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Premenstrual Syndrome

By JoAnn V. Pinkerton, MD, University of Virginia Health System

Premenstrual syndrome (PMS) is a group of physical and psychologic symptoms that start several days before and usually end a few hours after a menstrual period begins.

  • PMS includes any combination of the following: becoming irritable, anxious, moody, or depressed or having headaches or sore, swollen breasts.

  • Doctors base the diagnosis on symptoms, which are usually tracked in a monthly calendar.

  • Consuming less sugar, salt, and caffeine and exercising may help relieve symptoms, as does taking certain supplements, pain relievers, birth control pills (sometimes), or antidepressants.

Because so many symptoms, such as a bad mood, irritability, bloating, and breast tenderness, have been ascribed to PMS, defining and identifying PMS can be difficult. About 20 to 50% of women of childbearing age have PMS. About 5% have a severe form of PMS called premenstrual dysphoric disorder.

PMS may occur partly because estrogen and progesterone levels fluctuate during the menstrual cycle. Some women are more sensitive to these fluctuations. Some women may have a genetic make-up that makes them more susceptible to PMS. Also, serotonin levels tend to be lower in women with PMS. Serotonin is a substance that helps nerve cells communicate (a neurotransmitter) and is thought to help regulate mood.

The fluctuations in estrogen and progesterone may affect other hormones, such as aldosterone, which helps regulate salt and water balance. Excess aldosterone can cause fluid retention and bloating.


The type and intensity of symptoms vary from woman to woman and from month to month in the same woman. The various physical and psychologic symptoms of PMS can temporarily upset a woman’s life.

Symptoms may begin a few hours up to about 10 days before a menstrual period, and they often disappear completely a few hours after the period begins. Women who are approaching menopause may have symptoms that persist through and after the menstrual period. Symptoms may become more severe during stress or during the years before menopause (called perimenopause—see Perimenopause symptoms). The symptoms of PMS may be followed each month by a painful period (cramps, or dysmenorrhea), particularly in adolescents.

Other disorders may worsen while PMS symptoms are occurring. They include the following:

  • Seizure disorders, with more seizures than usual

  • Connective tissue disorders, such as systemic lupus erythematosus (lupus) or rheumatoid arthritis, with flare-ups

  • Respiratory disorders, such as allergies and congestion of the nose and airways

  • Migraines

  • Mood disorders, such as depression

Mood disorders can cause similar symptoms, and those symptoms may worsen just before a menstrual period, even in women who do not have PMS or premenstrual dysphoric disorder.

In premenstrual dysphoric disorder, premenstrual symptoms are so severe that they interfere with work, social activities, or relationships. Interest in daily activities is greatly reduced, and some women may even become suicidal. Symptoms end when or shortly after menstrual periods start.


The diagnosis is based on symptoms. To identify PMS, doctors ask a woman to keep a daily record of her symptoms. This record helps the woman be aware of changes in her body and moods and helps doctors identify any regular symptoms and determine what treatment is best.

Premenstrual dysphoric disorder cannot be diagnosed until a woman has recorded her symptoms for at least two menstrual cycles.

If women have symptoms of depression, they may be given standardized tests for depression or be referred to a mental health care practitioner. However, doctors can usually distinguish PMS or premenstrual dysphoric disorder from mood disorders based on factors such as the timing of symptoms. If the symptoms disappear soon after the menstrual period begins, they are probably caused by PMS or premenstrual dysphoric disorder.

Did You Know...

  • Taking birth control pills sometimes relieves symptoms but may make them worse.


Women can do the following to help relieve symptoms:

  • Get enough rest and sleep.

  • Exercise regularly, which may help lessen bloating as well as irritability, anxiety, and insomnia.

  • Use stress reduction techniques (meditation or relaxation exercises).

  • Avoid stressful activities.

  • Consume more protein and calcium and less sugar and caffeine (including that in chocolate).

  • Consume less salt, which often reduces fluid retention and relieves bloating.

  • Take certain supplements: vitamin B complex (especially vitamin B6), calcium (1000 milligrams a day), vitamin D, and magnesium.

Women should talk to their doctor before they take supplements, especially vitamin B6, which may be harmful if taken in high doses. Nerve damage is possible with as little as 200 milligrams a day.

Doctors may prescribe the diuretic spironolactone (which helps the kidneys eliminate salt and water from the body). This drug helps reduce fluid retention.

Taking nonsteroidal anti-inflammatory drugs (NSAIDs—see Nonopioid Analgesics : Nonsteroidal Anti-Inflammatory Drugs) may help relieve headaches, pain due to abdominal cramps, and joint pain.Taking birth control pills that contain estrogen and a progestin (combination oral contraceptives) reduces pain, breast tenderness, and changes in appetite in some women but worsens these symptoms in a few. (Progestins are a synthetic form of the female hormone progesterone, produced by the body). Taking oral contraceptives that contain only a progestin usually does not help but may reduce menstrual bleeding. Oral contraceptives that result in shorter menstrual periods or that increase the interval between periods to as much as 3 months may help some women.

Women who have more severe PMS symptoms or premenstrual dysphoric disorder may benefit from taking antidepressants such as fluoxetine, paroxetine, or sertraline (see Table: Drugs Used to Treat Depression). These drugs are used to prevent symptoms, and to be effective, they should be taken before symptoms begin. Taking these drugs after symptoms begin usually does not relieve symptoms as well as taking them before symptoms begin. These drugs are most effective in reducing irritability, depression, and some other symptoms of PMS. Doctors may ask a woman to continue keeping a record of her symptoms so that they can judge the effectiveness of treatment.

For women who havepremenstrual dysphoric disorder, agonadotropin-releasing hormone (GnRH) agonist (such as leuprolide or goserelin—see Drugs Commonly Used to Treat Endometriosis), given by injection, may help relieve symptoms. GnRH agonists are a synthetic form of a hormone produced by the body. They control the rapid fluctuations in hormone levels that occur before menstrual periods and that contribute to symptoms. GnRH agonists cause the ovaries to produce less estrogen and progesterone. Thus, if symptoms persist despite other treatments, these drugs can be used with estrogen plus a progestin, taken in a low dose by mouth or a patch.

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