Premenstrual syndrome (PMS) encompasses a range of physical and psychological manifestations that occur during the menstrual cycle, particularly a few days before menstruation. The symptoms of PMS occur simultaneously with the hormonal fluctuations of the menstrual cycle, such as increased oestrogen levels and progesterone deficiency. Symptoms can also be associated with serotonin levels.
These symptoms can range from mild to severe and include:1
- Changes in appetite
- Abdominal pain
- Mood swings
Treatment aims to provide relief and reduce its effects on daily life, a combination of pharmacotherapies (eg. pain killers, oral contraceptive pills, antidepressants) can be coupled with nonpharmacological therapies mainly including exercise, nutritional modifications and cognitive and behavioural therapies. All of which have proven to be effective. It is advisable to consult your healthcare provider to guide you with a suitable treatment plan based on the symptoms you experience.
Causes of premenstrual syndrome
The purpose of the monthly menstrual cycle is to prepare the body for pregnancy. Menstrual cycles vary in length and intensity and are the process by which an egg is released from the ovaries. The lining of the uterus sheds when the egg is not fertilised and there are a series of hormonal changes occurring. The menstrual cycle can be divided into four phases, the menstrual, follicular, ovulation and luteal phases. PMS spans a range of physical, emotional and behavioural symptoms which may be experienced during the last week of the luteal phase, just before the onset of your period. Nearly 48% of PAFAB who are of reproductive age experience PMS and about 20% of them have symptoms severe enough to affect their regular routine.2
The definitive cause is not conclusive but some people are affected more severely than others and it can be due to any of these causes.
Cyclical changes in hormones
Oestrogen and progesterone levels decrease dramatically after ovulation and could play a role in the development of PMS symptoms.
Chemical changes in the brain
Fluctuations in the levels of serotonin that are considered to play a crucial role in mood. Also, a drop in oestrogen can prompt the release of adrenaline which leads to the reduction of dopamine, serotonin and acetylcholine, and these may trigger depression and sleep problems.3
Existing mental health conditions
A family history of PMS, anxiety and depression, including postpartum depression can also increase this risk. You might also notice premenstrual exacerbation. This means that symptoms of underlying mental health conditions, like depression or anxiety, intensify before your period begins.
Certain habits or potential lifestyle factors can worsen as well as increase the severity of PMS symptoms. These include:
- Consuming foods high in fat, sugar and salt
- Lack of quality sleep
- Not exercising regularly
Also, the level of stress may worsen symptoms, as stress amplifies the activity of the sympathetic nervous system, which would result in an increase in the intensity of uterine contractions.4
A large number of factors may act together to influence the symptoms of PMS. It is likely that other hormones such as progesterone may exert their effects on neurotransmitters, which may impact your mood, like:
- Endogenous opioids
- Higher prolactin levels
- Fluctuations in glucose metabolism
- Insulin resistance
- Nutritional electrolyte deficiencies
Signs and symptoms of premenstrual syndrome
The duration of affective symptoms can vary from a few days to 2 weeks. Symptoms often worsen a week before and spike two days before menstruation begins and symptoms can be categorised as being either affective or somatic.5 Affective symptoms are those that affect mood or emotional responses, whilst somatic symptoms are physical symptoms.
- Depressed mood or dysphoria(distress)
- Social withdrawal
- Inability to focus
- Abdominal bloating
- Joint/muscle pain
- Breast tenderness
- Lack of energy
- Weight gain
For some, the physical pain and emotional distress are severe enough to interfere with their daily lives and these PMS symptoms are thought to disappear within four days after the start of the menstrual period. But a small number of women with PMS experience disabling symptoms every month and this form of PMS is called premenstrual dysphoric disorder (PMDD). Fortunately, a variety of treatments and self-care measures can effectively control the symptoms for most women.
Management and treatment for premenstrual syndrome
For PMS, treatment options may vary depending on a person’s specific symptoms. These can be managed by taking medications, making dietary changes, exercising and self-care methods.
Engage in at least 30 minutes of brisk walking, cycling, swimming or other aerobic activity most days of the week. Regular daily exercise can help improve your overall health and reduce certain symptoms, such as bloating, swelling, fatigue and a depressed mood.6
Vitamins and supplements
Ensure you are nourishing your body and eating a diet rich in nutrients. Some research suggests that including adequate amounts of vitamin D, calcium, thiamine (vitamin B1) and riboflavin (vitamin B2) in your diet can reduce the risk of developing PMS symptoms.7,8
Furthermore, magnesium deficiency can cause the onset of symptoms such as anxiety, depression, irritability and muscle weakness.9 Taking magnesium supplements has been suggested to help relieve PMS-related symptoms, like headaches, bloating, and irritability. Furthermore, taking magnesium with vitamin B6 may be even more beneficial than taking magnesium alone.10
Eating a balanced diet
Drinking plenty of fluids and eating smaller, more frequent meals prevents excessive bloating as well as limiting salt intake to reduce fluid retention. Incorporating foods high in complex carbohydrates such as fruits, vegetables and whole grains and having less caffeine or alcohol is also beneficial.
Ensuring adequate sleep
Aiming to get 7 to 9 hours of sleep each night will help to relieve fatigue and improve overall well-being.
Managing stress using relaxation techniques
The combination of stress and PMS may create a cycle of exacerbation. If you experience anxiety or irritation before your period, try breathing exercises, yoga or mindfulness-based stress reduction.11,12,13
Keep a diary of your symptoms for at least 2−3 menstrual cycles
These can be taken to a GP appointment so that they can diagnose you effectively.
Treatment also focuses on relieving physical and psychiatric symptoms. Many of these medications used can target the body’s hormonal activity (through suppression of ovulation) and others can affect the concentration of neurotransmitters such as serotonin, noradrenaline or dopamine in the brain.
Taking over-the-counter medication can also help to relieve painful symptoms such as abdominal cramps and headaches, and these include:
- Pain relievers such as acetaminophen to relieve muscle pain, cramps and headaches
- Non-steroidal anti-inflammatory drugs, to reduce cramp pain and muscle aches
- Diuretics to help relieve bloating and soreness
If these do not help, your doctor may also prescribe you a class of medications termed selective serotonin receptor inhibitors (SSRIs) which are used as first-line treatment of PMS that predominantly display emotional symptoms.14 Your doctor may also recommend taking the combined contraceptive pill to control hormone levels and therefore stop ovulation to reduce PMS symptoms.
If you have severe symptoms, speak to your GP about cognitive behavioural therapy (CBT) which may help to learn new ways to reframe and cope with PMS symptoms.13
Diagnosis of premenstrual syndrome
There is no single test that can diagnose PMS or PMDD, however, a doctor may diagnose PMS when symptoms:
- Interfere with daily activities
- Appear 5 days before the period and end 4 days within it starting
- Occur for at least 2−3 consecutive months
There are several risk factors that may make you more prone to developing PMS, and these include:15,16,17
- Family history
- Mood disorders
- Alcohol intake
- Diet high in salt, fat and sugar
Can I prevent premenstrual syndrome?
While there’s no cure for PMS, you can take steps to ease your symptoms by taking medications, making dietary changes, exercising and self-care methods.
How common is premenstrual syndrome?
PMS is particularly common during child-bearing age in PAFAB, with as many as 80% of them reporting at least one physical or psychiatric symptom.18
When should I see a doctor?
If PMS symptoms become severe enough to interrupt your regular routine on a monthly basis, the next step would be to reach out to your doctor. Healthcare professionals can diagnose PMS or PMDD and help you explore potential treatment options.
PMS manifests as a wide variety of symptoms including:
- Mood swings
- Muscle pain
- Mood disturbances
Symptoms tend to recur in a predictable pattern, but the emotional and physical changes you experience with PMS may interfere with your daily life. Whilst the cause for PMS is not established, it is thought to be due to cyclic changes in hormone levels as well as fluctuations in the levels of serotonin and other chemical neurotransmitters in the brain. Fortunately, treatments and lifestyle adjustments can help you to reduce or manage the signs of PMS.
- Gudipally PR, Sharma GK. Premenstrual Syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 May 8]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK560698/
- Borenstein JE, Dean BB, Endicott J, Wong J, Brown C, Dickerson V, et al. Health and economic impact of the premenstrual syndrome. J Reprod Med. 2003 Jul;48(7):515–24.Available from: https://pubmed.ncbi.nlm.nih.gov/12953326/
- Bu L, Lai Y, Deng Y, Xiong C, Li F, Li L, et al. Negative Mood Is Associated with Diet and Dietary Antioxidants in University Students During the Menstrual Cycle: A Cross-Sectional Study from Guangzhou, China. Antioxidants. 2019 Dec 26;9(1):23.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7023165/
- Vaghela N, Mishra D, Sheth M, Dani VB. To compare the effects of aerobic exercise and yoga on Premenstrual syndrome. J Educ Health Promot. 2019 Oct 24;8:199.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6852652/
- Ryu A, Kim TH. Premenstrual syndrome: A mini review. Maturitas. 2015 Dec;82(4):436–40.Available from: https://pubmed.ncbi.nlm.nih.gov/26351143/
- Ravichandran H, Janakiraman B. Effect of Aerobic Exercises in Improving Premenstrual Symptoms Among Healthy Women: A Systematic Review of Randomized Controlled Trials. Int J Womens Health. 2022 Aug 16;14:1105–14.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9392489/
- Bertone-Johnson ER, Hankinson SE, Bendich A, Johnson SR, Willett WC, Manson JE. Calcium and vitamin D intake and risk of incident premenstrual syndrome. Arch Intern Med. 2005 Jun 13;165(11):1246–52. Available from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/486599
- Chocano-Bedoya PO, Manson JE, Hankinson SE, Willett WC, Johnson SR, Chasan-Taber L, et al. Dietary B vitamin intake and incident premenstrual syndrome. Am J Clin Nutr. 2011 May;93(5):1080–6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3076657/
- DiNicolantonio JJ, O’Keefe JH, Wilson W. Review: Subclinical magnesium deficiency: a principal driver of cardiovascular disease and a public health crisis. Open Heart [Internet]. 2018 [cited 2023 May 8];5(1). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5786912/
- Fathizadeh N, Ebrahimi E, Valiani M, Tavakoli N, Yar MH. Evaluating the effect of magnesium and magnesium plus vitamin B6 supplement on the severity of premenstrual syndrome. Iran J Nurs Midwifery Res. 2010 Dec;15(Suppl1):401–5. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3208934/
- Kjellgren A, Bood SÅ, Axelsson K, Norlander T, Saatcioglu F. Wellness through a comprehensive Yogic breathing program – A controlled pilot trial. BMC Complement Altern Med. 2007;7:43.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2231388/
- Wl W, Ty L, Ih C, Jm L. The acute effects of yoga on cognitive measures for women with premenstrual syndrome. J Altern Complement Med N Y N [Internet]. 2015 Jun [cited 2023 May 8];21(6). Available from: https://pubmed.ncbi.nlm.nih.gov/25965108/
- Bluth K, Gaylord S, Nguyen K, Bunevicius A, Girdler S. Mindfulness-based Stress Reduction as a Promising Intervention for Amelioration of Premenstrual Dysphoric Disorder Symptoms. Mindfulness. 2015 Dec;6(6):1292. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4651211/
- Marjoribanks J, Brown J, O’Brien PMS, Wyatt K. Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database Syst Rev. 2013 Jun 7;2013(6):CD001396.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7073417/
- Hofmeister S, Bodden S. Premenstrual Syndrome and Premenstrual Dysphoric Disorder. Am Fam Physician. 2016 Aug 1;94(3):236–40. Available from: https://www.aafp.org/pubs/afp/issues/2016/0801/p236.html
- Hashim MS, Obaideen AA, Jahrami HA, Radwan H, Hamad HJ, Owais AA, et al. Premenstrual Syndrome Is Associated with Dietary and Lifestyle Behaviors among University Students: A Cross-Sectional Study from Sharjah, UAE. Nutrients. 2019 Aug 17;11(8):1939. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723319/
- Fernández M del M, Saulyte J, Inskip HM, Takkouche B. Premenstrual syndrome and alcohol consumption: a systematic review and meta-analysis. BMJ Open. 2018 Apr 16;8(3):e019490.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5905748/
- Wittchen HU, Becker E, Lieb R, Krause P. Prevalence, incidence and stability of premenstrual dysphoric disorder in the community. Psychol Med. 2002 Jan;32(1):119–32.Available from: https://pubmed.ncbi.nlm.nih.gov/11883723/