Premenstrual Syndrome: PMS is a disorder characterized by a set of hormonal changes that trigger disruptive symptoms in a significant number of women for up to two weeks prior to menstruation. Of the estimated 40 million suffers, more than 5 million require medical treatment for marked mood and behavioral changes. Often symptoms tend to taper off with menstruation and women remain symptom-free until the two weeks or so prior to the next menstrual period. These regularly recurring symptoms from ovulation until menses typify PMS, premenstrual syndrome.
Over 150 symptoms have been attributed to PMS. After complaints of feeling “out-of-control", anxious, depressed and having uncontrollable crying spells, the most common complaints are headache and fatigue. But symptoms may vary from month to month and there may even be symptom-free months. No women present with all the PMS symptoms. Characteristically symptoms may be both physical and emotional. They may include physical symptoms as headache, migraine, fluid retention, fatigue, constipation, painful joints, backache, abdominal cramping, heart palpitations and weight gain. Emotional and behavioral changes may include anxiety, depression, irritability, panic attacks, tension,lack of co-ordination, decreased work or social performance and altered libido.
Originally described in 1931 by an American neurologist, the grouping of symptoms has remained the same:
Aside from the regularity of symptoms seen prior to menstruation, there are certain elements which distinguish PMS from other disorders:
*PMS may often be triggered by hormonal changes. It tends to begin at puberty, after pregnancy, after starting birth control pills, after hormone related surgery as hysterectomy or tubal ligation or around the onset of the menopause. In fact, it is not unusual for the PMS sufferer to confuse her symptoms with those of an early menopause.
*Lifting of symptoms (including headache) with pregnancy, especially in the second and third trimester.
*Heredity appears to be a factor although specific symptoms may differ between sisters or mother and daughters.
*There is often an aura of increased activity prior to the worse symptoms of PMS or migraines. At this time, the woman may clean the house, function with little sleep, and feel euphoric. This is followed by the PMS symptoms, migraine, fatigue, exhaustion, depression and the inability to function. Women typically feel “out of control” at this time and this can cause the signs and symptoms of depression.
The exact cause of PMS, headaches and depression are unknown. In fact, it is not known why some women have severe symptoms, some have mild ones, while others have none. It is generally believed that PMS, migraine and depression stem from neurochemical changes within the brain. Hormonal factors, such as estrogen levels, had not been appreciated until recent studies.
The female hormone estrogen starts to rise after menstruation and peaks around mid-cycle (ovulation). It then rapidly drops only to slowly rise and then fall again in the time before menstruation. Estrogen hold fluid and with increasing estrogen comes fluid retention: many women report weight gains of five pounds premenstrually. Estrogen has a central neurologic effect: it can contribute to increase brain activity and even seizures. Estrogen can also contribute to retention of salt and a drop in blood sugar. PMS patients and migraineurs benefit from both salt and sugar restriction and a mild diuretic.
A special form of PMS is the severe depression experienced after delivery. Most women experience a “let down” from the high hormone levels during pregnancy. Because of this, there is a normal amount of feeling “blue” immediately after childbirth. But the depth of depression experienced with postpartum depression is much deeper. These individuals cannot tolerate the hormonal disruption to their nervous system: their actions may harm themselves or their infants. That is why the treatment of PMS in the postpartum period is first to replace the missing hormones. If unsuccessful, then other hormonal preparations can be included as well.
PMS and Migraine Diet
Depending on the patient’s individual symptoms and their severity, the doctor may recommend how one may take an active role in the management of PMS and premenstrual migraine by following these guidelines:
*Eat six small meals at regular three-hour intervals, high in complex carbohydrates and low in simple sugars. This helps to maintain a stead blood glucose level and avoid energy highs and lows.
*Substantially reduce and eliminate use of caffeine, alcohol, salt, fats, and simple sugars to reduce bloating, fatigue, tension and depression.
*Daily supplemental vitamins and minerals may be administered to relieve some PMS symptoms. A multivitamin with B6(100 mcg), B complex, magnesium (300mg), Vitamin E (400 IU) and vitamin C (1000 mg) may be recommended to alleviate irritability, fluid retention, joint aches, breast tenderness, anxiety, depression and fatigue. Be sure to check with your doctor before taking any medication for PMS.
*Exercise is helpful for PMS because it reduces stress and tension, acts as a mood elevator, provides a sense of well-being and improves blood circulation by increasing natural production of beta-endorphins. It is recommended, if your physician so advises, to exercise at least three times weekly for 20-30 minutes. Aerobics, walking, jogging, bicycling and swimming are a few of the suggested ways to exercise.
The Psychiatric Treatment of PMS
The psychiatric literature since the 1930’s has portrayed women as the weaker sex and in need of medical treatment for their “hysterical” and “hysteronic” complaints [pertaining to the uterus]. With the availability of psychotropic drugs, 1)the tricyclics (Elavil, Triavil, Sinequan), 2) the tranquilizers (Valium, Ativan, and Xanax), and 3) the selective serotonin reuptake inhibitors, there have been many documented studies showing the benefit to the patient in taking this medication for severe P.M.S.
The problem with the treatment approach when used for more than a few cycles, is that it fails to address the underlying hormonal problems. So the result is the woman taking these medications may become sleepy, forgetful or not communicative. For this and other reasons, our primary approach has been hormonal.
Medical Treatments of PMS
Since 1953, hormonal therapies have been the mainstay of the treatment of premenstrual distress and premenstrual syndrome. Kathrina Dalton, M.D., a family practitioner in England, evaluated the effectiveness of a program of aqueous progesteone suppositories on her own symptoms. When they were relieved, she repeated the study with 50 patients under the care of a leading gynecologic endocrinologist. They also experienced improvement.
These aqueous progesterone suppositories have been found effective. They are safe during pregnancy, as the placenta produces many more times progesterone than the pregnancy. They are safe in men too! In the 1940’s, progesterone was injected into men– no side effects except they fell asleep! And since we use a slightly smaller dose to help women conceive, progesterone can be continued until well in the menopause.
Since 1979, Day and others have reported on the use of low dose danazol to control the worst PMS. Danazol is taken all month long and prevents the rise and fall of estrogen levels. In more than 10 medical articles, the success fate for controlling PMS in more than 80 percent. See article by Deeny. Although danazol has the side effects in some of acne and fluid retention, most are easily treated. Rarely has there been liver or bone changes with these dosages of medication. Some patients are so well controlled on hormonal therapy that they are able to discontinue the medications prescribed by the psychiatrist.
SSC Yen in 1985 showed that luprolide acetate, a long-acting agent for endometriosis, can rapidly eliminate the worse PMS symtpoms. Although luprolide is not usually used for these symptoms, it does confirm what these women have known for years–THE PAIN AND MOOD SWINGS ARE REAL!
So women need not feel that they are going crazy for these two weeks every month. They are experiencing an exaggeration of normal function. The physician can help the patient by first explaining the process, secondly using an anti-estrogenic hormonal medication to lower and stability the estrogen level, and lastly, using psychotropic medications for short periods of time.
PMS IS REAL– AND THE PRESCRIPTION MEDICATION MUST ADDRESS THE WOMAN’S NEED AND THE UNDERLYING HORMONAL IMBALANCES.
Edward Lichten, M.D.,PC
555 South Old Woodward Suite #700
Birmingham, MI 48009
A- Anxiety: irritable, crying without reason, verbally and/or physically abuse, feeling “out of control", or Dr. Jekyl/Mr.Hyde changes.
D- Depression: confused, clumsy, forgetful, withdrawn, fearful, paranoid, suicidal thoughts and rarely suicidal actions.
C- Cravings: food cravings, usually for sweets or chocolate; diary products including cheese, an on occasion, alcohol or food in general.
H-Heaviness or Headache: Fluid retention leading to headache, breast tender, abdominal bloating and weight gain.
Contrary to popular belief, the treatment of PMS dos not rely on tranquilizers and sedatives. Rather, the disease is caused by an excess of estrogen and a definiency of progesterone in the last two weeks of the woman’s cycle. Supplementation with addtional progesterone as suggested by Katrina Walton MD in the 1960’s, just doesn’t work for many. I prefer, and the literature supports the use of 100-200mg of Danazol twice daily to suppress the excess estrogen production.
Side-effects of this low dosage of danazol are few. I counteract the fluid retention by adding spirolactone 100mg twice daily and any slowing of the metabolism by adding Armour thyroid 1 grain 1-2 times daily. All PMS symptoms, including menstrual pain, dysmenorhea, migraine, mood swings and heavy menstrual flow are usually very controllable.