Available Medical Treatments
Lifestyle and dietary changes generally provide some degree of relief to all women who experience PMS-related distress. If your condition improves only modestly, however, your doctor may suggest a medical approach. Since there are many claims made for the benefits offered by vitamins, food supplements, and some over-the-counter medications, you should not use any of them without consulting your physician. It is important to remember that while some physicians support the use of certain vitamins and supplements and believe in their possible effectiveness, others cite the lack of scientific evidence of any benefit, and warn of possible harm if the products are consumed in large doses. Among the many “PMS formulas” on the market are a number of multivitamins containing some combination of vitamin B6, magnesium, zinc, and vitamin A. The use of vitamin B6 for PMS dates back to the 1940s. For those who believe in its effectiveness, the connection thought to be in the vitamin's interaction with certain brain chemicals. However, its effectiveness has not been clinically proven and large amounts have been shown to be harmful. As little as 200 to 300 milligrams a day has been reported to cause toxic reactions resulting in pain or numbness in the hands or feet, awkwardness in walking or general clumsiness and nerve damage.
Some physicians have claimed that oil of evening primrose (Efamol), which contains linoleic acid and gamma-linoleic acid, helps relieve breast tenderness. However, this finding has not been confirmed in scientific studies; and the U.S. Food and Drug Administration has not approved the product as a food additive. Nevertheless, it remains widely available through health food stores and mail-order houses.
The benefits of some vitamins and food supplements, though still unproven, seem a bit more promising. In one study, vitamin E in dosages of 150 to 300 milligrams daily was reported to reduce PMS symptoms. Another study suggested that magnesium supplements may counter some of the behavioral changes associated with PMS, though magnesium can also be toxic in high doses and can impair calcium absorption. Finally, the amino acid L-tryptophan, classified as a food supplement and sold over the counter, has seemed to help some women. It may raise the serotonin level, allowing for a more restful sleep and reducing restlessness and food cravings.
Your physician may also choose from an array of prescription medications, though no “PMS drug” has yet been developed, and the effectiveness of pharmaceuticals in treating PMS has generated considerable debate. In fact, some of the medications used for PMS are potentially harmful, so you and your doctor should plan a conservative course of symptom management rather than generalized drug therapy.
Diuretics, or “water pills,” help the body eliminate excess fluid through the kidneys. Your doctor may prescribe a diuretic to reduce bloating if restricting your salt intake does not help. Although studies on the benefits of diuretics for PMS have shown mixed results, they have been used longer in PMS treatment than any other medication, and have been shown to ease other symptoms, such as fatigue and depression.
Because it inhibits the action of the hormone that causes water retention, spironolactone (Aldactone) is also selected to treat PMS symptoms. Physicians typically prescribe 25 milligrams of spironolactone four times a day from the time of ovulation to the onset of menstruation.
Bromocriptine (Parlodel), a drug that suppresses lactation after childbirth, is sometimes used to reduce PMS-related breast discomfort, though there is no evidence that women taking this medication show greater improvement than those who don't. The usual dosage is 2.5 milligrams once or twice daily from the date of ovulation until your period begins. Because there is a risk of side effects, your doctor will probably start this drug cautiously at low doses.
Mefenamic acid (Ponstel) is a non-steroidal, anti-inflammatory drug that is sometimes used to relieve premenstrual pain. The usual starting dose is 500 milligrams when symptoms appear, followed by 250 milligrams twice a day for two to three days. A major risk with this medication is its uncertain effect on a developing baby. Since PMS follows ovulation, you may not know you are pregnant until your period is late. Therefore, your physician may advise you to use a barrier contraceptive before prescribing mefenamic acid or other medications used to treat PMS symptoms. A variety of nonsterodial anti-inflammatory drugs are available, including such over-the-counter products as ibuprofen (Advil, Motrin). However, all carry a risk of stomach inflammation with habitual use.
Progesterone therapy has also gained many advocates, despite the fact that neither natural progesterone or synthetic progestins has been shown to be effective in scientific studies. In fact, the use of progesterone to treat PMS has not been approved by the FDA, and some scientists question the long-term safety and consequences of this therapy. Nevertheless, because some physicians claim to have seen improvements in their own patients, the use of progesterone to treat PMS symptoms remains common. According to the American College of Obstetricians and Gynecologists, the standard dosage for treating PMS is 50 to 100 milligrams of progesterone administered daily by intramuscular injections or 200 to 400 milligrams twice a day by vaginal or rectal suppositories. Treatment is started several days before symptoms are expected and is continued through the onset of a woman's period.
SPELLING OUT PMDD
Listed below are the official criteria for a diagnosis of “premenstrual depression.” “Luteal phase” refers to the second half of the menstrual cycle, following release of an egg. “Follicular phase” refers to the first half of the cycle. “Dysphoric” is medical jargon meaning “unhappy.”
Criteria for Late Luteal Phase Dysphoric Disorder
In most menstrual cycles during the past year, symptoms in B occurred during the last week of the luteal phase and remitted within a few days after onset of the follicular phase. In menstruating females, these phases correspond to the week before, and a few days after, the onset of menses. (In nonmenstruating females who had a hysterectomy, the timing of luteal and follicular phases may require measurement of circulating reproductive hormones.)
At least 5 of the following symptoms have been present for most of the time during each symptomatic late luteal phase, at least one of the symptoms being 1, 2, 3 or 4:
Marked affective lability, e.g., feeling suddenly sad, tearful, irritable, or angry.
Persistent and marked anger or irritability.
Marked anxiety, tension, feelings of being “keyed up” or “on edge.”
Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts.
Decreased interest in usual activities, e.g., work, friends, hobbies.
Easy fatigability or marked lack of energy.
Subjective sense of difficulty in concentrating.
Marked change in appetite, overeating, or specific food cravings.
Hypersomnia or insomnia.
Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of “bloating,” weight gain.
The disturbance seriously interferes with work or with usual social activities or relationships with others.
The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depression, panic disorder, dysthymia (chronic mild depression), or a personality disorder (although it may be superimposed on any of these disorders).
Criteria A, B, C, and D are confirmed by prospective daily self-ratings during at least two symptomatic cycles. (This diagnosis may be made provisionally prior to this confirmation.)
Source: American Psychiatric Association, Washington, DC.
A few studies indicate that medicines used to block ovarian function, known as “medical ovariectomy,” can halt the symptoms of PMS. In clinical trials, this has been accomplished by using Lupron as an injection or Synarel as a nasal spray to block the action of GnRH, the hormone that starts the menstrual cycle with stimulation of the ovaries.
However, blocking ovarian function essentially creates an artificial menopause, which can lead to osteoporosis and other postmenopausal medical problems. As a result, this approach is considered only in severe and disabling cases of PMS: the 5 percent to 10 percent of women whose PMS symptoms cause incapacitating disruptions to their jobs or family life. Therapy is generally discontinued after six months.
Some physicians prescribe tranquilizers or antidepressants, including fluoxetine hydrochloride (Prozac) for patients diagnosed with PMS. However, these medications can cause serious, even fatal, reactions in combination with other drugs and can lead to a wide range of side effects. They are generally reserved for serious illnesses such as major depression; and you should question any PMS treatment plan that seems to rely on these types of drugs without evidence of an underlyng emotional disorder.
Other Treatment Approaches
Nontraditional approaches to PMS treatment, such as acupuncture, chiropractic adjustment, and therapeutic massage have, in the past, been ignored by the medical community although this is slowly changing. Some women experience symptom relief, although no studies have
documented the effectiveness of nontraditional approaches and any benefits are considered speculative.
On the other hand, many women unquestionally benefit from joining a PMS support group. This can be particularly helpful when you are trying to modify certain behaviors, such as dietary habits. Meeting and talking with other women who share the condition, and having access to current PMS research are important benefits of support groups, as are the empathy and reassurance.
It's also possible that even the most classic cycle of PMS symptoms is masking an unrelated psychological or psychiatric problem. A skilled therapist can help uncover the presence of any hidden conditions. In general, psychotherapy can also help a woman explore the specific emotional issues that affect her premenstrually and learn healthy ways to express anger and frustration—common manifestations of PMS.
In any event, it's important to collaborate with your doctor while finding a treatment that works for you. Remember that even with your doctor's help, you may have to try several different approaches before you find relief. Keep charting your symptoms and remember that no single treatment for PMS is a one-step or permanent cure. If after a month or two of treatment, there is no change in your symptoms, you and your doctor can modify your action plan.
Taking Control
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If left undiagnosed or untreated, PMS can have a major impact on a woman's life. Whether at home or on the job, you may have to struggle to function normally when symptoms occur. Emotional distress caused by PMS may trigger marital or family conflicts. You may feel an increased desire for intimacy with your partner yet feel sexually unattractive. You may even notice that PMS prompts you to withdraw socially.
Recognizing these changes in your body and mood and planning strategies to accomodate them is half the battle. The more you understand yourself and your monthly menstrual cycle, the better you can manage your PMS symptoms.
Follow your treatment program faithfully and learn to communicate your feelings with others. On the days you feel most anxious or tired, enlist the help of family members to prepare meals or run errands so you can reduce the pressure on yourself. While the goal of PMS management is to maintain a normal lifestyle even during your most difficult days, don't create needlessly difficult targets for yourself by adopting the standards of a superhero.
Many women find that there are days when PMS interferes with productivity or relationships at work. Though some physicians still advocate avoiding or postponing extra tasks on days when PMS symptoms are the most challenging, many women find that taking charge of their health and moving forward with planned schedules and tasks helps them get through their PMS symptons. As you undertake some of the strategies in
this chapter and reduce the overall impact of PMS on your life, you may discover that your job, too, seems more manageable.
Although much work remains to be done before PMS is fully understood, the good news is that millions of women successfully manage their homes, jobs, academic pursuits, and creative endeavors at every phase of their menstrual cycle. Until the cause of PMS is finally established and a standardized treatment is developed, your best tactic is to understand your own PMS symptoms and take the initiative to control them.
