Premenstrual Syndrome (PMS)

Symptoms of PMS

Symptoms begin after ovulation, usually 5 to 11 days before a period, and improve within 4 days of bleeding starting. Over 150 symptoms have been described. The most common:

Emotional and behavioral

• irritability or anger
• mood swings
• anxiety or tension
• sadness or crying spells
• trouble concentrating
• changes in appetite, food cravings
• poor sleep or sleeping more
• withdrawal from social activities

Physical

• bloating and weight gain from fluid retention
• breast tenderness or swelling
• fatigue
• headaches or migraine
• muscle and joint aches
• acne flare-ups
• constipation or diarrhea

PMS vs PMDD

Premenstrual exacerbation

Some people have an underlying condition, such as depression, anxiety, migraine, IBS or epilepsy, that worsens before periods. This is called premenstrual exacerbation and is treated by managing the underlying condition, sometimes with extra support around periods.

PMS or pregnancy?

Early pregnancy and PMS share symptoms such as breast tenderness, fatigue, bloating and mood changes. Pregnancy is more likely if your period is late, and you may have nausea or light spotting. PMS symptoms ease once the period starts. A home pregnancy test from the first day of a missed period gives the answer.

Causes

PMS is not caused by abnormal hormone levels. Instead, some people are more sensitive to the normal rise and fall of estrogen and progesterone, which affects brain chemicals such as serotonin and GABA. Contributing factors:

• genetics and family history
• stress
• low physical activity
• high salt, caffeine and alcohol intake
• history of depression or trauma

Diagnosis

There is no lab test. Doctors diagnose PMS from a daily symptom diary kept for at least 2 menstrual cycles, showing symptoms in the second half of the cycle and a symptom-free week after the period. Tools such as the Daily Record of Severity of Problems are commonly used. Blood tests may check thyroid function or anemia to rule out other causes.

Treatment and relief

Lifestyle

• Regular aerobic exercise most days, which can reduce mood and physical symptoms
• Sleep: a consistent schedule
• Diet: smaller, frequent meals with complex carbohydrates; reduce salt, sugar, caffeine and alcohol in the second half of your cycle
• Calcium: adequate intake through diet or supplements has evidence for reducing PMS symptoms
• Stress management: relaxation, yoga, mindfulness, CBT

Over-the-counter options

• NSAIDs such as ibuprofen or naproxen at the label dose for cramps, headaches and aches, starting a day or two before the period
• Heat for cramps

Prescription treatments

• SSRIs such as fluoxetine, sertraline or paroxetine, taken daily or only during the luteal phase, are the most effective treatment for severe PMS and PMDD. They often work within days in this setting.
• Combined hormonal contraception, particularly pills containing drospirenone taken continuously or with short breaks, suppresses ovulation.
• Spironolactone for bloating and breast symptoms.
• GnRH agonists for severe, resistant cases, with add-back hormone therapy, under specialist care.

Frequently asked questions

What are the most common PMS symptoms?

The most common are irritability, mood swings, anxiety, bloating, breast tenderness, fatigue, food cravings, headaches and trouble sleeping. They occur in the 1 to 2 weeks before a period and ease within a few days after bleeding starts.

How do I know if it is PMS or PMDD?

PMDD is a severe form of PMS with intense mood symptoms such as depression, anger, anxiety or hopelessness that seriously disrupt life. Tracking symptoms daily for 2 cycles helps a doctor tell them apart.

How can I relieve PMS symptoms fast?

For quick relief, try an NSAID like ibuprofen for cramps and headaches, a heating pad, a walk or other exercise, reducing salt and caffeine, and getting enough sleep. If symptoms are severe or frequent, talk to a doctor about SSRIs or hormonal options.

Is it PMS or am I pregnant?

The two can feel similar. A missed period, nausea or light spotting point more toward pregnancy, while symptoms that end when your period starts point to PMS. A home pregnancy test taken after a missed period is the most reliable way to know.

Does PMS get worse with age?

Many people notice PMS changes in their late 30s and 40s, as perimenopause causes larger hormone swings. Symptoms usually stop after menopause. If symptoms suddenly worsen, see a doctor to rule out other causes.