Definition

Causes, incidence, and 
    risk factors

Prevention

Symptoms

Signs and tests

Epectations
Complications

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Alternative names: 
premenstrual tension; PMS; premenstrual dysphoria 

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Definition: 
A symptom or collection of symptoms that occurs regularly in relation to the menstrual cycle, with the onset of symptoms 5 to 11 days before the onset of menses and resolution of symptoms with menses or shortly thereafter. 

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Causes, incidence, and risk factors: 
An exact cause of PMS has not been identified; however, it may be related to social, cultural, biological, and psychological factors. PMS can occur with apparently normal ovarian function (regular ovulatory cycles). 

PMS is estimated to affect 70 to 90% of women during their childbearing years. Thirty to 40% of women are thought to have PMS symptoms severe enough to interfere with daily living activities, and 10% are believed to have symptoms so severe they are considered disabling. The incidence is higher in women between their late 20s and 40s years old, those with at least one child, those with a family history of a major depression disorder, or women with a past medical history of either post-partem depression or an affective mood disorder. 

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Prevention: 
Some of the lifestyles changes often recommended for the treatment of PMS 
may actually be useful in preventing symptoms from developing or getting worse. Regular exercise 3 to 5 times per week and a balanced diet (with increased whole grains, vegetables, fruit, and decreased or no salt, sugar, alcohol, and caffeine) may prove beneficial. Recognizing that the body may have different sleep requirements at different times during a woman's menstrual cycle, it is important to assure adequate rest. 

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Symptoms: 
A wide range of physical or emotional symptoms have been associated with PMS. By definition, such symptoms must occur during the second half of the menstrual cycle (14 days or more after the first day of the menstrual period) and be absent for about 7 days after menstrual period ends (during the first half of the menstrual cycle). 

Exacerbation of Other Medical Problems in the Premenstrual 
Phase
Migraines
Some studies have reported that half of women with migraines experience them during menstruation, although a recent one suggested that a true menstrual migraine (one that occurs regularly and only between two days before and three days after a period) occurs only in a small group of women.

Diabetes
The menstrual cycle may also affects diabetes, a disease that is defined by low levels of insulin or resistance to this hormone that is critical for efficient use of sugar (glucose) in the body. High estrogen and progesterone levels, which occur in the luteal phase, affect insulin, although their effects vary widely among individuals. In one study of women with insulin-dependent diabetes, 27% experienced higher blood sugar levels and 12% lower levels in the week before their period than at other times in the cycle. Some experts argue, however, that these blood sugar changes are due to cravings and dietary responses to PMS, not to insulin changes.

Asthma
Women with asthma are at higher risk for asthma attacks during the premenstrual phase. One study found that a combination of asthma-inducing effects, including lower resistance to stress and infections and increased hyperreactivity in the airways of the lungs, occurred during this time.

Other Disorders
Many other chronic disorders may be exacerbated during the premenstrual phase, including epilepsy, multiple sclerosis, systemic lupus erythematosus, and irritable bowel syndrome. Women are also more prone to seasickness in the premenstrual phase.

Emotional Consequences of PMS
Premenstrual syndrome, particularly premenstrual dysphoric disorder (PMDD), can have an adverse effect on a woman's relationships with co-workers, partners, and children. No studies, however, have found that women become mentally incompetent because of PMDD. Adolescents with severe PMS may be prone to high-risk behavior and suicidal thoughts. One study suggested that women who attempt suicide, in fact, are more likely to do so during the premenstrual phase or in the first week of the period. Women who are alcoholics or have close relatives who are alcoholics have a much higher risk for drinking during the premenstrual period. Alcohol increases the risk for prolonged cramping (dysmenorrhea) in women with severe PMS. One study showed a strong association between PMDD and eating disorders.

Breast Pain
Many women with severe breast pain (cyclic mastalgia) are worried about an increased risk for breast cancer. It is not yet known if such concern is warranted. One study found that women with cyclical mastalgia had a greater incidence of abnormal breast cells than those without severe premenstrual breast pain, although more research is needed to confirm any actual increased risk for breast cancer. Such women are more likely to have mammograms at an early age than others, although such tests are not generally useful in detecting breast cancer in women under 35.

The most common symptoms include: 

Symptoms must occur during the last week of the luteal phase in most menstrual cycles. They should resolve within a few days after the period starts.

Five or more of the following symptoms must be present:
1. Feeling of sadness or hopelessness, possible suicidal thoughts
2. Feelings of tension or anxiety
3. Mood swings marked by periods of teariness
4. Persistent irritability or that anger affects other people
5. Disinterest in daily activities and relationships
6. Trouble concentrating
7. Fatigue or low energy
8. Food cravings or bingeing
9. Sleep disturbances
10. Feeling out of control
11. Physical symptoms, such as bloating, breast tenderness, headaches, and
        joint or muscle pain

From The American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, DC, Copyright American Psychiatric Association 1994.

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Signs and tests: 
There are no physical examination findings or lab tests specific to the diagnosis of PMS. It is important that a complete history, physical examination (including pelvic exam), and in some instances a psychiatric evaluation may be conducted to rule out other potential causes for symptoms that may be attributed to PMS. 

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Researchers are still uncertain about the causes of premenstrual syndrome. Some experts are concerned that the inclusion of premenstrual dysphoric disorder (PMDD) in the psychiatric diagnostic literature may misrepresent the full problem. They warn that such categorization may restrict research on PMS only to psychiatric areas and, furthermore, that both women with PMDD and their physicians may view their PMS only as a psychiatric disorder and not as condition that may have physiologic causes unrelated to classic depression.

Reproductive Hormones and Neurotransmitters
Drugs known as gonadotropin-releasing hormone (GnRH) agonists relieve PMS symptoms by suppressing the hormones that cause ovulation. As a result, researchers can assume that reproductive hormones play an important role in PMS. Exactly what their roles are, however, is unclear. Premenstrual syndrome appears to be a complicated interaction between these reproductive hormones and neurotransmitters -- chemical messengers in the brain. The two neurotransmitters most likely to be involved in PMS are serotonin and gamma-aminobutyric acid (GABA). Low levels of serotonin are associated with depression and carbohydrate cravings, and GABA deficiences are linked to anxiety and susceptibility to seizures. Progesterone converts to pregnanolone, a compound known as a neurosteroid, which is essential for enhancing the effects of GABA, while estrogen appears to play an essential role in maintaining sufficient levels of serotonin. It should follow, then, that these hormones should protect against PMS. Nevertheless, a number of studies have indicated that progesterone may intensify symptoms, and a recent study has demonstrated that estrogen also appears to worsen symptoms in women with PMS (but not in women without the syndrome). Some studies are indicating PMS patients may be less responsive to the anti-anxiety effects of progesterone than women without PMS. The findings on estrogen are unexpected, however, since during the follicular phase, when progesterone levels are low and estrogen levels are high, women do not experience PMS symptoms. The researchers concluded that women with PMS have an abnormal response to normal hormonal variations. Another study found that high concentrations of both estrogen and luteinizing hormone, which is released by the pituitary gland during the premenstrual phase, were associated with severe symptoms in women with PMS.

Calcium and Magnesium Imbalances
Calcium and magnesium levels vary widely during the menstrual cycle, and some researchers believe certain imbalances in these minerals may play a part in premenstrual disorder. One study observed very low levels of magnesium and high levels of calcium during the premenstrual phase. Calcium and magnesium affect communication between nerve cells and the opening and closing of blood vessels -- functions that may be important in the development of PMS symptoms. Some experts hypothesize that deficiences in magnesium or excess amounts of calcium may be responsible for triggering symptoms. The effects may be more complicated than this, since taking calcium supplements appears to reduce PMS symptoms, and taking magnesium seems to have no effect.

Stress Hormones
Other hormones under investigation are the neurotransmitters and hormones related to stress. Following a stressful event, the part of the brain called the hypothalamic-pituitary-adrenal (HPA) system releases certain neurotransmitters called catecholamines, particularly those known as dopamine, norepinephrine, and epinephrine (adrenaline). These chemicals trigger the release of the steroid hormones known as glucocorticoids, which in turn produce cortisol -- the primary stress hormone. Cortisol affects systems throughout the body. Some studies indicate that the stress response in women with PMS may be more intense than in those without the syndrome.

Other Factors
Some researchers are studying certain peptides and other hormones that vary during the menstrual cycle among women with and without PMS. These substances include arginine vasopressin (AVP), which affects water retention, and atrial natriuretic peptide (ANP), which increases sodium elimination. Some PMS symptoms, particularly breast pain, may be caused by excess levels of prolactin, a hormone produced by the pituitary gland that stimulates the glands in the breasts. Results of a study of women who had both PMS and heavy bleeding (menorrhagia) suggested that substances in the endometrium might cause PMS symptoms, at least in women who also have menorrhagia (heavy menstrual bleeding).

Premenstrual syndrome is reported in women in all cultures worldwide. Although only 2% of women fit the strict criteria for premenstrual syndrome, an estimated 40% of women in their reproductive years experience PMS symptoms severe enough to impair daily activities. In a survey of adolescents, 88% reported moderate to severe premenstrual symptoms. In another study, younger women also had a higher risk for severe premenstrual syndrome than older women, and women with more children were more likely to experience severe symptoms than those with fewer children. Other risk factors included having a mother with PMS and being sedentary. The results of this study indicated that genetic susceptibility and stress probably play a role in the severity of symptoms.

Treatment: 
Self-care methods include exercise and dietary measures mentioned previously under the "Prevention" category. It is also important to maintain a daily diary or log to record the type, severity , and duration of symptoms. A "symptom diary" should be kept for a minimum of 3 months in order to correlate symptoms with the menstrual cycle. The diary will greatly assist the health care provider not only in the accurate diagnosis of PMS, but also with the proposed treatment methods. 

Nutritional supplements may be recommended. Vitamin B6 , calcium, and magnesium are commonly used. 

Prostaglandin inhibitors (aspirin, ibuprofen, other NSAIDS) may be prescribed for women with significant pain, including headache, backache, menstrual cramping and breast tenderness. Diuretics may be prescribed for women found to have significant weight gain due to fluid retention. 

Psychiatric medications and or therapy may be used for women who exhibit a moderate-to-severe degree of anxiety, irritability, or depression. 

Hormonal therapy may include a trial on oral contraceptives which may either decrease or increase PMS symptoms. The use of progesterone vaginal suppositories during the second half of the menstrual cycle is still controversial. 

Diet
Making dietary adjustments starting about 14 days before a period may help some women with premenstrual syndrome and, perhaps, some mild menstrual disorders. Some experts suggest eating frequent small meals with no more than three hours between snacks. The general guidelines for any healthy diet are recommended, including eating plenty of whole grains, fresh fruits and vegetables and avoiding saturated fats and commercial junk foods. Avoiding red meats and dairy products during the premenstrual period may be beneficial for some women. A recent study found that reducing salt does not alleviate bloating or other symptoms, but salt reduction in the study was modest and may have been too small to effect improvement. Moderating salt intake is always wise, in any case. Reducing caffeine, sugar, and alcohol intake may be beneficial. While regular consumption of alcohol can reduce the risk for developing cramps in women who don't have them, it increases the length of cramping time in women who ordinarily do experience pain during menstruation. It should also be noted that having even one drink a day increases the risk for breast cancer, so alcohol is never recommended to prevent menstrual cramps, and any women with severe menstrual pain who drinks should consider stopping altogether. Increasing the amount of fish in the diet may help reduce menstrual disorders. In one study of Danish women, menstrual pain was greater in women with lower levels of omega 3 fatty acids, which is found in fish oil. In another study, supplements of fish oil appeared to reduce heavy bleeding in adolescent girls.

A complex carbohydrate powdered drink mix called PMS Escape appears to alleviate symptoms in some women and is available over the counter. In one study, patients reported improvement in anger, depression, tension, and confusion between an hour and a half and three hours after drinking the mixture. Within that time cravings for sweet and starchy foods diminished. Other studies have also found that the carbohydrate drink helps reduce food cravings as well as mood swings and problems in concentration. The powder is made of compounds that increase levels of tryptophan, a substance that is important in the production of serotonin, the chemical messenger in the brain that affects appetite and mood.

Exercise
Exercise is very important in maintaining good health. One study indicated that PMS is more severe in women who do not exercise. (Exercise, however, does not appear to have any affect on menstrual cramps, either in decreasing or increasing them.) Even just taking a 30-minute walk every day is beneficial. Although very vigorous exercise can cause menstrual irregularity and even amenorrhea, few women exercise to the extent that these occur. For those who do, a recent study found that simply adding calories can restore menstruation in women who experience amenorrhea from extreme weight loss, excessive exercise, or both. Competitive athletes do not have to stop exercising, then, to restore fertility; they simply need to eat more.

Calcium and Magnesium
During PMS magnesium and calcium levels fluctuate. In one study, taking 1200 mg of calcium daily reduced all PMS symptoms by nearly half after three months, and some experts now recommend taking calcium before trying antidepressants. Some women take magnesium supplements for PMS symptoms, but studies have not confirmed any benefit.

Vitamins
There have been some reports that premenstrual symptoms or menstrual disorders may be caused by deficiencies of vitamins A, E, B-6, and thiamin or other nutrients, including the minerals zinc and magnesium. No studies, however, have confirmed this. Some women report that taking between 50 mg and 300 mg of vitamin B6 daily alleviates their PMS symptoms. It should be noted that very high doses (500 mg to 2,000 mg daily over long periods) can cause nerve damage with symptoms of instability and numbness in the feet and hands. Food sources of B6 are meats, oily fish, poultry, whole grains, dried fortified cereals, soybeans, avocados, baked potatoes with skins, watermelon, plantains, bananas, peanuts, and brewer's yeast. (Women prone to Candida vaginitis -- the so-called yeast infection -- should not increase their intake of dietary yeast.) One study reported relief from menstrual pain using vitamin B1 (thiamin). Thiamin is found in almost all foods, but the best source is pork and other, good sources are dried B-fortified cereals, oatmeal, and sunflower seeds. Vitamin E supplements have also been tried for PMS symptoms and cramps, but no studies have shown them to be more effective than placebos.

Herbal and Other So-Called Natural Remedies
Studies have not found herbal or other so-called natural remedies to be any more effective than placebo for relieving PMS symptoms or reducing menstrual disorders, and they can be expensive. It is certainly possible that some herbal medicines may be helpful, but patients should always be wary of unproven claims for quick cures. Some women have reported that taking evening primrose oil helped symptoms of bloating, depression, and breast tenderness. An analysis of the few studies done on primrose oil found no value for PMS, however. Ginger tea is safe and may help in relieving nausea. The Chinese herb dong quai has chemical properties that dilate blood vessels and may prevent blood vessel spasms. It has traditionally been used for helping to relieve menstrual cramps, although no studies have proven its effectiveness. The herb increases the skin's sensitivity to the sun and should not be taken in high amounts. Another herbal remedy commonly used for PMS is black cohosh. It has properties that open blood vessels and may also affect estrogen levels. It can cause dizziness and headache in high amounts. Women with PMS appear to have lower levels of melatonin, a powerful hormone that regulates sleep, but there are no studies to indicate whether taking melatonin supplements is beneficial.

Until scientific studies determine actual benefits, proper doses, and side effects of unregulated herbal and other natural products, the patient is at risk for ineffective or even harmful treatments. It is dangerous to assume that simply because a substance is "natural", it has no side effects and is completely safe. High doses of any herbal or so-called natural medicine are not necessarily safer than traditional drugs, and because of the lack of manufacturing standards and knowledge about toxicity or interactions with other drugs, they may be even more dangerous.

Selective Serotonin-Reuptake Inhibitors
Selective serotonin-reuptake inhibitors (SSRIs) are drugs that keep increased levels of serotonin (also called 5-HT) available in the brain. Serotonin is important in the regulation of depression, sleep, and appetite. These drugs are also useful for reducing anxiety, which may account for their greater success in treating PMS compared to other antidepressants. Standard SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxitine (Paxil), and fluvoxamine (Luvox). Studies using Prozac and Zoloft have reported that they relieve premenstrual depression, irritability, and tension. Other SSRIs are also being investigated for this benefit.

Women who become pregnant while taking SSRIs should not be unduly alarmed. A number of studies have indicated that SSRIs are generally safe for pregnant women, although one study found an increase in minor birth defects, such as smaller than normal fingernails when women took Prozac in the first trimester.

Overdose of SSRIs is much less harmful than with the other types of antidepressants. SSRIs can cause agitation, nausea, and sexual dysfunction, including delay or loss of orgasm and low sexual drive. Taking a drug "holiday" on weekends may improve sexual function during that time, although this should be done under a physician's direction. Withdrawal symptoms can include sleep problems, exhaustion, and dizziness, and returning depression. Such a tactic for improving sexual drive may not work for those taking Prozac, which is longer-acting than other SSRIs and so takes longer than a weekend for the drug's effects to lessen. Intermittent Prozac therapy (taking the drug only during the 14-day premenstrual period) may be as effective as continuous therapy for PMS and would considerably reduce the risk for adverse effects. Prozac does have some major side effect, however, and all unorthodox uses of the medication should be conducted under the careful supervision of a physician. During the first few weeks of treatment, some patients lose a small amount of weight, but they generally regain it. Other side effects include dizziness, headaches, insomnia, increased anxiety, and exhaustion. High doses or interactions with other drugs may cause hallucinations, confusion, changes in blood pressure, stiffness, and irregular heartbeats. Drugs that may have particularly dangerous interactions with SSRIs include other antidepressants and illegal drugs (e.g., LSD, cocaine, or "ecstasy").

GnRH Analogs
Injections of potent hormonal agents, particularly gonadotropin-releasing hormone (GnRH) agonists, such as nafarelin (Synarel), goserelin (Zoladex), leuprolide (Lupron Depot), and histrelin (Supprelin) have been used for the treatment of PMS. Ovulation is suppressed during this treatment, creating a temporary menopause-like state. Certain symptoms of PMS improve, including breast tenderness, fatigue, and irritability; GnRH analogs, however, appear to have little effect on depression. They are useful for relieving symptoms of severe endometriosis, fibroids, or menorrhagia. GnRH agonists are also used to determine if symptoms are actually caused by PMS. If they persist after the drug is taken, then PMS is unlikely to be the cause.

Because loss of estrogen can lead to irreversible osteoporosis (bone loss), the drugs are not taken for more than six months. If they are, low-dose estrogen replacement, called add-back therapy, is needed. Some experts do not believe GnRH analogs should be used as primary treatment for PMS for even as short a period as six months. Women who are at risk for osteoporosis should consider GnRH analogs with caution. Risk factors for osteoporosis include smoking, alcohol abuse, long-term use of certain drugs (such as corticosteroids) that reduce bone density, and a family history of osteoporosis. Women should be sure they are not pregnant before using these drugs, because they increase the risk for miscarriage. Other common side effects include hot flashes, mood swings, reduced sexual drive, headache, nausea and vomiting, memory loss, changes in the skin and hair, rapid heartbeat, vaginitis, and weight changes. The risks and benefits of long-term therapy are not known. Small studies of women who used leuprolide for up to three years have not reported any permanent pituitary damage that could affect fertility. To help offset side effects, researchers are testing the use of add-back therapy, which provides low doses of estrogen and progestin. These hormones are added to the GnRH analog regime at levels that are too low to offset the beneficial effects of the GnRH analog, but which are high enough to reduce its side effects and prevent bone loss. Studies have shown this add-back regimen to be helpful for endometriosis and fibroids, but in severe PMS, the beneficial effects of GnRH are diminished. Women who are taking GnRH analogs or other non-contraceptive hormones should use non-hormonal birth control methods (such as the diaphragm, cervical cap, or condoms) while on these treatments, because the drugs can increase the risk for birth defects if pregnancy occurs.

Estrogen and Progesterone
Both estrogen and progesterone are elevated during the luteal phase when PMS occurs. Progesterone has been thought for some time to be a factor in worsening symptoms, although rectal or vaginal progesterone suppositories have had some success in reducing symptoms, including improving mood. Experts have believed that estrogen, on the other hand, may be beneficial, but a recent study indicated that it, too, might also worsen PMS symptoms. In one study, however, about half of the women who used estrogen skin patches reported reduced PMS symptoms after eight months. In women with asthma, the use of estrogen may reduce the severity of symptoms during the premenstrual phase, when they are often worse than at other times. Oral contraceptives containing estrogen appear to reduce hyperreactivity in the airways associated with asthma attacks.

Antianxiety Drugs
Antianxiety drugs may be helpful for women with severe PMS who also suffer from anxiety. The most common of these are the benzodiazepines. In one three-month study, 37% of women taking alprazolam (Xanax), a common benzodiazepine, felt that symptom severity was reduced by half compared to 30% of those taking either progesterone or a placebo. Common side effects are daytime drowsiness and a hung-over feeling. Respiratory problems may be exacerbated. Overdose is very serious, although rarely fatal. Benzodiazepines are potentially dangerous when used in combination with alcohol. The drug must be used sparingly, because dependence is a common danger and can occur after as short a time as three months of use. By using Xanax for only a few days per month when symptoms are most severe, the risk of dependence is reduced. A unique anti-anxiety drug, buspirone (BuSpar), may have some value for premenstrual symptoms of anxiety and depression, although in one study it was not as effective as the SSRI antidepressant Prozac. BuSpar belongs to a class of drugs called azapirones, which have less severe side effects than benzodiazepines and no significant potential for addiction.

Clomipramine
Clomipramine (Anafranil) is one of the tricyclic antidepressants. It has also been effective in treating obsessive-compulsive disorders. Patients report more side effects with Anafranil than with SSRIs, although low doses are used for premenstrual syndrome. It is important that this drug not be taken with the antidepressants known as monoamine oxidase inhibitors (MAOIs).

Diuretics
Diuretics are prescription drugs that increase urination and help eliminate water and sodium from the body. They reduce bloating in women with PMS and also have a beneficial effect on mood, breast tenderness, and food craving. Spironolactone (Aldactone) is most commonly used for this purpose. Other common diuretics include hydrochlorothiazide (Esidrix, HydroDiuril) and furosemide (Lasix). Unless potassium is replaced, many diuretics deplete the body's supply of potassium, possibly leading to heart rhythm disturbances. Spironolactone, however, is known as a potassium-sparing drug and does not have this problem. Diuretics should not be used for mild or moderate PMS symptoms. Diuretics should not be taken with certain antidepressants; women taking other medications should check with their doctors about possible drug interactions.

Danazol
Danazol (Danocrine) is a synthetic substance that resembles male hormones. It suppresses estrogen and menstruation and is used, sometimes in combination with an oral contraceptive, to reduce dysmenorrhea, menorrhagia, fibroids, and symptoms of endometriosis. It has also been used for pain relief from cyclical mastalgia -- severe breast pain. In one study, 65% of women who took it for six consecutive menstrual cycles achieved pain relief. Adverse side effects include facial hair growth, deepening of the voice, weight gain, acne, and dandruff. It may increase the risk for unhealthy cholesterol levels. There is no experience to date with long-term use. Pregnant women or those trying to become pregnant should not take this drug, because it may cause birth defects.

Tamoxifen
Tamoxifen is a drug used for treating and, possibly, for preventing breast cancer. In one study it was more effective in relieving breast pain from cyclical mastalgia than danazol. Tamoxifen also has properties that may benefit the heart, although it increases the risks for blood clots and endometrial (uterine) cancer.

Bromocriptine
Bromocriptine (Parlodel) is a drug that is useful for breast pain caused by abnormalities in prolactin secretion.

Cognitive-behavioral methods are effective ways to reduce stress and may be useful for women with PMS. They include identifying sources of stress, restructuring priorities, and finding methods for managing and reducing stress. Some work is aimed at reframing women's perception of menstruation as a more positive experience in order to reduce functional impairment during the days around menstruation. One study showed promise with this technique and the researchers stressed the need for further work.

Often women do not recognize that the decline in their mood and the premenstrual phase coincide. It is useful to start the process of stress reduction with an informal diary of daily events and activities tracked by days of the menstrual cycle. The first step is to note those activities that put a strain on energy and time, trigger anger or anxiety, or precipitate a negative physical response (e.g., a sour stomach or headache). Positive experiences should also be noted -- those that are mentally or physically refreshing or produce a sense of accomplishment. While this exercise might itself seem stress producing -- yet one more chore -- it need not be done in painstaking detail. A few words accompanying a time and date will usually be enough to serve as reminders of significant events or activities. Women should try to identify two or three events or activities that have been significantly upsetting or overwhelming. Priorities and goals should then be carefully examined. Women should question whether the stressful activities meet their own goals or someone else's, whether they have taken on tasks that they can reasonably accomplish, and which tasks are in their control and which ones aren't, particularly during the premenstrual phase.

The next step is to attempt to shift the balance from stress-producing to stress-reducing activities. A recent study indicated that daily pleasant events have positive effects on the immune system. In fact, adding pleasurable events has more benefit than simply reducing stressful or negative ones. Planning ahead for such activities during the premenstrual phase may be very helpful. When eliminating stress is not practical, there may be ways to reduce its impact. Making time for recreation is as essential as paying bills or shopping for groceries. Many people are afraid of being perceived as selfish if they make decisions that benefit only themselves; the truth is that self-sacrifice may be inappropriate and even damaging if the person making the sacrifice is unhappy, angry, or physically unwell as a result. In most cases, small daily decisions for improvement can accumulate and work to reconstruct a stressed existence into a pleasant and productive one.

The concept of communication and "letting your feelings out" has been so excessively promoted and parodied that it has nearly lost its value as good psychological advice. Nevertheless, feelings of anger or frustration that are not expressed in an acceptable way may lead to hostility, a sense of helplessness, and depression. Expressing feelings does not mean venting frustration on waiters and subordinates, boring friends with emotional minutia, or wallowing in self-pity. The primary goal is to explain and assert one's needs to a trusted individual in a positive way. Direct communication with another person may not even be necessary; relief from stress can sometimes be achieved by writing in a journal or composing a letter that is never mailed. Expressing one's feelings is not enough, however; learning to listen, empathize, and respond to others with understanding is just as important for maintaining the strong relationships necessary for emotional fulfillment and reduced stress.

Negative feelings not only foster hostility but also hamper people from achieving goals. Learning to focus on positive outcomes helps to reduce tension levels. Knowing intellectually that the premenstrual phase will end does not always relieve emotional stress, but it is important to keep the end in mind. It may also be helpful to envision undertaking activities during other times of the month when symptoms are not as severe.

Keeping a sense of humor during any difficult situation is a common recommendation from stress management experts. Laughing releases the tension of pent-up feelings and helps keep perspective. Research has shown that humor is a very effective coping mechanism for acute stress.

Acupuncture and Other Alternative Techniques
Some women have reported relief from pelvic pain after acupuncture. Of particular interest is reflexology, a technique that uses manual pressure on acupuncture points on the ears, hands, and feet. In one study comparing this technique to a sham procedure, those who had true reflexology had significantly fewer PMS symptoms than did women in the other group. Yoga, other exercises, and meditative techniques that promote relaxation may also be helpful.

Phototherapy, which uses fluorescent light up to 50 times more intense than ordinary light, is now a recommended treatment for seasonal affective disorder (SAD), which is a form of depression related to reducing sunlight in winter months. Some experts now believe that phototherapy may be useful for premenstrual dysphoric disorder, in which there appear to be low levels of melatonin, the hormone in the brain that regulates sleep. There are a few side effects, including headache, eyestrain, and irritability. Patients taking drugs for psoriasis or vitiligo, certain antibiotics, or antipsychotic drugs should not use light therapy.

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Expectations (prognosis): 
After adequate diagnosis and symptom-specific treatment has been initiated, most women with PMS obtain significant relief. 

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Complications: 
PMS symptoms may become severe enough to prevent women from maintaining normal function. Women with depression may note increasing severity of symptoms during the second half of their cycle and may require associated medication adjustments. The incidence of suicide in women with depression is significantly higher during the latter half of the menstrual cycle. 

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Calling your health care provider: 
Call for an appointment with your health care provider if PMS does not resolve to self treatment measures, or if symptoms occur that are severe enough to limit functional ability. 

Recent Literature
Allopregnanolone in women with premenstrual syndrome. Horm Metab Res 1998 Apr;30(4):227-30

Antidepressant for premenstrual syndrome. HealthNews, October 1997

Asthma and menstruation: the relationship between psychological and bronchial hyperreactivity. Br J Med Psychol 1998 Mar;71 ( Pt 1):47-55

Cardiovascular response to cognitive stress in subjects with menstrually related disorders. Cephalalgia 1997 Dec;17 Suppl 20:5-7

Citalopram increases pregnanolone sensitivity in patients with premenstrual syndrome: an open trial. Psychoneuroendocrinology 1998 Jan;23(1):73-88

Comparison of fluoxetine, bupropion, and placebo in the treatment of premenstrual dysphoric disorder. Journal of Clinical Psychopharmacology. August 1997

GABA(A) receptor alpha4 subunit suppression prevents withdrawal properties of an endogenous steroid. Nature 1998 Apr 30;392(6679):869-70

Intermittent fluoxetine dosing in the treatment of women with premenstrual dysphoria. Psychopharmacol Bull 1997;33(4):771-4

Luteal-phase estradiol relates to symptom severity in patients with premenstrual syndrome. J Clin Endocrinol Metab 1998 Jun;83(6):1988-92

Luteal phase ovarian steroids, stress arousal, premenses perceived stress, and premenstrual symptoms. Res Nurs Health 1998 Apr;21(2):129-42

Incidence of premenstrual syndrome and remedy usage: a national probability sample study. Altern Ther Health Med 1998 May;4(3):75-9

Patients with premenstrual syndrome have a different sensitivity to a neuroactive steroid during the menstrual cycle compared to control subjects. Neuroendocrinology 1998 Feb;67(2):126-38

Pituitary-adrenal hormones and testosterone across the menstrual cycle in women with premenstrual syndrome and controls. Biol Psychiatry 1998 Jun 15;43(12):897-903

Premenstrual dysphoric disorder and eating disorders. Cephalalgia 1997 Dec;17 Suppl 20:25-8 34

Premenstrual dysphoric disorder: controversies surrounding the diagnosis. Harv Rev Psychiatry 1996 Jan-Feb;3(5):293-5

Premenstrual syndrome -- Pathophysiologic considerations. The New England Journal of Medicine, 1/22/98

Premenstrual syndromes. Clin Obstet Gynecol 1997 Sep;40(3):564-76

Premenstrual symptoms. Prevalence and severity in an adolescent sample. J Adolesc Health 1998 May;22(5):403-8

Prevalence and impact of cyclic mastalgia in a United States clinic-based cample. American Journal of Obstetrics and Gynocology, July 1997

Sex steroid hormones modulate serum ionized magnesium and calcium levels throughout the menstrual cycle in women. Fertil Steril 1998 May;69(5):958-62

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