Premenstrual Syndrome
Premenstrual Syndrome (PMS) and its more severe variant, Premenstrual Dysphoric Disorder, are a poorly defined clinical condition that group a wide variety of physical and/or mental symptoms that appear repeatedly between ovulation and the period, and which usually subside at the start of menstruation.
The severity and frequency of appearance are highly variable, and frequently interfere in the woman's life.
Premenstrual symptoms affect 75-80% of women to some degree, but the symptoms are very severe in only 3-8% of cases. These symptoms can vary from one month to another in the same woman because of changes in the menstrual pattern and stress; they can also appear at any age, although the majority of women usually seek help in their thirties, having its maximum peak in their forties and disappearing in the majority of cases with the menopause.
In Premenstrual Dysphoric Disorder (2% of patients with PMS) emotional symptoms predominate, which interfere severely with the carrying out of women's social, family and work duties; this disorder has been classified as a mental illness and requires attention, care and treatment.
Causes
It seems that progesterone and its balance with oestrogens in the second phase of the cycle and its relationship with neurotransmitters on a central level (above all serotonin) could be the origin of the disorder, although it is not known why this happens only in certain women. PMS seems to be an abnormal response to normal hormonal changes that happen after ovulation.
Additionally, it is known that some systemic manifestations are due to dysregulation of the calcium channels.
Among the predisposing factors are a genetic component (variations in the ESR1 gene and in the oestrogen receptor alpha), although multiple factors have an influence, such as environmental, hormonal, neural, stress (anxiety disorders), smoking, personality features, hereditary, nutritional factors…
Symptoms
Symptoms usually begin between five and seven days before menstruation and disappear when it starts.
More than 150-200 symptoms have been described:
a) Somatic symptoms: mastodynia (breast pain), abdominal bloating, weight gain, oedemas, acne, oily skin, oilier or drier hair, hirsutism, extreme fatigue, headache, joint and muscular pain, insomnia, altered libido, nausea, diarrhoea, palpitations, dizziness, vertigo, tremors…
b) Emotional symptoms: mood swings, depression, attacks of anger, irritability, anxiety/tension, feeling of lack of control, sleep disorders, changes in appetite, worse concentration, decreased interest, social withdrawal...
Symptoms are highly variable from one woman to another. However, the symptoms of the same woman are usually quite similar every month. A woman with many emotional symptoms has a higher risk of developing mood disorders at some point in her life.
Diagnosis
In light of a patient suspected of having premenstrual syndrome, the evaluation should include a complete medical history focused on menstrual history and its relationship with symptoms, the severity, the impact on quality of life and the concomitant use of medications and hormone therapies. In addition, a physical examination and complementary tests will be included, which must be normal in order to be able to rule out other conditions that may have similar symptoms (such as thyroid disorders). For the diagnosis, the exacerbation of other underlying psychiatric conditions, as well as the symptoms related to the transition to the menopause, thyroid disorders and mood disorders (depressive disorder or anxiety disorders) must be ruled out.
Follow-up should be performed of symptoms during at least two menstrual cycles and to check the pattern of the symptoms, with it being a fundamental diagnostic requirement that there are symptom-free days after menstruation.
The severity of symptoms varies from mild to frankly incapacitating.
Treatment
Given that the causative mechanism is not entirely clear, the objective of treatment is the relief of symptoms.
If the symptoms are mild, measures regarding lifestyle (regular exercise and reduction of stress) are recommended which, although their effectiveness has not been demonstrated, there is evidence of their benefit.
It seems that a diet with a high vitamin B6 content (from a non-supplementation diet) is associated with reduced PMS.
The dietary supplement which has been demonstrated to be higher than placebo is calcium (1200 mg/day).
There are many alternative treatments which have not been studied or without clear scientific evidence: vitamin E, magnesium, agnus castus, evening primrose oil, ginkgo biloba, homeopathy…
In cases of moderate/severe symptoms and always under supervision and medical prescription, drug treatment is indicated after ruling out underlying conditions (depression, anxiety disorder or thyroid problem). Antidepressants are recommended as a first-line therapy: selective serotonin reuptake inhibitors (fluoxetine, sertraline, paroxetine). You have to wait several cycles to confirm their efficacy. Therapy can be continuous or intermittent between ovulation and the period. Second-line drugs include oral contraceptives in a continuous regimen (i.e. without a pill-free week to inhibit menstruation), anxiolytics at low doses and surgery as a last resort (bilateral oophorectomy).