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Understanding premenstrual syndrome
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What are the symptoms?
What's the cause?
How do I know if I have PMS?
What's the treatment for PMS?
What is premenstrual dysphoric disorder?
What should friends and family do?
My teenage daughter has PMS. How can I help?
References
Useful organisations
Useful websites
Further reading
'Just before my period, things my partner does can make me so angry. However, I hate it when he dismisses my anger as just PMS. The fact is, I would still get angry at other times in my cycle I just wouldn t be angry enough to actually say something.'
'I used to get so depressed just before my period. Work or going out would feel impossible, and I would cry all the time. I even thought about suicide. Whenever I got to my lowest point, everything would seem a lot brighter the next morning. It took a while to make the connection with the timing of my periods. Since having counselling for my anxiety and depression, my PMS is nowhere near as bad as it used to be. I think this is partly because I assert myself more, and so have less reason to be angry or depressed. Just being aware that what I am going through is PMS also makes it much easier to bear.'
Premenstrual syndrome can make life a misery. This booklet explains what happens and why, and tells you what you can do to improve your psychological symptoms.
What are the symptoms?
Premenstrual syndrome (PMS) can occur any time up to fourteen days before your period, stopping within the first few days of menstrual bleeding. PMS can bring with it a host of symptoms, both physical and mental. It's thought that at least 40 per cent of women having periods get PMS, and for around 5 to 10 per cent the problem is severe. Some studies have even suggested that 95 per cent of women experience some symptoms.
Women have reported about 150 symptoms, all in all. Some of the most common ones are listed here.
Physical
Swollen, tender breasts; bloating and water retention; headaches and migraine; stomach cramps; skin rashes or allergic reactions; acne; sleep disturbances; food cravings; increased thirst; asthma; clumsiness; backache; dizziness; fatigue; increased or decreased sexual desire, and eye problems.
Mental
Mood swings; tension; agitation; irritability; anxiety; depression; sadness or tearfulness; feeling overwhelmed, anger or aggression; panic attacks; loss of confidence; low self-esteem; impulsiveness; poor concentration; indecisiveness; creativity, and forgetfulness.
Any woman between the years of puberty and the menopause can experience PMS. In some cases, women having hormone replacement therapy after their menopause can have PMS symptoms. It's thought that certain factors, including pregnancy, miscarriage, extreme weight loss, the contraceptive pill, abdominal surgery, gynaecological disorders, poor diet, and stress can make PMS more likely, or make existing symptoms worse. The risk of being affected by PMS also increases with age.
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What's the cause?
There is no clear information about this. It used to be thought that it was caused by having too little of the hormone progesterone, in relation to oestrogen, during the second half of the menstrual cycle, but there's no evidence to support this. There's very little difference in hormone levels between women who get PMS and those who don't. Hormone therapy is not recommended for PMS in The British National Formulary (the doctor s handbook), although it is still being prescribed.
It's still thought that the hormones involved in reproduction are responsible in some way, but current theories are quite complicated. The levels of progesterone and oestrogen in a woman's body are at their highest during the luteal phase of her menstrual cycle. This is the segment of the menstrual cycle between one and 14 days before the onset of a period. It's thought that women experiencing PMS are more sensitive to the effect the higher levels of these hormones have on the brain chemicals serotonin and gamma-aminobutyric acid (GABA). Reduced serotonin levels have been linked to depression, anger, irritability, impulsive behaviour and carbohydrate cravings. GABA is thought to offer protection against anxiety.
Some researchers believe mineral imbalances contribute to PMS. Calcium and magnesium help nerve cells to communicate, and blood vessels to widen and narrow.
Another idea is that PMS may have something to do with the part of the brain that regulates our response to stress, and controls reproduction, appetite and feelings of wellbeing. This system, called the hypothalamic-pituitary-adrenal system (HPS), is responsible for producing cortisol, a stress hormone. Low levels of cortisol are linked with depression.
Social and psychological causes
Social and psychological pressures may also play their part. Women often grow up believing that it's wrong to feel or express anger, and may begin to feel that the only time they can admit to anger is before their period. Anger at the 'time of the month' is seen as more socially acceptable, although at the risk of not being taken seriously.
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How do I know if I have PMS?
The key to whether you have PMS is not so much the symptoms, but their timing. If you suspect you have PMS, your first step should be to keep a diary of your symptoms for two or three months. It's important to keep the diary on a daily basis, rather than filling it in from memory, and to record your symptoms in detail: what they are, when they started, their regularity and severity. Sometimes, underlying symptoms such as migraine or epilepsy can become worse, just before a period. The symptoms you experience can vary from month to month. By keeping a diary, it should be possible to see whether there's a pattern emerging during the luteal phase. You should also be able to see if troublesome symptoms are all actually related to PMS.
PMS can be diagnosed with the help of your diary or chart, so you should take it to your GP or practice nurse. Many surgeries now have PMS clinics to help women identify and cope with PMS symptoms. You will probably have blood and urine tests to rule out other possibilities, such as thyroid problems or anaemia.
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What's the treatment for PMS?
This booklet focuses on treatments for the mental symptoms of PMS. There are other treatments that target the physical symptoms, such as Evening Primrose Oil, diuretics and antiprostaglandins. To find out more about these other treatments, ask your doctor, or contact one of the PMS charities listed under Useful organisations.
Talking therapies
During this part of your cycle, your emotions may feel unmanageable and frightening. They may seem so different to how you feel during the rest of the month that you can't see the point of talking about them. But, if you examine them closely when the PMS has passed, you may find the emotions are still present but to a much lesser degree. If this is true for you, talking to someone could help your PMS.
You may want to talk to a friend or relative, or you could explore your emotions and their underlying causes with a counsellor or psychotherapist. This could help you to see yourself differently and may improve your relationships. A counsellor or psychologist practising cognitive behavioural therapy could help you to identify your feelings and their consequences before developing coping strategies and more positive ways of thinking. (See Further reading.)
You could ask your GP to refer you to a counsellor or psychologist, or you can contact the regulatory bodies listed under Useful organisations and ask for voluntary organisations and private practitioners in your area. If at any time you feel overwhelmed, you could call Samaritans (see Useful organisations).
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Dealing with anger
Assertiveness classes can help you to express yourself, so feelings of anger and frustration don't build up. There are other exercises you can use to release your pent-up anger, such as writing down what you feel on a piece of paper, and then tearing it up. Or you could keep it, and look at it once your PMS has passed. It could help you think about the cause of your anger, and whether you now want to take any action.
In this way, the PMS becomes a useful tool, because it amplifies your feelings to a point where they have to be heard. You can then begin to identify what, in particular, is making you unhappy, or when you need to be more assertive. (See Mind booklets, How to assert yourself and How to deal with anger.)
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Targeting the causes of stress
In the midst of PMS, practical problems can seem impossible to solve. When the PMS has passed, you can begin to think about the stresses you experience and take steps to reduce them. Talking therapies can help you to identify and deal with causes of stress, such as relationship difficulties. There are many charities set up to help people with more practical problems, such as debt and housing. (For more information on local organisations, see your phonebook, contact the MindinfoLine, or read The Mind guide to managing stress.
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Relaxation and complementary therapies
Learning relaxation techniques, or practising yoga and meditation, can help tackle stress and anxiety symptoms. Complementary therapies, such as aromatherapy, reflexology and acupuncture can also help you relax, and restore equilibrium to your body s hormonal system. (More information can be found in The Mind Guide to ... series of booklets)
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Exercise
Any form of physical activity that you enjoy doing will either relax or invigorate you and make you feel less depressed. It can help channel any anger and aggression in a positive way and can improve your sleep. Exercise is considered beneficial for PMS symptoms. (See The Mind guide to physical activity.)
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Diet
It's important to eat a balanced diet and keep your blood sugar levels stable. If you don t eat regularly, or if you consume a lot of food containing processed white sugar (including biscuits, sweets, soft drinks or convenience foods), your blood sugar levels can actually drop. This activates adrenalin in your system, which can cause anxiety symptoms.
It's important to eat when you wake up in the morning, and to eat regularly during the day, to keep your blood sugar levels constant. The National Association for Pre-menstrual Syndrome recommends that you eat small portions every three hours, even if it's just a slice of crisp bread. Avoid sweet and salty foods. Your diet should be balanced and include complex carbohydrates, such as potatoes, pasta, granary or seeded bread, and rye crisp breads. The sugars found in these foods are released more slowly, allowing your body to maintain blood sugar levels. Eating complex carbohydrates also seems to increase levels of helpful serotonin.
Saturated fats in your food can stop your body using essential fatty acids properly, and this can lead to hormonal imbalances and PMS symptoms. Foods such as soya, tofu and yams are thought to help balance hormonal levels. (For more general information about how diet seems to affect mental health, see The Mind guide to food and mood.)
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Calcium and magnesium
It s a good idea to change your diet to increase your levels of calcium and magnesium. Good sources of calcium include dairy products, such as milk and cheese; green leafy vegetables, such as broccoli and cabbage; soybean products; nuts; bread and anything made with calcium-fortified flour; and fish, such as sardines and pilchards (where you eat the bones). Good sources of magnesium include green leafy vegetables (such as spinach) and nuts. Bread, fish, meat and dairy foods also contain magnesium.
Women with PMS may find it helpful to take extra calcium and magnesium (about 500mg of calcium and 250mg of magnesium). The Food Standards Agency recommends taking no more than 1500mg of calcium a day and no more than 400mg of magnesium (any more may give you stomach pain and diarrhoea).
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Vitamin B6 (pyridoxine)
This vitamin can be found in red meat, chicken, turkey, cod, whole cereals (such as oatmeal, wheatgerm and rice), eggs, vegetables, soya beans, peanuts, milk, potatoes and some fortified breakfast cereals.
Some women may require supplements. But you should err on the side of caution. There are concerns that prolonged use of B6 in high doses can lead to peripheral neuropathy. This means losing feeling in your arms and legs, which may continue when the supplement is stopped. Doctors should prescribe no more than 100mg a day. Start with 10mg a day and increase this, gradually, if your symptoms don't improve. It may be best to take Vitamin B6 only during the premenstrual part of your cycle. Keep up the same dose for two menstrual cycles so that you can establish how effective it is.
Once you've found the right dose for you, maintain it for six months and then gradually reduce it. If the symptoms return, increase the dosage again. You need to be cautious. If you start getting more headaches, pins and needles, tingling, numbness and nausea, or if your sleep is disturbed, your dosage of Vitamin B6 may be too high.
Vitamin B6 can help with breast tenderness, anxiety, headaches, irritability and mood swings. It can also improve the body's use of essential fatty acids. If you're worried about taking Vitamin B6, or need advice about it, ask your GP or local pharmacist. You could also try taking magnesium and calcium supplements first.
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Agnus castus fruit extract (chaste tree berry)
Several studies suggest that agnus castus fruit may help with the symptoms of PMS. The compounds in this substance have similar effects to female hormones. This natural remedy may have (unreliable) contraceptive qualities.
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Phototherapy (light treatment)
Phototherapy uses fluorescent light, which is up to 50 times more intense than ordinary light. It's used to treat seasonal affective disorder (SAD), a form of depression related to the reduction of sunlight in winter months. Some experts now believe that phototherapy may be useful for depression associated with PMS. For information about how to get phototherapy, contact the SAD Association. (See Useful organisations for details.)
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Antidepressants
Some doctors may prescribe an antidepressant to help with the symptoms of PMS, although no antidepressants are licensed for this use in the UK. However, SSRI (selective serotonin reuptake inhibitors) antidepressants may be appropriate if you have severe PMS or premenstrual dysphoric disorder. They may help with tiredness, food cravings, and sleep problems, as well as feelings of depression. However, they may have negative side effects which outweigh their benefits, and some people have withdrawal symptoms which make it difficult to come off them. The studies which suggest that certain antidepressants are ffective for PMS have so far only involved women over 18, who were not taking an oral contraceptive.
It may be worth trying calcium and magnesium or B6 supplements first, but if you and your doctor decide that antidepressants are a good option, it may be best to take them only during the second (premenstrual) half of your cycle. Studies show that this is just as effective as taking the drug every day, and taking them for short periods would make withdrawal symptoms less likely.
Usually, antidepressants don't take effect for two to four weeks, but with PMS and (PMDD) they seem to work within a few days.
You could consider taking the herbal antidepressant St John's wort during the premenstrual period, but you need to be careful about what else you are taking, since there may be interactions between them. Importantly, St John's wort interacts with the oral contraceptive pill, making it less effective, so that there is a risk of unintended pregnancy. (See Mind’s booklet Making sense of antidepressants, and Mind's factsheet St John's wort.)
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Combined oral contraceptive pill
Some women find the pill makes their symptoms better, others find it makes them worse. The pill can also cause side effects. If you want to use the pill as a remedy for PMS, it is best to discuss this with your GP, who can then prescribe the best type of pill for the purpose. This may be the combined pill, because it contains both oestrogen and progesterone.
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What is premenstrual dysphoric disorder?
There is some debate as to whether there is such a thing as premenstrual dysphoric disorder (PMDD), and it s important to rule out other mental health problems first. The symptoms for PMDD are very similar to PMS, but the difference is in their severity. They have a significant impact on a woman's ability to function socially or at work, and may also lead to suicidal thoughts. The timing of the symptoms in relation to the menstrual cycle is crucial to the diagnosis, just as it is for ordinary PMS. PMDD is thought to affect between three and eight per cent of women of childbearing age. The problem is also called simply severe premenstrual syndrome.
Historically, many feminists have opposed the diagnosis because they believe it has a negative effect on general attitudes towards women. The condition hasn t yet been included in the main body of the DSM-IV (The American Psychiatric Association's Diagnostic and statistical manual of mental disorders ), but it is listed in the Appendix, for research purposes. There's some concern that women might be diagnosed with this condition when it s more likely that they are already experiencing another mental health problem, such as depression or anxiety, which is heightened by PMS.
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What should friends and family do?
PMS can affect relationships, especially if the sufferer is irritable and angry. It helps if you can take the anger or distress seriously and don't simply dismiss it because it's 'that time of the month'. This said, you should not have to take physical or verbal abuse at any time. If you find that you do, you may find Mind's booklet How to assert yourself useful.
If your partner or relative says or does things that upset you, try to discuss this, once the PMS has passed. Talk about how you feel, without being critical, and listen to how she feels. If you both agree that PMS is the problem, work out together what, if anything, you can do to help.
Listening and acknowledging how she feels when she has PMS is important. You can remind her that she seemed to feel similarly last month, but that the feelings seemed to ease after her period started. You could also help with practical tasks, such as housework, cooking, shopping and childcare. Try to be encouraging and help her to feel better about herself. Where possible, postpone any important discussions to another time.
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My teenage daughter has PMS. How can I help?
You will need to be patient, offer reassurance and show you are available, if she wants to talk. She may be very alarmed if her feelings seem beyond her control. Try not to take anything she says during her PMS too personally, although there may be issues you should discuss when it has passed. Be careful not to dismiss your daughter's anger as just the result of hormones. If you are able to talk to her about it, you may help her to learn how to handle and express her anger appropriately. You could also try to help her with any underlying causes of stress, such as problems with school or relationships. If talking of these issues is difficult for you, you could suggest she talk to a counsellor. Details of young people's counselling services are available from the MindinfoLine. It may also be useful to pass information leaflets on PMS to your daughter.
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References
The British National Formulary 46, Sept 2003(www.bnf.org)
DSM-IV-TR: The American Psychiatric Association’s diagnosticand statistical manual of mental disorders 2000
‘Efficacy of progesterone and progestogens in managementof premenstrual syndrome: systematic review’ K. Wyatt et al(British Medical Journal 2001) 323, 776-780
‘Efficacy of selective serotonin-reuptake inhibitors in
premenstrual syndrome: a systematic review’ P. W. Dimmocket al (The Lancet 2000) 356, 1131-1136
Making us crazy – DSM: the psychiatric bible and the creationof mental disorders H. Kitchings, S. Kirk (Constable 1999)
The PMS diet book (Sheldon Press 2003)
No more PMS M. Stewart (Random House UK Distribution 1998)
‘Recognition of premenstrual dysphoric disorder and its treatment’ M. Steiner (The Lancet 2000) 356, 1126-1127
‘Treatment for the premenstrual syndrome with agnus castus fruit extract: prospective randomised, placebo controlled study’ R. Schellenberg (British Medical Journal 2001) 322, 134-7
www.umm.edu/patiented/articles/what_premenstrual_syndrome000079_2.htm
www.womens-health-concern.org
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Useful organisations
British Association of Anger Management (BAAM)
tel. 0845 1300 286
web: www.angermanage.co.uk
For men, women and children needing anger management
British Association for Behavioural and Cognitive Psychotherapies (BABCP)
tel. 0161 797 4484
web: www.babcp.com
Can provide details of accredited therapists. Full directory of psychotherapists available online
British Association for Counselling and Psychotherapy (BACP)
tel. 0870 443 5252 minicom: 0870 443 5162
web: www.bacp.co.uk
For details of local practitioners
Institute for Complementary Medicine
Unit 25, Tavern Quay Business Centre, Sweden Gate, London SE16 7TX
tel. 020 7231 5855
web: www.i-c-m.org.uk
Online database of complementary practitioners
Premenstrual Society (PREMSOC)
PO Box 429, Addlestone, Surrey KT15 1DZ
tel. 01932 872 560
Information and support for women who suffer from
premenstrual syndrome and period pains. Free publications with an SAE
SAD Association
PO Box 989, Steyning, BN44 3HG
web: www.sada.org.uk
Information about how to obtain phototherapy
Samaritans
Chris, PO Box 9090, Stirling FK8 2SA
helpline: 08457 90 90 90 minicom: 08457 90 91 92
email: jo@samaritans.org
web: www.samaritans.org
24-hour telephone helpline offering emotional support
Useful websites
www.nhsdirect.nhs.uk
NHS Direct online. Health information
www.pms.org.uk
National Association for Pre-menstrual Syndrome (NAPS)
www.womens-health-concern.org
www.womenshealthlondon.org.uk
Health information for women
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Further reading
The anger control workbook: simple innovative techniques for managing anger and developing healthier ways of relating M. McKay, P. Rodgers (New Harbinger Press 2000)
The assertiveness workbook: how to express your ideas and stand up for yourself at work and in relationships R. J. Paterson (New Harbinger Press 2000)
How to assert yourself (Mind 2006)
How to cope with panic attacks (Mind 2006)
How to cope with relationship problems (Mind 2006)
How to cope with sleep problems (Mind 2005)
How to cope with suicidal feelings (Mind 2007)
How to deal with anger (Mind 2006)
How to help someone who is suicidal (Mind 2004)
How to improve your mental wellbeing (Mind 2007)
How to increase your self-esteem (Mind 2007)
How to look after yourself (Mind 2006)
How to restrain your violent impulses (Mind 2006)
Making sense of antidepressants (Mind 2004)
Making sense of cognitive behaviour therapy (Mind 2001)
Manage your mind: the mental health fitness guide G. Butler, T. Hope (OUP 2007)
Managing anger G. Lindenfield (Thorsons 2000)
The Mind guide to food and mood (Mind 2006)
The Mind guide to managing stress (Mind 2006)
The Mind guide to massage (Mind 2004)
The Mind guide to physical activity (Mind 2006)
The Mind guide to relaxation (Mind 2006)
Overcoming anger and irritability W. Davies (Robinson 2000)
Overcoming anxiety H. Kennerley (Robinson 1997)
Overcoming low self-esteem: a self-help guide using cognitive behavioural techniques M. Fennell (Robinson 1999)
Understanding anxiety (Mind 2006)
Understanding depression (Mind 2007)
Understanding talking treatments (Mind 2005)
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This booklet was written by Louise Flory. Revised by Mind
First published by Mind 1998. Revised edition © Mind 2008
ISBN 9781874690757
No reproduction without permission
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