Premenstrual Syndrome and Premenstrual Dysphoric Disorder

Premenstrual syndrome (PMS) is a collection of physical, psychological and behavioural symptoms that occur in the luteal or secretory phase of the menstrual cycle, between ovulation and start of menstruation. 

Anyone assigned female at birth can experience this so those who identify as trans, non- binary or gender fluid may experience PMS/PMDD. Some women are more sensitive to the hormonal changes that occur during this time and can lead to distressing symptoms that include: 

• mood swings
• feeling depressed, anxious or irritable
• tiredness and fatigue
• sleep disturbance
• headaches
• appetite changes
• bloating
• acne and greasy hair
• breast changes
• loss of libido.

The experience of symptoms is extremely individual and may vary enormously from month to month. Symptoms usually resolve with the onset of menses.

Most women will experience some degree of PMS but approximately 25 per cent women get severe PMS that prevents them from fulfilling their daily activities, affecting work, relationships, intimacy and the enjoyment of life. PMS can start at any time in a woman's reproductive life and may also worsen in the perimenopausal phase. 

Premenstrual Dysphoric Disorder (PMDD)

PMDD is a severe type of PMS, affecting an estimated 5 % of women. It can occur at any time in a woman’s reproductive life but typically occurs at menarche or peri-menopausal age. It is a complex condition characterised by disabling symptoms of poor mental health and unmanageable physical pain. It is frequently under recognised and under diagnosed.

• anxiety and panic attacks
• suicidal thoughts
• extreme mood swings
• uncontrollable anger 
• sleep issues such as insomnia or hypersomnia (sleeping too much)
• headaches, joint pain and bloating.

Podcast: Laura Murphy - Premenstrual Dysphoric Disorder

Please find below a short podcast from Laura Murphy, Director of Education and Awareness at the International Association For Premenstrual Disorders (IAPMD).

Diagnosis

Nurses should take a thorough history and ask about the impact of symptoms. Recording a diary over at least two consecutive menstrual cycles which can help identify a pattern and aid diagnosis. 
This can be used to identify patterns, plan interventions and evaluate treatment.

Management

This should be individualised to each woman and should usually be managed in primary care but women with severe symptoms or who those who do not respond to treatment should be referred onwards for specialist advice.

Lifestyle measures include:

• exercise to release 'feel good' endorphins and aid rest and relaxation 
• healthy balanced diet to optimise nutrition and stabilise blood sugars. Increasing foods rich in Vitamin B6 may help boost mood
• stress reduction activities such as pilates, yoga or mindfulness 
• ensuring seven hours quality sleep
• smoking cessation and the reduction of alcohol and caffeine consumption.

Psychological support

Cognitive Behavioural Therapy (CBT) is a talking therapy that may be effective in enabling women to find new ways of managing symptoms so they have less of an impact on their life.

Vitamins and supplements

More evidence is required to before recommending specific use of supplements in the management of PMS/PMDD but initial data in small studies in the use of  calcium,  vitamin D,  magnesium, agnus Castus, isoflavines and St. John’s Wort are encouraging and some women may find them helpful. Evening Primrose oil may be helpful in alleviating cyclical breast pain.

Non-Hormonal options

Antidepressants – Selective serotonin reuptake inhibitors (SSRIs) or serotonin-noradrenaline re-uptake inhibitors (SNRIs) taken intermittently during the premenstrual phase or continuously can be effective. A trial of at least 3 months is recommended. Women should be fully advised of potential side effects.

Hormonal options

The use of hormones can be useful in suppressing ovulation to avoid cyclical changes.

Combined hormonal contraception in the form of oral pills, transdermal patches or vaginal rings can be used in extended regimens or used continuously to suppress ovulation, provided that the woman meets the medical eligibility criteria to use them safely.

Gonadotrophin-releasing  Hormone  (GnRH ) analogues as a nasal spray or injection cause a temporary menopause to stop periods.  They are usually used for six months but this can be extended if combined with HRT to protect bone mineral density.

Referral to a gynaecologist for specialist advice on treatments may be necessary.

Surgical treatment

This may be the next step if PMS/PMDD are resistant to all medical treatments and lifestyle interventions.  A bilateral salpingoophrectomy or total hysterectomy are not reversible, and all other options should be explored first.

A trial of GnRH analogues for three to six months before a hysterectomy will to determine how effective surgery may be and to see what HRT will be suitable.