PMS is not a straightforward issue. Women's experiences of PMS don't fit into neat categories - they are far too varied. There is no single remedy and not all women are successful in finding solutions. There is controversy within the medical profession about how to define and treat PMS. In the medical literature, there are reports of trials of many different drugs. Some of these show a benefit to some women and others show no benefit compared with a placebo (dummy pill). Different researchers get different results using the same drug, so it becomes impossible to draw conclusions. Claims are also made by vitamin companies, nutritionists and alternative practitioners. Nearly everyone offering help for PMS sufferers swears success for their cure and heaps scorn on other treatments
The reason for this confusion is that PMS is not a disease like diabetes or flu. It is a mixed bag of individual responses to an ordinary event: the menstrual cycle. The word PMS lumps together a vast collection of symptoms which have little in common besides their timing. To have a better understanding of PMS we need to look at the whole woman and see how stress, a long history of negative social attitudes towards menstruation, women's roles, jobs, relationships, nutrition and lifestyle interact with hormonal changes and other bodily processes.
The term PMS covers a range of emotional and physical symptoms experienced by women during part of the menstrual cycle the two to 14 days before a period starts. These symptoms usually clear up once the bleeding starts, but for some women they persist for a day or two into the period. There are many changes during the menstrual cycle but they are only labelled as PMS when they are distressing or disabling. Period pain is not included in the definition of PMS.
Over 150 different symptoms have been described but the most common are headache, breast swelling and tenderness, bloating, water retention, fatigue and depression, tension and irritability, and craving for sweet or salty food. Existing conditions such as depression, asthma, allergies, and epilepsy can become worse premenstrually.
But the menstrual cycle isn't just a cycle of negative symptoms. The following are some of the positive symptoms experienced:
- Productivity
- High energy levels
- Sexual desire
- Intense and vivid dreaming
- Creativity
How are women affected?
The way women experience these changes varies considerably. Some women suffer intensely and feel desperate. Some aren't aware of anything other than menstruating. Some women only experience premenstrual symptoms once they stop taking the Pill or have a baby. Premenstrual symptoms can continue even after a hysterectomy. Many women find that with every cycle they experience different symptoms, or that the intensity of the symptoms varies from cycle to cycle. If you suffer from PMS you are not neurotic, a hypochondriac, or a malingerer (as some old fashioned medical text books have claimed). It is also clearly not "all in your mind".
What is PMS?
The term PMS or Premenstrual Syndrome is used in this leaflet to mean both the physical and mental symptoms which occur before a period. The term PMT or Premenstrual Tension usually refers just to emotional changes.
How many women are affected?
If you are affected premenstrually, it is comforting to know you have plenty of company, although it's difficult to say how many women are affected. Investigators have come up with very different figures, depending on their definition of PMS and how they collected their information. Up to 95% of women have some premenstrual symptoms; 40% are affected by distressing symptoms, with about 5-10% experiencing severe, incapacitating symptoms.
So a small minority of women have no premenstrual symptoms at all, an equal number are incapacitated and the vast majority have symptoms ranging from mild to severe. There is not a sharp distinction between women with or without PMS.
Coping with Premenstrual Syndrome
Recording your symptoms
If you keep a menstrual diary to record physical and emotional symptoms during the month, you can see for yourself how you change, if you do. Women are often advised to record only the most distressing symptoms such as irritability, depression, tension or headaches, but this leads to a distorted picture. It is just as true to consider feelings of well being and highs in energy level.
It is very difficult to keep an accurate menstrual cycle diary when monitoring moods, especially when everyone is telling you to expect terrible things before your period. It is tempting to record an irritable day if it occurs premenstrually, but to have a "legitimate" reason for the same irritability at other times and so not record it. There are many women who don't need to keep a menstrual cycle diary because their symptoms are so clearly connected with the premenstrual phase and disappear completely with bleeding. Rather than looking for anything in particular, just record what goes on for you. Compare your diary with other women's diaries and see the range of experiences that are cyclical in nature. See a sample of a menstrual cycle diary.
Many women experience irritability, tension, aggression, anxiety or depression when they are premenstrual. If these feelings are not too severe, it usually helps to know that they will pass once your period starts. It also helps to know that they are normal human emotions. It is not a sign of illness to be tense or aggressive, even when you can't find an obvious cause. It is not always possible or necessary to look for explanations for mood changes.
But many women who suffer premenstrually are too badly affected to ride it through. They feel overcome, and express their anger despite their best intentions. When it gets to this state, most women start looking for solutions.
First of all, consider yourself worthy of a healthier, happier life. You are not looking for a solution to PMS to improve your children's or your partner's lives but because you, yourself, deserve it. As a woman, you have been brought up to nurture others. It's just as important to nurture yourself.
Secondly, look at the things in your life which make you irritable premenstrually and try to do something about them. Are you under too much stress? Some women take on too much and have an unrealistic idea of what they can achieve. But most have no choice about the amount of stress in their lives. For example, raising children is a very demanding job with little support and recognition from partners and society.
"I need more time or else I become very aggressive. The children have to spend more time with their father. When I first suggested it, I felt I was being selfish but I'm only asking him to come home on time and put in a bit more effort and commitment a few days a month."
Many women crave time on their own premenstrually. Some find it a creative time. The irritability and tension experienced may be a reaction against the invasion of work, school, children or other people when they are desperate to be alone. Yoga, meditation, sleeping, listening to music, reading or just sitting are some of the things which give you time on your own.
You may not need time on your own but time for yourself, without being interrupted to care for others. Identifying and meeting your needs is difficult, sometimes nearly impossible but it's crucial to try and organise your life so that your needs are met.
"I can't afford to work part time so I have to put up with being tired three or four days a month. I cope by making sure (where possible) that I don't have any extra activities during those days. It sounds like Greta Garbo but I really do want to be alone."
Thirdly, don't be too quick to dismiss your anger. Just because it occurs cyclically doesn't mean that it's not valid. You may be able to suppress your irritation during most of your cycle but not premenstrually, when you are in a more sensitive and vulnerable state. Would anger be a more appropriate reaction the rest of the time? Women are conditioned to be caring, sensitive, responsive to others, reasonable and responsible. The forces in society are powerful enough to make women feel guilty, abnormal and sick if they do behave irrationally or angrily. But the reality for many women is that, like it or not, they feel angry. And there are enough difficult, trying and stressful situations in most women's lives to justify anger.
"He was late home again. It was becoming so regular and I didn't just yell at him, I threw his dinner in the bin then threw the plate at him. When he said he was sorry and he understood that I was so upset because I was due to come on, I went berserk. I know if I hadn't been feeling tense I would only have yelled at him but it doesn't make my feelings any less real or what he was doing right. He still doesn't understand. It's as though anything I say for a week a month has no meaning because I'm due to come on. I feel like I'm on a short fuse during that week but my feelings are just as real. I'm beginning to think that my responses during the other three weeks may be the wrong ones because I put up with too much."
Support
Many women find that the support they get from friends, family and fellow sufferers is crucial. If possible, join or start a support group where you can talk about what is going on in your life without being dismissed. In a support group, you can compare information about PMS remedies and talk about ways you are affected by your menstrual cycles.
If you go to your GP, Well Woman Clinic or a complementary practitioner, only talk to those who listen to you, believe what you say and are caring and flexible in their approach. If you find that your doctor is insensitive, impatient, unsympathetic or disbelieving (as many are), don't waste your time. Look around for someone else who will take you seriously.
Exercise
Exercise is good for PMS. It is said to help counteract fluid retention. It also helps the release of endorphins, the body's chemicals which are responsible for increased feelings of well being.
The type of exercise is not important; more important is a routine that you can maintain even when beset by premenstrual depression or tension. If you're not into sport, you can exercise by walking. The goal is to walk briskly (your pulse rate needs to be raised) for half an hour at least three times a week.
If exercise is new to you, build it up slowly. It shouldn't be painful or tiring. If you are at home with small children or not able to get out and walk for any reason, try another form of exercise that suits you better. Yoga, relaxation exercises, dancing, and swimming are just a few of the types of physical activity which women with premenstrual symptoms find helpful.
In order to benefit, you do need to make regular exercise part of your life. There's not much point in just exercising for half an hour when you're premenstrual.
Nutrition Tips
The value of good nutrition
Lack of certain vitamins and minerals is said to affect the level of the hormones of the menstrual cycle. Some researchers claim that women with PMS have either an imbalanced diet or existing deficiencies in their body which are not being corrected by their diet. A typical British diet includes a great deal of sugar, processed foods, additives and salt, and is not a good source of vitamins and minerals. These researchers claim that a change in diet and the use of certain vitamins and minerals have been highly effective for many women.
Women with chronic deficiencies may need dietary supplements but there is no single vitamin or mineral which is appropriate for all women. The exact supplements and their quantities depend on each woman's individual symptoms. According to the Women's Nutritional Advisory Service, it is necessary to find out the exact nutritional cause of PMS in each woman and then to work out a nutritional programme to overcome her symptoms. At the moment, this service is not available on the NHS. It can be obtained from the Women's Nutritional Advisory Service (see Resources section) but it is expensive.
There are a few scientific studies showing that Vitamin E, Vitamin B6, multivitamins and magnesium supplements are more effective than a placebo, but the nutritional approach is not universally accepted by the medical profession. However, many women report that they get relief by taking supplements or changing to a wholesome diet.
Tip for women whose premenstrual symptoms include hunger, headaches, fatigue, and cravings for sweets and fried foods: Eat frequent (every 2 3 hours) wholesome snacks and small meals.
Good foods to eat
- Fresh vegetables and fruit every day
- Whole foods - not refined or processed - such as wholemeal bread, whole grains, brown rice, nuts, seeds
- Lean meat, fish, chicken
- Unsaturated fats such as cold pressed unhydrogenated vegetable oils (sunflower or safflower seed oil)
- Low fat dairy products in moderation: skimmed milk, low fat cheese and yoghurt
Good drinks
- Lots of water
- Fruit juices
- Herbal teas
- Decaffeinated teas
- Decaffeinated coffee
Foods to limit or avoid
- Junk foods sweets, cakes, chocolates, honey, sugar in tea and coffee and refined flour products
- Caffeinated drinks: coffee, tea, coke, soft drinks
- Alcohol
- Salt in cooking, at the table and in crisps, bacon etc.
- Saturated fats: red meat, foods fried in saturated fats, butter
Dietary supplements
If a wholesome diet on its own is not helping, you may find that dietary supplements have an effect. These are not a substitute for a wholesome diet. Although supplements can be bought without prescription in pharmacies and health food shops, it's best to treat them like any other drug, and take them only under the supervision of a qualified doctor or complementary practitioner.
Vitamin B6 (pyridoxine)
Vitamin B6 has a role in the functioning of nerves. The advice on how to try Vitamin B6 varies, and it is best to consult a sympathetic doctor about the best dose for you. During 1997 there was a lot of controversy over the safety of vitamin B6, and there was discussion about limiting the recommended upper daily dose to 10 mg. However in early 1998 the recommended safety limit was set at 100 mg per day, pending an enquiry and report from an expert group.
When taken on its own in high doses (more than 200 mg a day) for a long period of time (more than six months), Vitamin B6 has caused numbness and tingling in the arms and legs, shooting pain, headaches, tiredness and depression in a small number of women. These effects disappeared when the vitamins were stopped. It seems safest, when experimenting with Vitamin B6, to stay in the lower dose range and to give it up if you notice no improvement after several months.
Vitamin B6 is available on prescription or from chemists and shops. Some researchers suggset that a magnesium supplement enhances the absorption of vitamin B6.
Evening Primrose Oil
Evening primrose oil contains an essential fatty acid called gamma linolenic acid that is needed for the synthesis of a hormone called prostaglandin. Evening primrose oil is very effective in relieving premenstrual breast pain. There are no major reported side effects, but occasionally women experience nausea, headaches and indigestion. Taking the capsules with or after food can lessen these effects. Another possible side effect if you have food or other allergies is that you may develop skin rashes.
Evening primrose oil is available on NHS prescription for the treatment of sore breasts, from health food stores and pharmacies, or from Premsoc (see Resources for their address).
Vitamin E
Some women find that vitamin E supplements are helpful, particularly for premenstrual anxiety and depression.
Medical Treatments
Progesterone
One of the medical treatments for women with severe and incapacitating PMS is progesterone therapy. Progesterone is the menstrual cycle hormone which is produced after ovulation and drops to a low level before menstruation begins. Some researchers think that PMS is caused either by a deficiency in progesterone, by the drop in progesterone or by a lower ratio of progesterone to oestrogen. Dr Katharina Dalton is the main proponent of this theory and of progesterone therapy for women with severe, strictly defined PMS.
Two kinds of progesterone are used in the treatment of PMS: "natural" and synthetic. "Natural" progesterone is derived from yams or soybeans and is chemically similar to the progesterone produced by your body. It is given in rectal or vaginal suppositories or as an injection because it can't be absorbed when taken by mouth. The synthetic progesterones (drugs which act like progesterone in the body) are called progestogens. These can be taken as tablets. The most commonly prescribed progestogen for PMS is called Duphaston.
Although progestogens have been prescribed for PMS for over 35 years, the British Medical Association does not officially recommend them for the treatment of PMS.
However, many women say progesterone or progestogen has worked for them, although many other women have not found it helpful.
Progestogens can cause side effects such as: itchy skin; worsening of certain types of migraine and epilepsy; acne; weight gain; digestive disorders; depression; irregular periods; changes in sex drive; breast discomfort; insomnia; hair loss; excess hair growth; and worsening of premenstrual symptoms.
If you have a history of colitis, you should not use rectal suppositories, and women with vaginal infections and recurrent cystitis should not use vaginal pessaries.
Progestogens are taken a few days before premenstrual symptoms are expected and stopped when menstruation begins. The doses should be tailored to suit the individual woman. For progesterone suppositories and pessaries (Cyclogest is the trade name), the dose varies from 200 to 800 mg daily. For progesterone injections (Gestone is the trade name), women are started on 5 or 10 mg daily. Duphaston is prescribed in doses of 10 mg twice daily and increased if necessary.
Contraceptive Pill
If you choose the Pill as your method of contraception, you might find that it clears up your premenstrual symptoms, especially depression, irritability and anxiety, or you might find that your symptoms get worse. This is common among younger women.
Some studies show that the progestogen-only pill helps premenstrual symptoms.
Hormone Replacement Therapy
Some researchers think that a lack of oestrogen (rather than progesterone) is the problem behind PMS. Studies have found that some women benefit from hormone replacement therapy, either in the form of oestrogen implants or patches, combined with seven days a month of oral progestogen. The oestrogen stops ovulation, and the progestogen causes a monthly bleed and protects you from endometrial cancer. This treatment is only for women with severe PMS and requires close supervision by a gynaecologist. There are increased risks of breast cancer and blood clots with long term use of HRT. For more information see the Women's Health leaflet on Hormone Replacement Therapy.
Bromocriptine
(Trade name Parlodel). This is used mainly as treatment for premenstrual breast pain. Possible side effects include nausea, vomiting, dizziness, and lower blood pressure. It is worth trying evening primrose oil first.
Danazol
(Trade name Danol). This is a powerful hormonal drug used for the treatment of endometriosis, breast pain, heavy bleeding, and other menstrual problems. It commonly produces disturbing side effects such as nausea, swollen feet/ankles, weight gain, acne/oily skin, and excess body hair. Because of these side effects, other treatments should be tried first.
Diuretics
(Trade names Navidrex, Moduretic, Saluric, Lasix). These are used for weight gain associated with bloating and swelling, but not for other symptoms. They are an artificial way to make your kidneys excrete more fluid but you run the risk of excreting too much potassium. There are side effects and they shouldn't be taken long term.
A study of 38 women showed that a daily supplement of 200 mg of magnesium reduced mild premenstrual fluid retention.
Mefenamic Acid
(Trade name Ponstan). This is a painkiller and can be used for headache, muscle, joint or period pain.
Antidepressants
Recent studies have shown that the more modern antidepressants, for example the selective serotonin re-uptake inhibitors (SSRIs), such as Prozac, can help with the emotional symptoms of PMS, particularly in women who also have an underlying depressive illness.
GnRH agonist analogues
(e.g. Zoladex) These drugs are used to treat endometriosis, but also relieve PMS because they stop the ovaries from functioning. However this also causes menopausal symptoms, so these drugs are only given for six months. After treatment stops, the symptoms of PMS return.
Light therapy
Researchers at the Royal Postgraduate Medical School in London claim success in treating PMS with a light mask. The treatment involves wearing a mask for 15 minutes each day. The mask contains miniature lights, one in front of each eye, which gently flicker in pre-programmed rhythms. It is believed that the light therapy re-sets the body's internal clock, which becomes de-synchronized during PMS. In the London study, 12 out of the 17 participants no longer had PMS after using the mask for six months.
Complementary Therapies
Some complementary therapies are available on the NHS but most must be paid for privately. These practices are holistic: they don't treat just the PMS, but the whole woman. As well as providing specific individual treatments, they will expect you to look at all aspects of your life, and will give advice on nutrition, lifestyle, stress reduction and exercise. See the Resources section for contact information.
Traditional Chinese Medicine
Traditional Chinese medicine is based on the belief that energy in the body flows along channels. When these are blocked the balance of Yin and Yang in the body is disturbed, and ill-health results. Chinese medicine has two main strands: acupuncture and herbalism. Acupuncture unblocks the channels with the use of needles in particular points in the body. Chinese herbalism also works on the energy flows in the body.
Homeopathy
Homeopathy uses microscopic quantities of naturally occurring substances from plants and animals. Although most homeopaths work privately, there are five NHS homeopathic hospitals in the UK. You will need a letter of referral from a GP to attend these.
Homeopathic remedies are available over the counter, but there are many different remedies which could be used for PMS, and it is best to get advice from a homeopath to find the best remedies for individual circumstances.
Naturopathy
Naturopathy uses nutrition and diet and body manipulation to help the body heal itself.
Aromatherapy
Aromatherapy heals using essential oils derived from the bark, leaves, seeds, flowers or roots of plants. The oils can be mixed with a base oil and massaged into the skin, vaporised in the bath or in an essential oil burner or given as compresses, enemas or douches.
Some oils can be harmful so it's best to consult a practitioner.
Herbalism
Many women have found herbal preparations effective in clearing or reducing premenstrual symptoms. As with other complementary therapies, herbs are most effective when taken as part of a general programme of improving your well being. This means adopting a wholesome diet, exercising regularly, and looking for ways to reduce stress.
Herbs can be taken as teas, tinctures or tablets and are available from health food stores, herbalists or you can grow them yourself. Herbal teas are prepared from dried herbs steeped for 10 minutes in freshly boiled water. Usually a teaspoon of dried herb is used per cup of boiling water. Tinctures must be bought from a herbalist.
Resources and Links
Books
The PMS Diet Book
Karen Evennett
(Sheldon, 1997)
Gives helpful recipes to try to eliminate PMS symptoms.
No More PMS
Maryon Stewart
(Vermilion, Random House, 1997)
A positive and natural approach to PMS. Shows the reader how to look at her symptoms and create a tailor-made diet.
Problem Periods
Dr Shreeve
(Piccadilly Press, 1994
This is a self help guide to period problems.
PMS: The Complete Guide to Treatment Options
Suzie Hayman
(Piatkus, 1996
Looks at what PMS is and its effects on relationships, as well as the treatment options.
Organisations
PREMSOC
PO Box 429
Addlestone
Surrey KT15 1DZ
Tel: 01932 872560
Provides support for PMS self help groups and individuals; runs courses and publishes a newsletter. Answers general enquiries by phone and post. Send an SAE for information plus publication list.
Women's Nutritional Advisory Service
PO Box 268
Lewes
East Sussex BN7 2QN
Tel: 01273 487 366
Nutritional treatment for PMS. For a fee your symptoms, diet, medical history and lifestyle will be analysed and a dietary treatment plan devised. Access to counsellors by phone.
National Association for Premenstrual Syndrome (NAPS)
7 Swifts Court
High Street
Seal TN15 0EG
Tel: 01732 760 011 (office)
NAPS aims to help women suffering from PMS and to further research and understanding of PMS. Produces booklets and a quarterly newsletter.
Other Sources of Help
There are some NHS clinics for PMS which require a letter of referral from your GP. Some women's health centres have information or support groups as well.
Complementary Practitioners
For a list of registered practitioners, send a large stamped self-addressed envelope to the organisations listed below.
National Institute of Medical Herbalists
56 Longbrook Street
Exeter EX4 6AH
British Homeopathic Association
27A Devonshire Street
London W1N 1RJ
Society of Homoeopaths
11 Brookfield
Duncan Close
Moulton Park
Northampton NN3 6WL
tel: 0845 450 6611
email: info@homeopathy-soh.org
web: www.homeopathy-soh.org
Publishes register of homoeopaths who are trained, insured and abide by the Society's Code of Ethics.
For homeopathy on the NHS, ask your GP to refer you to a homeopathic hospital:
Bristol Homeopathic Hospital
Cotham Hill
Bristol BS6 6UJ
Tel: 0117 973 1231
Glasgow Homeopathic Hospital
1000 Great Western Road
Glasgow G12 0NR
Tel: 0141 211 1616
Liverpool Homeopathic Hospital
Old Swan Health Centre
St Oswald Street
Liverpool
Tel: 0151 228 6808
The Women's Clinic
Royal London Homeopathic Hospital
Great Ormond Street
London WC1
Tel: 020 7837 8833
British Acupuncture Council
Park House
206 Latimer Road
London W10 6RE
Tel: 020 8964 0222
The Register of Chinese Herbal Medicine
PO Box 400
Wembley
Middlesex HA9 9NZ
Tel: 020 7224 0803
General Council and Register of Naturopaths
Goswell House
2 Goswell Road
Street
Somerset BA16 0GJ
Helpline 01458 840072
The Register of Qualified Aromatherapists
PO Box 6941
London N8 9HF.
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