No Explanation Yet
The term premenstrual syndrome was coined in 1931, when researchers first suggested that the condition was due to a hormonal imbalance related to the menstrual cycle. More recent studies have documented that PMS does, in fact, occur only during the childbearing years between puberty and menopause and subsides during pregnancy. PMS can also affect women who have had their uterus removed leading researchers to conclude that the uterus is not part of the problem.
Despite these clues and the recognition of PMS as a legitimate medical concern, researchers have been unable to find a cause. Even today, no one knows for certain what triggers PMS, though a number of theories have been advanced.
Much of the research has focused on the hormones estrogen and progesterone, which are produced by the ovaries and are known to interact with certain brain chemicals. At about day 5 of the menstrual cycle, estrogen signals the lining of the uterus to grow and thicken, in preparation for receipt of a fertilized egg. Once an egg is released from one of the ovaries at mid-cycle, about day 14 of a 28-day cycle, progesterone production begins, causing the release of nutrients and the swelling of blood vessels to prepare for pregnancy. If the egg is not fertilized, the uterine lining and the egg are shed in menstruation.
Thus, estrogen, which interacts with important brain chemicals affecting your mood and energy, dominates the first half of the menstrual cycle, while progesterone, which tends to suppress the actions of these brain chemicals, is more prevalent during the second half.
THE PROGESTERONE CONNECTION
PMS coincides with the final enrichment of the uterine lining in preparation for arrival of a fertilized egg (see “A” at left). Not coincidentally, this phase of the lining's growth depends on increased levels of the hormone progesterone, which begins to appear as soon as an ovary releases its egg.
In addition to its effect on the uterus, the extra progesterone is thought to have a damping effect on certain chemicals in the brain, possibly accounting for the agitation and mood swings that often accompany PMS. But the connection—if there is one—is still far from clear. Many doctors find that additional progestrone, taken as a daily shot or suppository, helps to reduce symptoms of PMS.
Whatever the truth of the matter, this much is certain: If conception fails to occur, progestrone levels decline precipitously, and the hormone-starved uterine lining sloughs off in the monthly menstrual flow. During the following 2 weeks, when progesterone levels are low and the lining is relatively lean (see “B” at left), PMS symptoms generally abate.
Despite this, levels of the hormones themselves appear to be normal in women with PMS. To confound the issue further, one major study found that women with PMS continued to show symptoms even after their menstrual cycles were artificially “reset” with medication. Researchers are studying the possibility that some unknown outside factor disrupts the normal interaction of estrogen and progesterone with chemicals made in the brain to cause some PMS symptoms.
One theory links fluctuations in the levels of serotonin with PMS. Serotonin (a byproduct of L-tryptophan, an essential amino acid found in many foods) plays several important roles in the body: it helps regulate sleep and menstrual cycles as well as the appetite. Some researchers speculate that low levels of serotonin may underlie PMS, throwing off the delicate timing of ovulation and prompting the restlessness and food cravings so often experienced by women with PMS.
Other theories proposed by researchers include: a deficiency of endorphins, the chemicals in the brain that create a “natural high”; defects in the metabolism of glucose or vitamin B 6; low concentrations of zinc in the blood; fluctuations in prostaglandins, a family of hormone-like compounds found in most body tissue; low magnesium levels; an imbalance in the body's level of acidity; and chronic candidiasis, a vaginal yeast infection.
As of yet, there is no conclusive evidence to support any of these theories, making a definitive cure difficult, if not impossible. But research has shown that PMS responds well to a variety of treatments and that most women can minimize its effects by understanding and carefully managing their symptoms.
Deciding Whether You Have It
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The first step toward effective treatment is to confirm that your symptoms actually are caused by PMS. This is usually done by process of elimination, as there are no reliable tests to diagnose the condition.
Your doctor may first recommend some simple laboratory tests, such as blood tests or urinalysis, to rule out other conditions with similar symptoms, particularly diabetes or thyroid problems. If you regularly experience pelvic pain, your doctor may check for the presence of sexually transmitted diseases such as gonorrhea or chlamydia. You should also receive a thorough physical examination, including breast and pelvic exams, to rule out other undiagnosed medical conditions.
COLLECTING THE EVIDENCE
Mark your calendar on the day your period starts as Day 1. Number each subsequent day and use a letter code such as “A” for anger, “B” for breast tenderness, “C” for cravings, or “F” for fatigue to record any symptoms on the days they occur. You can use capital letters if the symptoms are severe and small letters if they're moderate, or use letters in combination with a rating scale of 1 to 10 to indicate mild to severe. Additional details to record include your daily weight and, to pinpoint when ovulation occurs, your basal temperature, taken after you wake up but before you get out of bed. Your local pharmacy should stock a basal thermometer.
Alternatively, design a simple chart that lists all of your symptoms down one side of a page and the days of your menstrual period across the top. Fill in the boxes that correspond with a given symptom and the day of your cycle in which it occurs. On days that you experience only mild symptoms, color in half the box.
The next step in establishing a diagnosis is to record your symptoms over a period of time to verify their appearance, severity, and duration. In fact, the only way PMS can be accurately diagnosed is by keeping a careful record of when each symptom appears each month. Simple record-keeping can be done with an ordinary calendar. See the nearby box on “Collecting the Evidence” for two methods.
It also helps to keep a diary that describes not only your symptoms but also their effect on your daily activities. Feelings of social withdrawal, outbursts at family members or co-workers, or difficulties in coping can be more thoroughly described in such a journal.
It's important to maintain your records for at least three menstrual cycles. Record your entries every day, while the symptoms and their effects are fresh in your mind. You and your doctor can then review the charts and journal to help determine whether you have PMS and the extent to which it affects your life.
Simple Steps
You Can Take Yourself
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After you've been able to document the cyclical nature of your symptoms and their severity, you and your doctor can develop a treatment plan. Your doctor may first recommend simple lifestyle changes, since PMS often responds remarkably well to modifications in eating habits, stress management, and increased amounts of sleep or exercise.
Caffeine is a major culprit of PMS symptoms. Found in a variety of substances—coffee, tea, soft drinks, chocolate and some over-the-counter medications—caffeine is a stimulant that is often consumed precisely for the “lift” it provides. Nevertheless, caffeine can exaggerate PMS-related problems such as anxiety, insomnia, nervousness, and irritability, and it can interfere with carbohydrate metabolism by depleting your body of vitamin B. Reducing your caffeine intake is a smart move to counteract PMS symptoms and can provide almost instant relief. In fact, some doctors routinely advise eliminating caffeine from the diet before every menstrual period as a first step in coping with PMS.
Many women with PMS gain several pounds during the two weeks preceding their period, much of this in fluid weight. Avoiding salty foods can dramatically reduce bloating and water buildup, resulting in less breast and abdominal tenderness and less swelling in the hands and feet. Since brain cells also have a tendency to retain fluid, you may find that a salt-free diet eliminates or curbs headaches and allows you to concentrate better.
Sugar can also play havoc on your body, especially in the days preceding your period. Eating sugary foods often initiates a vicious cycle of additional sugar cravings, as an increase in your body's need for B-complex vitamins prompts even more craving for sugar-laden simple carbohydrates. Although a link between PMS and difficulties in metabolizing sugar has not been proven, consuming sweets can put your body on a roller coaster between feeling weak and feeling high strung and jittery—your body's response to low sugar levels at one extreme, and elevated sugar levels at the other.
PMS OR PMDD?
PMS has been linked to serious psychological problems in a small group of women. In Great Britain, women have been acquitted of various crimes on the grounds that the PMS from which they were suffering at the time of their action caused a temporary psychiatric disturbance. Though PMS is not recognized as a valid legal defense in the United States, the American Psychiatric Association (APA) recently recognized the possible psychiatric implications of PMS when it classified the related Premenstrual Dysphoric Disorder (PMDD) as a “depressive disorder not otherwise specified,” and included it in the appendix of the APA's Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV.
PMDD, which is thought to affect fewer than 5 percent of menstruating women, is described by the APA as a pattern of severe, recurrent symptoms of depression and other negative moods that occur during the last week of the menstrual cycle and markedly interfere with daily living. While PMDD is not an official diagnostic category, the APA hopes its inclusion in DSM-IV will encourage further psychiatric research into the condition. (See “Spelling out PMDD.”)
Nicotine, a brain stimulant, can magnify PMS symptoms much like caffeine, so reducing or eliminating smoking should be part of any treatment program. Alcohol can also intensify symptoms because it depletes the body of vitamin B, disrupts the metabolism of carbohydrates, and affects the liver's ability to process hormones.
Some foods may genuinely relieve PMS symptoms. Complex carbohydrates such as whole grains, beans, fresh fruits, and vegetables help to maintain your body's essential vitamins and minerals. Eating a low-fat diet based on grains and vegetables while reducing your intake of red meat—especially during the two weeks prior to the beginning of your period—may help to control your PMS symptoms. And at least one study has suggested that a modest increase in calcium, to 1,300 milligrams per day, may reduce irritability and physical symptoms such as backaches.
Many women also find that exercise produces positive benefits in moderating PMS symptoms, while improving their general health. Consider a monthly workout plan that rotates activities designed to strengthen your muscles, reduce fat, and relieve tension. Vigorous exercise—running, biking, swimming, aerobics, racquet sports and the like—has been shown to elevate your mood and improve alertness, while calisthenics and body-building tone muscles and improve strength. Contrary to popular belief, exercise helps to control—not increase—your appetite.
With your doctor's approval, try a program that mixes more vigorous cardiovascular exercises during the early days of your menstrual cycle with stretching, flexibility exercises, and less vigorous cardiovascular work such as walking on the days when you're most prone to PMS symptoms. This regimen can increase your heart-lung capacity and improve your overall physical condition while reducing the strain on your breasts, thighs, and abdomen during the latter phase of your cycle.
PMS is also associated with disruptions in a woman's normal sleep patterns. Women with moderate to severe PMS symptoms are more likely to complain of insomnia and are known to spend less time in deep sleep than those who are symptom-free. Reducing caffeine intake can help. You may also benefit from short naps on certain days. In any event, try to get at least eight hours of uninterrupted sleep each night, especially during the latter half of your cycle.
You may also benefit from some stress management techniques. Unlike diet, exercise, and sleep, outside stress is the one factor of daily life that no one can control. How you approach and handle stress, however, can have a tremendous impact on your behavior and mood.
The causes of stress can be physical, such as chronic or episodic illness or injury; psychological, such as fears, anxieties, or frustrations; and social, such as crying children, rush-hour traffic, and even holiday preparations. These everyday aggravations are particularly annoying during the days you're experiencing PMS symptoms.
A stress management class can help you channel the tension caused by stress so you are less likely to lose control, a common complaint of women with PMS. Whether they emphasize breathing exercises, visualization, biofeedback, or other stress management techniques, a common theme is to help you maintain a positive attitude and develop realistic expectations.
How much improvement you can expect from these remedies—and how quickly—depends largely on your commitment to them and your willingness to change your habits. You may notice dramatic improvements almost immediately, or gradual improvement over several menstrual cycles. As you continue to record your symptoms, you may observe that more sleep or a brisk walk helps during certain premenstrual days, while modifying your diet helps during others. The bottom line is to focus on continual improvement rather than dwell on the symptoms.
Even though you can make many of these lifestyle and dietary changes without seeing a physician, it's better to enlist your doctor's expertise in developing a program tailored to your particular PMS symptoms and other health factors. Since no single treatment is uniformly effective for PMS, you can benefit from your physician's experience with other women who are successfully managing their condition.
