PMS

Julie was bewildered at her erratic behavior over the past few days. On certain days, she would feel jubilant, confident, and on top of the world. Other days would degenerate into confusion, panic, irritability, and inability to cope with even simple problems. With depression in her family, she often thought she was going crazy. Her mother suggested she should be evaluated for a low blood sugar problem. Her neighbor thought she might be manic-depressive. Julie dismissed these suggestions. The symptoms were not ameliorated by food nor were they extreme enough to think she was manic on the good days. She did feel depressed at times. She really did not what to do. One day after a particularly trying episode in which she ranted against her husband for all of her woes, she heard him mutter, "I bet you start your period tomorrow."

In a normal menstrual cycle, the follicular phase, characterized by the development of the egg in the ovary, lasts approximately two weeks. The days of this phase are counted from the first day of the period. As the egg and lining of the uterus are stimulated, the estrogen level begins to rise. As the estrogen level increases, the pituitary gland is stimulated to release high levels of LH and FSH in order to cause the egg to be released from the ovary. The luteal phase follows ovulation. In these next two weeks, the uterine lining prepares for pregnancy, the cells left over in the ovary where the egg has been released produce progesterone, and the levels of this hormone increase. If the egg is not fertilized, the levels of estrogen and progesterone decline, the uterine lining sloughs off as the menstrual flow, and the process begins all over.

The "premenstrual" time of the cycle refers to the luteal phase: the time between ovulation and menstruation. Some women, during this time, feel differently than they do the rest of the cycle. The symptoms are quite variable and range from mild bloating to depression. Many women have no or very few symptoms. In some, the symptoms only occur 24 to 48 hours before their periods start; in others, the symptoms are severe the whole two weeks. In surveys of large numbers of women, up to 50% find some of these symptoms troublesome.

Because almost any symptom occurring in a cyclical manner can be labeled under the Premenstrual Syndrome, the syndrome itself was not taken seriously for many years. Women during these years were treated only symptomatically. PMS, like so many labels, is a term defined by the patient herself.

The symptoms of PMS vary from woman to woman. Many women feel like they holding onto more fluid. Their rings and shoes become tighter. At times, their abdomen feels "bloated", and the clothes they could previously wear are too tight. Breasts may become tender from the fluid retention as well as from the direct effect of progesterone on them. Craving for carbohydrates, especially chocolate may occur leading not only to fluid weight gain but also to fat weight gain because of the excess calories consumed. Progesterone appears to affect the brain's level of serotonin. Serotonin may affect appetite, sleep, energy level, and mood. The most alarming of the PMS symptoms are the psychological problems which may include: anxiety, irritability, insomnia, confusion, and depression.

Other medical disorders may also become worse during this phase of the menstrual cycle. Those with migraines may have more headaches: those with epilepsy may experience an increased frequency of seizures. Diabetic patients may have changes in their blood sugar levels. Blood pressure may also increase as a result of the fluid retention properties of progesterone.

One theory of PMS is that it is not a disease in itself but rather an exacerbation of some mild underlying tendency that is always present. This "weakest link" theory may explain the varied presentations of the syndrome.

Although no specific blood test will diagnose the problem, some medical conditions may lead to changes in the menstrual cycle which can cause PMS. Thyroid disorders, peri-menopausal changes, excessive male hormone production, or excessive prolactin (hormone which causes the breast to secrete milk) can be looked for and diagnosed by simple blood tests. Treatment of these disorders may lead to an amelioration of the PMS symptoms.

To determine if PMS is the reason for the patient's symptoms, the physician may ask the woman to keep a "PMS Calendar". Listed on this calendar are a wide variety of symptoms. Each day, the woman checks off the symptoms and grades its severity. Also included are the days of the menstrual period. By analyzing this calendar, one can not only determine if the symptoms are cyclical but also if the symptoms improve by medication or other interventions.

If you have been diagnosed with PMS or suspect that you may have it, it helps to keep a list of symptoms during the whole month. The following is a general list of what you can do to help yourself:

	Limit those food that you crave or blunt their impact. Avoid sugar, caffeine, and chocolate. If you feel excessively hungry, it helps to eat snacks of complex carbohydrates (starches, breads, etc.) or protein in-between meals prior to becoming ravenous. This type of eating attenuates the fluctuations in blood sugar that some have during this time.
	Avoid salt and highly salted food if you have a tendency to swelling and bloating. Drink more water.
	Avoid or limit caffeine during this time because it will accentuate the feelings of tension and stress as well as increasing irritability. However, DO NOT abruptly stop caffeine if you are a heavy coffee drinker because, like any drug, you will go through withdrawal which will be worse than the PMS.
	Practice relaxation techniques or meditation to help relieve stress. Limit commitments during this time by asserting yourself to just say no. Take out time for yourself especially on PMS days.
	Exercise more or start exercising during this time. Exercise not only helps with stress but it also aids sleep, and improves depression, anxiety, irritability, and fluid retention.
	Get plenty of sleep. Sleep deprivation only exacerbates the symptoms of PMS.
	Make an appointment to have an examination by your physician to rule out any other causes for PMS.

If the above interventions do not prove to be totally effective and no other medical problems have been diagnosed to cause this problem, certain medications have been used to ameliorate or eliminate the most prominent symptoms of PMS.

Natural progesterone (Oragest or Progol) may be helpful in some women. The extra progesterone may be helpful if a progesterone deficiency is present, for example, in women between the ages of 40 and 50 who are approaching menopause. Unfortunately, the progesterone may also cause other PMS symptoms such as fluid retention.

If fluid retention is the main problem, a medication such as Aldactone (spironolactone) which blocks the fluid retaining effects of hormones, may be used. Aldactone also aids in blocking the effects of male hormones on those with a hormone imbalance.

For those with severe depression, anxiety, or irritability, the newer antidepressants which increase serotonin in the brain may prove to be helpful. Studies have been done with Prozac in PMS and this medication has been quite effective. Because of its long half-life, Prozac may be taken 1 to 2 times a week during the follicular phase and daily during the luteal phase. Zoloft has also been used in this manner as well.

If you think you may have PMS or have cyclical episodes of the symptoms mentioned in this article, discuss your symptoms with your physician.

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Kathryn Jean Lucas, MD 611 N 35th St Morehead City, North Carolina 28557

Kathryn Jean Lucas, MD
611 N 35th St
Morehead City, North Carolina 28557