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Premenstrual Syndrome

Original Editor - Khloud Shreif
Top Contributors - Khloud Shreif, Hana Menessi, Kim Jackson and Aminat Abolade


Definition

Premenstrual Syndrome (PMS) is a combination of physical, psychological/emotional, or behavioral symptoms that start one or two weeks before the beginning of menstruation after the ovulation period. The severity ranges from mild to severe which may hinder their work and ADL activities. The symptoms start to resolve at the beginning of menstruation as the hormone levels start to return to normal. PMS symptoms may change throughout your life in severity and complaints. Depression, stress, or a history with postpartum depression are all contributing factors that may worsen your symptoms. PMS may get worse when women approach menopause, especially at the end of their 30s or 40s, and stop after menopause. If the woman has a history of seizure disorders, migraines, asthma, or allergies they will get worse during the PMS period. PMS represents about 75% of women of reproductive age, and severe symptoms are found in about 5–8% of women. There is an increased risk of suicide with PMS and PMDD compared with women without premenstrual disturbances[1].

Premenstrual dysphoric disorder (PMDD) is similar to PMS but characterized by severe irritability, depression, and anxiety and affects 3–8% of menstruating women[2].

Cause of Premenstrual Syndrome

The definite cause for PMS is still not fully understood and may be multifactorial causes:

  • The most suggested is fluctuation in hormones levels (ovarian hormones) during the menstruation cycle which in turn affects central neurotransmitters. There is evidence suggesting that a low level of circulating serotonin and enhanced progesterone sensitivity can explain PMS in some cases.
  • Prostaglandin (PG) deficiency, PG has a role in forming prostaglandin precursors from linoleic acid[3].
  • Genetic factors and depression may worsen the symptoms of PMS[4].
  • The role of minerals and vitamins in etiology is still debatable and their role in treatment also[3].
  • Stress increases the intensity of uterine contractions, by amplifying the sympathetic activity.[5]

[6]

Clinical Presentation

Symptoms can last from few days up to 2 weeks, they often get worse a week before menstruation and spike 2 days before the start of menstruation.[7]

Physical symptoms:

  • Abdominal bloating and cramping.
  • Fatigue.
  • Constipation
  • Headache.
  • Breast tenderness.
  • Constipation or diarrhea.
  • Change in appetite.
  • Disturbance with sleeping ( sleeping more than usual or sleeping too little)
  • Skin problems, acne.
  • Gastrointestinal symptoms.
  • Muscles and joint pain
  • Low back pain
  • Weight gain
  • Low tolerance to noise and light


Emotional symptoms:

  • Depression.
  • Anxiety.
  • Anger.
  • Oversensitivity.
  • Mood swing.
  • Crying spells
  • Less interest in sex.
  • Insomnia.
  • Poor concentration.
  • Drowsiness
  • Concentration and memory problems
  • Loss of confidence

Diagnostic Procedures

There is no definitive diagnostic test and the diagnosis of PMS depends on reporting the symptoms for at least two or three months.

When rating the symptoms they must be present five days before the start of menstruation (during the luteal phase) for at least two cycles as recommended by RCOG, and these symptoms resolve within 4 days after the start of a period, these symptoms should:

  • Negatively affect her ADLs and may cause some impairments.
  • Exclude other diagnoses that may cause similar symptoms.
  • One of the four physical symptoms (abdominal bloating, headache, breast tenderness, and swelling of extremities), and one of the following (angry spells, depression, anxiety, confusion, irritability, and social withdrawal) according to American College of Obstetricians and Gynecologists[3].

She can use daily reporting severity scale to record her symptoms daily.

Outcome Measures

Visual analogue scale[8].

Premenstrual Tension Syndrome Observer (PMTS-O)

Premenstrual Tension Syndrome Self-Rating (PMTS-SR).

Management / Interventions

Medical management

Selective serotonin reuptake inhibitors (SSRIs) are the first pharmacological line recommended by RCOG guidelines for severe PMS, it was effective in treating moderate and severe symptoms of PMS, and should be discontinued gradually to avoid withdrawal symptoms if given on a continuous[9].

Combined oral contraceptive pills (COC)[9].

GnRH analogs are effective in the treatment of PMDD and cannot be used for a long period it may cause genital atrophy and bone loss because of estrogen deficiency. Used when SSRI and COC failed to treat symptoms.

Diuretics (water pills) such as Spironolactone.

Vitex agnus-castus[10][11], is the only herbal medicine for Controlling PMS-associated mood swings and irritability. It is safe to use and was superior to placebo, however, further research about Vitex is still needed[3].

Antidepressant.

NSAID.

Cognitive Behavioral Therapy

RCOG guidelines stated that "When treating women with severe PMS, CBT should be considered routinely as a treatment

option" level of evidence A. CBT help women to control and manage their symptoms can be useful for some women, and its effect will maintain for a period of time[12][13].

Dietary Modification

Reduction of the following:[14][15][16]

  1. Caffeine: Excessive Caffeine intake can exacerbate mood swings and anxiety[17]
  2. Alcohol: Disrupt hormonal balance and affect serotonin levels in the brain, which can exacerbate mood swings, depression, and anxiety. Additionally, alcohol can lead to dehydration and bloating, which may intensify physical discomfort during menstruation.[18]
  3. Processed foods: Contains unhealthy fats, sugars, and additives that contribute to hormonal imbalances.
  4. Salty foods: can lead to bloating and water retention.

Physical Therapy Management

Exercise

Exercises and a healthy diet is the first-line treatment for PMS, repeated muscle contraction during physical exercises prevents accumulation of PG and other substances so reduces back and abdominal pain, it also has a positive effect on stress management, reduces depression, and improves mood[19].

Aerobic exercises for example increase RBC, decrease the levels of progesterone and estradiol, increase beta-endorphin level and increase pain tolerance, resulting in improvement of concentration, fatigue, and the majority of PMS symptoms[20][21].

Swimming

In swimming exercise, the body weighs only one-tenth of its actual weight relieving the normal gravity pressure on both muscles and joints. The pressure of water on the skin and muscles improves venous return. The massage like soothing effect of water on the skin causes special brain responses with calming of the body. Adding water jets or bubbles of air exaggerates these effects.

Females were instructed to engage into swimming exercise 30 min daily, three times weekly for 3 months.

Exercise was ceased on the first 3 days of menstrual cycle and then resumed afterwards.

The exercise included three stages: warming up, swimming, and cooling down:

  1. Warming up phase involved 5 min of breathing, circulatory, and stretching exercises.
  2. The second phase of treatment was swimming for 20 min starting with 5 min walking inside the pool around its edges, and then forth and back swimming without reaching fatigue level for 15 min.
  3. The last phase was cooling down phase which was the same exercises of the warming up phase for 5 min.
Myofascial Release Technique[22]

To be done with dry hands, without lubricating oils or creams.

  1. 3 minutes of tension will be applied to the superficial fascia, transversalis fascia and extraperitoneal fascia for antero-lateral release.
  2. followed by, 3 minutes of tension will be applied to the thoracolumbar fascia and erector spinae muscle for posterior abdominal wall release.
  3. To wrap it up with, 3 minutes of tension applied to the cervical region.

This technique is known to raise the pain threshold and decrease pain intensity. It is believed that the improvements in pain management occur due to the relaxation of the fascia, which reduces sensitivity, and the subsequent increase in blood flow.

Yoga

Yoga demonstrated a strong effect on depression symptoms and can be used as a complementary treatment for PMS management[23] to reduce physical and emotional symptoms associated with PMS[24] it reduces body aches, breast tenderness, and abdominal cramps and is composed of (breathing, Asanas, and Meditation Phase).

Yoga postures (Asanas)

Yoga reduces stress, the inflammatory mediators, and regulates levels of IgA so has a positive effect on the immune system. In another study when Yoga was performed for 10 weeks, 3 sessions per week, 60 min for each session this was associated with improvements in sleeping disturbance[25] .

Aromatherapy

Aromatherapy depends on applying essential oils on the skin for massage, spraying in the air, inhaling with normal breathing, or pouring them into bath water, it stimulates the brain to exert such as dopamine and serotonin that regulate the mood, hence it is used to manage stress, anxiety, depression, and other mood disorders[26]. Aromatherapy was effective to improve both the physical and emotional symptoms associated with PMS[27][28]. It is used one week before the menstruation by applying drops of essential oil on an eye pad and placing it at a distance of 30 cm from the nose and inhaled in for 5 min with normal breathing[29].

Essential oils such as; lavender, lemon, bergamot, Rosa Damascena, and Citrus Aurantium are used.

Acupuncture and Acupressure

Acupuncture and Acupressure, there is still limited evidence to support its role in the management of PMS symptoms, and the mechanism of it still unclear but there are studies that demonstrated a positive effect of acupuncture on reducing the severity of PMS symptoms[30]. Acupressure and Yoga were both effective but Yoga was more effective when was compared with acupressure[31].

Kinesio taping[32]

Taping in the sacroiliac joint, showed decreased menstrual pain, which are able to eliminate muscle tension in the pelvic area by taping, thereby alleviating compression against the uterus and thus increasing blood flow. It also increases blood circulation due to the effects of the vasomotor reflex of the spine.

Taping technique: the therapist should attach one of the tapes to the center of the subject’s back above the cleft between the buttocks and the sacrum. The tape should point obliquely upwards. The tape is then pulled, with minimal stretch, diagonally upwards and outwards, but should stay on the sacrum, within the prominent iliac bone. Above the sacrum, the tape should continue along the top of the iliac crest. Then, one end of the second tape was attached exactly over the base of the first tape. This tape was then applied in the same manner as the first tape, across the other half the sacrum.

Heat therapy[32]

Application of heat 40-45 degrees Celsius (in the form of a hot pack) on the lower back and sacrum, for 30 minutes.

this will lead to the expansion of capillaries and the promotion of blood circulation, producing various physiological effects, including metabolic stimulation, pain relief, and re-balancing of the autonomic nervous system.

Differential Diagnosis

Depression.

Generalized anxiety disorder.

Hypothyroidism

Perimenopause.

Endometriosis.

Substance abuse disorders[4].

Resources

Management of Premenstrual Syndrome, RCOG Guidelines

References

  1. ↑ Prasad D, Wollenhaupt-Aguiar B, Kidd KN, de Azevedo Cardoso T, Frey BN. Suicidal risk in women with premenstrual syndrome and premenstrual dysphoric disorder: a systematic review and meta-analysis. Journal of Women's Health. 2021 Dec 1;30(12):1693-707.
  2. ↑ Gao M, Gao D, Sun H, Cheng X, An L, Qiao M. Trends in Research Related to Premenstrual Syndrome and Premenstrual Dysphoric Disorder From 1945 to 2018: A Bibliometric Analysis. Frontiers in Public Health. 2021 Apr 21;9:380.
  3. ↑ 3.0 3.1 3.2 3.3 Dilbaz B, Aksan A. Premenstrual syndrome, a common but underrated entity: review of the clinical literature. Journal of the Turkish German Gynecological Association. 2021 Jun;22(2):139.
  4. ↑ 4.0 4.1 Dickerson LM, Mazyck PJ, Hunter MH. Premenstrual syndrome. American family physician. 2003 Apr 15;67(8):1743-52.
  5. ↑ Gudipally PR, Sharma GK. Premenstrual Syndrome. 2022 Jul 18. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. 2023.
  6. ↑ Reactions. What Causes PMS? . Available from: http://www.youtube.com/watch?v=W5BvYvyfarw[last accessed 14/1/2022]
  7. ↑ Ryu A, Kim TH. Premenstrual syndrome: A mini review. Maturitas. 2015 Dec 1;82(4):436-40.
  8. ↑ Steiner M, Streiner DL, Steinberg S, Stewart D, Carter D, Berger C, Reid R, Grover D. The measurement of premenstrual mood symptoms. Journal of affective disorders. 1999 Jun 1;53(3):269-73.
  9. ↑ 9.0 9.1 Sammon CJ, Nazareth I, Petersen I. Recording and treatment of premenstrual syndrome in UK general practice: a retrospective cohort study. BMJ open. 2016 Mar 1;6(3):e010244.
  10. ↑ Verkaik S, Kamperman AM, van Westrhenen R, Schulte PF. The treatment of premenstrual syndrome with preparations of Vitex agnus castus: a systematic review and meta-analysis. American Journal of Obstetrics and Gynecology. 2017 Aug 1;217(2):150-66.
  11. ↑ Cerqueira RO, Frey BN, Leclerc E, Brietzke E. Vitex agnus castus for premenstrual syndrome and premenstrual dysphoric disorder: a systematic review. Archives of women's mental health. 2017 Dec;20(6):713-9.
  12. ↑ Hofmeister S, Bodden S. Premenstrual syndrome and premenstrual dysphoric disorder. American family physician. 2016 Aug 1;94(3):236-40.
  13. ↑ Ussher JM, Perz J. Evaluation of the relative efficacy of a couple of cognitive-behavior therapy (CBT) for Premenstrual Disorders (PMDs), in comparison to one-to-one CBT and a waitlist control: A randomized controlled trial. PloS one. 2017 Apr 18;12(4):e0175068.
  14. ↑ Siminiuc R, Ţurcanu D. Impact of nutritional diet therapy on premenstrual syndrome. Frontiers in nutrition. 2023 Feb 1;10:1079417.
  15. ↑ Farasati N, Siassi F, Koohdani F, Qorbani M, Abashzadeh K, Sotoudeh G. Western dietary pattern is related to premenstrual syndrome: a case–control study. British Journal of Nutrition. 2015 Dec;114(12):2016-21.
  16. ↑ MoradiFili B, Ghiasvand R, Pourmasoumi M, Feizi A, Shahdadian F, Shahshahan Z. Dietary patterns are associated with premenstrual syndrome: evidence from a case-control study. Public health nutrition. 2020 Apr;23(5):833-42.
  17. ↑ Rossignol AM. Caffeine-containing beverages and premenstrual syndrome in young women. American Journal of Public Health. 1985 Nov;75(11):1335-7.
  18. ↑ del Mar Fernández M, Saulyte J, Inskip HM, Takkouche B. Premenstrual syndrome and alcohol consumption: a systematic review and meta-analysis. BMJ open. 2018 Mar 1;8(3):e019490.
  19. ↑ Vaghela N, Mishra D, Sheth M, Dani VB. To compare the effects of aerobic exercise and yoga on Premenstrual syndrome. Journal of education and health promotion. 2019;8.
  20. ↑ Dehnavi ZM, Jafarnejad F, Goghary SS. The effect of 8 weeks aerobic exercise on the severity of physical symptoms of premenstrual syndrome: a clinical trial study. BMC women's health. 2018 Dec;18(1):1-7.
  21. ↑ Maged AM, Abbassy AH, Sakr HR, Elsawah H, Wagih H, Ogila AI, Kotb A. Effect of swimming exercise on premenstrual syndrome. Archives of gynecology and obstetrics. 2018 Apr;297(4):951-9.
  22. ↑ Ovgun CD, Tuzun EH. The effect of progressive muscle relaxation technique and myofascial release technique on premenstrual symptoms, blood circulation, and quality of life in women with premenstrual syndrome: A single-blind randomized controlled study. Medicine. 2023 Jul 7;102(27):e34223.
  23. ↑ Ghaffarilaleh G, Ghaffarilaleh V, Sanamno Z, Kamalifard M. Yoga positively affected depression and blood pressure in women with premenstrual syndrome in a randomized controlled clinical trial. Complementary therapies in clinical practice. 2019 Feb 1;34:87-92.
  24. ↑ Wu WL, Lin TY, Chu IH, Liang JM. The acute effects of yoga on cognitive measures for women with premenstrual syndrome. The Journal of Alternative and Complementary Medicine. 2015 Jun 1;21(6):364-9.
  25. ↑ Ghaffarilaleh G, Ghaffarilaleh V, Sanamno Z, Kamalifard M, Alibaf L. Effects of yoga on quality of sleep of women with premenstrual syndrome. Altern. Ther. Health Med. 2019 Sep 1;25:40-7..
  26. ↑ Nan Lv X, Jun Liu Z, Jing Zhang H, Tzeng CM. Aromatherapy and the central nerve system (CNS): therapeutic mechanism and its associated genes. Current Drug Targets. 2013 Jul 1;14(8):872-9.
  27. ↑ Es-Haghee S, Shabani F, Hawkins J, Zareian MA, Nejatbakhsh F, Qaraaty M, Tabarrai M. The Effects of Aromatherapy on Premenstrual Syndrome Symptoms: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Evidence-Based Complementary and Alternative Medicine. 2020 Dec 21;2020.
  28. ↑ Uzunçakmak T, Alkaya SA. Effect of aromatherapy on coping with premenstrual syndrome: A randomized controlled trial. Complementary therapies in medicine. 2018 Feb 1;36:63-7.
  29. ↑ Heydari N, Abootalebi M, Tayebi N, Hassanzadeh F, Kasraeian M, Emamghoreishi M, Akbarzadeh M. The effect of aromatherapy on mental, physical symptoms, and social functions of females with premenstrual syndrome: A randomized clinical trial. Journal of family medicine and primary care. 2019 Sep;8(9):2990.
  30. ↑ Armour M, Ee CC, Hao J, Wilson TM, Yao SS, Smith CA. Acupuncture and acupressure for premenstrual syndrome. Cochrane Database of Systematic Reviews. 2018(8).
  31. ↑ Kucukkelepce DS, Unver H, Nacar G, Tashan ST. The effects of acupressure and yoga for coping with premenstrual syndromes on premenstrual symptoms and quality of life. Complementary Therapies in Clinical Practice. 2021 Feb 1;42:101282.
  32. ↑ 32.0 32.1 Choi JH. Effects of kinesio taping and hot packs on premenstrual syndrome in females. Journal of physical therapy science. 2017;29(9):1514-7.
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