Premenstrual Syndrome

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

Definition[edit | edit source]

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 range from mild to severe that may hinder their work and ADL activities. And they start to resolve with the beginning of the menstruation as the levels of the hormones start to return to their levels. PMS symptoms may change throughout your life in severity and complain, depression, stress, or 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 find in about 5–8% of women. There is 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[edit | edit source]

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].


Clinical Presentation[edit | edit source]

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


Emotional symptoms:

  • Depression.
  • Anxiety.
  • Anger.
  • Oversensitivity.
  • Mood swing.
  • Crying spells
  • Less interest in sex.
  • Insomnia.
  • Poor concentration.

Diagnostic Procedures[edit | edit source]

There is no definitive diagnostic test and the diagnosis of PMS depends on reporting to 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[edit | edit source]

Visual analogue scale[6].

Premenstrual Tension Syndrome Observer (PMTS-O)

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

Management / Interventions
[edit | edit source]

Medical management[edit | edit source]

Selective serotonin reuptake inhibitors (SSRIs) is the first pharmacological line recommended by RCOG guidelines for sever PMS, it was effective to treat moderate and severe symptoms of PMS, and should be discontinued gradually to avoid withdrawal symptoms if given on a continuous[7].

Combined oral contraceptive pills (COC)[7].

GnRH analogs is effective in the treatment of PMDD and could not 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[8][9], is safe to use and it was superior to placebo, however, further research about Vertix is still needed[3].



Cognitive Behavioral Therapy[edit | edit source]

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[10][11].

Physical Therapy Management[edit | edit source]

Exercise photo.jpg

Exercises and a healthy diet is the first-line treatment for PMS, repeated muscle contraction during physical exercises prevent accumulation of PG and other substances so reduces back and abdominal pain, it also has a positive effect on stress management, reduces depression, and improve mood[12].

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[13][14].

Yoga demonstrated a strong effect on depression symptoms and can be used as a complementary treatment for PMS management[15] to reduce physical and emotional symptoms associated with PMS[16] 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[17] .

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[18]. Aromatherapy was effective to improve both the physical and emotional symptoms associated with PMS[19][20]. 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[21].


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

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[22]. Acupressure and Yoga were both effective but Yoga was more effective when was compared with acupressure[23].

Differential Diagnosis
[edit | edit source]


Generalized anxiety disorder.




Substance abuse disorders[4].

Resources[edit | edit source]

Management of Premenstrual Syndrome, RCOG Guidelines

References[edit | edit source]

  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. Reactions. What Causes PMS? . Available from:[last accessed 14/1/2022]
  6. 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.
  7. 7.0 7.1 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.
  8. 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.
  9. 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.
  10. Hofmeister S, Bodden S. Premenstrual syndrome and premenstrual dysphoric disorder. American family physician. 2016 Aug 1;94(3):236-40.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. 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.
  17. 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..
  18. 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.
  19. 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.
  20. 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.
  21. 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.
  22. 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).
  23. 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.