Premenstrual syndrome (PMS) is a collection of physical, psychological and emotional symptoms that many women experience during the one to two weeks before a menstrual period. These symptoms disappear soon after the start of menstrual bleeding.

Several theories have been proposed to explain why PMS occurs. The most popular explanation is that these symptoms are related to cyclic changes in female sex hormones, pituitary hormones, prostaglandins and certain brain chemicals known as neurotransmitters. Some researchers have suggested that PMS may be related to abnormally low blood sugar (hypoglycemia), abnormally low levels of thyroid hormones (hypothyroidism) or a diet low in B vitamins, calcium or magnesium. Recent studies do not support these theories. Preliminary studies indicate that magnesium deficiency could play a role.

It is believed that lifestyle may play a significant role in PMS. Symptoms appear to be most troubling in women who smoke, lead stressful lives, rarely exercise, sleep too little or whose diet is high in caffeine, alcohol, salt, red meat or sugary foods such as chocolate or candy. It's not clear whether these factors increase your risk of PMS or if PMS accounts for these differences in lifestyle. For example, studies looking at the influence of stress do not find a relationship between stress and the severity of PMS. It is more likely that PMS causes stress rather than that stress causes PMS.

It's possible that medications may exaggerate the symptoms of PMS. Oral contraceptives (birth control pills) have been known to cause symptoms of PMS in some women. However, some women report that their symptoms improve or disappear while using birth control pills.

In recent years, there has been some controversy in the medical community about the difference between premenstrual discomfort and true PMS. Premenstrual discomfort is fairly common among women of childbearing age, affecting about 75% of all menstruating women. However, only about 3% to 8% of women have symptoms that are severe enough to disrupt their personal relationships or interfere with their normal work and home responsibilities. Some doctors feel that only these women who have severe symptoms (a small number of women) have true PMS. Severe mood symptoms are sometimes named premenstrual dysphoric disorder. However, other doctors use a less stringent definition for PMS, which includes mild to moderate symptoms.

Symptoms of PMS fall into two general categories:

Physical symptoms

• Bloating
• Breast tenderness
• Swelling of feet and ankles
• Fluid retention and weight gain
• Painful uterine cramps just before and during the first few days of menstruation
• Headaches
• Food cravings (especially for salty or sweet foods)
• Acne breakout
• Low energy or fatigue
• Palpitations
• Dizziness
• Backaches or muscle pain

Psychological and emotional symptoms

• Fatigue
• Mood swings
• Irritability
• Depression
• Aggressiveness or hostility
• Crying spells
• Difficulty concentrating
• Increased appetite
• Forgetfulness
• Changes in libido (sexual desire)

Although the specific symptoms of PMS vary from woman to woman, the top three complaints seem to be irritability, fatigue and bloating.

Your doctor will ask you about your PMS symptoms, the timing of these symptoms in relation to your menstrual period and the regularity of symptoms (every month, every other month, etc.). Your doctor will ask about the general quality of your life. Questions may include:

• Are you feeling sad, tense or anxious lately?
• Do you notice mood swings? Fatigue? Difficulty concentrating?
• Are you having relationship difficulties with your spouse, family members or coworkers?
• Are you so rushed that you sleep poorly and skip meals?
• Do you live a sedentary life with little exercise?
• Do you smoke cigarettes?
• Do you drink alcohol or caffeinated beverages?
• Is your diet high in red meat, salty foods or sugar?

After asking about your PMS symptoms and lifestyle, your doctor will review your medical history and ask about any medications that you are taking. Your doctor will examine you, and will do a pelvic exam with a Pap smear. Although no single physical finding can confirm the diagnosis of PMS, a thorough physical exam can check for other medical problems, such as low levels of thyroid hormone (hypothyroidism) or a tumor of the breast, brain or ovary. Although no single laboratory test can confirm that you have PMS, blood tests can rule out medical disorders such as hypoglycemia or hypothyroidism, or other hormonal problems as the cause of your symptoms.

If there are no physical findings and your laboratory test results are normal, your doctor may ask you to keep a daily record of your symptoms for two or three months. This record will include the type of symptoms, the severity of symptoms, the timing of your menstrual periods and a description of any stresses affecting your life. Once this record is complete, your doctor will review the information. If your symptoms follow a pattern that is consistent with PMS, this will help to establish the diagnosis.

Generally, premenstrual symptoms must be absent for about two weeks, from shortly after the start of menstruation until the next ovulation, to qualify for the diagnosis of PMS.

PMS can be a long-term condition. In some women, symptoms of PMS flare up before every menstrual period, and this pattern continues until menopause (the age-related end to menstrual cycles). In other women, PMS symptoms seem to decrease after age 35.

Because doctors are not exactly sure what causes PMS, there is no way to prevent it. However, you may be able to alleviate some PMS symptoms by leading a healthier lifestyle.

The treatment of PMS depends on the severity and type of symptoms, and how much they bother you. For example, if your symptoms are mild and do not interfere with your daily life or personal relationships, your doctor may suggest that you try one or more of the following lifestyle changes:

• Start regular exercise (three to five sessions per week).
• Do not skip meals. Follow a meal schedule to maintain a more stable blood sugar level.
• Eat a balanced diet low in refined sugars.
• Try to get a good night's sleep. Avoid staying up all night.
• If you smoke, quit.
• Cut down on caffeine, alcohol, red meat and salty foods.
• Practice stress reduction techniques. Take a long bath, or try meditation or biofeedback.

Your doctor may suggest that you try taking supplements of vitamin B6, calcium or magnesium. Always follow the dosage recommended by your doctor. Do not take more than 100 milligrams per day of vitamin B6. Nerve damage has been associated with vitamin B6 at doses higher than 100 milligrams per day.

If your symptoms are moderate to severe and interfere with your normal daily activities, your doctor may prescribe medications aimed at relieving specific symptoms.For example, if you are troubled by bloating and weight gain, your doctor may prescribe a diuretic to help your body eliminate excess water. Oral contraceptives, especially birth control pills containing both estrogen and progestin, may be used to minimize the severity of cramps and the length of your period.

If you have symptoms of irritability, social withdrawal, angry outbursts or depression that interferes with your work, home responsibilities or your personal relationships, your doctor may suggest that you try an antidepressant. The most effective antidepressants for relieving PMS are selective serotonin reuptake inhibitors (SSRIs), which include fluoxetine (Prozac, Sarafem and others), sertraline hydrochloride (Zoloft) and clomipramine (Anafranil). Other antidepressants include nefazodone (Serzone) and venlafaxine (Effexor). These can be taken for two weeks prior to each period or can be taken every day.

For very severe symptoms, or when other medications fail, your doctor may prescribe a medication that causes the ovaries to stop producing estrogen so that ovulation stops. Danocrine (Danazol) is a synthetic androgen that suppresses the hormones in the brain that trigger ovulation. Gonadotropin-releasing hormone agonists, such as leuprolide (Lupron), create a temporary menopausal state by suppressing hormones in the brain that control the production of ovarian hormones and ovulation. These medications can be used only for short periods of time. They commonly lead to hot flashes and other symptoms of menopause. If therapy needs to continue for more than six months, you will also have to take estrogen to prevent bone loss. Whether your symptoms are mild or severe, it always helps to have your family's understanding and support while you are being treated for PMS. For this reason, your doctor will encourage you to speak frankly with family members about your symptoms and your treatment.

Call your doctor if your premenstrual symptoms cause you significant distress or discomfort, if they make it hard for you to function in daily life, or if they interfere with your personal relationships. If you think you are in danger of causing harm to yourself or others, call your doctor for an emergency appointment.

In most women, PMS symptoms begin to subside after age 35 and end at menopause. Women who have PMS or premenstrual dysphoric disorder are at greater risk of developing depression.

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