Premenstrual syndrome (PMS) is characterized by somatic and psychologic symptoms that occur during the week before menses begins (luteal phase) and end within a few days of the onset of bleeding (follicular phase). PMS symptoms do not occur in prepubertal, postmenopausal, anovulatory (e.g., pregnant) women, or women who have undergone oophorectomy. PMS may begin at any age and remits at menopause. Approximately 75% of women experience PMS to some degree; 20% to 50% find that symptoms disrupt their daily activities; and 3% to 5% are incapacitated by the severity of symptoms.

While associations between the menstrual cycle and changes in mood and behavior have been made since antiquity, the physiologic and pathologic determinants of PMS are not completely defined. Theories regarding etiology include abnormalities of gonadal steroids (e.g., estrogen excess, progesterone deficiency), hypoglycemia, vitamin B₆ deficiency, abnormalities of prostaglandin metabolism, excessive fluid retention, and endogenous opiate peptide withdrawal.

• History of depressive, mood, anxiety, or biopolar disorders
• History of postpartum depression or psychotic episodes
• History of dysmenorrhea
• Family history of depression or bipolar disorder
• High stress
• High consumption of caffeine, salt, chocolate, tobacco, and alcohol

Over 150 symptoms have been attributed to PMS. The most common are the following.

• Abnormal bloating and weight gain
• Breast swelling and tenderness
• Mood swings involving crying spells, irritability, and persistent anger
• Depression (e.g., feeling sad, hopeless, or suicidal) and anxiety (e.g., feeling tense or "on edge")
• Fatigue often accompanied by sleep disorders (e.g., insomnia, hypersomnia) and lethargy
• Skin disorders (e.g., oily skin, hirsutism, acne)
• Changes in appetite, including food cravings (e.g., carbohydrates, chocolate) and overeating
• Sexual dysfunction (e.g., decreased or increased libido)
• Headaches, backaches, and cramps
• Inability to concentrate, loss of interest in usual activities, and confusion

A differential diagnosis should be made for each major symptom; thus, eliminating possibilities becomes a daunting endeavor. Possible psychiatric disorders, especially depression and anxiety disorders, as well any underlying medical disorders, must be ruled out.

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) classifies PMS as late luteal-phase dysphoric disorder, specifying the following four diagnostic criteria.

• A symptom complex consistent with PMS must be present in most menstrual cycles for the past year.
• Symptoms must occur within the luteal phase of the menstrual cycle (e.g., appearing a week prior to menses) and disappear at the beginning of the follicular phase (e.g., within a few days of the onset of bleeding).
• Symptoms must cause significant disruption of occupational or social functioning (e.g., marital discord).
• Symptoms must not be an exacerbation of symptoms of another disorder.

A detailed history of symptoms, paying particular attention to the occurrence of these symptoms throughout the menstrual cycle, is imperative. Detailed family and medical histories are also important. Full physical and gynecologic examinations can rule out other medical conditions. Women must chart their symptoms and their severity daily for one to two months on PMS calendars so that the pattern of each symptom can be evaluated. A psychosocial evaluation may indicate the need for a mental health professional.

There are no laboratory or imaging studies to confirm a diagnosis of PMS; however, laboratory and radiologic studies can evaluate the signs and symptoms.

• Papanicolauo smear
• Complete blood count
• Serum chemistry screen
• Fasting blood glucose determinations
• Thyroid studies

Progesterone and its metabolites, secreted in prodigious amounts in the luteal phase, and their variable extrahepatic metabolism may be responsible for PMS. Decreased synthesis during the luteal phase of serotonin, a CNS neurotransmitter responsible for mood changes, suggests an important role of this neuroendocrine mechanism. The actions of gamma-aminobutyric acid (GABA), which suppresses brain function, can be manipulated by medications to improve mood.

Minnesota Multiphasic Personality Inventory (MMPI) is often normal if administered in the follicular phase of the menstrual cycle but abnormal during the luteal phase in women with PMS.

There is no consensus about treatment strategies. Simple interventions such as exercise and dietary restrictions (e.g., avoid salt, caffeine, alcohol, chocolate) are attempted first, as improvement may result. Stress reduction may also result in relief of some symptoms. Drug therapy may be necessary for severe symptoms.

• Potassium-sparing diuretics, for bloating and water retention
• Analgesics, for headaches and cramps
• Beta-blockers and calcium-channel blockers, for prophylactic treatment of migraine headaches
• Prostaglandin inhibitors (e.g., mefenamate, 100 mg every six hours), for dysmenorrhea
• Spironolactone (100 mg one or two times a day for last 14 days of cycle), for oily skin, hirsutism, and acne
• Anovulatory agents: danazol (200 to 400 mg/day); oral contraceptives (e.g., 35 mcg estrogen-progestin or progestin only): side effects are common, and oral contraceptives are contraindicated in women who are pregnant or have breast cancer, abnormal uterine bleeding, or phlebitis; medroxyprogesterone acetate (30 mg/day tablets): abnormal uterine bleeding is common, limiting its usefulness; depomedroxyprogesterone acetate (150 mg intramuscularly every one to three months).
• Bromocriptine (2.5 mg bid for last 14 days of cycle), for breast soreness
• Anxiolytics agents (e.g., buspirone or alprazolam), for symptoms of anxiety
• Tricyclic antidepressants (e.g., clomipramine, nortriptyline, fluoxetine), for depression
• Progesterone—the most commonly requested medicine (100 mg bid to tid), for relief of symptoms; however, progesterone does not outperform placebo, and severe PMS symptoms have been noted at times of peak progesterone levels.

Hysterectomy including oophorectomy with estrogen replacement therapy in PMS patients whose symptoms are severe and refractory to treatment.

CAM therapies may be useful at decreasing intensity and duration of symptoms. Nutritional deficiencies may be found in patients who suffer from PMS and should be treated. Both herbs and homeopathy can be effective and may be prescribed concurrently. Three months treatment is required before evaluating effectiveness.

Avoid caffeine and saturated fats (both induce inflammatory prostaglandins that exacerbate symptoms), sugar (increases urinary excretion of magnesium, which is depleted in PMS sufferers), salt (fluid retention), and dairy, meat, and poultry (to decrease exogenous hormones, and improve magnesium absorption). Correct nutritional deficiencies by supplementation with the following.

• Vitamin B₆ (100 to 200 mg/day) with B-complex (50 to 100 mg/day)
• Magnesium (400 mg/day)
• Vitamin E (400 to 600 IU/day), especially with breast tenderness
• Essential fatty acids: omega-3 and omega-6 (3,000 to 4,000 mg/day for three months, then decrease dose by 1,000 mg every two months)
• Chromium (250 mcg one to two times/day) to reduce sugar cravings

Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or tinctures (alcohol extraction, unless otherwise noted). Dose for teas is 1 heaping tsp. herb/cup water steeped for 10 minutes (roots need 20 minutes). For PMS, teas or tinctures are preferred; however, dried extract dosages are also included.

• Chaste tree (Vitex agnus castus) for PMS with irregular menses (175 mg/day)
• Black cohosh (Cimicifuga racemosa) binds to estrogen receptors to balance hormones, especially with dysmenorrhea and/or mood changes (100 to 600 mg/day).
• Valerian (Valeriana officinalis) for PMS with insomnia and anxiety (150 to 300 mg one to four times/day, or before bed for insomnia); kava kava (Piper methysticum) can be used for the same purpose (200 mg one to four times/day, or before bed). Reduce dose of either herb if drowsiness occurs.
• Milk thistle (Silybum marianum) supports liver in conjugating estrogens (200 to 600 mg/day)

Use the above herbs in combination, either as tincture (60 drops tid) or tea (1 cup bid to tid).

• Dandelion (Taraxacum officinale) root and/or leaves as a tea or tincture are diuretics, historic use as a liver tonic. With biliary problems, consult with an experienced practitioner.
• St. John's wort (Hypericum perforatum) (300 mg bid to tid) for depression associated with PMS. Must be taken consistently throughout the month; direct sun exposure may cause rashes in some patients.

An experienced homeopath would consider an individual's constitutional type to prescribe a more specific remedy and potency. Some of the most common acute remedies are listed below. Acute dose is three to five pellets of 12X to 30C every one to four hours until symptoms resolve.

• Belladonna for dysmenorrhea with profuse bright red bleeding, especially with restlessness
• Chamomilla for dark clotted blood with labor-like pains, great irritability, and restlessness
• Borax for irritability, headaches, and sleeplessness
• Calcarea carbonica for early, profuse, and long-term bleeding, swollen and painful breasts, poor stamina
• Kreosotum for irritability, headache, nausea, and severe vaginitis
• Nux vomica for extreme irritability, sharp cramping pain, cravings for alcohol, coffee, and spicy foods
• Pulsatilla for painful irregular periods with headaches and weepiness
• Sepia for painful, scanty menses with irritability and an aversion to sex

Acupuncture is helpful in balancing hormones and reducing symptoms of PMS, including anxiety, depression, insomnia, cramping, and fatigue.

Ongoing follow-up and periodic evaluations are imperative.

Women with PMS who make lifestyle changes around menstruation such as reducing stress, increasing exercise, and making dietary changes can often prevent exacerbations of PMS symptoms. Medications and psychotherapy may be useful in more severe cases.

Severe symptoms of PMS can disrupt relationships with family members, friends, and colleagues at work. Some drug regimens can have serious and debilitating side effects. A diagnosis of PMS can mask serious psychological disorders.

The prognosis of PMS is variable but can be excellent with proper education and individualized treatment modalities. At times, it may be important to involve the family, especially the spouse, in this process.

All symptoms of PMS disappear during pregnancy; however, approximately 68% of women report that symptoms of PMS worsen after pregnancy. Women who are trying to conceive should avoid prostaglandin inhibitors, diuretics, spironolactone, and danazol.

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