Premenstrual Syndrome PMS

Premenstrual syndrome, PMS, is a condition experienced by women who have menstrual periods. It is characterised by the distressing physical, behavioural and psychological symptoms that regularly happen during the luteal phase of the menstrual cycle. The luteal phase is the time of the cycle starting with ovulation, and ending with the start of a period. The symptoms of PMS should disappear or significantly reduce by the end of the period (menstruation). There are a number of variants of PMS. Premenstrual Dysphoric Disorder (PMDD) is one and is the American Psychiatric Association’s definition of one type of severe PMS. Premenstrual Exacerbation (PME) refers to the premenstrual exacerbation/worsening of the symptoms of another disorder, such as major depressive disorder or generalised anxiety disorder.

The precise causes of PMS are still not understood, but there is compelling evidence that symptoms are directly related to the fluctuation of hormone levels in the monthly menstrual cycle. It is estimated that as many as 30% of women can experience moderate to severe PMS, with 5-8% suffering severe PMS/PMDD.

A diagram to show the menstrual cycle

Diagram from NHS shared care: Making a decision about heavy periods

Symptoms of PMS

Over 150 symptoms have been identified and no-one experiences all the symptoms, each person is individual. One symptom may be worse than the others, it may vary during the cycle and not necessarily be the same in each cycle. Symptoms may change over time and PMS can worsen as hormones change in perimenopause, which is the time leading up to menopause and hormones can fluctuate.

Psychological and behavioural symptoms include: mood swings, depression, tearfulness and feeling low, tension and unease, tiredness, fatigue or lethargy, anxiety, feeling out of control, irritability, aggression, anger, clumsiness /poor co-ordination, difficulty concentrating, sleep disorder, food cravings, change in sexual desire,

Physical symptoms include: breast tenderness, swollen/bloating feeling, puffiness of the face, abdomen or fingers, weight gain, clumsiness, headaches, appetite changes, acne or other skin rashes, constipation or diarrhoea, muscle or joint stiffness, general aches or pains, back ache, abdominal aches or cramps

PMS symptoms may be experienced in a number of ways. For some people the symptoms are felt continuously from ovulation to menstruation, for others they are present for 7 days before the period starts, or they could be felt at ovulation for 3-4 days and again just prior to the menstrual period, and in other patterns. Some women do not experience relief from symptoms until the day of the heaviest flow of their period.                                          

Diagnosing PMS

It is important to use a menstrual diary. This should be completed over two cycles, the chart will provide you with a close understanding of your cycle and the symptoms you are experiencing. Your menstrual chart contains a strong evidence basis from which to begin diagnosis and treatment.

Diagnosing PMDD

These are questions which help us but tracking the symptoms through two cycles is very important.

  • Mood/emotional changes (e.g. mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)*
  • Irritability, anger, or increased interpersonal conflicts*
  • Depressed mood, feelings of hopelessness, feeling worthless or guilty*
  • Anxiety, tension, or feelings of being keyed up or on edge*
  • Decreased interest in usual activities (e.g., work, school, friends, hobbies)
  • Difficulty concentrating, focusing, or thinking; brain fog
  • Tiredness or low-energy
  • Changes in appetite, food cravings, or overeating
  • Hypersomnia (excessive sleepiness) or insomnia (trouble falling or staying asleep)
  • Feeling overwhelmed or out of control
  • Physical symptoms such as breast tenderness or swelling, joint or muscle pain, bloating or weight gain

A diagnosis of PMDD requires the presence of at least five of these symptoms, one of which must be a “core emotional symptom” (*indicated in bold with an asterisk above). Remember that the use of oral contraceptives suppresses natural ovulation, which makes it impossible to diagnose PMDD – the diagnosis should not be made unless premenstrual symptoms are reported as present and as severe when a person is not taking an oral contraceptive.

What are the treatments for PMS?

Lifestyle changes:

  • Reducing stress – this will help balance serotonin
  • Diet: with complex carbohydrate, and with foods rich in tryptophan including whole milk, canned tuna, cheese and peanuts can increase serotonin
  • Exercise: increases serotonin in the brain
  • Increase exposure to light, human skin has a way of making serotonin in response to light
  • lLimiting alcohol and smoking

Cognitive behavioural therapy: a type of talking therapy

Complementary therapies: there is evidence that certain complementary therapies may be beneficial – Agnus Castus and Magnesium in particular.

Medical treatments: for moderate to severe PMS, these are divided into two categories:

  • Hormonal treatment to suppress ovulation, either using a certain type of combined contraceptive pill or using oestrogen patches or implants, with a cyclical progestogen or a 52mg LNG IUD such as a Mirena.
  • SSRIs- Selective Serotonin Re-uptake inhibitors (a type of antidepressant) taken at low or higher dose, for part of the month or daily, under the advice of your doctor
  • If these are not helpful then GnRH analogue therapy can be used
  • With severe symptoms not responding to treatment then a hysterectomy with removal of the ovaries is recommended

For further information please visit the following websites:

Other references include:

Please use this as guidance in order to speak to your doctor and read the information on the accompanying links for support. If you are concerned you are having suicidal thoughts please talk to a health professional, call the Samaritans, visit Accident and Emergency or call 999

Dr Carys Sonnenberg Rowena Health October 2024

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