Management of Pre-menstrual Syndrome

Premenstrual syndrome (PMS) refers to the range of physical and
emotional symptoms that many women experience in the lead-up to
menstruation (the period). Most menstruating women are affected, with
symptoms ranging from relatively mild to severe. Women aged between 30
and 40 years appear to be at most risk.

Since the cause remains unknown, PMS can’t be cured or prevented.
However, it can be successfully managed with appropriate self-care and a
range of different treatments. Consult with your doctor before starting
any PMS treatment program.
Keeping a PMS diary
There
are more than 150 recognised PMS symptoms, and PMS differs from one
woman to the next. Common symptoms include irritability, moodiness,
fluid retention, breast tenderness and food cravings. There are no
specific tests for PMS, so diagnosis depends on ruling out other
possible causes.
In most cases, you can identify PMS by keeping a
symptoms diary. Include the details of your menstrual cycle for
example, the first and last days of your menstrual period and any
ovulation symptoms. Keep this diary for at least three menstrual cycles.
If your symptoms are due to PMS, the following pattern should occur:
Symptoms are experienced in the two weeks before your period starts.

Symptoms resolve with the period.

Once the period is over, you experience at least seven days with no symptoms.
Symptoms start to return about mid-cycle or in the week before your period starts.
If
symptoms continue throughout the menstrual cycle without change, PMS is
probably not the cause see your doctor for further investigation.

PMS management
PMS can be successfully managed with
lifestyle changes, dietary modifications, supplements and medications.
You may have to experiment to find the balance of treatments that works
best for you. It’s a good idea to continue your PMS diary and record any
symptoms while you trial the remedies. Be sure to consult with your
doctor.

Lifestyle changes

Recommended lifestyle changes include:
Exercise regularly, at least three times a week – try to exercise daily in the premenstrual period.




Don’t smoke.
Cut back on caffeineand alcohol in the two weeks before menstruation.




Ensure that you get enough sleep.
Manage your stress in whatever way wrks for you – for example counselling, Tai Chi or meditation, walking or gardening.
Dietary changes

Women
experiencing PMS symptoms crave high fat and high sugar foods like
chocolate, biscuits and icecream. They usually increase their food
intake by about 20 per cent.
You can manage your weight and help reduce your PMS symptoms by making a few dietary changes, including:




Eat smaller meals more often for example, have six ‘mini-meals’ instead of three main meals.

Reduce your intake of salty foods.

Include more fresh fruits and vegetables and wholegrain foods in your daily diet.
Boost your dairy food intake, but switch to reduced fat or non-fat versions.

Don’t keep high fat and high


sugar foods in the house.
Make sure you always have tasty and healthy snack alternatives on hand.

Record your food choices in your PMS diary – charting your food intake
may help you become more aware of high fat and high sugar snacking.

Supplements

Check with your doctor before taking any type of supplement.
Complementary therapies should be viewed as a medicine and should be
treated with the same respect.
Supplements that have been shown to help reduce PMS symptoms include:
Calcium:
about 1,200mg per day of calcium carbonate can reduce PMS symptoms by
half. You need to take these supplements for at least three cycles
before you may notice an improvement.
Magnesium:
about 200mg per day of magnesium can reduce PMS-related bloating, fluid
retention and breast tenderness by 40 per cent. You need to take these
supplements for at least two cycles before you may notice any
improvement. Food sources of magnesium include nuts, legumes, whole
grains, dark green vegetables, seafood (oysters), and meats.
Chaste tree:
a study showed that the herbal supplement chaste tree (also known as
chaste berry, or vitex agnus castus) reduces PMS symptoms by half. It
has been shown in some studies to reduce symptoms of irritability, mood
swings, anger, headache and breast fullness. This herbal treatment needs
to be taken for at least three months and should only be prescribed by
qualified herbalists.
Vitamin E: about 400 units
of vitamin E per day may reduce breast tenderness. Vitamin E taken with
selenium supplement of 25–50 micrograms daily may be beneficial. High
doses of selenium can cause toxicity and should not exceed 100
micrograms per day.

Evening primrose oil: Gamma-linoleic acid (GLA) is the active
agent found in evening primrose oil. Much like mefenamic acid, GLA
blocks prostaglandin synthesis, resulting in decreased breast
tenderness, bloating, and weight gain. The standard dose is 3 grams per
day, and it should be started less than 1 week before the onset of your
period. This agent is available without a prescription at health food
stores and certain pharmacies. A review of the studies on evening
primrose oil, however, showed no proven effect on the symptoms of PMS.

Ginkgo biloba: Shown to reduce the symptom of breast pain but not other PMS symptoms.

Vitamin B6 (pyridoxine): evidence is mixed about the
effectiveness of vitamin B6 supplements. High doses of vitamin B6 are
toxic to the nervous system. Use with caution and avoid long-term use.

Other supplements: Black cohosh, and dandelion are anecdotally
thought to reduce PMS symptoms. However, their effects have not been
established. There are some concerns that black cohosh may harm the
liver in some individuals. Always consult your doctor before taking any
supplement, including herbal supplements.
St John’s Wort:
is a mood stabiliser and has been shown to improve mood. This
supplement may interact with other medications so always check with your
doctor before taking St John’s Wort.

Medical treatments
There is no cure for PMS. If lifestyle
changes and supplements do not work, there is also a range of hormone
treatments and medications available to help you manage your symptoms.

Hormonal treatments

The aim of
hormone treatment is to suppress ovulation and reduce the hormones of
the premenstrual phase. Many different hormone therapies have been
trialled for PMS:

The combined oral contraceptive pill: ‘the pill’ may relieve
premenstrual symptoms. The monophasic pill is preferable, where all the
hormone tablets are the same dose. Studies show mixed results. A
pill-free interval of 3–4 days seems to give better results.
Oestrogen therapy:
high-dose non-oral oestrogen to inhibit ovulation has been effective.
The oestrogen is given either as a patch or an implant. Unless the woman
has had a hysterectomy, progesterone-like therapy will also be needed.
This may cause side effects similar to PMS.
GnRH agonists:
these medications are usually prescribed as a treatment for
endometriosis or fibroids and are used for a maximum of six months. They
stop ovulation and periods, creating a temporary menopause. Tibolone is
often added to relieve menopause-like symptoms. Hormones: Hormones such
as nafarelin (Synarel) and leuprolide (Lupron) prevent your body from
releasing eggs and undergoing a menstrual cycle. Therefore, if you take
these medications, you will not ovulate and will not menstruate. This
treatment eliminates PMS symptoms in more than half of all women
receiving it. These hormones are like birth control pills in that they
suppress the menstrual cycle, but the cycle returns when they are
stopped. However, women taking the birth control pill still bleed every
month. Women on this therapy have no periods at all. However, most
contraceptive pills and patches can be used in a continuous fashion to
reduce or eliminate withdrawal bleeding.



Mirena IUD: this IUD (intra uterine device)
releases a low-dose progesterone-like hormone, which may suppress
ovulation and reduce symptoms in some women.
Danazol: this medication may also stop ovulation and reduce PMS, but has significant side effects.
Depo-Provera:
this injectable contraceptive stops ovulation and may relieve PMS
symptoms. Side effects may include irregular bleeding and mood changes.



Bilateral salpingo-oophorectomy: removing both
ovaries can abolish PMS but can also lead to menopause and severe
menopausal symptoms if oestrogen and progesterone-like treatment is not
given after the operation.


Medications
There are a number of medications that have been trialled for PMS:
Anti-anxiety drugs:
Benzodiazepines are drugs that decrease anxiety by depressing the
central nervous system. Alprazolam (Xanax) is a member of this class. It
can be effective in treating the anxiety associated with premenstrual
syndrome. You may feel drowsy if you take this type of medicine.
Benzodiazepines can be addictive.
Antidepressants:
Fluoxetine (Sarafem, also known as Prozac), sertraline (Zoloft), and
paroxetine (Paxil) are medicines that help the body increase the
activity of serotonin, a brain chemical that has been shown to be low in
some women with PMS . Clinical trials show that they effectively treat
mood symptoms such as depression, anxiety, and anger. However, other
symptoms of PMS, such as tiredness and decreased sexual drive, may not
improve or may become worse on these drugs.
Anti-inflammatories:
These drugs prevent the body from producing prostaglandins, which have
been suggested as a cause of PMS. Reducing the amount of prostaglandins
in the body may eliminate many of the inflammatory symptoms of PMS such
as menstrual cramps, breast pain, headache, swelling, and other
discomforts. Several types of anti-inflammatory agents are used for PMS.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended
initially, and there are several that may be purchased without a
prescription. COX-2 inhibitors are a new type of NSAID that must be
obtained with a prescription. These are longer-acting than most NSAIDs
and have less risk of causing stomach discomfort or ulcers.





NSAIDs include the following medicines.
Diclofenac (Cataflam, Voltaren)
Ibuprofen (Motrin)
Ketoprofen (Orudis)
Meclofenamate (Meclomen)
Mefenamic acid (Ponstel)
Naproxen (Aleve, Naprosyn)
Diuretics:
Diuretics (commonly called water pills) are drugs that help the body to
shed excess water through the kidneys. These medicines significantly
help reduce the weight gain, breast swelling, pain and bloating
associated with PMS. Metolazone (Mykrox, Zaroxolyn) and spironolactone
(Aldactone) are 2 commonly used diuretics.

Many of these treatments can have side effects, so make sure you are
well informed about them before you and your doctor decide on your
treatment.

Complementary therapies:


Many women feel they benefit from a variety of natural therapies,
although a lack of controlled studies means there is no clear evidence
of their benefits.


Options include:
Cognitive behavioural relaxation
therapy: uses one or a variety of relaxation techniques to relieve
psychological and/or physical symptoms.



Complementary therapies: such as acupuncture or naturopathy.