Fact sheet: Premenstrual syndrome

Most women will sometimes have abdominal pain or a headache, be tense, sad and irritable or feel bloated and uncomfortable in the days leading up to their period. The medical term for this phenomenon is “premenstrual syndrome” (PMS), also known as “premenstrual tension” (PMT). Some women have such severe PMS that they are unable to do everyday activities during that time. Some also have a hard time because of the prejudice that exists about women and hormones: as though they are at the mercy of their hormones and therefore irrational and unpredictable at times. For most women, the symptoms are not severe, and they take these swings around a period more or less in their stride.

But whether they have serious difficulties before a period, or are only bothered a little by it, many women would like to know what could be done to handle it better. In this fact sheet we look at PMS, how to cope and what could be done to relieve the symptoms.

What is premenstrual syndrome and how is it diagnosed?

Premenstrual syndrome is a set of physical and psychological symptoms that arise about a week to 10 days before a woman gets her monthly period (menstruation). For example, many women have breast tenderness and headaches, as well as pain in their lower belly and back. Others have fluid retention, sleep problems or indigestion. They often feel tired, depressed or irritable in the days leading up to their period. Some feel insecure, sad, and anxious, cry easily, find it hard to concentrate and have the feeling that they are no longer in control of their own body and emotions.

PMS symptoms usually go away again when a woman’s period starts. But they might carry on for the first few days of her period. If the problem really is PMS, though, it will go away – and then it will come back with the next cycle. It will not necessarily be the same throughout the years: PMS can come and go.

Some women report that they experience positive changes in the days leading up to their period, like having more energy and finding it easier to get things done. About 15 out of 20 girls and women who menstruate have PMS symptoms to some extent every now and again (75%). But up to 1 out of 20 women (5%) regularly have such severe PMS that it can affect their everyday lives. If a woman’s PMS is severe and clearly affects her mental health – causing, for example, depression, anxiety, tension and despair – some experts refer to it as premenstrual dysphoric disorder (PMDD).

The type and severity of premenstrual symptoms vary from woman to woman. Because PMS symptoms are so different in each woman, it is difficult to say how they will develop over time. One thing is sure though: they will go away after the menopause at the latest.

Most women who have PMS cope well with it in everyday life. Premenstrual syndrome is not easy to diagnose because the symptoms vary so much from woman to woman. The same symptoms can also have other causes. To be sure that it is PMS, the doctor will first ask exactly what symptoms you have and when you have them. She or he may ask you to keep a diary over two to three months, in which you would make notes about your menstrual cycle and symptoms. This helps to find out whether the symptoms have other causes like other abdominal problems or depression.

What causes PMS?

It is not clear what causes PMS. It is probably various biological and psychosocial factors, which play a role. From a medical point of view it is associated with variations in hormone levels during the menstrual cycle, but women who have PMS do not necessarily have changes in their hormone levels. One possible explanation is that some women’s bodies overreact to the by-products made when the hormone progesterone is broken down. This hormone is mainly released in the second half of the menstrual cycle, before the woman’s period starts. You can read more about the menstrual cycle here.

Whether or not a woman has PMS and how severe it is could also depend on other factors, such as psychosocial stress, cultural influences, her relationship with her own body and sexuality, food or other medical conditions.

How can I relieve my PMS symptoms?

Many women who have PMS try to take it easy around that time of the month, and balance out everyday stress with relaxing activities. You are the best judge of what will help you relax: you may find that it helps to have a few quiet evenings at home curled up on a sofa with a book or watching TV, or perhaps a warm bath, chatting with friends or going on a walk will do you good. Some women appreciate having this “time out”, using it as an opportunity to slow down and retreat from the pressures of everyday life.

There is a lot of advice out there about what changes you can make in order to relieve PMS or even make it go away completely. For example:

• regularly getting enough sleep,
• movement and exercise,
• relaxation techniques and meditation,
• not smoking,
• cutting down on alcohol and caffeine,
• a high-carbohydrate and/or low-salt diet.

Most of these strategies have not been scientifically proven to work. Some researchers have started to test exercise and relaxation in PMS. That does not mean that all this does not help – there simply has not been enough good-quality research in this area so far. You can find out if any of these strategies work for you by trying them out yourself. You could keep track of what happens over several menstrual cycles in your calendar or diary to see whether it affects your PMS symptoms.

Some women find it helps to talk to their partner about their PMS so that he or she can be more understanding, considerate and supportive about it. But others say that they sometimes find it hard to talk to their partner about premenstrual symptoms. Others are afraid to say that they have PMS in case people do not take them seriously when they are irritable or angry, putting it down to PMS instead of addressing problems. The effects the symptoms have on relationships – both at work and personal – as well as on women’s sexual lives can be the most difficult aspect of PMS. This possible impact has not been very well studied, however, although this was addressed in some research on psychological approaches to the problem, where improvement in symptoms appeared to also improve a couple’s sexual life.

Are there any psychological approaches that can help relieve PMS?

Cognitive behavioral therapy (CBT) is a psychological treatment that is often used to treat depression and anxiety disorders, as well as help cope with the symptoms of a variety of diseases. This approach involves trying to identify and change current unhelpful thought patterns and behavior. The aim is to find ways to cope better in everyday life. CBT is usually done in a number of sessions with a specially trained therapist. You can read more about how it works here.

First research results indicate that CBT might be a useful treatment for women who have PMS symptoms, because it might possibly help to reduce some of the depressive symptoms, for example. CBT is a treatment where you need to work actively with the therapist. It takes a while for cognitive behavioral therapy to start helping – it took just over a month in the trials. Unlike drugs that only work while you take them, if CBT works for you, the effects might last over time. There were no reports of adverse effects in the trials. At the moment the quality of the available studies is not sufficient to make a clear statement on the efficiency of CBT in premenstrual syndrome.

Are there any herbal products or dietary supplements that can help?

Some women also take herbal products or dietary supplements for their PMS, such as calcium, pyridoxine (vitamin B6), magnesium, evening primrose oil, chaste tree (vitex agnus castus), St John's wort (hypericum) and Ginkgo biloba.

Calcium supplements and vitamin B6 have been tested quite well in trials: calcium can possibly relieve PMS symptoms if it is taken twice a day at a dose between 750 and 1,000 mg. Vitamin B6 (pyridoxine) was found to ease PMS in studies too. Researchers concluded that it can probably relieve PMS symptoms at a dose between about 50 and 100 mg per day. But these supplements can also have adverse effects: pyridoxine sometimes leads to a nerve problem (“peripheral neuropathy”) which can cause leg pain. For calcium and pyridoxine to be able to have a positive effect, they have to be taken every day, not just on the days leading up to menstruation.

None of the other herbal products or dietary supplements has been shown to help relieve PMS symptoms in trials. Research on magnesium and evening primrose oil has produced contradictory results. You can read more about the research in this area here. And you will find general information about considering or choosing herbal products and dietary supplements in our fact sheet.

What medications are there?

There are several medications used to relieve different PMS symptoms. It is important to note, however, that most of these drugs are not licensed for treating premenstrual syndrome. If a medication is used in a disorder it has not been approved for, this is called “off-label use”. You can read more about off-label use here. Your doctor has to inform you about it and you might have to pay out of your own pocket for a medication when it is used off-label.

In order to relieve the typical PMS symptoms, women often use hormonal medications, which suppress the production of certain hormones produced naturally in the body and interfere with the menstrual cycle. Examples of such medications include hormonal contraceptives and GnRH analogs. The hormone progesterone is sometimes used too.

Other treatment options include taking diuretics, painkillers and antidepressant medications.

Hormonal contraceptives

The most common way to influence the menstrual cycle using hormones is by taking hormonal contraceptives, such as the “pill”. This treatment is obviously not suitable for women who would like to become pregnant. You can read more about how hormonal contraception works and what possible adverse effects it might have here.

In two trials researchers found indications that a contraceptive pill which contains two particular hormones – the progestin drospirenone and a low-dose estrogen – might help women with PMS: participants had fewer symptoms, coped better in everyday life, were more socially active, and were happier in their relationships. But the pill had adverse effects too, including nausea, breakthrough bleeding (“spotting”) and breast tenderness.

The trials only looked at severe PMS symptoms and only lasted three months. Moreover, their reliability is limited due to the fact that there were no results for a considerable number of participants, because they did not want to or were unable to participate in the trials’ follow-up. It also remains unclear what effect this pill has on milder symptoms and what effect it has in the long term. At the moment, European regulatory authorities are looking into whether pills containing drospirenone might carry a higher risk of blood clotting (thrombosis) than other pills.

There are a lot of hormonal contraceptives, containing different hormones in different combinations. There has not been enough research on which of these can help against PMS. But that does not mean that they cannot help. If you would like to use hormonal contraception, you can talk to your doctor about which pill could be suitable for you.

GnRH analogs

GnRH (gonadotropin-releasing hormone) is a hormone that regulates the release of so-called gonadotropins. Gonadotropins are sexual hormones that lead to the growth and maturation of egg cells and cause ovulation.

GnRH analogs are sometimes used to treat severe PMS. This means a great intervention in the hormone balance, which needs to be carefully considered. These drugs greatly reduce the production of hormones in the ovaries. But they often lead to menopausal-like symptoms while women are taking the drugs, such as hot flashes and sleeping  difficulties. PMS-like symptoms can also occur, episodes of depression for example. GnRH analogs should not be taken for longer than six months.

If a woman’s treatment lasts several months, she usually takes low doses of estrogen at the same time in order to replace the hormones whose production is affected by the GnRH analogs. This so-called “add-back therapy” aims to reduce the estrogen deficiency the drug can cause. But it might also allow the PMS symptoms to return. During a treatment with GnRH analogs you cannot become pregnant.

There has not been enough research to be able to say whether women with PMS can benefit from taking GnRH analogs.

Progesterone

Some women use the hormone progesterone during the few days leading up to their period. The reasoning behind this is that PMS might be caused by a low level of progesterone or by one that falls quickly in the second half of the menstrual cycle, so taking this hormone could help. In Germany, a gel containing progesterone is licensed for treating premenstrual breast tenderness. In an analysis of two studies in which progesterone tablets or progesterone vaginal suppositories were compared with a fake medication (placebo), the women in the group that took hormones did not feel better than the women who took the placebo. These women were also more likely to have irregular menstruation. But the studies were not very conclusive, so it is not possible to draw any clear conclusions about whether progesterone can help or not. Taking progesterone does not prevent pregnancy.

Diuretics (“water pills”)

Some women who have fluid retention and breast tenderness use diuretics (drugs that help your body get rid of excess fluid) because they hope it will make them feel better, both physically and mentally. Diuretics can cause adverse effects such as nausea and headaches. The body can also get used to the effect so that it retains more water once the diuretics are no longer taken. It is therefore important to use them with care and talk to a doctor about whether they are suitable for you before using them. If you do use diuretics, make sure you do not take more than instructed on the package insert because otherwise there is a danger that you will lose too much fluid.

Painkillers

Various painkillers are used in the treatment of PMS, including nonsteroidal anti-inflammatory drugs (NSAIDs), which is a group of drugs that reduce inflammation and relieve pain. Research on NSAIDs in PMS has mainly focused on the drugs naproxen and mefenamic acid. Many women who have headaches, belly ache and backache before their period use these painkillers. They are also used to treat period pain – you can read more about that here. The most common adverse effects of NSAIDs are stomach problems, nausea, vomiting, headaches and drowsiness.

Antidepressant medications

PMDD with significant psychological impacts like depression, anxiety and despair can be treated with medications that are usually used in depression – usually with the so-called “selective serotonin reuptake inhibitors” (SSRIs). These medications increase the concentration of serotonin, a neurotransmitter, in the brain. It is thought that serotonin influences the way in which women’s bodies react to certain hormones that are released in greater amounts before menstruation.

Researchers from the Cochrane Collaboration, an international research network, did a review of trials that compared SSRIs with a fake medication (placebo) for at least two menstrual cycles. In some of the trials the women took the tablets continuously, whereas in other trials they only took them in the second phase of their menstrual cycle. The researchers found that SSRIs can help women with severe PMS or PMDD: they were shown to relieve psychological symptoms in the trials. The women also coped better in everyday life again. But SSRIs only start relieving symptoms after taking them for at least three cycles.

If you are considering taking medication, it is important to know what adverse effects it could have. SSRIs can cause, for example, nausea, sleep problems and decreased libido. Several regulatory authorities, including the German Federal Institute for Drugs and Medical Devices (BfArM), issued a safety alert about a possible link between SSRIs and suicidal thoughts and self-harming behavior in children, teenagers and young adults.

Why does PMS have such a bad reputation?

Most of us will have heard comments and jokes about women and PMS – and women affected sometimes joke about it themselves. While it could help cope with the mood swings that are so common around periods, PMS is somehow both exaggerated and trivialized by this reputation. Then there is a danger that every bad mood is blamed on PMS, and other serious issues are ignored.

Remnants of old attitudes about women being unstable because of their hormones unfortunately survive, both in the medical world and everyday life. Men do not have to deal with their irritability being dismissed or put down to hormonal changes. What is more, there has been surprisingly little research on the positive changes that many women experience in the second half of their menstrual cycle.

Although women all around the world say they experience physical changes related to menstruation (like cramps or breast tenderness), PMS and the associated mood swings seem to be more common in Western cultures. This may mean that PMS is influenced by cultural factors and the modern demands on women in Western industrialized countries.

This does not, of course, mean that the changes women experience leading up to their periods are not real. However the kind of changes that occur and the symptoms they cause not only vary from woman to woman, they can also be influenced by society’s attitude towards menstruation and womanhood in general. Cyclical changes are then seen as an annoyance rather than a natural process. This might be little comfort when you are struggling with the effects in your life. But it might help to develop a more positive attitude to an experience that is shared by most women.


Author: German Institute for Quality and Efficiency in Health Care (IQWiG)

© IQWiG (Institute for Quality and Efficiency in Health Care)