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Reviewed by the Faculty of Harvard Medical School

Dealing With PMS

Do you get annoyed when someone asks you "Is it that time of the month again?" Do you do something about your premenstrual symptoms, or simply tolerate them? It always surprises me how much women put up with when it comes to monthly symptoms of cramps, moodiness, irritability and pain. Some call it PMS (premenstrual syndrome). When it is more severe, it is called PMDD (premenstrual dysphoric disorder). Maybe you've tried a few things in the past, but are you aware of the latest options

I was reminded of the need for medical advances after the visit of a close friend, also a physician, who has been battling her monthly symptoms for years. My friend is the most optimistic, upbeat, pleasant person I know, until that time of the month. It's at this time that her tolerance goes down, comments fly out of her mouth and conflicts with friends and co-workers seem to occur. Sometimes it's been so bad that we have all suggested she might need to avoid contact with certain co-workers during those times of the month. It had become clear that her symptoms were getting harder to ignore.

When To Seek Help

Premenstrual syndrome includes several different symptoms that begin one to two weeks before your period and disappear within a few days after your period starts.

Emotional or psychological symptoms can include depression, low self-esteem, irritability, anxiety, low energy, anger and feeling overwhelmed or out of control.

Physical symptoms can include breast tenderness, abdominal bloating, headache, swelling of the legs or feet, cramps, changes in sleeping patterns and/or appetite, backache and muscle pain.

While as many as 90% of women have some symptoms of PMS, only 2% to 10% of women have the more severe form of PMS, PMDD. When PMS becomes PMDD:

  • You are unable to do normal activities.
  • Your symptoms affect your personal relationships.
  • Your symptoms affect your work at home or outside the home.
  • Your symptoms are noticeable and concerning to others.
What You Can Do

For women who fit the PMDD category, most health care professionals will prescribe selective serotonin reuptake inhibitors (SSRIs), which I discuss below. But everyone potentially can benefit from a few recommendations about lifestyle changes. The first recommendations come from studies showing that women who had certain lifestyle habits tended to have PMS more often than others. The recommendations include:
  • Reducing the amount of salt, fat and caffeine in your diet, especially during the one to two weeks before your period
  • Stopping smoking
  • Restricting alcohol use
  • Increasing the amount of sleep
  • Learning how to reduce stress in your life

If your main symptoms are painful, heavy and uncomfortable periods, I recommend one of two approaches. For women who have predictable periods, trying ibuprofen a few days before the period and continuing through the first day or two of the period can lessen symptoms. For some women, ibuprofen can even decrease the amount of blood flow. Oral contraceptives also can help to reduce painful or symptomatic periods. But they can worsen emotional and psychological symptoms. It depends on the person and the formulation of hormones. If those symptoms are the most troublesome, it may be best to try another approach first.

The best treatments to address emotional and psychological symptoms are the selective serotonin reuptake inhibitors (SSRIs). Several medications have been studied for use with PMS or PMDD, including sertraline (Zoloft), fluoxetine (Prozac), citalopram (Celexa) and clomipramine (Anafranil). In addition, studies now show that using these medications for just the one to two weeks before your period is effective. This limits side effects, cost and problems with staying on the medications every day.

If these classes of medications fail, and symptoms are severe, there are other options. While oral contraceptives are one way to stop ovulation, using gonadotropin-releasing hormone agonists (GnRH agonists) such as leuprolide is another way to do it. This treatment requires taking injections monthly but can be more effective than oral contraceptives. Danazol is another type of hormone that can stop ovulation but can have more hormonal side effects.

Alternative Medicines

In addition to lifestyle changes, vitamin B6, magnesium and calcium carbonate have been studied with some evidence that they work. Evening primrose oil is the herb that may be the most effective, but many providers worry about the poor regulation of herbal formulations and the lack of information on potential side effects. Talk to your health care professional before starting any of these supplements or herbal therapy.

If my friend's story sounds familiar to you, consider seeing your health care professional for an evaluation. Anything that affects you enough that your friends notice deserves an evaluation. Sometimes, examination and testing finds another treatable condition that makes your symptoms worse — a thyroid problem, fibroids or anemia, especially if periods are heavy. You shouldn't have to suffer from PMS, and it certainly shouldn't affect the way you live your life.

Alice Y. Chang, M.D., is an instructor in medicine at Harvard Medical School, and on the faculty of the Department of General Medicine at Brigham and Women's Hospital. Her clinical interests and experience are in the fields of primary care, women's health, hospital-based medicine, and patient education.

Last updated January 10, 2009




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