apps/doc/A437059646/AONE?u=mlin_oweb&sid=googleScholar&xid=3b3d1b1e [accessed 04 Mar 2024].</ref>
The first formal description of what is now called PMS as a medical problem, rather than a normal and natural variation, goes back to 1931, in a paper presented at the New York Academy of Medicine by Robert T. Frank titled "Hormonal Causes of Premenstrual Tension".<ref name=":3" /> He incorrectly attributed premenstrual symptoms to an excess of the newly discovered sex hormone, estrogen.<ref name=":3" />
The specific name premenstrual syndrome first appeared in the medical literature in 1953.<ref name=":3" /><ref>Template:Cite journal</ref> At that time, medical researchers incorrectly thought that PMS was caused by a deficiency in progesterone.<ref name=":3" />
Since at least the 1990s, when PMDD became accepted, the definitions of PMS have focused on psychological symptoms.<ref name=":3" /> Throughout the history of PMS, many of the symptoms associated with it have been stereotypical feminine behaviors, such as expressing emotions or "nagging".<ref name=":3" />
Since then, PMS has been a continuous presence in popular culture, occupying a place that is larger than the research attention accorded it as a medical diagnosis. Some have argued that women are partially responsible for the medicalization of PMS.<ref name="Markens-22" /> They claim that women are partially responsible for legitimizing this disorder and have thus contributed to the social construction of PMS as an illness.<ref name="Markens-22" /> The public debate over PMS and PMDD may have been affected by organizations who had a stake in the outcome including feminists, the American Psychiatric Association, physicians and scientists.<ref name="Figert-23" />
Alternative views
Some supporters of PMS as a social construct believe PMDD and PMS to be unrelated issues: according to them, PMDD is a product of brain chemistry, and PMS is a product of culture, i.e. a culture-bound syndrome. Women are socially conditioned to expect PMS, or to at least know of its existence, and they therefore report their symptoms accordingly.<ref name="Tavris 1992"/><ref name=":3" /> Becoming educated about PMS narrows their interpretation of their experiences by teaching them that certain symptoms are accepted as part of PMS, and that other symptoms are not, even though an accepted symptom might be unrelated to PMS for that woman (who might have a different medical condition), and an excluded symptom might be part of PMS, but not mentioned because they did not think it was relevant.<ref name=":3" /> Social psychologist Carol Tavris also says that PMS is blamed as an explanation for rage or sadness.<ref name="Tavris 1992" />
The identification of PMS as a medical disorder has been criticized as inappropriate medicalization.<ref name=":3" /> These critics are concerned that society is pathologizing the menstrual cycle itself, even when the signs and symptoms are non-disruptive.<ref name=":3" />
The view of PMS as primarily a psychological situation, rather than primarily a biologically driven, medical condition dominated by physical symptoms, has also been criticized.<ref name=":3" /> This view makes it harder to address psychosocial factors, such as external stress and a lack of social support, that exacerbate premenstrual symptoms.<ref name=":3" /> Treating PMS as a psychological situation also makes it difficult to address menstrual exacerbation of other conditions, including catamenial epilepsy, menstrual migraine, and cyclical asthma.<ref name=":3" />
The limitation of PMS to premenstrual symptoms, rather than having a diagnosis that covers all symptoms associated with the menstrual cycle, has also been criticized.<ref name=":3" /> Critics of this limitation think that excluding common physical symptoms that appear during the menstrual phase, such as period pain, fatigue, and back pain, is an arbitrary distinction that tends to reinforce the view of PMS as primarily an emotional problem, rather than a biological one.<ref name=":3" /> They propose a focus on perimenstrual symptoms instead of strictly pre-menstrual ones.<ref name=":3" />
Research directions
Open research questions related to treatment include how to predict who will respond to SSRIs, which non-drug treatments are effective, and how to manage people who have PMS in addition to other medical conditions.<ref name=":02">Template:Cite book</ref>
Researchers are also working towards a single, uniform set of diagnostic criteria and to identify any objective characteristics that could be useful for diagnosis, such as any possible genetic predisposition.<ref name=":02" />