Premenstrual Syndrome
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Premenstrual Syndrome

Pre-menstrual syndrome (PMS) is a common gynecological complaint. The diagnostic criteria from ACOG and the Diagnostic & Statistical Manual of Mental Disorders-IV agree that symptoms of PMS are distressing and moderate to severe enough to interfere with a woman’s normal activities and quality of life. Yet, there has been an absence of internationally accepted diagnostic criteria for PMS (Andrea, Rapkin & Winer, 2009). So, how is PMS really diagnosed & distinguished from other similar syndromes? How is it treated in Western medicine? And what are some complementary and alternative methods of treatment?

DIAGNOSIS
Pre-menstrual syndrome (PMS) is defined by physical and psychological symptoms arising only in the second phase of the menstrual cycle (the luteal phase). Timing is the most important diagnostic criteria. The physical and psychological symptoms must occur 5 days before a woman’s period, end within 4 days after her period starts, for at least three consecutive menstrual cycles (American Congress of Obstetricians and Gynecologists, 2011). The psychological and physical symptoms can be due to the low levels of allopregnanolone [a progesterone metabolite], and serotonin deficiency associated with PMS (Johnson, Thomas, Oscar, 2011), in addition to other imbalances. 

Psychological Symptoms
The psychological or cognitive symptoms include crying spells, depression, hostility, anxiety, irritability, increased or decreased libido, and relationship conflict (Johnson, Thomas, Oscar, 2011). 

Physical Symptoms [ACOG, 2011] 

  • Thirst, appetite changes, food cravings
  • Breast tenderness
  • Bloating and weight gain
  • Headache
  • Swelling of the hands or feet
  • Aches and pains
  • Fatigue
  • Skin problems
  • Gastrointestinal problems
  • Abdominal pain
 
Other Disorders
PMS is a cyclic occurrence, and also a diagnosis of exclusion. But there are no specific criteria, or screens for differentiating PMS from [or associating it with] some other disorders (Andrea, Rapkin & Winer, 2009). These other disorders include cyclothymic disorder; dysfunctional marital situation; poor diet; endocrine abnormalities; alcoholism or drug abuse; tumors of the brain, breast, and ovaries (Johnson, Thomas, Oscar, 2011). There is an 80% lifetime incidence of psychiatric disorders such as bipolar and depression in women experiencing PMS.  

PMS vs PMDD
PMDD [premenstrual dysphoric disorder] is the severe form of PMS. PMDD has  11 diagnostic criteria, out of which 4 are requisites: dysphoria, anxiety/tension, affective liability, and irritability. The problem is that neither ACOG nor the Diagnostic & Statistical Manual of Mental Disorders-IV  suggests a way to measure the degree of severity as an objective marker of impairment on a spectrum from PMS to PMDD. 

PMS Screening
Some screen indirectly measure the severity of PMS [Andrea, Rapkin & Winer, 2009]: 

  • Calendar of Premenstrual Experiences (COPE), a follicular and luteal phases questionnaire.
  • The Menstrual Distress Questionnaire (MDQ) differentiates between menstrual, premenstrual, and inter menstrual symptoms.
  • The Daily Record of Severity of Problems (DRSP) a longitudinal questionnaire beginning on the first day of menses, deemed to be a validated screen for women who may have PMS/PMDD.
  • The Medical Outcomes Study Short Form-36 (SF-36) a validated quality of life measure of overall health status, and treatment outcome in a disease-specific population.
  • The Social Adjustment Scale-Self Report (SAS-SR) assesses role performance, function vs impairment, and treatment outcome over a 2-week period.
  • The Center for Epidemiological Studies-Depression Scale (CES-D 10) specifically measures the depressive symptoms.
 
Premenstrual Symptoms Impact Survey (PMSIS)
This validated screen is a more direct measure of PMS, but it relies upon the DSM-IV diagnostic criteria and rating scales for PPDM. It approach PPMD and PMS as one - PMS/PMDD. It differentiate PMDD/PMS from or associates it with other disorders, (Andrea, Rapkin & Winer, 2009). It is at least agreed upon that using this questionnaire over 2 menstrual cycles is more accurate than using it over 1 cycle in meeting the DSM-IV diagnostic criteria for PMDD/PMS. 

The PMSIS can differentiate women at risk for PMDD from those at risk for PMS, and measures the impact of PMS on quality of life. This differentiation is important because the treatment for PMDD can be as extreme as surgery; whereas PMS may be managed with diet, nutrition, and lifestyle changes. PMSIS also by-passes the inconsistent results achieved when other screens are applied to diverse populations (Wallenstein, Blaisdell-Gross, Gajria et al, 2008). 

PMSIS is a web accessible tool for females 18 years of age and older with regular menstrual cycles (Optum, 2015). This survey combines ACOG's diagnostic criteria for PMS with the DSM-IV diagnostic criteria,which determines a woman's risk for PMDD; and the Medical Outcomes Study Short Form (SF-12) Health Survey for impact on quality of life (Andrea, Rapkin & Winer, 2009). 

Daily Record of Severity of Problems (DRSP)
The DRSP is perhaps the best screen because it explicitly differentiates between the "spectrum" of PMS experiences. The Royal College of Obstetricians and Gynecologists (2007) diagnostic guideline for PMS was published in 2007, with a 2014 revision in progress. Like ACOG and DSM-IV, the Royal College qualifies that the physical and psychological symptoms should be recorded prospectively, over 2 cycles, and specifies using the Daily Record of Severity of Problems (DRSP)- retrospective recall of symptoms is unreliable. The "spectrum" of PMS experiences measured by DRSP:

  • Premenstrual PMS: symptoms leading up to menstruation and completely relieved    by the end of menstruation syndrome
  • Mild PMS: Does not interfere with personal/social and professional life.
  • Moderate PMS: Interferes with personal/social and professional life but still able to   function and interact, although  sub-optimally
  • Severe PMS- Unable to interact personally/socially/professionally—withdraws from   social and professional activities.
  • Premenstrual Exaggeration: Background psychopathology, physical or other    condition. Treatment resistant with incomplete relief of symptoms when  menstruation exaggeration ends.
  • Premenstrual Dysmorphic Disorder: Adopted by the dysphoric disorder American  Psychiatric Association.
  • This guideline also evaluates complementary and alternative modalities (CAM) to treat the spectrum of PMS.

TREATMENT
Western Drugs
SSRIs [and sometimes NSRIs] are the drug of choice to treat PMS irritability, tension & dysphoria. Benzodiazapines are restricted to severe PMS/PMDD. Women who do not respond are candidates for ovulation suppression with the GnRH agonist called Danzol. It suppresses LH and FSH. It has many side effects, and need to be taken with add-back estrogen and progestin, as well as Fosomaxx to prevent bone mineral loss. Aldactone is given for fluid retention and significantly reduces physical and psychological symptoms. NSAID and HRT. Surgical removal of the ovaries [oophorectomy] for women with GnRh PPMD.

Nutrition & Supplements
Dr. Jeffery Bland (Bastyr College of Naturopathic Medicine) cites Dr. Abraham, who categorizes PMS into 4 or 5 symptom clusters, Each cluster is responsive to particular vitamins & minerals:

  • PMS A/ Anxiety--Anxiety, Irritability, mood swings. Elevated estrogens, low seratonin and dopamine. Nutrients: B6 (pyroxidine), bioflvanoids.
  • PMS C/Cravings-- sweet tooth, headache, dizziness, fainting (effects 25% of sufferers) Hormone-regulated insulin binding, prostaglandins reduce insulin secretion. Nutrients: zinc, chromium, GLA. 
  • PMS D/Depression--confusion, insomnia, suicidal thoughts (effects < 25% of sufferers). Low nerve synapsing due to low estrogen. Nutrients: GLA, calcium 1000 mg daily + magnesium. Avoid foods containing tyramine (such as cheese) and DO NOT SUPPLEMENT WITH B6 which aggravates Type D. 
  • PMS H/ Headache--water retention, ABD bloating, peripheral edema (effects 50% of sufferers). Excess aldosterone due to stress, excess estrogens, dopamine deficiency. Nutrients: vitamin B6, vitamin E [150, 300, 600 IU] daily, stress reduction, exercise, decreased refined sugar, fat & salt. Vitamin E also shown benefit for breast tenderness/ cyclic fibrocystic breasts changes.
  • PMS P / Pain- cramping, breast tenderness (effects 65-75% of sufferers). Nutrients: B6, magnesium, decrease salt intake. 
  • Other : low magnesium, manganese, low progesterone, estrogen dominancecopper toxicity. 

I do not know who developed this popular (unvalidated) screens on PMS, premenstrual tension [PMT] and nutritional intervention:

  • PMT TYPE A Nervous tension, weepiness, anxiety, mood swings and irritability. Periods start suddenly and are heavy with clots. Intervention: Vitamin E.
  • PMT TYPE B Stress is the main factor: mood changes, irritable, more depression than aggression, weight gain, swelling of hands & feet and breast tenderness. Intervention: Decrease table salt intake and replace with sea salt (minerals). Use a natural diuretic such as cypress, celery or juniper. Drinking more water will actually flush your system. Your organs of elimination including your kidneys work better with hydration.
  • PMT TYPE C headache, fatigue, moodiness and irritability. Intervention: Magnesium [and chromium] assists in insulin metabolism. Eat smaller frequent meals. Include complex carbohydrate and quality proteins. Avoid sugar and refined foods.
  • PMT TYPE D depression, forgetfulness, insomnia, confusion, and tearfulness. Intervention: Kelp, spirulina and potassium oxide. Eat simple foods that are easily digested.
  • PMT TYPE H bloating, breast tenderness, swollen hands & feet. Intervention: Decrease sodium and alcohol intake.

Chinese Medicine
The patterns associated with PMS symptoms in Chinese Medicine include liver depression/qi stagnation, phlegm fire, liver blood deficiency, liver/ kidney yin deficiency, and SP/K yang deficiency. The differential diagnosis requires a consult. But Paul Pitchford simplifies PMS [and dysmenorrhea] according to Chinese medical therapy for self-treatment. If one category of herbs and/or essential oils does not help, try the other category:

  • Cold or Deficient which are treated with warming & nurturing herbs and oils such as mugwort, dang gui, basil and John's wort oil.
  • Hot or Excess which are treated with cooling & calming herbs and oils such as mugwort, black cohosh, lobelia, motherwort, chamomiles, and lavender.

Western Herbs & Essential Oils
Vitex is well worth looking into. It is used by Naturopathic and Western herbal medicine for PMS symptoms- claimed to regulate progesterone, estrogen, LH and FSH. Vitex is called Man Jin Zi in Chinese herbal medicine but it is prepared in a certain way and used for completely different purposes- it is not used to regulate hormones in modern day Chinese medicine (see article). 

Dandelion leaf is a diuretic (potassium-rich), and the root is a nutritive Liver tonic, both beneficial for PMS complaints. especially breast tenderness/ cyclic fibrocystic breast changes. Calendula is a gentle de-obstructant (microvascular circulation) that over time untangles the psycho-emotional aspects of PMS. Essential oils for low libido, : jasmine, neroli, Mysore sandalwood, ylang ylang, clary sage, sage, or patchouli.

References
American Congress of Obstetricians and Gynecologists. (2011). Premenstrual syndrome (PMS). Retrieved from www.acog.org/-/media/For-Patients/faq057.pdf?dmc=1&ts=20150226T0107497170

Andrea, j., Rapkin, A., Winer, S. (2009). Premenstrual syndrome and premenstrual dysphoric disorder: Quality of life and burden of illness. Expert Review of Pharmacoeconomics  and  Outcomes Research 9(2), 157-170. Retrieved from www.medscape.com/viewarticle/705605_6 

Johnson, J., Thomas, D. Oscar, B. (2011). Women's health problems. In L. Dunphy, J. Winland-Brown, B> Porter, D. Thomas (Eds.). The art and science of advanced practice nursing (pp. 661 - 734). Philidelphia, PA: E.A. Davis Company.

Optum. (2015). Premenstrual Symptoms Impact Survey (PMSIS). Retrieved from www.optum.com/optum-outcomes/what-we-do/disease-specific-health-surveys/pmsis.html

Royal College of Obstetricians and Gynecologists. (2007). Management of premenstrual syndrome. In Green-top Guideline No. 48. Retrieved from www.rcog.org.

Wallenstein, G., Blaisdell-Gross B., Gajria, K. et al. (2008). Development and validation of the Premenstrual Symptoms Impact Survey (PMSIS): A disease-specific quality of life assessment tool. Journal of Women’s Health 17(3), 439-450. 










 

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