Keywords premenstrual, syndrome, PMS, PMDD,  Sarafem, Prozac, Zoloft, Paxil, endocrine, endocrinology hormones, progesterone, Vitamin E, exercise, mood, depression, antidepressant, adrenal, ovary, treatment, diagnosis, complication, mood, bloating, irritability, weight, gain

The term PMS stands for Premenstrual Syndrome, a familiar acronym used to describe a cyclical challenge with a confusing array of physical, emotional or behavioral responses experienced by an amazingly large number of women every month in the days and even weeks before their menstrual periods begin. In spite of widespread myth, misinformation and politically incorrect sexist jokes, the truth about PMS is that it is real-as real as any other legitimately recognized physical condition with a combination of physical and emotional responses that are all too often dismissed as trivial. In fact, PMS responses are known to challenge health, change normal routine and impact lifestyle.

Recent studies show that as many as 80% of American women have PMS at some time during the average 400 menstrual cycles occurring between menarche and menopause, or the time between when the menstrual period start at puberty and when it ceases after menopause. Although there is no therapeutic "cure" for PMS, the good news is that there are significant, new advancements in understanding and managing it--break-throughs that mean improvements in the quality of life for literally millions of women.

Though there is no doubt that women suffer from PMS, many endure the discomfort and pain in silence or complain only to family and friends because they do not realize that anything can be done to help them. Not so, but the way PMS is managed depends on identifying specific challenges, when they occur and how severe they are.

Taking Control of PMS

It is important for a woman to take charge of understanding her PMS patterns and learning about what's happening within her body. Only then can she realistically evaluate their effects on her life and make informed decisions about management.

The first step in assessing and managing PMS usually involves keeping a menstrual diary, documenting responses and noting when they occur, how severe they are and for how long. This diary can be kept on a calendar by simply entering each response on each day as it happens, noting the day the menstrual cycle begins by calendar date and recording day #1 as the day the menstrual period starts. Use a rating scale of 0 to 10 ( 0= response is absent; 10 = response is severe). It is important to keep a record of how PMS responses affect both body and mood changes as well as how they impact daily life, responsibilities and relationships for two to three months in order to determine individual PMS assessment and recurring patterns. Most women find that PMS responses occur in varying degrees during the last 3-14 days before their periods begin and although responses tend to follow patterns, certain months may be better or worse than others.

Identifying Emotional and Physical PMS Responses

For most women, common PMS responses are cyclical and fall into two different, general categories: emotional or psychological, and physical. Common emotional responses include temporary uncharacteristic irritability, depression, sadness, feelings of "fogginess," difficulty concentrating, indecisiveness, forgetfulness, stress, anxiety, disinterest in sex, and lack of control or impulsivity. On the job or at home, many women feel that the emotional responses of PMS sometimes influence their ability to perform at their best and can even trigger relationship conflicts. Some women say that PMS responses cause them to feel temporarily antisocial, avoiding friends and rejecting invitations. They say they experience cyclical feelings of low self-esteem, tend to have negative, sad thoughts and experience a transitory lack of enthusiasm and energy.

It is very important to understand that the vast majority of women with PMS do NOT have underlying emotional problems. They lead normal lives and experience PMS responses only during the premenstrual phase and recover quickly, even though temporary depression and tension can lead a woman to think she is mentally or physically ill.

As one patient described, "PMS is a gigantic mood swing. Not only do I dread what happens to me emotionally and physically. Sometimes I honestly think I'm losing my mind. My reactions to common occurrences are dramatically different from other times of the month. When I'm suffering PMS symptoms, I burst into tears or want to argue over the slightest things. I can't sleep, I eat too much of the wrong foods because I'm starving. I feel depressed and lethargic and avoid my usual physical exercise regimen. PMS responses affect me about ten days out of each month. That's a big chunk of my life, and I'd really like to find management that can help me."

This personal description of PMS is very real, and modern healthcare has found numerous ways to help patients who experience similar challenges. As this particular patient noted, there are both emotional and physical responses to PMS, which often occur in combination with each other. Patients and physicians alike have an important responsibility to identify and evaluate each response carefully. Let's take a look at the most common physical responses.

Physical PMS responses include cyclical discomfort and pain from tender, swollen breasts, bloating and weight gain, painful cramps, abdominal swelling, constipation before the period, insomnia, headache, stiff neck and a marked appetite increase with cravings for carbohydrates and sweets (especially chocolate).

In addition to common physical and emotional responses, there are rare but more extreme cases and conditions linked to PMS. PMS is known to amplify other underlying challenges such as clinical depression, anxiety disorders, paranoia and even rare psychotic experiences. Mitral valve prolapse (a mild heart condition characterized by irregular heart beats, chest pains and anxiety) is common among women with PMS, and these responses are often exacerbated during PMS time. PMS has also been identified as a contributing factor in the increased incidence of migraine headaches, obesity, sleep disorders and acne.

WHAT CAUSES PMS?

Although the causes of PMS are not totally clear, medical research points to the changes that occur in hormone levels before menstruation begins. We do know that PMS only occurs during that part of life between puberty and menopause -- the time when the ovaries are working to make both estrogen and progesterone. Women who do not ovulate do not have PMS, and often pregnancy is a welcome relief to the PMS sufferer. Research also shows that PMS tends to be more troublesome at the beginning and ending phases of the reproductive life cycle (puberty and menopause) and in the month immediately following pregnancy and childbirth as the menstrual cycle begins again.

All women have both female and male hormones within the natural balance of the body. However, increased levels of male hormones as well as increased levels of prolactin ( which is responsible for the production of breast milk) can result in a delayed ovulation and low levels of progesterone, leading to PMS. Studies conducted at Duke University, the University of Southern California and other major academic institutions have shown that suppression of ovulation (by inhibiting the pituitary gland with estrogen or a new drug called Lupron) also suppresses PMS.

We know that the physical responses to PMS can also be caused by a problem known as endometriosis, a condition most likely caused by a hormone imbalance in which tissue that looks and acts like the lining of the uterus is found outside of the uterus in the pelvis. At menstruation, this tissue bleeds lightly. The blood irritates nearby tissue and causes pain.

In addition, there are other medical problems not necessarily related to PMS which can cause similar symptoms. For example, fibrocystic breast changes, in which benign (not cancerous) lumps in the breast become swollen and painful, are often akin to the tender, swollen breast responses occurring during PMS.

In summary, a working definition of the cause of PMS is simply that PMS is the result of "a less than perfect ovulation." The condition resulting in a "less than perfect ovulation" stems from a hormone imbalance. Research substantiates this definition with findings that show PMS responses may well be caused by the way estrogen and progesterone ( the menstrual hormones) interact with other chemicals generated in the brain.

There is new evidence showing that low levels of serotonin, an important chemical produced by the brain, may in fact be the major cause of PMS responses. Serotonin is a key player in many body processes and cycles. It helps regulate sleep cycles and carbohydrate metabolism and influences the regulation of estrogen and progesterone. Women with PMS tend to have low and varying levels of serotonin -- a condition that can cause early or delayed ovulation and trigger an imbalance of estrogen and progesterone. The bottom line is that low serotonin affects ovulation, and a "less than perfect ovulation" lowers levels of serotonin in the brain, leading to the vicious cycle known as PMS.

"The less than perfect ovulation" explanation substantiates the success of hormone therapy used to suppress and regulate ovulation and correct hormone imbalances which trigger PMS responses in the first place. And since stress is known to disrupt ovulatory patterns, this theory gives stress a major role in the cause of PMS.

A Cyclical Experience

The average menstrual cycle is 28 days. At mid cycle (about day 14), production of the luteinizing hormone (the hormone responsible for ovulation) surges, which in turn triggers ovulation. During the second half of the menstrual cycle (about days 14 - 28), if the balance of estrogen and progesterone is stabilized, PMS responses are absent. However, if progesterone levels are abnormal, serotonin levels are lowered and depression can be triggered.

During what I defined as an abnormal menstrual cycle, there is a change in the secretion pattern of the pituitary gland (a master gland in the brain which produces hormones that stimulate the thyroid, adrenal glands, ovaries, smooth muscles and the kidneys). This change in the secretion pattern of the pituitary gland will cause the hormone surge to occur either too early (about day 11) or too late (about day 18). During this time, progesterone levels may also be low compared to estrogen levels. This imbalance causes the unpleasant and even painful PMS responses.

PMS and Appetite Surges

There is a theory that the common PMS response of increased appetite with cravings for carbohydrates may be caused by low serotonin levels. The theory is that when serotonin levels are low, the brain signals the body to eat carbohydrates, which in turn stimulates the production of serotonin from its naturally occurring amino acid "building block." Just in case women have ever wondered why their appetites seem out of control and willpower goes out the window during PMS, factors as strong as brain chemicals and hormone production may be powerful influences over behavior and physical cravings.

As one PMS patient describes, "I'm swollen, bloated and my weight increases five to ten pounds every month. I even have special clothes I save for PMS days. I feel fat and bloated, and it's as though there's a hungry monster inside me craving to be fed. As soon as my period starts, the monster goes away, and my normal appetite returns. However, every month it's a vicious cycle. It makes it hard to stabilize my weight and maintain a positive body image."

Although there is scientific substantiation for appetite increases and food cravings associated with PMS, there is value in following special, individually prescribed diets for PMS patients. Restricting sugar, salt and fat content generally helps decrease bloating and swelling, while avoiding caffeine, sugar, nicotine, and alcohol eases irritability and improves sleep patterns. Dietary recommendations for PMS sufferers vary from woman to woman, and because women with PMS can have other underlying conditions such as hypoglycemia and high blood pressure, special assessment and management are necessary prior to making dietary recommendations.

What Works In Managing PMS?

There are various management options, all of which need to be carefully monitored because of individual responses. Since both menstrual cycles and PMS responses are variable, caution must be exercised before pronouncing a "cure." The reason for caution is that even the most positive effects can be short lived, and management variation may be required for successful results to continue.

An article in the New England Journal of Medicine found that women who suffer from PMS were also often found to have a subtle low thyroid condition. This condition can be uncovered by specialized testing, and management of a low thyroid condition can alleviate PMS responses.

Regular aerobic exercise (1 hour sessions 3 - 5 times per week) is beneficial and may reduce PMS responses because it increases production of endorphins (the body's natural painkiller), which in turn may raise the serotonin level. Regular aerobic exercise also reduces stress and promotes regular sleep patterns. Vitamin and mineral supplements - especially vitamins B-6 and E and calcium and magnesium - are often effective in lessening PMS responses such as breast tenderness and bloating. Certain relaxation techniques such as deep breathing exercises or visualization and biofeedback have also proven therapeutic in reducing PMS responses. Physical exercise increases sympathetic tone, a condition that lowers heart rate and reduces anxiety sensations.

For many females with PMS, prescription medications are very effective in the management of individual responses. For example, Spironolactone, a medication that blocks the hormone responsible for bloating and swelling, can relieve these PMS responses and reduce excess water weight. Blood pressure medications known as beta blockers work to oppose the flow of adrenaline within the body and have proven to be effective in controlling anxiety attacks associated with PMS.

In certain cases, birth control therapy - in the form of oral contraceptives -is used to suppress and regulate ovulation and lessen PMS responses overall. Since synthetic progesterone used in certain birth control pills has actually been shown to cause PMS, great care and experience are necessary in managing this therapy.

Other management involves antidepressants such as Prozac, Paxil, Sarafem (which is the same as Prozac) and Zoloft, which raise levels of serotonin. These medications have proven to be very effective in managing PMS responses because they block the break down of serotonin in the brain and increase the amount of serotonin present.

In rare situations where PMS responses are severe, conditions are not sufficiently improved by any medications or other therapies and when pregnancy is not the objective, a surgical procedure involving a partial hysterectomy can be considered. In certain well qualified cases, this surgery has enabled women to lead PMS-free lives.

Each woman is unique - just like the delicate balance of hormones within her body. PMS assessment and management should be done by a qualified physician who is experienced and specialized in this area. PMS doesn't disappear instantly. There will always be good, better and best days, but by taking control of PMS and learning how to live life out from under the PMS black cloud, it is very possible to learn how to feel better all month long.