Premenstrual Syndrome: Symptoms, Types, Causes and Treatment

Premenstrual Syndrome (PMS) is a common, yet often misunderstood, condition that affects millions of women worldwide. For many, it is a recurring monthly challenge that can impact emotional well-being, physical comfort, and daily life. In this comprehensive article, we’ll break down the symptoms, types, causes, and treatment options for PMS, providing clarity and support for those seeking answers.

Symptoms of Premenstrual Syndrome

PMS expresses itself through a wide variety of symptoms, both physical and psychological, which typically arise in the luteal phase of the menstrual cycle and subside with the onset of menstruation. The diversity and severity of these symptoms can range from subtle discomforts to life-disrupting challenges.

Category	Example Symptoms	Frequency/Severity	Sources
Emotional	Irritability, mood swings, depression, anxiety	Most common, moderate to severe	1 2 5 7
Physical	Abdominal bloating, breast tenderness, headaches, fatigue	Common, severity varies	3 5 7
Behavioral	Changes in appetite, sleep disturbances, lethargy	Often present, moderate	5 7 8
Cognitive	Difficulty concentrating, forgetfulness	Less common, mild to moderate	5 6

Table 1: Key Symptoms

Understanding the Spectrum of Symptoms

PMS is not a one-size-fits-all condition. The number, type, and severity of symptoms can vary significantly from one individual to another, and even for the same person across different cycles.

Emotional and Psychological Symptoms

• Irritability, mood swings, and depression are frequently reported and often the most distressing for women with PMS. Anxiety and increased sensitivity to stress are also common emotional symptoms 1 2 5 7.
• Some women experience heightened emotional reactivity, including anger, tearfulness, or a sense of being overwhelmed 2 6.

Physical and Somatic Symptoms

• Breast tenderness, abdominal bloating, headaches, and fatigue are hallmark physical complaints 3 5 7.
• Other physical issues include muscle and joint pain, acne, and gastrointestinal discomfort 7 8.

Behavioral and Cognitive Changes

• Common behavioral symptoms include changes in appetite (often cravings for sweets or salty foods), sleep disturbances (insomnia or hypersomnia), and lethargy 5 7 8.
• Cognitive symptoms such as difficulty concentrating and forgetfulness are less common but can further disrupt daily life 5 6.

Symptom Patterns and Functional Impact

• Symptoms typically develop after ovulation, worsen in the days leading up to menstruation, and resolve with or shortly after onset of periods 3 6 8.
• For some, especially those with severe PMS or premenstrual dysphoric disorder (PMDD), symptoms can significantly interfere with work, relationships, and quality of life 1 2 5.

Types of Premenstrual Syndrome

Not all PMS is created equal. While most women of reproductive age experience at least mild symptoms, a smaller subset faces more severe forms, such as PMDD. Understanding the spectrum and classification of PMS is crucial for appropriate management.

Type	Description	Prevalence	Sources
Mild PMS	Few, mild symptoms; little functional impact	Most common	5 10
Moderate PMS	Multiple symptoms; moderate discomfort	Fairly common (~30-40%)	1 5 7
Severe PMS	Marked symptoms, daily life affected	5-8% of women	2 5 7
PMDD	Severe, mostly psychological, meets DSM criteria	3-8% of women	1 2 7

Table 2: Types of PMS

PMS: The Common Form

• Most women experience mild to moderate PMS, characterized by a combination of symptoms that, while uncomfortable, do not drastically hinder daily life 5 10.
• These symptoms can vary by month and may be influenced by lifestyle, stress, and diet 10.

Severe PMS

• Severe PMS is less common but can be debilitating. Symptoms significantly impact occupational, social, and personal functioning 2 5 7.
• Women with severe PMS may struggle to maintain their usual routines during the premenstrual phase.

Premenstrual Dysphoric Disorder (PMDD)

• PMDD is the most severe form of premenstrual disorder, classified as a depressive disorder in DSM-5 1 7.
• PMDD is distinguished by a predominance of psychological symptoms, including intense mood swings, irritability, and depression, often requiring clinical intervention 1 2 7.
• Diagnosis requires at least five symptoms, with one being a severe mood disturbance, and symptoms must be prospectively documented for at least two cycles 15.

Premenstrual Exacerbation of Other Disorders

• Some women experience premenstrual worsening of chronic conditions, such as migraine, depression, or epilepsy 9.
• This is not PMS per se, but the hormonal fluctuations of the cycle can exacerbate underlying health issues.

Functional Impact

• The severity and type of PMS have a direct bearing on quality of life. Severe PMS and PMDD can disrupt relationships, work, and overall well-being 1 2 5 7.
• Accurate classification is essential for choosing the right management approach.

Causes of Premenstrual Syndrome

The exact cause of PMS is still not fully understood, but research points to a complex interplay of hormonal, neurochemical, and lifestyle factors. Let’s explore what current science reveals.

Factor	Description	Role in PMS	Sources
Hormonal Fluctuations	Changes in estrogen, progesterone	Triggers symptoms	1 2 6 7
Neurotransmitter Dysfunction	Serotonin and GABA abnormalities	Modulates mood symptoms	1 6 7 9
Sensitivity/Genetic Predisposition	Individual hormonal sensitivity	Increases risk	1 6 7
Lifestyle/Diet	Smoking, high-fat/sugar diet, low calcium/Vit D	May worsen symptoms	10 11

Table 3: Key Causes and Contributors

Hormonal Changes and Sensitivity

• PMS symptoms emerge during the luteal phase—the second half of the menstrual cycle—when progesterone and estrogen fluctuate 1 2 6.
• It’s not abnormal hormone levels themselves, but rather increased sensitivity to these normal hormonal changes that triggers PMS in susceptible women 1 6 7.

Neurotransmitter Changes

• Serotonin, a key neurotransmitter involved in mood regulation, is thought to play a major role. Many women with PMS have altered serotonin activity in the brain 1 6 7 9.
• Fluctuations in GABA (gamma-aminobutyric acid), another neurotransmitter, may also contribute, especially to anxiety and mood symptoms 7.
• This neurochemical theory helps explain why treatments targeting serotonin, like SSRIs, are effective for many women 12 13.

Genetic and Individual Factors

• There is evidence that genetic susceptibility and individual differences in hormone responses influence who develops PMS 1 6 7.
• Family history may increase risk; some women are simply more sensitive to hormonal shifts.

Lifestyle and Environmental Influences

• Certain lifestyle factors can aggravate PMS, including:
  • Smoking (increases risk of psychological and behavioral symptoms)
  • Diets high in fat, sugar, and salt (worsen physical symptoms)
  • Low intake of fruit, calcium, or vitamin D (associated with increased symptom severity) 10 11.
• Stress, lack of exercise, and poor sleep may also exacerbate symptoms 10.

Other Contributing Factors

• Low serum calcium and vitamin D during the luteal phase have been linked to more severe PMS, which is why supplementation can help some women 11.
• In some cases, PMS is associated with an underlying neuroendocrine anomaly—how the ovaries and brain communicate 1 4.

Treatment of Premenstrual Syndrome

Managing PMS is highly individualized, often requiring a combination of approaches. Treatments range from lifestyle adjustments and nutritional supplements to medications and, in rare cases, surgical intervention.

Approach	Examples	Typical Use/Effectiveness	Sources
Lifestyle/Non-Pharmacologic	Exercise, CBT, diet, supplements (Ca, Vit D, Vitex)	First-line, mild to moderate cases	1 7 11 15 16
Pharmacologic	SSRIs, oral contraceptives, GnRH agonists	Moderate to severe PMS/PMDD	1 2 7 12 13 15
Hormonal	GnRH analogs, estradiol patches, OCPs	For ovulation suppression	2 4 7 15
Complementary	Acupuncture, herbal remedies (Vitex agnus castus)	Some evidence, variable	1 14 16

Table 4: Main Treatment Modalities

Lifestyle and Non-Pharmacologic Strategies

• Diet and Exercise: Regular aerobic exercise, stress management, and a healthy diet are foundational 7 10 15.
  • Reducing intake of salt, caffeine, and refined sugar can help minimize bloating and mood swings.
  • Increasing fruit, calcium, and vitamin D intake has shown benefit in reducing symptoms 10 11.
• Cognitive Behavioral Therapy (CBT): Effective for managing emotional symptoms and improving coping skills 1 7 15.
• Supplements: Calcium and vitamin D are both low-risk, accessible options for many women 11 15.
• Herbal Remedies: Vitex agnus castus (chasteberry) is used by some women, with meta-analyses suggesting potential benefit, though evidence is not definitive 1 16.

Pharmacologic Treatments

• Selective Serotonin Reuptake Inhibitors (SSRIs): The gold standard for moderate to severe PMS and PMDD. SSRIs like fluoxetine, sertraline, and paroxetine can be taken daily or only during the luteal phase; both regimens are effective 1 7 12 13 15.
  • They alleviate not only mood symptoms but also physical and behavioral symptoms 12 13.
  • Side effects (e.g., nausea, insomnia) may cause discontinuation in some women 12 13.
• Oral Contraceptives (OCPs): Suppress ovulation and help regulate hormonal fluctuations. Particularly effective for physical symptoms, with some newer formulations (e.g., drospirenone-containing pills) showing promise for both physical and mood symptoms 1 2 7 15.
  • Not all OCPs are equally effective; certain progestins may worsen symptoms in some women 15.
• Gonadotropin-Releasing Hormone (GnRH) Agonists: Used in severe, refractory cases to suppress ovarian cyclicity, often with add-back hormone therapy to minimize side effects 2 4 7 15.
• Other Medications: Anxiolytics, spironolactone (for water retention), and tricyclic antidepressants can be considered, though evidence is less robust 15.

Hormonal Therapies

• Estradiol Patches or Implants: May help by suppressing ovulation, but evidence quality is low and long-term risks are unclear 4 7 15.
  • Must be combined with progestogen to protect the endometrium; side effects can mimic PMS 4.
• Surgical Options: Rarely, surgical menopause (oophorectomy) is considered for intractable, disabling PMS after all other treatments have failed 8.

Complementary and Alternative Medicine

• Acupuncture and Acupressure: Some studies suggest benefit for both psychological and physical symptoms, but evidence is limited and of low quality 14.
• Herbal Supplements: Vitex agnus castus shows promise, but studies are heterogeneous and risk of bias is high 16.

Treatment Selection and Personalization

• Treatments should be tailored to the individual, based on symptom severity, preference, contraindications, and response to previous therapies 1 7 8.
• Most women benefit from a step-wise approach, starting with lifestyle modifications and progressing to medications if needed.

Conclusion

Premenstrual Syndrome is a complex, multifaceted condition that can significantly impact the lives of affected women. Understanding its symptoms, types, causes, and treatment options empowers individuals to seek effective care and improve quality of life. Here’s a summary of what we’ve covered:

• PMS involves a wide range of psychological, physical, and behavioral symptoms that recur in the luteal phase and resolve with menstruation.
• Types range from mild PMS to severe PMDD, with the latter requiring more intensive intervention.
• Causes are multifactorial, including hormonal fluctuations, neurotransmitter dysfunction (especially serotonin), individual sensitivity, and lifestyle factors.
• Treatment is highly individualized, often starting with lifestyle changes and dietary supplements, progressing to medications like SSRIs and OCPs, and considering hormonal or complementary therapies for refractory cases.
• Early recognition and tailored management can drastically improve well-being and daily functioning for those with PMS.

By staying informed and working closely with healthcare providers, women with PMS can find strategies that work best for their unique needs and lead fuller, more comfortable lives.