Symptoms
Nearly every woman at some point has some symptoms related to fluctuating hormone levels as menstruation approaches. For about half of these women, symptoms are mild and do not affect normal daily life. The other half report symptoms severe enough to impair daily life and relationships. And, between 3% and 5% of women report extremely severe symptoms.
In general, premenstrual syndrome (PMS) is a set of physical, emotional, and behavioral symptoms that occur during the last week of the luteal phase (a week or two before menstruation) in most cycles. The symptoms should typically resolve within four days after bleeding starts and not start until at least day 13 in the cycle. Women may begin to experience premenstrual syndrome symptoms at any time during their reproductive years. Once established, the symptoms tend to remain fairly constant until menopause, although they can vary from cycle to cycle. About 100 symptoms have been identified with the premenstrual phase.
Physical Symptoms
- Breast engorgement and tenderness.
- Abdominal bloating.
- Constipation or diarrhea.
- Acne.
- Headache.
- Alcohol intolerance.
- Fluid retention.
- Weight gain.
- Clumsiness.
- Nausea and vomiting.
- Heart palpitations (rapid heartbeats).
Breast Pain (Cyclical Mastalgia)
In one survey, 68% of women experienced breast symptoms associated with menstruation. According to studies, between 8% and 22% of women experience breast pain that is moderate to severe, a condition called cyclical mastalgia (also called cyclic mastopathy). (Some women experience breast pain that is unrelated to menstruation and so referred to as noncyclical mastalgia.)
This condition occurs after ovulation, increasing in intensity during the premenstrual phase and then receding at menstruation. It is often associated with PMS, but studies are reporting that most women with this disorder do not have PMS. Some experts believe, then, that this condition may be a unique chronic pain syndrome and require treatments that are different from those of PMS. A 2003 study suggested that women with mastalgia, both cyclical and noncyclical, may have wider milk ducts than others. The wider the duct, the more severe and persistent the pain.
Managing Cyclical Mastalgia
Life-style approaches designed to relieve cyclical mastalgia include the following:
- Support bras.
- Reducing caffeine.
- Quitting smoking.
- Taking vitamin E.
- Taking primrose oil or flaxseed oil.
- Using over-the-counter pain relievers (Advil or aspirin).
Severe cases may require potent drugs, such as bromocriptine mesylate (Parlodel), danazol (Danocrine), or tamoxifen citrate (Nolvadex). However, these agents all have severe side effects and life-style measures should be tried first.
Breast Cancer Fears
Many women with cyclic mastalgia are worried about an increased risk for breast cancer. It is not yet known if such concern is warranted. One study found that women with cyclical mastalgia had a greater incidence of abnormal breast cells than those without severe premenstrual breast pain. More research is still needed to confirm any increased risk for breast cancer. These women are more likely to have mammograms at an early age than others, although mammograms are not generally useful in detecting breast cancer in women under 35.
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Emotional Symptoms
- Depression. Severe depression before menstruation, called premenstrual dysphoric disorder, occurs in about 5% of women with PMS.
- Anxiety and panic attacks.
- Insomnia.
- Change in sexual interest and desire. (Although some women lose interest, others have a heightened drive.)
- Irritability.
- Hostility and outbursts of anger. In severe cases, violence toward self and others.
- Paranoia.
- Increased appetite often with specific food cravings (especially salt and sugar).
- Delusions and hallucinations. (These symptoms are very rare and most likely caused by an accompanying psychologic disorder).
Behavioral and Mental Symptoms
- Mood swings. (Although angry outburst or negative emotions are common, some women experience very positive bursts of creative energy before a period.)
- Inability to concentrate and some memory loss. (It should be noted that although women often report these symptoms, small studies have reported no actual differences in mental and thinking tasks between women with PMS or premenstrual dysphoric disorder and women without these syndromes during the premenstrual stage.)
- Withdrawal from other people.
- Confusion.
- Being accident prone.
- Lethargy and fatigue.
Premenstrual Dysphoric Disorder
Premenstrual dysphoric disorder (PMDD), also called late-luteal dysphoric disorder, is a condition marked by severe depression, irritability, and tension before menstruation. Studies in Europe and the US estimate that PMDD affects between 3% and 8% of women in their reproductive years. PMDD has features of both anxiety and depression disorders, although increasingly experts believe it is a distinct disorder with specific biochemical actions.
Diagnostic Criteria. Symptoms must occur during the last week of the premenstrual (luteal) phase in most menstrual cycles. They should resolve within a few days after the period starts.
Five or more of the following symptoms must be present:
- Feeling of sadness or hopelessness, possible suicidal thoughts.
- Feelings of tension or anxiety. (Panic attacks, in fact, may be much more common in patients with PMDD than in the general population.)
- Mood swings marked by periods of teariness.
- Persistent irritability or anger that affects other people.
- Disinterest in daily activities and relationships.
- Trouble concentrating.
- Fatigue or low energy.
- Food cravings or bingeing.
- Sleep disturbances.
- Feeling out of control.
- Physical symptoms, such as bloating, breast tenderness, headaches, and joint or muscle pain.
Some experts are concerned that the inclusion of premenstrual dysphoric disorder (PMDD) in the psychiatric diagnostic literature may misrepresent the physical nature of the problem. They warn that such categorization may restrict research on PMS only to psychiatric areas. Furthermore, both women with PMDD and their physicians may view their PMS only as a psychiatric disorder and not as a condition that may have physiologic causes unrelated to classic depression.
From The American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, DC, American Psychiatric Association 1994.
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