Every month every woman in her reproductive age has to experience her monthly menstrual cycle commonly called the “period”. It is a natural phenomenon that once the woman reaches puberty her body starts preparing for reproduction and her womb starts getting conditioned to give birth to a new life.
When this happens, a lining of blood starts forming in the uterus. Now if reproduction does not happen the body has to give up all this preparation and it is lost in form of menstrual blood. During the subsequent month, a new blood lining is formed in anticipation of reproduction by the body. In this process, the women’s body undergoes many changes physically as well as physiologically.
Hormones play an important role during this period and they are the major factors that bring about these changes. Apart from these, a woman can even undergo certain behavioral changes that are also attributed the hormones.
These changes can be seen a few days before the period starts. This phase is called PMS. Many even call PMS a myth. In this blog, we will discuss in detail regarding PMS, its associated signs and symptoms, and also the treatment options.
What Is PMS?
To understand what is PMS let us first look into the menstrual cycle in brief. The menstrual cycle often begins at puberty between the ages of 8 and 15 (average age of 12) and consists of four phases namely menstruation, the follicular phase, ovulation, and the luteal phase (1).
- Menstruation– is the elimination of the internal lining of the uterine wall along with other secretions from the body through the vagina.
- The follicular phase– starts on the first day of menstruation and ends with ovulation during which the follicle-stimulating hormone is released and produces 10 to 20 follicles in the ovary. Out of these follicles, only one keeps growing and travels to the ovarian surface
- Ovulation- indicates the formation of a mature egg by one of the ovaries.
- The luteal phase– During this phase, the follicle from which the mature egg bursts out releases a large quantity of progesterone and some estrogenic hormones. If fertilization does not occur, the progesterone levels decrease, leaving the uterine lining unstable which then falls away.
The term ‘premenstrual’ actually refers to the entire luteal phase of the menstrual cycle. The American College of Obstetricians and Gynaecologists defines PMS as the period which occurs approximately five days before menstruation and ends a few days after menstruation starts and is accompanied by physical and psychological symptoms (3). It was first formally described in 1931 (2). The symptoms typically begin between the ages of 25 and 35 years.
Causes of PMS
The causes of PMS are multifactorial and are still unclear. Various theories have suggested that there is a relationship between PMS and ovarian hormone levels, serotonin levels, and Gamma-
Aminobutyric acid (GABA) levels in the body (2). Some evidence also suggests that PMS is related to enhanced sensitivity to progesterone in women with underlying serotonin deficiency. Genetic factors also seem to play a role (4).
Symptoms of PMS
Numerous symptoms have been attributed to the syndrome and include a broad spectrum that includes physical, behavioral, and emotional domains. Symptoms commonly reported by women seeking PMS treatment are as follows
Physical– Breast swelling and tenderness, diarrhea or constipation body aches, headache, cramps bloating and gas, fluid retention and weight gain, fatigue, vertigo, inability to tolerate noise or bright lights, and acne (1).
Behavioral– Sleep disturbances, appetite changes, poor concentration, decreased interest, social withdrawal, aggressive behavior.
Mood– Irritability, mood swings, anxiety/tension, depression, feeling out of control, and reduced libido.
These changes occur due to the sudden drop in the levels of progesterone and estrogen hormones. However, they disappear a few days after menstruation once hormones are back to their elevated levels.
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Diagnosis of PMS
PMS impacts the quality of life of women negatively. Studies have shown that women with PMS also had significantly more days per month of impairment in relationships with others, as well as impairment in work, school, and household activities hence it becomes important to recognize the symptoms and treat them accordingly (5).
The diagnosis of PMS is based on the type of symptoms and the time of emergence in the menstrual cycle. To associate the symptoms with PMS, at least one physical and psychological symptom should occur five days before menstruation, these symptoms should end four days after menstruation, they should continue at least three menstrual cycles, and should adversely affect daily activities and interpersonal relationships (2).
Depression and anxiety most often mimic the psychological symptoms of PMS. In this context, it should be determined whether the woman’s mood disorder is related to the menstrual cycle. Therefore, women who are thought to be experiencing PMS should be consulted appropriately to rule out these diseases. Although there are no laboratory tests for PMS diagnosis, blood and urine analysis can be used to exclude other diseases (2).
A measure of the severity of PMS is the extent to which the symptoms impair functioning. If a symptom causes functional impairment, it should be considered worthy of treatment.The evidence that women with clinically significant PMS frequently experience impairment in one or more aspects of daily functioning provides a diagnostic tool for determining the severity of the problem.
The woman’s perception of her impairment due to PMS can be obtained by a clinical inquiry about the degree of impairment and what domains are affected (6).
Treatment of PMS
No single treatment is universally accepted as effective for PMS. It is recommended that PMS Management be carried out gradually by a multidisciplinary team. An integrated holistic approach has to be adopted.
First Step- Education and Consulting
- Raising Awareness
Although this situation varies according to culture, many women do not think that PMS can be treated and do not refer to their physicians because they hesitate to talk to others about it.
It is suggested that the woman should keep a PMS diary so that she can recognize the symptoms she has experienced and determine the type and severity of symptoms, when and how they occur, and how much they affect her life. For example, women who hold a diary can rearrange their meetings that correspond to the premenstrual period.
- Lifestyle Changes
Most women can only cope with PMS by making lifestyle changes
-Women are advised to exercise at least 30 minutes a day. Aerobic exercises, including walking, running, cycling, and swimming increases heart rate, lung function, sleep quality, and endorphin levels, while reducing fatigue and depressive mood.
-Adequate (at least 8 hours a day) and qualified sleep is recommended to reduce fatigue and depressive mood.
-Smoking is recommended to be stopped because it is known that nicotine worsens premenstrual symptoms.
-It is recommended that women communicate with their spouses, family members, and friends and share their feelings to be understood about how they feel during this period and to receive help from social support systems.
-If there is general bloating or body swelling, clothing that is not tight should be preferred, comfortable and supportive shoes should be worn, and supportive bras and elastic waistbands are recommended.
- Diet Regulation
Nutrition can be modified as follows to reduce the severity of PMS symptoms
-Six small meals, rather than three main meals per day should be preferred.
-Less fat, sugar, and alcohol consumption and more fiber, vegetables, and fruit consumption are recommended.
-Caffeine (tea, coffee, cola) and salt consumption should be reduced to decrease irritability and bloating.
-The consumption of whole-grain bread, barley, brown rice, beans, and lentils should be encouraged, as well as including food with a high level of protein, and complex carbohydrates can reduce cravings during this period.
-Iron-rich foods should be consumed with sources of vitamin C to replace iron lost in menstruation,
-Walnuts, chia seeds and flax seeds (1 spoonful/day) which are rich in omega-3 and fatty fishes should be added to the diet.
-Consuming calcium-rich foods such as yogurt and green leafy vegetables are recommended.
-Healthy snacking is recommended
- Coping With Stress
Stress increases the severity of PMS hence coping with stress significantly simplifies PMS management. The recommended methods of coping with stress are
-Relaxation exercises such as meditation and yoga,
-Having a bath, sleeping enough, dealing with a hobby or a massage may help depending on individual preferences.
Second Step- Non-Pharmacological Treatment
If daily life, work-life or interpersonal relationships are negatively affected, then a woman may even benefit from certain non-pharmacological treatment options along with the above recommended first line of treatment. These non-pharmacological treatment methods include cognitive-behavioral therapy (CBT) and complementary and alternative treatment (CAT).
Third Stage- Pharmacological Treatment
If the first two lines of treatments are proving to be insufficient and it is observed that the symptoms are not reducing certain drugs may be recommended. The first option is non-hormonal therapy to increase the transmission of serotonin hormone. The second option is hormonal therapy to increase the ovarian hormone level.
At the same time, symptomatic treatment may be applied to improve some premenstrual symptoms.
Fourth Stage- Surgical Treatment
This treatment option is resorted to as the ultimate treatment. It is recommended that women consult their gynecologists and opt for this option on their recommendation only. The surgical procedures done include oophorectomy or removal of ovaries from the body. Estrogen replacement is needed after this surgery. Other surgical approaches include the removal of the uterus along with the ovaries.
PMS is a common health problem, and women spend half their life with premenstrual problems and experience a reduction in self-confidence, social isolation, a decline in academic achievement, an increase in accident tendency, and loss of labor. With the management of PMS, the quality of life can be improved. The first step in PMS management is to create awareness, to make women self-screen, adopt lifestyle changes, apply nutrition suggestions and use stress coping methods.
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Author: Dr Pooja Nilgar (Content writer and editor)
- Makhanova, A. (2018) ‘Menstrual Cycle’, Encyclopedia of Evolutionary Psychological Science, pp. 1–6. doi: 10.1007/978-3-319-16999-6_426-1.
- Abay, H. and Kaplan, S., 2019. Current approaches in premenstrual syndrome management. Bezmialem Science, 7(2), pp.150-156.
- King, S., 2020. Premenstrual Syndrome (PMS) and the myth of the irrational female. The Palgrave handbook of critical menstruation studies, pp.287-302.
- Dickerson, L.M., Mazyck, P.J. and Hunter, M.H., 2003. Premenstrual syndrome. American family physician, 67(8), pp.1743-1752.
- Braverman, P.K., 2007. Premenstrual syndrome and premenstrual dysphoric disorder. Journal of pediatric and adolescent gynecology, 20(1), pp.3-12.
- Freeman, E.W., 2003. Premenstrual syndrome and premenstrual dysphoric disorder: definitions and diagnosis. Psychoneuroendocrinology, 28, pp.25-37.