Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder
(PMDD) with Gabriela Rosa

Listen to the episode here.

This handout comprises information about PMS and PMDD as well as information discussed on The Level Up Podcast with Sharelle Grant and Danielle Antonellos November 2021. General resources: The Whole Lemon Drink Recipe Recipe Video Explanation Evidence-based infographics All infographics published by The Rosa Institute.

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Facts about Premenstrual Syndrome (PMS)

Commonly referred to as PMS, Premenstrual Syndrome is a symptom pattern characterized by physical, emotional, and behavioral symptoms that usually occur 1 to 2 weeks before menstruation. Once you begin to menstruate (start your period), these symptoms typically resolve. However, it is common for up to 20% of women of reproductive age to suffer PMS symptoms, although only 3 to 8% of cases1 report clinical symptoms.2 Age, race, ethnicity, health status can influence PMS, although this varies within the population. However, symptoms are relatively constant over successive menstrual cycles, particularly concerning emotional symptoms.2,3 PMS can negatively impact activities of daily living and quality of life.4 Some women may experience psychological symptoms before menstruation. Psychological symptoms may include 2,5:
  • Appetite changes (overeating/cravings)
  • Anger
  • Anxiety/tension
  • Decreased interest in usual activities, or social withdrawal
  • Depression
  • Difficulty concentrating/confusion
  • Fatigue, tiredness
  • Feeling out of control/overwhelmed
  • Hypersomnia/insomnia
  • Irritability
  • Mood swings
  • Sense of feeling overwhelmed
  • Withdrawing from your friendship group or family
Physical Symptoms may include:
  • Abdominal bloating
  • Appetite disturbance (usually increased)
  • Breast tenderness
  • Headaches
  • Lethargy or fatigue
  • Muscle aches and/or joint pain
  • Sleep disturbance (usually hypersomnia)
  • Swelling of extremities

Facts about Premenstrual Dysphoric Disorder (PMDD)

PMDD, or Premenstrual Dysphoric Disorder, is a more severe form of PMS characterized by significant premenstrual mood disturbance, often accompanied by mood reactivity and irritability. PMDD may occur 1-2 weeks before menstruation; however, these mood disturbances usually resolve when a woman begins to menstruate. The literature reports that women who have untreated PMDD are likely to experience a loss of three years during their lifetime resulting from premenstrual symptoms.6 PMDD affects 3-8% of women of reproductive age, with symptoms usually occurring when a woman is in her twenties.6 Symptoms of PMDD may intensify with age, particularly as a woman enters menopause.7 Several factors can cause PMDD, including a history of an anxiety or mood disorder, a family history of premenstrual mood dysregulation, and heightened stress experienced by women aged between 20-30 years.8 Psychological symptoms may include:
  • Anxiety
  • Feeling overwhelmed or out of control
  • Increased depressed mood
  • Irritability
  • Mood Swings
  • Sense of feeling overwhelmed
  • Sensitivity to rejection
  • Social withdrawal
  • Sudden sadness or tearfulness
Physical symptoms may include:
  • Abdominal bloating
  • Appetite disturbance (usually increased)
  • Breast tenderness
  • Headaches
  • Lethargy or fatigue
  • Muscle aches and/or joint pain
  • Poor Concentration
  • Sleep disturbance (usually hypersomnia)
  • Swelling of extremities
  • Fatigue
  • Forgetfulness
PMDD should be distinguished from other medical and psychiatric conditions by a woman’s treating health professional. PMDD has features in common with chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and migraine disorder. In addition, mental illnesses such as anxiety and depression may heighten during premenstrual, mimicking PMDD. Non-pharmacological Treatment for PMS and PMDD Lifestyle modification Regular aerobic exercise, especially regular, moderate-strength aerobic exercise for at least six weeks, can decrease PMS symptoms mimicking.9
  • Aerobic exercise has been reported to reduce premenstrual mood symptoms and has other obvious potential health advantages.10
  • Avoidance of stressful events, and adjustment of sleeping habits, are beneficial during the premenstrual period.10
Strength training conducted during the follicular phase has been shown to increase muscle strength.
  • One study showed that participants that perform lumbar stabilization exercises (or strengthening your core) reduced lower back pain caused by PMS.11
  •  Another study reported that 3-month regular aerobic exercise, whether moderate or intense, can improve and help reduce PMS symptoms such as negative mood, discomfort, and edema.12
  • Benefits around the effects of aerobic exercise are associated with a general improvement in many premenstrual symptoms. Research indicates that participants who engage in aerobic exercise have improved psychological and physical symptoms, especially relative to premenstrual depression.13
  • However, conflicting reports have also suggested that there is no evidence-based research to support exercise for the treatment of PMS and PMDD, although recommended for overall good health.14
Women who increase their intake of complex carbohydrates may also exhibit an increase in levels of tryptophan, a serotonin precursor.10 Moreover, a study of 300 university students found that consuming fruits rich in antioxidants and non-starchy vegetables reduced PMS symptoms.15 Smoking has also been linked to increased psychological and behavioral symptoms, while consuming high-calorie, fat, sugar, and salt foods can exacerbate physical symptoms.15 Relaxation techniques and other therapies may assist with improving PMS symptoms. Cognitive-behavioral therapy (CBT) can reduce disruptive thoughts, behaviors, and emotions.16

Pharmacological Treatment

Herbal and other supplementation may also assist with alleviating PMS.  
    • Vitex agnus-castus (chasteberry)
      • This herbal medicine helps control mood swings and irritability associated with PMS and PMDD.17
      • The extract may be associated with decreased gonadotropin, estrogen, progesterone, and prolactin levels, secondary to its role as a dopamine agonist.17
      • In one study, participants were given forty drops of chaste berry extract for six days before the onset of menstruation for six consecutive months. Findings indicated a reduction in severe symptoms of PMS.18
    • Crocus sativus (Saffron)
      • A study reporting findings on fifty female participants administered 30 mg/d of saffron experienced reduced symptoms of PMS on the third and fourth treatment cycles.20
    • Ginkgo Biloba
      • A study of ninety women with PMS was administered 40 mg leaf extract of G. biloba from day 16 to day 5 of their next menstrual cycle. Women reported experiencing a significant reduction in physical and psychological symptoms of PMS.21
Nutritional supplementation may also assist with alleviating PMS.  
  • Magnesium
    • Magnesium and vitamin B6 can reduce PMS-related anxiety, but not the effects of stress in women with dysmenorrhea.32
    • In terms of reducing PMS-related anxiety, magnesium and vitamin B6 are ineffective.32
  • Calcium
    • Due to lower levels of calcium (lower than normal levels) in women with PMS, calcium supplementation of about 1000mg can significantly decrease the severity of PMS as it correlates with the production of serotonin and tryptophan metabolism.22–25
    • Another study showed low doses of calcium supplementation (500mg) significantly reduced PMS symptoms.26
  • Fish oil
    • A randomized controlled trial involving forty-five women revealed that prolonged intake of omega-3 supplements could significantly reduce PMS symptoms.32
    • Studies have also shown that daily omega-3 supplementation can reduce PMS and PMDD symptoms.33
    • Essential fatty acids, in general, are shown to be effective in reducing PMS-related stress.32
  • Several studies have suggested an association between supplements’ administration, including vitamin D and E, thiamin, riboflavin, and decreased PMS symptoms.27–31
  • Intake of non-heme iron, zinc, potassium, and copper can lower the risk of PMS.28

References:

1. Yonkers, K. A. & Casper, R. F. Epidemiology and pathogenesis of premenstrual syndrome and premenstrual dysphoric disorder.
2. Rapkin, A. J. & Winer, S. A. Premenstrual syndrome and premenstrual dysphoric disorder: quality of life and burden of illness. Expert Rev. Pharmacoecon. Outcomes Res. 9, 157–170 (2009).
3. Sternfeld, B., Swindle, R., Chawla, A., Long, S. & Kennedy, S. Severity of premenstrual symptoms in a health maintenance organization population. Obstet. Gynecol. 99, 1014–1024 (2002).
4. Borenstein, J. E. et al. Health and economic impact of the premenstrual syndrome. J. Reprod. Med. 48, 515–524 (2003).
5. Kessel, B. Premenstrual syndrome. Advances in diagnosis and treatment. Obstet. Gynecol. Clin. North Am. 27, 625–639 (2000).
6. Yamada, K. & Kamagata, E. Reduction of quality-adjusted life years (QALYs) in patients with premenstrual dysphoric disorder (PMDD). Qual. Life Res. Int. J. Qual. Life Asp. Treat. Care Rehabil. 26, 3069–3073 (2017).
7. Baker, L. J. & O’Brien, P. M. S. Premenstrual syndrome (PMS): a peri-menopausal perspective. Maturitas 72, 121–125 (2012).
8. Health, M. C. for W. M. PMS & PMDD. MGH Center for Women’s Mental Health https://womensmentalhealth.org/specialty-clinics/pms-and-pmdd/.
9. Ryu, A. & Kim, T.-H. Premenstrual syndrome: A mini review. Maturitas 82, 436–440 (2015).
10. Sayegh, R. et al. The effect of a carbohydrate-rich beverage on mood, appetite, and cognitive function in women with premenstrual syndrome. Obstet. Gynecol. 86, 520–528 (1995).
11. Shakeri, H., Fathollahi, Z., Karimi, N. & Arab, A. M. Effect of functional lumbar stabilization exercises on pain, disability, and kinesiophobia in women with menstrual low back pain: a preliminary trial. J. Chiropr. Med. 12, 160–167 (2013).
12. Tsai, S.-Y. Effect of Yoga Exercise on Premenstrual Symptoms among Female Employees in Taiwan. Int. J. Environ. Res. Public. Health 13, 721 (2016).
13. Steege, J. F. & Blumenthal, J. A. The effects of aerobic exercise on premenstrual symptoms in middle-aged women: A preliminary study. J. Psychosom. Res. 37, 127–133 (1993).
14. Biggs, W. S. & Demuth, R. H. Premenstrual syndrome and premenstrual dysphoric disorder. Am. Fam. Physician 84, 918–924 (2011).
15. Hashim, M. S. et al. Premenstrual Syndrome Is Associated with Dietary and Lifestyle Behaviors among University Students: A Cross-Sectional Study from Sharjah, UAE. Nutrients 11, 1939 (2019).
16. Lustyk, M. K. B., Gerrish, W. G., Shaver, S. & Keys, S. L. Cognitive-behavioral therapy for premenstrual syndrome and premenstrual dysphoric disorder: a systematic review. Arch. Womens Ment. Health 12, 85–96 (2009).
17. Girman, A., Lee, R. & Kligler, B. An integrative medicine approach to premenstrual syndrome. Am. J. Obstet. Gynecol. 188, S56-65 (2003).
18. Zamani, M., Neghab, N. & Torabian, S. Therapeutic effect of Vitex agnus castus in patients with premenstrual syndrome. Acta Med. Iran. 50, 101–106 (2012).
19. Rocha Filho, E. A., Lima, J. C., Pinho Neto, J. S. & Montarroyos, U. Essential fatty acids for premenstrual syndrome and their effect on prolactin and total cholesterol levels: a randomized, double blind, placebo-controlled study. Reprod. Health 8, 2 (2011).
20. Agha-Hosseini, M. et al. Crocus sativus L. (saffron) in the treatment of premenstrual syndrome: a double-blind, randomised and placebo-controlled trial. BJOG Int. J. Obstet. Gynaecol. 115, 515–519 (2008).
21. Ozgoli, G., Selselei, E. A., Mojab, F. & Majd, H. A. A randomized, placebo-controlled trial of Ginkgo biloba L. in treatment of premenstrual syndrome. J. Altern. Complement. Med. N. Y. N 15, 845–851 (2009).
22. Akhlaghi, F., Hamedi, A., Javadi, Z. & Hosseinipoor, F. EFFECTS OF CALCIUM SUPPLEMENTATION ON PREMENSTRUAL SYNDROME. Razi J. Med. Sci. 10, 669–675 (2004).
23. Ghanbari, Z., Haghollahi, F., Shariat, M., Foroshani, A. R. & Ashrafi, M. Effects of calcium supplement therapy in women with premenstrual syndrome. Taiwan. J. Obstet. Gynecol. 48, 124–129 (2009).
24. Masoumeh pourmohsen, Akram Zoneamat Kermani, Simin Taavoni & Agha Fatemeh Hosseini. Effect of combined calcium and vitamin E consumption on premenstrual syndrome. Iran J. Nurs. 23, 8–14 (2010).
25. Masoumi, S. Z., Ataollahi, M. & Oshvandi, K. Effect of Combined Use of Calcium and Vitamin B6 on Premenstrual Syndrome Symptoms: a Randomized Clinical Trial. J. Caring Sci. 5, 67–73 (2016).
26. Shobeiri, F., Araste, F. E., Ebrahimi, R., Jenabi, E. & Nazari, M. Effect of calcium on premenstrual syndrome: A double-blind randomized clinical trial. Obstet. Gynecol. Sci. 60, 100–105 (2017).
27. Abraham, G. E. Nutritional factors in the etiology of the premenstrual tension syndromes. J. Reprod. Med. 28, 446–464 (1983).
28. Chocano-Bedoya, P. O. et al. Intake of selected minerals and risk of premenstrual syndrome. Am. J. Epidemiol. 177, 1118–1127 (2013).
29. Salamat, S., Ismail, K. M. K. & Brien, S. O. Premenstrual syndrome. Obstet. Gynaecol. Reprod. Med. 18, 29–32 (2008).
30. Shobeiri, F., Oshvandi, K. & Nazari, M. Clinical effectiveness of vitamin E and vitamin B6 for improving pain severity in cyclic mastalgia. Iran. J. Nurs. Midwifery Res. 20, 723–727 (2015).
31. Shobeiri, F. & Jenabi, E. The effects of vitamin E on muscular pain reduction in students affected by premenstrual syndrome. Iran. J. Obstet. Gynecol. Infertil. 17, 1–5 (2014).
32. McCabe, D., Lisy, K., Lockwood, C. & Colbeck, M. The impact of essential fatty acid, B vitamins, vitamin C, magnesium and zinc supplementation on stress levels in women: a systematic review. JBI Database Syst. Rev. Implement. Rep. 15, 402–453 (2017).
33. Behboudi-Gandevani, S., Hariri, F.-Z. & Moghaddam-Banaem, L. The effect of omega 3 fatty acid supplementation on premenstrual syndrome and health-related quality of life: a randomized clinical trial. J. Psychosom. Obstet. Gynaecol. 39, 266–272 (2018).
34. Yonkers, K. A. et al. Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder. Obstet. Gynecol. 106, 492–501 (2005).
35. Lopez, L. M., Kaptein, A. A. & Helmerhorst, F. M. Oral contraceptives containing drospirenone for premenstrual syndrome. Cochrane Database Syst. Rev. CD006586 (2012) doi:10.1002/14651858.CD006586.pub4.
36. Kelderhouse, K. & Taylor, J. S. A review of treatment and management modalities for premenstrual dysphoric disorder. Nurs. Womens Health 17, 294–305 (2013).
37. Halbreich, U. et al. Are there differential symptom profiles that improve in response to different pharmacological treatments of premenstrual syndrome/premenstrual dysphoric disorder? CNS Drugs 20, 523–547 (2006).

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