Chapter 33 Premenstrual syndrome

With contribution from Dr Gillian Singleton

Introduction

A great majority of women will experience premenstrual symptoms at some time in their lives. Some women, however, experience more severe and troublesome symptoms that can impact daily living. This condition is defined as premenstrual syndrome (PMS). PMS can affect up to 90% of women of childbearing age with 2–10% of women experiencing severe, incapacitating symptoms. PMS is characterised by the cyclical recurrence of broad and varied symptoms which are in the luteal phase of the menstrual cycle, and which remit at the onset of menstruation or in the days following.¹^–⁵ These symptoms include emotional, behavioural and physical symptoms (which are outlined in more detail in Table 33.1).^6,⁷ Some women predominantly experience mood, cyclical mastalgia or dysmenorrhoea symptoms during the luteal phase.

Table 33.1 Common symptom of PMS

Psychological	Irritability, anger, depressed mood, tearfulness, anxiety, tension, mood swings, difficulties with concentration and memory, confusion, restlessness, decreased self-esteem, tension, feelings of being overwhelmed, of loneliness and hopelessness
Behavioural	Insomnia, changes in libido, food cravings or overeating
Physical	Fatigue, dizziness, headaches, mastalgia, back pain, abdominal pain and bloating, weight gain, constipation, fluid retention (up to 1kg of weight), nausea, myalgias and arthralgias

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	Markedly depressed mood, feelings of hopelessness, self-deprecation Affective lability. Suddenly feeling sad or tearful, with increased sensitivity to personal rejection Decreased interest in usual activitiesLethargy, fatigue, marked lack of energy Accompanying depressive symptoms there is always the danger for suicidal ideation and risk-taking behaviours Marked changes in appetite and cravings for certain foodsInsomnia or hypersomnia
Anxiety symptoms	Marked anxiety, and tension Persistent or marked irritability, anger, and subsequent increased interpersonal conflicts Feeling overwhelmed or out of control
Cognitive symptoms	Subjective sense of having difficulty concentrating
Physical symptoms	Breast tenderness or swelling, headaches, joint or muscular pain, weight gain, bloating

Dysmenorrhoea

Primary dysmenorrhoea is defined as the occurrence of painful menstrual cramps, in the absence of pelvic pathology, and occurs in up to 80% of young women, with over 50% of these individuals experiencing limitations to their daily activities, such as work and schooling.¹² Primary dysmenorrhoea is hypothesised to be caused by uterine contractions in response to prostaglandin, leukotriene and vasopressin release.

This condition needs to be differentiated from secondary dysmenorrhoea where the pain is caused by an underlying disease process. Causes of secondary dysmenorrhoea include endometriosis, adenomyosis, post-surgical adhesions, endometrial fibroid tumours, pelvic inflammatory disease, psychosomatic disorders, depression, inflammatory bowel disease, diverticulitis, bladder problems and urogenital cancers. It is obviously important to exclude these secondary causes of pelvic pain prior to treatment.

Cyclical mastalgia

Breast pain or mastalgia is a common symptom experienced by women especially in the premenstrual phase. Overall, 92% of patients with cyclical mastalgia and 64% with non-cyclical mastalgia can obtain relief of their pain with the use of available therapies.¹³

Aetiology of premenstrual symptoms

Several hypotheses have been postulated as to the exacerbating factors for and causation of symptoms of PMS, PMDD, cyclical mastalgia and dysmenorrhoea. These include:

• excess or deficiency of progesterone

• abnormal secretion of oestrogen

• abnormality of endogenous opiates

• excess or deficiency of cortisone, androgens or prolactin

• excess anti-diuretic hormone from posterior pituitary gland

• excess or deficiency of prostaglandins

• psychological, social or genetic factors.

Pharmaceutical and hormone therapies

A number of pharmaceuticals and hormone therapies are used successfully for the management and alleviation of symptoms of PMS, PMDD, cyclical mastalgia and dysmenorrhoea but it is not within the scope of this chapter to cover these therapies. Pharmaceutical and hormone treatment include:

• prostaglandin inhibitors (e.g. non-steroidal anti-inflammatory medication)

• analgesics

• hormonal therapies — oestrogen, and/or progestogen treatment (e.g. IUD, oral contraceptive pill, minipill, depo provera) and testosterone

• antidepressants and anti-anxiolytic agents such as selective serotonin reuptake inhibitors

• antidiuretics and anti-diuretic hormone inhibitors

• anti-androgens.

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 review ¹⁶ 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.

Psychosocial support

It is important that the impacts of PMS/PMDD on a woman’s life and relationships are dealt with on a social level. The involvement of partners, friends, family, teachers and employers in the education process is important to allow them to understand the woman who is experiencing severe symptoms that may impact on her ability to function in her normal daily activities, and that she may benefit from empathy, social support and possibly financial assistance.

Counselling may also be required to address sexual, fertility and relationship consequences in women affected by chronic pelvic pain, dysmenorrhoea, mood changes, lowered libido and dyspareunia.

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).³⁵^–³⁸

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.