Premenstrual syndrome

Chapter 33 Premenstrual syndrome


With contribution from Dr Gillian Singleton




Premenstrual dysphoric disorder (PMDD)


When premenstrual symptoms are dominated by severe disturbances of mood and behaviour that are associated with major disruption to daily activities and relationships, the condition is known as premenstrual dysphoric disorder (PMDD).3 PMDD affects around 3–5% of women of reproductive age.5, 8, 9


Some studies have found an association between the luteal phase and exacerbations of psychiatric disorders, including obsessive-compulsive disorder, schizophrenia, increased alcohol consumption in alcoholism, and increased incidence of suicide attempts. This postulates serotonin dysregulation as a possible causative factor.10


The DSM IV diagnostic criteria for PMDD include at least 5 of 11 symptoms occurring in the week prior to menstruation for the majority of months of the previous year, which remit in the post-menstrual week.11 These symptoms markedly interfere with daily activities and interpersonal relationships.


Table 33.2 lists the common symptoms of PMDD.


Table 33.2 Common symptoms of PMDD using DSM IV criteria















Depressive symptoms




Anxiety symptoms


Cognitive symptoms Subjective sense of having difficulty concentrating
Physical symptoms Breast tenderness or swelling, headaches, joint or muscular pain, weight gain, bloating





Role of complementary medicine and integrative therapies in PMS


Treatment goals for PMS, PMDD, cyclical mastalgia and dysmenorrhoea are determined by the severity of the symptomatology, with the aim to ameliorate or eliminate symptoms and reduce the impact of symptoms on activities of daily living and interpersonal relationships.


The use of complementary medicine is popular amongst women with PMS, PMDD and dysmenorrhoea and plays an important role in management of symptoms.14 While mainstream medical treatment for PMS is commonly used, a large scale survey of medical and nurse practitioners, including gynaecologists, indicated that at least 90% reported recommending at least 1 complementary therapy, primarily for pain management for women with PMS.15 Chiropractic, acupuncture, massage, and behavioural medicine techniques such as meditation and relaxation training were cited as the most commonly recommended.


A 2003 systematic review16 identified 33 randomised control trials (RCTs) for complementary medicine use in PMS, 13 of which were for dysmenorrhoea. There is an increasing body of evidence supporting the use of complementary therapies and lifestyle interventions in the management of PMS symptoms. To date a number of therapeutic interventions including calcium supplementation, vitex agnus castus, stress reduction, cognitive behavioural therapy (CBT) and relaxation therapy and exercise have been shown to be beneficial. The authors’ conclude that preliminary studies indicate a role for further research on magnesium, vitamin B1 and B6, low-fat diet, fish oil supplementation for dysmenorrhoea, St John’s wort and L-tryptophan supplementation for PMDD.16


Another review of the literature for treatment of PMS and PMDD identified a number of useful non-pharmacological treatments with some evidence for efficacy including cognitive behavioural relaxation therapy, aerobic exercise, as well as calcium, magnesium, vitamin B6, L-tryptophan supplementation and a complex carbohydrate drink. 17


This chapter will outline in more detail potential lifestyle and non-pharmaceutical approaches which may assist PMS symptoms, including the evidence on efficacy and safety for these approaches.



General lifestyle interventions


Lifestyle interventions such as dietary changes, sodium and caffeine restriction, regular daily exercise, and stress reduction can improve quality of life (QOL) and significantly reduce symptoms of PMS, including mood and pain symptoms, experienced by women. Patient education and supportive strategies, such as use of a symptom diary, can help in diagnosing, understanding and managing the disorders. It is clear that women need reassurance and education about effective treatment options available to them.



Symptom diary and management


The PMS Symptom Management Program (PMS-SMP) includes non-pharmacological strategies incorporating self-monitoring, emphasis on personal choice, self-regulation, and self/environmental modification, with peer support and professional guidance. A study designed to establish the effectiveness of this program randomised 91 women with severe PMS to early treatment groups (n = 40) or waiting treatment groups (n = 51) over an 18-month period.18 The PMS-SMP was effective in reducing PMS severity by 75%, premenstrual depression, and general distress by 30–54%, as well as increasing wellbeing and self-esteem in women experiencing severe PMS compared with antidepressant drug treatments that report a 40–52% reduction in PMS severity in studies. The improvement was maintained in the long-term follow-up.18



Addressing attitude to menstruation and rest


An area rarely addressed in the literature is the importance of assessing the woman’s attitude towards menstruation. A woman’s attitude and perception can be influenced by her family member’s or her peer’s previous experiences with menarche and menstruation on the background of her own level of knowledge about this stage of her life. Negative experience of peers and female role models with menarche and menstruation can obviously influence a young woman’s perception of what to expect with her own menses. Alternatively, if menarche comes unexpectedly, she may respond negatively or positively, depending on her own life skills and her level of communication with her family members and peers.


There are a multitude of negative terms which have been used in many societies to describe menarche; conversely there are cultures where menarche is celebrated and viewed as a positive entrance into womanhood. An example of this is Ayurveda, which is an ancient Asian tradition of medicine that is over 2000 years old. Ayurvedic tradition views menstruation as an opportunity for a woman’s body to ‘purify’, rather than as a problem. They encourage respect for menstruation and aim to facilitate it and employ methods to experience greater comfort. The tradition promotes women to stay at home as much as possible during menstruation as the woman’s body undergoes changes. There any many traditional cultures with similar beliefs which advise women to rest during menstruation.


Minimising sexual activity during the premenstrual phase may help reduce pelvic pain.



Mind–body medicine



Cognitive and behavioural interventions


Improving knowledge, supportive therapy, addressing dysfunctional thinking and encouragement of behavioural changes can significantly impact on women’s perception of PMS and menstruation and on their ability to better manage their symptoms appropriately. Educating women about the biological changes in their bodies has been reported to facilitate an increased sense of control and relief of symptoms.19


There has been evidence of an increased placebo-response rate demonstrated in symptomatic improvement from formal psychological interventions such as relaxation therapy and CBT in some studies.20 These interventions include keeping a symptom diary to help identify when behavioural and psychological changes are necessary, having adequate rest and exercise, and making healthy dietary changes.21


A number of studies have supported the role of CBT in managing PMS, particularly for pain and dysphoric symptoms. A study of 84 women with PMS, examined the efficacy of enhanced coping skills training that included cognitive restructuring, reducing negative emotions, effective problem-solving assertiveness and relaxation training, in direct comparison with hormone treatment with Duphaston, a synthetic progestogen.22 The group of women randomised to coping skills training obtained substantial relief of affective and cognitive symptoms when compared to women in the hormone therapy group; this relief was particularly noted in women with severe PMS symptoms. These symptomatic benefits persisted at the 3-month follow-up following intervention.22


A 2005 Cochrane systematic review of 14 RCTs looking at management strategies for chronic pelvic pain, demonstrated that ‘counselling supported by ultrasound scanning was associated with reduced pain and improvement in mood’.23


A 2007 Cochrane systematic review of the effectiveness of behavioural therapies in management of dysmenorrhoea included 5 RCTs. The results of this review demonstrated that there is some evidence for the use of behavioural interventions such as relaxation techniques and pain management training in reducing symptoms to cause fewer restrictions in daily activities.24


Another study aimed to modify dysfunctional thinking as a means of impacting on negative premenstrual symptoms.25 The CBT group involved cognitive restructuring and assertion training. A comparison group called ‘information-focused therapy’ (IFT) were presented with information only on relaxation training, nutritional and vitamin guidelines, dietary and lifestyle recommendations, and assertion training, and did not address belief restructuring. Both groups equally displayed amelioration of anxiety, depression, negative thoughts and physical changes in women with PMS.


A 2009 systematic review of studies that investigated the use of CBT for PMS or PMDD identified 3 RCTs comparing CBT with pharmacotherapy and a number of case studies.26 The researchers highlighted the benefits of applying mindfulness and acceptance-based CBT interventions to individuals with PMS/PMDD and suggested more methodologically rigorous research be done in this area.




Stress reduction, relaxation therapies and massage


A number of studies have demonstrated that women can gain symptomatic benefit from the use of relaxation therapies and massage.


A 2004 study of 114 women divided them into high and low symptom severity PMS groups and compared these groups on stress and QOL variables. The results revealed that women with severe PMS symptoms had significantly more stress and poorer QOL than women with low symptom scores.27


A 5-month study published in Obstetrics and Gynecology, examined the effects of the relaxation response on PMS symptoms in 46 women who were randomly assigned to 1 of 3 groups: a charting group who kept a daily diary of symptoms experienced, a reading group who read leisure material twice daily in combination with charting symptoms, and a relaxation response group who elicited a relaxation response twice daily as well as charting symptoms.28 The relaxation response group showed significant improvement (58.0%), in comparison to the reading groups (27.2%) and the charting group (17.0%) of reduction in physical and emotional symptoms. The authors conclude that ‘regular relaxation response is an effective treatment for physical and emotional premenstrual symptoms, and is most effective in women with severe symptoms’.28


Another trial had 24 women with PMDD randomly assigned to either a massage therapy or a relaxation therapy group (Progressive Muscle relaxation therapy).29 The massage therapy group demonstrated reduction in pain, anxiety and depressed mood immediately after the massage sessions, especially in women treated weekly for 5 weeks, who also experienced reduced fluid retention and overall menstrual distress. The relaxation group also demonstrated improved symptoms but not to the same degree of benefit from massage therapy. While the findings demonstrate massage therapy may be an effective short-term treatment for severe symptoms of PMS, no long-term changes were observed in the massage therapy group.



Sleep


Sleep disturbances are common in women with severe symptoms of PMS, PMDD and dysmenorrhoea. Variations in core temperature, metabolic rate and hormones throughout the menstrual cycle may contribute to changes in sleep patterns and quality of sleep particularly in the luteal phase and menstruation.30 Women experiencing negative mood changes in the premenstrual period also demonstrate significantly less delta wave sleep during both menstrual cycle phases in comparison with asymptomatic subjects.31 Evidence also indicates that variations in other circadian rhythms, such as melatonin and cortisol, may also be affected in the luteal phase of the menstrual cycle which may negatively impact sleep patterns.


A study of 68 nurses under 40 years of age completed a survey evaluating sleep, menstrual function and pregnancy outcomes. Fifty-three percent of the women noted menstrual changes when working shift work and the findings suggest that sleep disturbances may lead to menstrual irregularities, and changes in menstrual function.32 Another study also demonstrated how disruption of circadian rhythms as seen in women working night shifts are more likely to report menstrual irregularities, longer menstrual cycles, abnormalities of reproductive function and mood changes than non-shift workers.33 The authors also concluded there was accumulating evidence ‘that circadian disruption increases the risk of breast cancer in women, possibly due to altered light exposure and reduced melatonin secretion’.33


A regular structured sleep schedule is therefore recommended, especially during the luteal phase, to minimise premenstrual symptoms.



Sunshine and vitamin D


It is likely that regular exposure to sunshine plays an important role in regulating hormones and sleep patterns, by affecting melatonin circadian rhythms, which is known to affect the menstrual cycle.


The primary source of vitamin D is sunshine exposure which is best combined with regular exercise and may play a role in normalising menstrual cycles.


In a very small study of women suffering polycystic ovarian disease, they received 50 000IU of vitamin D weekly or biweekly, and this helped to normalise their menstrual cycles in over 50% of patients.34 Whilst the exact underlying mechanism is unclear, it would appear more research is warranted in this area as vitamin D deficiency is common, particularly in cooler climates, in dark skinned women and women with certain dress codes (e.g. veils), and vitamin D may play an important hormone regulatory effect. It is also documented that vitamin D plays an important role in mood regulation, amelioration of depression, myalgias, back pain and in the management of migraine headaches and thus may reduce some of the symptoms experienced with PMS, PMDD and dysmenorrhoea (see chapters on depression, headaches and migraines and musculoskeletal medicine for more references).3538


Interestingly, a number of controlled studies of active bright light therapy in the late luteal phase significantly reduced depression and pre-menstrual tension scores in women with PMDD, compared to baseline, while placebo dim red light treatment did not.39, 40 These results suggest that bright light therapy can be an effective treatment for depression in the luteal phase, although exposure to daily sunshine and/or vitamin D supplementation (especially if sunshine exposure is not possible), may obviously be more feasible and convenient.



Physical activity/exercise


A number of studies demonstrate that exercise has a positive impact on symptoms of PMS, PMDD and dysmenorrhoea.


A prospective study examined the relationship between exercise participation and menstrual pain, physical symptoms, and negative mood in 21 sedentary women and 20 women who participated in regular exercise for 2 complete menstrual cycles.41 All women experienced pain during menses compared to the follicular and luteal phases. The findings demonstrated that exercise participants reported less pain than sedentary women during menses, however there was no reported difference in pain experienced in the follicular and luteal phases between the groups. The sedentary group also reported greater symptoms of anxiety during menses. Likewise, another study demonstrated moderate exercise training without major weight, hormonal or menstrual cycle alteration significantly reduced premenstrual and menstrual symptoms including circulatory symptom problems, psychic tension, irritable behaviour, belligerence, and other personality alterations.42


A preliminary study of middle-aged women demonstrated that women with PMS who practised regular aerobic exercise reported fewer symptoms than the control subjects.43


In a prospective, controlled 6-month trial of exercise training, 2 groups of women, 1 previously sedentary, were commenced on a 6-month conditioning exercise program of increased running or marathon training, and were compared with a control group of women who were not actively involved in an exercise training program but were normally active.44 Over the 6-month period of the study the first 2 groups demonstrated a reduction in PMS symptoms including fluid retention, depression and anxiety symptoms compared with the control group of women. The control group demonstrated no change in PMS symptomatology. This study demonstrates the direct positive effects of conditioning exercise on PMS. There was no documented hormonal, menstrual cycle, or weight changes in either groups.44



Nutritional influences



Diet


A growing body of evidence supports the use of dietary change in managing premenstrual symptoms. Individuals with diets rich in omega-3 fatty acids, calcium and vitamin D and low in animal fats, salt and caffeine are believed to have a reduced incidence of troublesome premenstrual symptoms. The following section outlines the evidence basis for suggesting these dietary changes in patients who experience such symptoms.




Vegetarian plant-based diet


A study of 33 women over 4 menstrual cycles was conducted in which the women adhered solely to a plant-based vegetarian diet for 2 menstrual cycles then returned to their normal diets and took a placebo supplement for a further 2 cycles. This study demonstrated that a low-fat, plant-based vegetarian diet of grains, vegetables, legumes and fruits, significantly reduced the duration (from 3.9 to 2.7 days) of pain and reduced associated premenstrual symptoms such as fluid retention and behavioural changes when the diet cycles were compared to the placebo cycles on a normal diet.46 Several reasons were postulated for its benefit. The plant-based dietary factors were found to raise serum sex-hormone binding globulin (SHBG) by 19% in the diet phase compared to the supplement phase. SHBG binds and inactivates estrogens. It is hypothesised that estrogenic stimulation of the endometrium is then reduced which in turn may limit proliferation of tissues which produce prostaglandins. Another possible reason for symptomatic benefit is that vegetarian diets are generally lower in total fat and that the ratio of omega-3 to omega-6 fatty acids is increased compared to diets rich in animal fats, which results in reduced fluid retention and reduced dysmenorrhoea.


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Dec 4, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Premenstrual syndrome

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