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R. Lanier Britsch and Terrance
D. Olson, eds., Counseling: A Guide to Helping Others, 2 vols. [Salt Lake
City: Deseret Book Co., 1983-1985], Volume 2 © 2001, Deseret Book, GospeLink
2001, Used by permission
9 Premenstrual Syndrome
Robert N. Gray, M.D.
Premenstrual syndrome,
or as many refer to it, PMS, has become a
household term over the past few years. It has been discussed widely by the
press, on television news and information programs, and to some degree in nearly
every type of magazine. PMS has become a major concern if not a problem for many
people.
What Is PMS?
Although recognized by clinicians for centuries, PMS was first described in
medical literature in 1931 by R.T. Frank, who called it "premenstrual
tension" and described it as "a feeling of indescribable
tension," "a desire to find relief by foolish and ill-considered
acts." fn Even though women have long experienced the symptoms of PMS, it
has been poorly understood by both the public and the medical profession Until
recent years few women with PMS reported their complaints, and those who did
seek medical attention were often thought to be irrational or emotionally
unstable. Since Frank's work and observations in 1931, considerable effort has
been directed toward the clinical characterization of the syndrome and toward
delineation of the physiology of PMS.
It has long been known that many women become tense, irritable, and anxious
or depressed during the seven to ten days before menstruation. This state
frequently leads to a deterioration in their relationships with family, friends,
and co-workers. These emotional changes have been responsible or at least
implicated in marital problems, child abuse, and even criminal behavior (any of
which may be totally out of character for the person except during that time in
her cycle). In two recent court cases in Great Britain involving women who
committed murder, PMS was recognized as a mitigating factor, resulting in the
court finding the women to have been in a state of "diminished
responsibility." However, in 1982 an attempt to use this plea in the United
States was unsuccessful. fn
With women playing an increasingly prominent role in business and industry,
attention has been focused on the effect of PMS on absenteeism and inefficiency.
It has been observed that 36 percent of 1,500 women in one plant sought sedation
in the premenstrual week, and estimates suggest that absenteeism due to PMS
caused a loss of $5 billion in 1969 alone. fn Although the association between
PMS and intellectual impairment has not been clearly established, there are an
increased number of psychiatric hospital admissions, accidents, and suicide
attempts in women during the premenstrual phase of their cycle.
Due to the tremendous exposure of society to the term PMS, the sensationalism
PMS has been afforded by the media over the past few years, and the frequently
non-specific symptoms it causes, PMS has become the female hypochondriac's
favorite diagnosis. Many women who feel they have PMS simply do not fit the
diagnostic criteria and are most likely experiencing anxiety or depression due
to other causes.
Symptoms of PMS
PMS encompasses emotional, behavioral, and physical symptoms. The symptoms
occur cyclically beginning seven to ten days before onset of menstrual bleeding
and regressing or disappearing at the onset of the menstrual period or within
one or two days thereafter. In most women with PMS, the symptoms are most severe
two to five days before their period, with rapid relief with the onset of
bleeding.
Pain after menstrual flow has started (dysmenorrhea) is an entirely different
problem. Dysmenorrhea and its treatment will be discussed later in this chapter.
Though PMS and dysmenorrhea are separate problems, some women experience both.
The symptoms most frequently associated with PMS are abdominal bloating,
swelling of the extremities, fullness and tenderness of the breasts, and mood
changes, including irritability, depression, and anxiety. Additional symptoms
include fatigue, headache, constipation, acne, and an increased thirst or
appetite, which may include a craving for sweets or salty foods. fn In some
women, the premenstrual symptoms are consistent from cycle to cycle; in others,
however, they vary in type and severity from month to month. Transient weight
gain may occur during the premenstrual period but is not a criterion or symptom
of PMS.
The most frequently reported emotional states associated with PMS are
tension, anxiety, depression, and hostility. Some women also report feelings of
loneliness or guilt. Some quite abruptly feel incompetent or worthless and,
consequently, become unwilling to take any risks for fear of being rejected.
Behavioral changes may include feelings of lethargy and inability to cope
with normal day-to-day activities. Some women cannot face going to work,
engaging in social activities, or interacting with people in anyway. They may
also have erratically alternating spells of lethargy and bursts of energy. Some
report sudden flurries of compulsive activity, such as housecleaning or desk
organization. In more severe cases of PMS, there may be abrupt outbursts of
anger and aggression, particularly toward family members. Another area of
behavioral change is fluctuation in sexual desires, which can increase or
decrease, depending on the individual.
The Incidence of PMS
In an effort to assess or establish the incidence of PMS in the general
population, several large studies have been done in the United States and in
Great Britain. These studies indicate that 80 to 95 percent of women have at
least one of the symptoms of PMS, and that 30 to 40 percent have symptoms severe
enough to temporarily disrupt their life-style through mental or physical
incapacitation. The diagnosis or classification of PMS is applied to this latter
group of 30 to 40 percent. The studies indicate that the onset of the symptoms
of PMS can occur at any time between the onset and the end of a woman's
menstrual life. In addition, some women may experience symptoms during the first
several months of pregnancy, usually at the same time a period would be due.
Women who have had a hysterectomy or other surgery on the reproductive system
may continue to have PMS or may develop PMS unless both ovaries were removed at
the time of surgery. Women who have had both ovaries removed, for whatever
reason, will no longer experience PMS, but will commonly have the hot flashes
and sweating that go along with a surgical menopause.
Painful Periods
Dysmenorrhea, or painful periods, needs to be differentiated from PMS. Media
coverage, particularly in women's magazines and on television talk shows, has
tended to lump PMS and dysmenorrhea together, suggesting that both are medical
disorders with a known cause and physiological basis and with accepted specific
medical treatments. fn This is not the case; the two problems are related only
by the fact that they both affect the reproductive system. The cause of
dysmenorrhea seems to be an excessive production of hormones called
prostaglandins. Prostaglandins appear to cause us to sense pain, particularly
visceral or deep pain. Since the discovery of the prostaglandins, control of
prostaglandin pain has changed radically through the development of drugs known
as anti-prostaglandins. These medications function by preventing the synthesis
or production of prostaglandins or by preventing binding of the prostaglandin at
the receptor sites. Some of the more common drugs in this group are Ponstel,
Motrin, Naprosyn, and Meclomen (trade names).
What Causes PMS?
The cause of PMS is not nearly as clearly defined as that of dysmenorrhea.
Since it was first described a variety of causes have been proposed.
In 1931, R. T. Frank was the first to propose that PMS was caused by an
excess of female sex hormone in the blood, and he recommended cathartics or
strong laxatives to try to eliminate excessive sex hormones. Similar studies
presented much discussion and deliberation about the two major female sex
hormones, estrogen and progesterone. Every woman with intact ovaries and
pituitary gland produces these hormones in a cycle each month of her menstrual
life, except during pregnancy. (See figure 1.) In figure 1, day one is the first
day of menstrual bleeding or flow. By following the lines you can see that
during the first six days of the cycle the hormone levels remain constant in
relation to each other. Between days six and eight the estrogen level begins to
rise and rapidly peaks out at day twelve, then falls just as rapidly to just
above baseline levels by day fifteen. Then it starts another slower rise to peak
at day twenty or twenty-one and then drops gradually to baseline levels by day
twenty-eight. Progesterone begins to rise at day twelve and continues to rise,
peaking at day twenty-two; then it makes a long, steady drop, reaching the
baseline level by day twenty-eight. During this time ovulation occurs about day
fifteen, interestingly enough, shortly after the hormone levels cross on the
graph, and menses begin again on day one of the next cycle. PMS occurs during
the last week or so of the cycle when both hormones have peaked and are in a
downward course.
Several proposals as to the cause of PMS involve the relationship of these
hormones during the premenstrual period of time. One proposes that women with
PMS have an estrogen excess; another proposes that they have a progesterone
deficiency in the premenstrual period. Another speculates that unopposed
estrogen causes fluid retention, swelling of the breasts, abnormal metabolism of
sugars, and accumulation of estrogen in the brain, thus causing the anxiety and
depression. However, in contrast, some women with normal estrogen levels still
had PMS. These researchers concluded that PMS must be due to progesterone
deficiency because of the rapid drop in progesterone in this phase of the cycle.
However, no large double-blind studies have been conducted that unequivocally
substantiate this fact, and trial therapy with progesterone has not been
completely successful in the treatment of PMS.
Vitamin-B therapy for PMS was popular in the 1940s and is used in some areas
today. Some physicians feel that vitamin B6 in large doses can correct defective
estrogen metabolism in women with PMS.
In 1947 Simkins proposed vitamin-A deficiency as a cause of PMS, although
little success was found in using vitamin A for therapy in PMS. It is doubtful
that a cyclic vitamin deficiency could exist, due to the composition of the
average diet in the United States and the amount of supplemental vitamins
present in our foods and taken as dietary supplements.
Some researchers have proposed hypoglycemia as a cause for PMS, but it seems
unlikely that hypoglycemic episodes could occur exactly when the symptoms of PMS
are present, nor does the ingestion of food seem to help PMS, whereas it does
relieve hypoglycemic symptoms.
Allergy to progesterone has been proposed as a possible cause of PMS. Some
interesting though not completely successful treatment has been carried out
using allergy management principles and small doses of progesterone.
Psychosomatic causes have been examined carefully, but there is no proof of a
psychological origin for PMS. Rather, the symptoms of PMS tend to cause
psychosomatic illnesses in the afflicted person.
Some researchers have cited water retention as the cause of PMS; however,
some rather involved studies regarding fluid retention show quite contradictory
results. Some women gained from one to three pounds at the time of ovulation and
again in the premenstrual period, but others actually lost weight during the
same times. Premenstrual breast swelling and pain does not correlate with an
increase in total body water. During the normal menstrual cycle, breast volume
gradually increases by 100 milliliters starting just before ovulation and
reaching a maximum on the first day of menstruation. Hence, again, there is no
correlation with the onset of PMS.
Numerous other causes have been and are under investigation, including many
so-called minor hormones such as renin, aldosterone, angiotensin, vasopressin,
prolactin, epinephrine, norepinephrine, dopamine, and most recently alpha-melanocyte
stimulating hormone and the endorphins. The latter two theories seem to present
some strong hopes for an answer to the real cause of PMS.
Treatment of PMS
Treatment of PMS has run the gamut from witchcraft and laxatives to
sophisticated hormone blocking agents. Presently experts begin treatment with
nondrug therapies, including insight into the problem, relaxation techniques,
biofeedback, exercise, weight reduction, and nonprescription medications such as
vitamin B6. If not successful, they progress to drug therapy with a variety of
agents including spironolactone (a diuretic and aldosterone antagonist),
bromocriptine (particularly effective for breast engorgement and irritability),
and natural progesterone (cannot be taken orally).
Specialists or clinics may or may not be effective in treating the average
woman with PMS. The success of treatment frequently depends as much on the
woman's relationship with her doctor as it does on the method of treatment.
Frequently the family doctor or the woman's own gynecologist will be much more
effective in her long-term care than the less personalized but perhaps more
scientifically oriented clinic.
Both lay counselors and professional counselors should not only be aware of
the existence of PMS but should have at least a rudimentary understanding of the
physiology involved and the variable symptoms. PMS should be considered whenever
a woman complains of cyclic disturbances of any kind. A counselor's knowledge of
PMS should be extensive enough that he or she may discuss the problem with the
woman and her family in at least enough depth to give them an overview of the
problem. The counselor should be able to suggest further care available to the
woman.
Suggested Reading
The most complete and most recent article on PMS is titled "Premenstrual
Syndrome," by Robert L. Reid and S.S.C. Yen. It was published in the
American Journal of Obstetrics and Gynecology, vol. 139, pp. 85-104. This
paper contains an extensive bibliography of 305 references relating to PMS. It
is well written and is relatively easy reading. It should be available through
most hospital medical libraries and will definitely be found in all
medical-school libraries.
Premenstrual Syndrome
1. R. T. Frank, "The Hormonal Causes of Premenstrual Tension, " Archives
of Neurology and Psychiatry, 26 (1931): 1053.
2. M. Laughlin and R. E. Johnson, "Premenstrual Syndrome," American
Family Physician, 29 (3), (March 1984): 265-69.
3. Robert L. Reid and S. S. C. Yen, "Premenstrual Syndrome,"
American
Journal of
Obstetrics and Gynecology, 139 (1981): 85-104.
4. H. Sutherland and 1. Stuart, "A Critical Analysis of the Premenstrual
Syndrome, Lancet, 1(1965): 1180.
5. R. M. Rose and J. M. Abplanalp, "The Premenstrual Syndrome," Hospital
Practice, 18 (6), (June 1983):129-41.
About the Author
Dr. Robert N. Gray, an emergency-room physician at Utah Valley Regional
Medical Center, received his undergraduate education at Adams State College in
Alamosa, Colorado, and his M.D. at Northwestern University Medical School. He
was a family practitioner for ten years before becoming an emergency-room
physician in 1978.
In the Church he has served as a seventies president, a bishop's counselor, a
bishop, a high councilor, and in a stake presidency.
Dr. Gray and his wife, Nancy, are the parents of five children.
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