Premenstrual syndrome (PMS) refers to a wide range of physical or emotional symptoms that typically occur about 5 to 11 days before a woman starts her monthly menstrual cycle. The symptoms usually stop when menstruation begins, or shortly thereafter.

See also: Premenstrual dysphoric disorder (PMDD)

An exact cause of PMS has not been identified. However, it may be related to social, cultural, biological, and psychological factors.

PMS is estimated to affect up to 75% of women during their childbearing years.

It occurs more often in women:

• Between their late 20s and early 40s
• Who have at least one child
• With a family history of a major depression
• With a history of postpartum depression or an affective mood disorder

The symptoms typically get worse in the late 30s and 40s as a woman approachs the transition to menopause.

As many as 50-60% of women with severe PMS have an underlying psychiatric disorder (premenstrual dysphoric disorder).

A wide range of physical or emotional symptoms have been associated with PMS. By definition, symptoms are considered to be PMS-related if they occur during the second half of the menstrual cycle (14 days or more after the first day of the menstrual period) and are absent for about 7 days after a menstrual period ends (during the first half of the menstrual cycle).

The most common symptoms include:

• Headache
• Swelling of ankles, feet, and hands
• Backache
• Abdominal cramps or heaviness
• Abdominal pain
• Abdominal fullness, feeling gaseous
• Muscle spasms
• Breast tenderness
• Weight gain
• Recurrent cold sores
• Acne flare-ups
• Nausea
• Bloating
• Constipation or diarrhea
• Decreased coordination
• Food cravings
• Less tolerance for noises and lights
• Painful menstruation

Other symptoms include:

• Anxiety or panic
• Confusion
• Difficulty concentrating
• Forgetfulness
• Poor judgment
• Depression
• Irritability, hostility, or aggressive behavior
• Increased guilt feelings
• Fatigue
• Slow, sluggish, lethargic movement
• Decreased self-image
• Sex drive changes, loss of sex drive
• Paranoia or increased fears
• Low self-esteem

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 be conducted to rule out other potential causes for symptoms that may be attributed to PMS.

A symptom calendar can help women identify the most troublesome symptoms and to confirm the diagnosis of PMS.

Exercise and diet changes can help relieve symptoms. It is also important to maintain a daily diary or log to record the type of symptoms you have, how severe they are, and how long they last. You should keep this "symptom diary" for at least 3 months. It will help your doctor make an accurate PMS diagnosis and recommend appropriate treatment.

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

Your doctor may recommend a low-salt diet and avoiding simple sugars, caffeine, and alcohol. Regular aerobic exercise throughout the month helps reduce the severity of PMS symptoms.

Aspirin, ibuprofen, and other nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed if you have significant pain, including headache, backache, menstrual cramping, and breast tenderness.

Birth control pills may decrease or increase PMS symptoms.

In severe cases, antidepressants may be helpful. The first options are usually antidepressants known as selective serotonin-reuptake inhibitors (SSRIs). Cognitive behavioral therapy may be an alternative to antidepressants.

Patients who have severe anxiety are sometimes given anti-anxiety drugs.

Diuretics may help women with severe fluid retention, which causes bloating, breast tenderness, and weight gain.

Bromocriptine, danazol, and tamoxifen are drugs that are occasionally used for relieving breast pain.

Most women who receive treatment for specific symptoms related to PMS have significant relief.

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 suicide rate in women with depression is significantly higher during the latter half of the menstrual cycle.

See also premenstrual dysphoric disorder (PMDD).

Call for an appointment with your health care provider if PMS does not go away with self-treatment measures, or if symptoms occur that are severe enough to limit your ability to function.

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 and a balanced diet (with increased whole grains, vegetables, fruit, and decreased or no salt, sugar, alcohol, and caffeine) may prove beneficial.

The body may have different sleep requirements at different times during a woman's menstrual cycle, so it is important to get adequate rest.

Lentz GM. Primary and Secondary Dysmenorrhea, Premenstrual Syndrome, and Premenstrual Dysphoric Disorder: Etiology, Diagnosis, Management. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007: chap. 36

Yonkers KA, O'Brien PM. Premenstrual syndrome. Lancet. 2008:371 (9619): 1200-10.