Premenstrual syndrome reference

Premenstrual syndrome (PMS) (historically called PMT or Premenstrual Tension) is a collection of physical, psychological, and emotional symptoms related to a woman's menstrual cycle. While most women of child-bearing age (about 80 percent) have some Premenstrual symptoms,[1] women with PMS have symptoms of "sufficient severity to interfere with some aspects of life".[2] Such symptoms are usually predictable and occur regularly during the two weeks prior to menses. The symptoms may vanish after the menstrual flow starts, but may continue even after the flow has begun.

For some women with PMS, the symptoms are so severe that they are considered disabling. This form of PMS has its own psychiatric designation: premenstrual dysphoric disorder (PMDD).

Culturally, the abbreviation PMS is widely understood in the United States to refer to difficulties associated with menses, and the abbreviation is used frequently even in casual and colloquial settings, without regard to medical rigor. In these contexts, the syndrome is rarely referred to without abbreviation, and the connotations of the reference are frequently more broad than the clinical definition.

Symptoms

PMS is a collection of symptoms. More than 200 different symptoms have been identified, but the three most prominent symptoms are irritability, tension, and dysphoria (unhappiness).[2] The exact symptoms and their intensity vary from woman to woman. Most women with premenstrual syndrome experience only a few of the problems. The following symptoms can also be attributed to PMS: [3] [4] [5] [6]

* Abdominal bloating
* Abdominal cramps
* Breast tenderness or swelling
* Stress or anxiety
* Aggression
* Depression
* Appetite changes and food cravings
* High sexual arousal or desire[citation needed]
* Trouble falling asleep (insomnia)
* Joint or muscle pain
* Inability to finish thoughts
* Headache
* Fatigue
* Acne
* Extreme tearfulness
* Mood swings
* Worsening of existing skin disorders, and respiratory (eg, allergies, infection) or eye (bulbar disturbances, conjunctivitis) problems

[edit] Risk Factors

* High caffeine intake[6]
* Stress may precipitate condition
* Increasing age
* History of depression
* Tobacco use
* Family history
* Dietary Factors[7] (Low levels of certain vitamins and minerals, particularly magnesium, manganese, and vitamin E)

Family history is often a good predictor of the probability of premenstrual syndrome; studies have found that the occurrence of PMS is twice as high among identical twins compared with fraternal twins.[2] Although the presence of premenstrual syndrome is high among women with affective disorders such as depression and bipolar disorder,[citation needed] a causal relationship has not been established.

Caffeine can be beneficial at this time.[citation needed] As a diuretic, it assists with bloating and the social activity of sharing a coffee with a friend mitigates some of the negative emotional impact.[citation needed] Vitamin B can also assist with unstable emotions.[citation needed]

[edit] Diagnosis

There is no laboratory test or unique physical findings to verify the diagnosis of PMS. To establish a pattern, a woman's physician may ask her to keep a prospective record of her symptoms on a calendar for at least two menstrual cycles.[3] This will help to establish if the symptoms are, indeed, premenstrual and predictably recurring. A number of standardized instruments have been developed to describe PMS, including the Calendar of Premenstrual syndrome Experiences (COPE), the Prospective Record of the Impact and Severity of Menstruation (PRISM), and the Visual Analogue Scales (VAS).[2]

In addition, other conditions that may explain symptoms better must be excluded.[2] A number of medical conditions are subject to exacerbation at menstruation, a process called menstrual magnification. These conditions may lead the patient to believe that she may have PMS, when the underlying disorder may be some other problem. A key feature is that these conditions may also be present outside of the luteal phase. Conditions that can be magnified perimenstrually include depression, migraine, seizure disorders, chronic fatigue syndrome, irritable bowel syndrome, asthma, and allergies.[2]

Although there is no universal agreement about what qualifies as PMS, two definitions are commonly used in research programs:

* The National Institute of Mental Health research compares the intensity of symptoms from cycle days 5 to 10 to the six-day interval before the onset of menses.[2] To qualify as PMS, symptom intensity must increase at least 30% in the six days before menstruation. Additionally, this pattern must be documented for at least two consecutive cycles.

* The definition formulated at the University of California at San Diego requires both affective (emotional) and somatic (physical) symptoms during the five days before menses in each of three consecutive cycles, and must not be present during the pre-ovulatory part of the cycle (days 4 through 13).[2] For this definition, affective symptoms include symptoms like depression, angry outbursts, irritability, anxiety, confusion, and social withdrawal. Somatic symptoms include symptoms like breast tenderness, abdominal bloating, headache, and swelling of hands and feet.

[edit] Etiology

The exact causes of PMS are not fully understood. While PMS is linked to the luteal phase, measurements of sex hormone levels are within normal levels. PMS tends to be more common among twins, suggesting the possibility of some genetic component.[2] Current thinking suspects that central-nervous-system neurotransmitter interactions with sex hormones are affected.[2] It is thought to be linked to activity of serotonin (a neurotransmitter) in the brain.[8] [5][9]

Genetic factors also seem to play a role, as the concordance rate is two times higher in monozygotic twins than in dizygotic twins. [10] Preliminary studies suggest that up to 40% of women with symptoms of PMS, have a significant decline in their circulating serum levels of beta-endorphin. Beta endorphin is a naturally occuring opioid neurotransmitter which has an affinity for the same receptor that is accessed by heroin and other opiates. Some researchers have noted similarities in symptom presentation between PMS symptoms and opiate withdrawal symptoms. [11]

[edit] Treatment

Many treatments have been suggested for PMS, including diet or lifestyle changes, and other supportive means. Medical interventions are primarily concerned with hormonal intervention and use of selective serotonin reuptake inhibitors (SSRIs).

* Supportive therapy includes evaluation, reassurance, and informational counseling, and is an important part of therapy in an attempt to help the patient regain control over her life. In addition, aerobic exercise has been found in some studies to be helpful.[2] Some PMS symptoms may be relieved by leading a healthy lifestyle: Reduction of caffeine, sugar, and sodium intake and increase of fiber, and adequate rest and sleep.[12]

* Dietary intervention studies indicate that calcium supplementation (1200 mg/d) may be useful. Also vitamin E (400 IU/d) has shown some effectiveness.[2] A number of other treatments have been suggested, although research on these treatments is inconclusive so far: Vitamin B6, magnesium, manganese and tryptophan.[12]
* SSRIs can be used to treat severe PMS[2] The drug most widely studied is fluoxetine at doses of 20-60 mg/d. Other drugs include sertraline, paroxetine, clomipramine, fluvoxamine, and nefadozone.[13] These drugs can also be given intermittently, that is when symptoms reappear.
* Hormonal intervention may take many forms:
o Hormonal contraception is commonly used; common forms include the combined oral contraceptive pill and the contraceptive patch.
o Progesterone support has been used for many years but evidence of its efficacy is inadequate.

*
o Gonadotropin-releasing hormone agonists can be useful in severe forms of PMS but have their own set of significant potential side effects.
* Diuretics have been used to handle water retention. Spironolactone has been shown in some studies to be useful.[2]
* Non-steroidal anti-inflammatory drugs (NSAIDs; eg ibuprofen) have been used.
* Evening Primrose Oil, which contains gamma-Linolenic acid (GLA), has been advocated but lacks scientific support.
* Clonidine has been reorted to successfully treat a significant number of women whose PMS symptoms coincide with a steep decline in serum beta-endorphin on a monthly basis.