The Challenges of Premenstrual Symptoms: PMS/PMDD

Midsouth Wellness Guide
OB/GYN
PMS/PMDD
The Challenges of Premenstrual Symptoms

By Riad Homsi, M.D., F.A.C.O.G.
Just For Women Premenstrual Disorders affect millions of American women during their reproductive years. It consists of a broad range of mood, behavioral and physical symptoms that are related to the menstrual cycle. These symptoms occur anywhere from several days to two weeks before a womans period and usually disappear with the menstrual ow. Even though the condition itself probably has not changed since it was rst described by the ancients, the name has changed from Late Luteal Phase Dysphoric Disorder (LLPDD) to Premenstrual Dysphoric Disorder (PMDD). However, gynecologists continued to use the term Premenstrual Syndrome or simply PMS.
What causes PMS?

The exact cause of PMS is unknown but considerable progress has been made in the past decade to understand some of its aspects. A number of factors may contribute to the condition. Women with a genetic predisposition have an increased vulnerability to develop these symptoms. Cyclic changes in ovarian hormones (estrogen & progesterone) seem to be an important cause, because signs and symptoms of PMS change with hormonal uctuations of the womans menstrual cycle and also disappear with pregnancy and menopause. Chemical changes in the brain may also be involved. One clue to the cause may be traced to uctuations of serotonin, a brain chemical (neurotransmitter) that is thought to play a role in mood states, especially depression. Insufcient amounts of serotonin may contribute to other symptoms of PMS, such as fatigue, food cravings and sleep problems. Occasionally, some women with severe premenstrual syndrome have undiagnosed depression, though depression alone does not cause all the symptoms associated with PMS.Stress also may aggravate some of the symptoms, but alone it is not the cause. Some PMS symptoms have been linked to low levels of vitamins and minerals. Other possible contributors include eating a lot of salty foods, which may cause uid retention, and drinking alcohol and caffeinated beverages, which may cause mood and energy levels disturbances.
What are the symptoms of PMS?

For many women the signs and symptoms of PMS are an uncomfortable and unwelcome part of their monthly menstrual cycle. The most common physical and emotional signs and symptoms include: Weight gain from uid retention Abdominal Bloating/constipation/diarrhea Breast tenderness and swelling Anxiety /Depressed mood Mood swings/ irritability/ anger/ crying spells/ tension Appetite changes and food craving Trouble falling asleep Joint or muscle pain Fatigue/Headache/Backache Trouble concentrating/remembering Skin problems/acne Although the list of signs and symptoms is long, most women with PMS experience only a few of these problems. But for some women, symptoms are so severe they are considered disabling. This form of PMS has its own psychiatric designation i.e. premenstrual dysphoric disorder (PMDD). This severe form of PMS has symptoms including severe depression, feelings of hopelessness, anger, severe anxiety, irritability and tension and low selfesteem.
How common?
The mild symptoms experienced by most women during the luteal phase (the 2 weeks before the onset of the cycle) are termed premenstrual molimina or changes. Most surveys have found that as many as75% of menstruating women report one or more premenstrual symptoms and are considered a normal aspect of ovulatory cycles. When these symptoms are sufciently bothersome to negatively affect a womans quality of life, they are described as premenstrual syndrome (PMS) .This occurs in approximately 20% of reproductive-age women. When the symptoms are severe enough to cause signicant impairment, this constitute premenstrual dysphoric syndrome (PMDD) which occurs in 5% of menstruating women.
Who is at Risk?
PMS and PMDD can occur in menstruating women of any age, most commonly between the late 20s and early 40s, have at least one child, have a family history of depression or have a past medical history of postpartum depression or a mood disorder. Genetics appears to play a role since the concordance rate of PMS is twice as high among Monozygotic (identical) twins as among dizygotic (nonidentical) twins. There are no signicant personality prole differences between women with PMS and normal women.Furthermore, PMS is not more likely to be diagnosed in women with higher level of stress. However, women who have PMS may not tolerate stress as well as women who do not have PMS. Premenstrual symptoms seem to affect women irrespective of culture or socioeconomic status, although specic symptoms may vary in frequency by culture.
What is the treatment?

The wide variety of symptoms associated with premenstrual disorders has resulted in numerous approaches being used for treatment. No one treatment works for every woman, so you may need to try different ones to see what works. Difculties vary from person to person, and often, from cycle to cycle. There is no one effective treatment for PMS and PMDD, but many women experience some relief of symptoms with changes in physical activity, diet, and lifestyle changes while others require more medication therapy.
How is PMS diagnosed?

There are no unique physical ndings or laboratory tests to positively diagnose PMS. However, your doctor may do routine baseline blood tests including a thyroid test. Your doctor may also ask you to keep a diary of your symptoms, the time and duration of their occurrences for at least two months. By doing this, you and your doctor can see if your symptoms correspond to certain times in your monthly cycle. While your symptoms may vary from month to month, a trend likely will appear after tracking your symptoms for few months.
1-Exercise: Try to incorporate some form of physical activity into your daily routine. Although aerobic activity (i.e., brisk walking, cycling, jogging, swimming, and roller blading)
April 2007 Midsouth Wellness Guide
Midsouth Wellness Guide

may have a greater benet, any type of exercise is benecial.Taking long walks with a pet, gardening, raking leaves, or practicing yoga or tai chi can be soothing. Exercise helps relieve constipation, fatigue, irritability, and sleep problems. On the other hand, you need to try to get enough rest and work on managing stress.
2- Nutrition: Follow a healthy diet .Do not skip meals. Going long periods of time between meals contributes to cravings, irritability, fatigue and sometimes headache. Most women do better eating smaller amount of food. Large meals often cause bloating and general discomfort. If necessary, eat a small snack between meals to curb hunger. Be sure to include fruits, vegetables, whole grain foods(whole wheat bread, whole grain crackers, oatmeal, brown rice, whole wheat pasta), protein-rich foods(sh, seafood, eggs, chicken, turkey, beef, pork, cooked dried beans, nuts, tofu, and soy products.),and calcium containing foods in your daily diet. New research has shown that a diet rich in calcium (Milk, Yogurt, Cheese, fortied soy milk, and fortied orange juice) and vitamin D (eggs, sh, sun exposure) may be associated with fewer symptoms. Cut back on salty foods starting a few days before your period is due. Most fast foods, chips, pretzels, olives, pickels, pizzas, pepperoni, sausage, cheese, Purchased soups, sauces and gravies are some examples of food high in salt. Limiting salty foods can help in alleviating bloating, swelling or weight gain. Limit your caffeine intake. Some women nd that less caffeine helps improve symptoms related to sleep, fatigue, and irritability. Cut down or avoid alcohol. Drinking alcohol has an effect on all the mood-related symptoms and can also disrupt sleep. 3-Supplements: Over the counter interventions with limited efcacy include multiples supplements:
A--Calcium: 1000-1500 mg of calcium per day may reduce some physical and Psychological symptoms of PMS. B--Magnesium: taking 400 mg of supplemental magnesium daily may help to reduce uid retention, breast tenderness and bloating. C--Vitamin B6: a daily dose of 50 to100 mg may help some women with PMS. D--Vitamin E: a daily dose of 400 IU or higher may help breast tenderness. E--Omega 3 essential fatty acids such as axseed oil, grapeseed oil, evening primerose oil, may alleviate pain, breast tenderness, bloating and irritability. F--Herbal medicine: Some women report relief of PMS symptoms with the use of herbs Such as black cohosh, ginger, raspberry leaf, dandelion, chasteberry, gingo biloba, St Johns wort, licorice rootHowever, few scientic studies prove the effectiveness of these herbs. G--Natural progesterone creams. These are derived from wild yams and soybeans. Some Women report that these creams relieve symptoms. No scientic studies prove their effectiveness. H--Over the counter medicine: Medicine over the counter usually combine aspirin or acetaminophen (Tylenol) with caffeine, antihistamines. Some brand names include Midol, Pamprin and PremsynPMS.Pain relievers include ibuprofen (Advil, Motrin, Nuprin), Ketoprofen (Orudis KT), and Naproxen (Aleve).
4-Prescription medication: Women with severe symptoms or with symptoms resistant to nonmedical approaches should be considered for drug therapy. a-Antidepressants: The only type of pharmacologic agent that is approved by the US Food and Drug Administration(FDA) for PMS/PMDD is a type of antidepressant i.e. a selective serotonin reuptake inhibitor(SSRI),since it was shown that persons with PMS/PMDD have a low level of a brain chemical called serotonin. The three SSRI approved are Sertraline (ZOLOFT), Fluoxetine (SARAFEM or PROZAC) and Paroxetine (PAXIL).These medications are effective when taken daily or intermittently (i.e. during the luteal phase or the 14 days prior to the onset of the menstrual cycle).Some studies have shown that these medications are effective up to 60% of improvement. The most common side effects are nausea, decreased libido, sedation, weight gain, and anxiety.
b-Diuretics(Fluid Pill):Because complaints of uid retention are common in the luteal phase(14 days before the onset of the menstrual cycle),diuretic therapy has been advocated.SPIRONOLACTONE is the only diuretic that has been shown to be of benet in PMS.In addition to decreasing physical symptoms associated with uid retention, it has been shown to increase positive symptoms(i.e., cheerfulness,well-being,feeling energetic, friendliness..) and to decrease negative symptoms(i.e., anxiety,tension,fatigue and irritability). c-Anxiolytics: Agents to decrease anxiety are often used to treat some aspects of PMS such as Alprazolam (XANAX) and Buspirone (BUSPAR) especially when used as adjunctive therapy with other medication. Side effects include sedation and lethargy. d--Birth control pills: these pills can help by evening out your hormone levels throughout your cycle. Some womens PMS symptoms get a lot better, some reported deterioration and some reported no effect. However, these results came from earlier studies using older traditional type of birth control pills. A new approach has been developed which is two fold: rst, the progestin component found in the previous BCP version ie.19-nortestosterone has been replaced by the new drospirenone , derived from 17-alpha-spironolactone (uid pill), and two, the 21/7 days regimen approach found in the classical BCP has been replaced by the 24/4 regimen where the active pills remain active for 24 days instead of 21 days in a 28 days cycle. This two fold approach, combined with a low dose estrogen component in the pill (YAZ), has been shown to be effective in reducing mood, behavioral, and physical symptoms of PMDD.This effect is similar to the result seen in studies of antidepressants.
Conclusion
Although not life threatening, premenstrual symptoms negatively affect the quality of life of millions of US women. As opposed to 15 years ago, there is now a body of data demonstrating effective therapy for PMS/PMDD, and the challenge is to individualize therapy based on the patients symptoms and goals.
About The Author

Riad Homsi, M.D., F.A.C.O.G. is a board certied Obstetrician/Gynecologist and Menopause Practitioner. He is the director of the practice Just For Women, located at 6025 Walnut Grove, suite 400, Memphis, TN 38120. For information, please call (901) 50-STORK or visit www.justforwomendoc.com
April 2007 Midsouth Wellness Guide

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Midsouth Wellness Guide

The Challenges of Premenstrual Symptoms

What causes PMS?

What are the symptoms of PMS?

What is the treatment?

How is PMS diagnosed?

April 2007 Midsouth Wellness Guide

Midsouth Wellness Guide

About The Author

April 2007 Midsouth Wellness Guide

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