Premenstrual syndrome

Premenstrual syndrome (PMS) refers to a group of symptoms that you may develop 3 to 10 days before your period – and that go away shortly after your period starts. The vast majority of people who menstruate will experience PMS at some point in their life.

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PMS symptoms vary from person to person

Factors that increase the likelihood of PMS

While everyone who menstruates experiences hormonal fluctuations, not everyone experiences PMS symptoms to the same degree. Some factors that increase your likelihood of having PMS symptoms include:

  • Being older: People in their 30s -through their 40s are more likely to experience severe PMS symptoms. This is because the body is starting to transition towards menopause, making hormonal fluctuations bigger and more unpredictable.
  • Having a personal or family history of depression or postpartum depression.
  • Having been pregnant: If you have been pregnant, you may experience more severe PMS symptoms or different symptoms than you experienced previously.
  • Having high levels of stress.

Emotional symptoms

Premenstrual syndrome can include emotional symptoms, such as:

  • Anxiety or feeling tense.
  • Changes in sex drive (libido).
  • Crying.
  • Forgetfulness, or trouble concentrating.
  • Increased anger.
  • Irritability.
  • Mood swings.

Physical symptoms

PMS symptoms vary widely and range from mild to intense. You may experience different symptoms with each cycle. The most common PMS symptoms are:

  • Abdominal cramps.
  • Acne, especially along the cheek, chin and jaw.
  • Back pain.
  • Bloating.
  • Breast tenderness or swollen breasts.
  • Constipation, which happens because the hormone progesterone can slow down digestion.
  • Diarrhea, which is the result of a build-up of a hormone called prostaglandin, which is released when your uterus lining starts shedding
  • Fatigue, or tiredness that does not go away with sleep.
  • Food cravings.
  • Headaches or migraines.
  • Joint and muscle aches.
  • Nausea.
  • Night sweats or hot flashes, especially if you are over 40.
  • Trouble sleeping (insomnia) or tossing and turning in bed.

Most people only experience a few of these symptoms, and they are usually mild and don’t get in the way of your life.

PMS symptoms can indicate other conditions

Premenstrual dysphoric disorder (PMDD)

About 5% of people who menstruate experience very severe PMS symptoms. This is referred to as premenstrual dysphoric disorder (PMDD). PMDD is a severe, chronic form of premenstrual syndrome that may require medical attention. If you are missing work or school because of PMS syndrome, you should talk to your doctor.

Conditions that share symptoms with PMS

These include irritable bowel syndrome (IBS), anemia, endometriosis, thyroid diseases, chronic fatigue syndrome and pregnancy. You will need to talk with your doctor to get a proper diagnosis.

What causes premenstrual syndrome?

The exact cause of PMS is not clear. However, it is likely connected to the hormonal fluctuations of your menstrual cycle and the chemicals in your brain.

The menstrual cycle happens every month to prepare the body for a possible pregnancy. It is largely controlled by the hormones progesterone and estrogen. First, your body prepares your uterus for pregnancy by thickening the uterine lining. Estrogen levels rise, and several eggs start maturing in your ovaries.

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Halfway through the cycle, a single, mature egg is released from your ovary (ovulation). After that, estrogen levels fall and progesterone levels take over. If the egg does not get fertilized, it is expelled from your body, and progesterone dips. This causes your uterine lining to start to shed, and you get your period.

Chemicals in your brain also fluctuate during your cycle. Serotonin is a chemical that helps control your mood, stress and sleep. It is thought to play a role in PMS symptoms like depression, fatigue, cravings and insomnia.

While everyone who menstruates experiences hormonal fluctuations, not everyone experiences PMS symptoms to the same degree.

How is PMS diagnosed?

There is no single test to diagnose PMS. Your doctor will start by asking you about your family and medical history and your symptoms. If your symptoms are predictable and cyclical, it might be harder for your doctor to diagnose PMS. Your doctor may recommend that you keep a journal of your symptoms for a few months. This way, you can better pinpoint the duration, intensity and frequency of symptoms. This can help you and your doctor create a better management plan.

For severe symptoms, your doctor may recommend additional tests to rule out other causes. These tests may include:

  • Pelvic exam: A gynecologist manually feels areas of your pelvis for signs of abnormalities, cysts, scar tissue or enlarged ovaries.
  • Blood tests: Your doctor may analyze a sample of your blood for thyroid hormones, signs of infection or pregnancy.

Additional tests may be called for if your doctor suspects another medical condition.

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PMS treatment and management

At-home steps

  • Drink lots of clear fluids to help ease pain, bloating and constipation.
  • Don’t smoke. Smoking can make PMS symptoms worse. If you do smoke, consider joining a smoking cessation program. If you don’t smoke, don’t start.
  • Try to stick to a healthy diet. You may want to consider reducing your sugar, salt, alcohol and caffeine intake leading up to your period. These can make PMS symptoms worse, even though you’re craving them. Instead, try eating fruits, vegetables and whole grains.
  • Get enough calcium. Calcium is an essential nutrient that is linked to PMS symptoms. If you’re experiencing PMS, try incorporating more calcium into your diet through low-fat milk or yogurt, whole wheat bread, leafy greens like kale (but not spinach), and fortified soy or almond beverages. You may want to talk to your doctor about taking a calcium supplement.
  • Get regular, aerobic exercise. You should try to get 30 minutes of aerobic exercise several times a week throughout the month. Exercise can boost your mood, help you fall asleep and improve your concentration.
  • Over-the-counter pain medications. Nonsteroidal anti-inflammatory medications like ibuprofen, aspirin and naproxen can help with cramps, breast tenderness, and back and muscle aches.
  • Find healthy ways to manage stress. Stress can worsen PMS symptoms. Try to find healthy ways to lessen or cope with your stress. Consider talking to friends or family, asking for help with challenging tasks or assignments, and taking time for yourself. If you have an underlying mental health condition, like anxiety or depression, you may want to seek professional help.
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Medications

Prescription medications for treating PMS include:

  • Hormonal birth control. Hormonal birth control pills, patches or gels can lessen PMS symptoms for some people by moderating hormonal fluctuations. However, not everyone will experience this effect, and you may have to try several different types of birth control before you find one that works for your symptoms.
  • Diuretics (water pills). These medications prevent water retention, which can help relieve symptoms like bloating, weight gain and breast tenderness.
  • Selective Serotonin Reuptake Inhibitors (SSRIs) are a group of antidepressants commonly used to treat emotional and behavioral PMS symptoms. While most antidepressants are taken every day, your doctor may recommend taking them only during the two weeks before your period.

Supplements

You may be hesitant to take prescription medications for PMS symptoms and want a more natural solution. Many vitamin and mineral supplements claim to help with premenstrual syndrome. Note, though, that evidence for their effectiveness is mixed, and supplements may cause unwanted side effects.

Some common supplements used to treat PMS include:

  • Calcium. Evidence suggests that calcium can help with some PMS symptoms, like fatigue and cravings. Calcium is also available in many healthy foods, including dairy, leafy vegetables, fortified bread and fortified milk alternatives.
  • Vitamin B6. Some evidence suggests that vitamin B6 may also help with PMS symptoms, like moodiness and bloating. It is also available in fish, chicken, potatoes and fruits.
  • Magnesium is an important mineral that may help with PMS symptoms like migraines. It is also found in leafy greens, nuts and whole grains.
  • Herbal supplements. Chasteberry, evening primrose and black cohosh are herbal supplements that some people suggest help with PMS. However, the evidence supporting this is very mixed, and some of these herbal supplements can interfere with other medications, like hormonal birth control.

In short, supplements are not regulated the same way as medications and may come with side effects. Always talk to your doctor and pharmacist before taking supplements so that you have a clear picture of their risks and benefits.

PMS vs. pregnancy

Reading over the symptoms of PMS, you might think they sound a lot like another condition: pregnancy. This is because progesterone rises both during the beginning of pregnancy like it does following ovulation. However, there are some things you should keep in mind:

Bleeding and spotting. Light spotting or bleeding is common with early pregnancy and is referred to as implantation bleeding. However, bleeding or spotting is not usually a symptom of PMS.

Nausea and vomiting. Morning sickness is a common pregnancy symptom, characterized by nausea and vomiting. Nausea can happen during PMS as well, but vomiting is much less common.

Food aversions. We have all heard about weird pregnancy cravings. However, early pregnancy is more likely to make you avoid the smell and taste of certain foods. This is different from the ravenous cravings you may get with PMS.

Missed period. If you are pregnant, the first sign may be a missed period. Generally, PMS symptoms will go away within a few days of your period starting. You can have PMS symptoms and then not have a period. You are more likely to miss a period if you experienced significant stress, physical exertion or consumed a lot of alcohol leading up to your period. However, your period should generally come on time with PMS.

The only way to know for sure whether you are experiencing PMS or pregnancy is to take a pregnancy test.

References

The Office on Women’s Health (OWH). Premenstrual syndrome (PMS) (https://www.womenshealth.gov/menstrual-cycle/premenstrual-syndrome)

MedlinePlus: National Library of Medicine. Premenstrual Syndrome (https://medlineplus.gov/premenstrualsyndrome.html)

National Center for Biotechnology Information (NCBI): National Library of Medicine. Premenstrual Syndrome (https://www.ncbi.nlm.nih.gov/books/NBK560698/)

American Academy of Family Physicians. Premenstrual Syndrome (https://www.aafp.org/pubs/afp/issues/2003/0415/p1743.html)