14
Premenstrual syndrome
Introduction
Premenstrual syndrome (PMS) can usefully be defined as ‘a condition manifesting with physical, behavioural and psychological symptoms in the absence of organic or psychiatric disease, which regularly occurs during the luteal phase of each ovarian cycle and which disappears or significantly regresses by the end of menstruation’. PMS is considered severe if it impairs work, relationships or usual activities. Some observers note that as many as 95% of women suffer mild symptoms, and between 5% and 10% of women have symptoms severe enough to disrupt their lives, principally in the 2 weeks leading up to the start of menstruation.
Over 150 symptoms have been attributed to PMS, but particularly:
mood changes/irritability
abdominal bloatedness
breast tenderness (cyclical mastalgia)
headaches
oedema.
Aetiology
The aetiology of PMS remains largely unknown. Ovulatory cycles are generally considered to be a necessary prerequisite. Many hypotheses have considered whether there might be abnormal levels of specific hormones, and research has focused on progesterone, oestrogen, adrenocorticotrophic hormone, vasopressin, luteinizing hormone, prolactin and thyroid-stimulating hormone. There is no consistent evidence that any of these are abnormal in PMS, but there are suggestions that it is the changing patterns of hormone levels, rather than the absolute levels, which is important. There may be an abnormality in levels of neurotransmitter function, particularly serotonin, and this is discussed further under ‘Management’, below.
Clinical presentation
As there are no specific biochemical tests for PMS, the diagnosis is dependent on a prospective charting of symptoms to confirm that there is a true exacerbation in the luteal phase when compared with the follicular phase of the cycle (Fig. 14.1). A simple calendar record of the presence or absence of a woman’s three principal symptoms and days of menstruation is appropriate. There are numerous specific criteria; many of them research tools which are not necessarily always applied strictly to clinical practice. An example of one of these is shown in Box 14.1.
GI, gastrointestinal.
Box 14.1
Example of a set of diagnostic criteria for PMS
1. The presence, by self-report, of at least one of the following somatic and affective symptoms during the 5 days before menses in each of the three previous cycles
| Affective symptoms: | Somatic symptoms: |
| Depression | Breast tenderness |
| Angry outbursts | Abdominal bloating |
| Irritability | Headache |
| Anxiety | Swelling |
| Confusion | |
| Social withdrawal |
2. Relief of the above symptoms within 4 days of the onset of the menses, without recurrence until day 12 of the cycle
3. Presence of the symptoms in the absence of any pharmacological therapy, hormone ingestion, drug or alcohol misuse
4. Reproducible occurrence of symptoms during two cycles of prospective recording
5. Identifiable dysfunction in social or economic performance by one of the following criteria:
discord in relationship confirmed by partner
difficulties in parenting
poor work or school performance
increased social isolation
legal difficulties
suicidal ideation
medical attention sought for somatic symptoms
From Mortola et al. 1990, Obstet Gynecol 76:302.
