What Is It?
Premenstrual syndrome (PMS) describes a wide range of severe, recurrent symptoms that occur from several days to two weeks before your period.
Premenstrual syndrome (PMS) describes a wide range of recurrent symptoms that occur from several days to two weeks before your period. PMS affects up to 75 percent of women in their childbearing years, although only 20 percent to 40 percent have difficulties as a result.
The symptoms of PMS can appear any time between puberty and menopause, but the most common age for it to start to become a problem is during the late 20s to early 30s.
Symptoms of PMS may get worse with age and stress, although the underlying causes are not well understood. Even women who have had hysterectomies can have PMS if at least one functional ovary is left. Women who are vulnerable to depressive illness, panic disorder, other psychiatric disorders or chronic medical conditions may also be susceptible to PMS, although these conditions may occur in women without PMS as well. Heredity may also play a role: if your mother or sister suffers from PMS, you may find you experience it, too.
As many as 150 physical and behavioral symptoms have been assigned to PMS, but the number of PMS symptoms that most women experience is much more limited. The most common symptoms include irritability, bloating, mood swings, anxiety, depressed mood, fatigue, appetite changes, water retention and breast tenderness, among others.
Menstrual cramps, or dysmenorrhea, is not considered a PMS symptom, although many women with PMS also experience menstrual cramps.
PMS appears to be caused by a sensitivity to the rising and falling levels of the hormones estrogen and progesterone, which may influence brain chemicals, including serotonin, a substance that has a strong affect on mood. It's not clear why some women develop PMS or PMDD and others do not, but researchers suspect that some women are more sensitive than others to changes in hormone levels.
Calcium may play a role in PMS, although the reason remains unclear. In one study, women who took 600 mg of calcium twice a day experienced fewer PMS symptoms than women who took a placebo.
Dietary changes and exercise may also help relieve the discomfort of PMS symptoms. When symptoms are severe, serotonergic antidepressant medication may be prescribed. It is thought that increased serotonin reduces PMS symptoms.
One of the most important strategies for coping with premenstrual discomfort is to be aware of any pattern your symptoms follow. The more aware you are of your symptoms—when they start and stop and what works best to relieve them, for example—the better you can develop strategies to recognize and cope with them—whatever they may be.
Premenstrual Dysphoric Disorder
Approximately three to eight percent of women experience premenstrual dysphoric disorder (PMDD), a condition that, like PMS, is associated with the menstrual cycle. The symptoms of PMDD are the same as PMS symptoms, although women with PMDD may experience more dysphoric (depressive) symptoms and more severe symptoms. In fact, to be diagnosed with PMDD, symptoms must be severe enough to disrupt a woman's daily function.
The most important criteria for a PMDD diagnosis are mood symptoms. Physical symptoms may also be present but aren't as critical to the diagnosis. The difference between PMDD and mild PMS is like the difference between a mild tension headache and a migraine, experts say.
Women who have a history of depression are at higher risk for PMDD than other women. Treatment for PMDD includes serotonergic antidepressant medications and a particular brand of birth control pills, called Yaz. Yaz contains drospirenone (a progestin) and ethinyl estradiol (a form of estrogen) and has been shown to be clinically effective at treating the emotional and physical symptoms of PMDD, but should only be used to treat PMDD if you choose to use it for birth control because other forms of treatment for PMDD don't carry the same risks as oral contraceptives. Another form of birth control pill containing drospirenone plus a daily dose of folic acid also is FDA-approved to treat PMDD. It is sold under the brand names Beyaz and Safyral.
Another approach in using birth control pills is to use continuous dosing with no hormone-free interval (for example, Lybrel). This reduced PMS and PMDD symptoms for many women, although findings in multiple studies were not consistent.
Birth control pills containing drospirenone may cause some serious side effects in rare cases, including blood clots in the legs and lungs, so be sure and talk to your health care provider about your risks and benefits. Oral contraceptives are not recommended for women who smoke because of increased cardiovascular risks.
Signs and Symptoms
There is no specific laboratory test to determine if you suffer from PMS, and diagnosis can take some time because symptoms are so varied. But there are certain characteristics that health care professionals consider. To qualify as PMS, symptoms must follow this general pattern:
- They tend to increase in severity as your cycle progresses.
- They improve within a few days of your menstrual period starting.
- They are present for at least two to three consecutive menstrual cycles.
More than 150 physical and behavioral symptoms may be associated with PMS. The most common are irritability and anxiety/tension. Other common symptoms include:
- Sudden mood swings
- Joint and muscle aches
- Food cravings
- Fluid retention
- Sleep disturbances
- Breast swelling and tenderness
The timing and severity of these symptoms are key to a PMS diagnosis. An average menstrual cycle spans 21 to 35 days. The follicular phase extends from menses to ovulation, and the luteal phase extends from ovulation to menses. PMS occurs during the luteal phase—approximately the last 14 days of your cycle, usually during the five to seven days before you get your period.
A premenstrual symptom chart or checklist (also called a menstrual cycle diary) is the most common method used to evaluate menstrual cycle symptoms. With this tool, you and your health care professional can track the type and severity of your symptoms, as well as when they occur, to identify a pattern that may indicate PMS.
Follow these simple steps to determine if your symptoms fit the PMS pattern:
- Track your symptoms using the first day of menstrual flow as Day 1. (Note: Don't be surprised if you do not have any symptoms to record before day 18 or so.)
- Have a person close to you (your partner, roommate, friend) chart his or her impression of your symptoms, when they occur and their severity.
- Chart your symptoms for at least three consecutive months to help you and your health care professional identify a pattern that may indicate PMS.
- Record the date when/if any of the following symptoms occur over two to three consecutive months and note their severity (for example: 1 = mild; 2 = moderate; 3 = severe). Different diaries use different rating systems, with point values to record severity ranging from 1 to 6. You can find an example here.
- Abdominal bloating
- Breast tenderness
- Swelling of hands/feet
- Depressed mood
- Mood swings
- Crying spells and tearfulness
- Decreased or increased appetite
- Difficulty concentrating
- Difficulty sleeping
In addition to suggesting that you keep a menstrual cycle diary, your health care professional likely will ask about your personal and family medical history and will give you a physical exam.
Laboratory tests are not routine but may be obtained to rule out other conditions with similar symptoms, such as low blood sugar (hypoglycemia), mania, depression, thyroid disorders, anemia, endometriosis, allergies, fibroids, dysmenorrhea, lupus, endocrine abnormalities, neurological problems such as brain tumors and heart problems.
Menopause and PMS share some of the same symptoms, so depending on your age and health history, your health care professional may want to make sure that you are indeed ovulating and therefore experiencing PMS, not menopausal symptoms.
To do this, you will probably be asked to use an over-the-counter ovulation testing kit. This is a simple test that you can do at home. The results tell you when ovulation is likely.
If you are approaching menopause (the average age is about 51 for U.S. women, but ranges from 42 to 60 years), blood hormone tests may also be used to confirm if you are menopausal. However, a single blood test is not informative because hormone levels change often.
Many premenstrual syndrome (PMS) symptoms improve with treatment. Treatment options range from medication therapy to birth control pills to diet modification, including vitamin and mineral supplementation, herbal medicines and exercise.
Antidepressant drugs called selective serotonin reuptake inhibitors (SSRIs) are typically recommended to women with severe mood-related symptoms such as anxiety, depression or mood swings.
Overall, common treatment options include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs). These medications are used to relieve premenstrual headache and other menstrual-cycle related pain. A variety of NSAIDs are available including over-the-counter ibuprofen products (Motrin) and others or naproxen sodium (Aleve). They usually cost less and have fewer side effects than other treatments. Prescription NSAIDs also are available.
Note: NSAIDS carry some risks, such as an increased risk of serious cardiovascular (CV) events, including heart attack and stroke. As a result, the FDA has issued a "black box" warning highlighting this risk, as well as the risk of potentially life-threatening stomach bleeding. If you've recently had heart surgery, you shouldn't take NSAIDS. All other women considering NSAIDS to ease PMS or any other condition should discuss these potential risks with their health care professional.
- Contraceptive hormones. Some women with PMS or PMDD experience relief of their symptoms after they start taking birth control pills. (Other women, however, feel worse on birth control pills.) You can take the pill continuously to avoid having a menstrual period, thus preventing the hormonal changes that can lead to PMS/PMDD. The combination birth control pills Yaz (containing 3 mg of drospirenone, a progestin, and 20 mcg ethinyl estradiol, a form of estrogen) and Beyaz and Safyral (containing 3 mg of drospirenone, 20 mcg ethinyl estradiol and a daily dose of folic acid) are FDA approved for the treatment of PMDD. However, these contraceptives should only be used to treat PMDD if you choose to use them for birth control because other forms of treatment don't carry the same risks as oral contraceptives. Birth control pills containing drospirenone may cause some serious side effects in rare cases, including blood clots in the legs and lungs, so be sure and talk to your health care provider about your risks and benefits. Oral contraceptives are not recommended for women who smoke because of increased cardiovascular risks.
- GnRH agonists (gonadotropin-releasing hormone). These medications include leuprolide (Lupron), among others. They belong to a class of hormones used to temporarily shrink fibroids and relieve endometriosis. They also may be recommended to treat PMS because they "turn off" the menstrual cycle by blocking estrogen production. Side effects may include menopausal symptoms like hot flashes, vaginal dryness and bone loss. That's why low-dose hormone therapy, a combination of estrogen and progestin hormones, is typically prescribed along with GnRH agonists. Some women may experience a return of their PMS symptoms with the additional hormone therapy. GnRH agonists are usually considered only as a short-term treatment option (given for no longer than six months) because of the increased health risks such as osteoporosis associated with low estrogen levels.
- Antidepressant medications. Antidepressant medications called selective serotonin reuptake inhibitors (SSRIs) are the preferred antidepressants for treating severe PMS and PMDD symptoms, including depression. SSRIs include sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro),and fluoxetine (Prozac, Sarafem). Other types of antidepressants may also be prescribed to treat PMS and PMDD, including venlafaxine (Effexor) and clomipramine (Anafranil). The U.S. Food and Drug Administration approved Zoloft, Paxil and Serafem for treatment of PMDD, but warns that women taking antidepressants should monitor their symptoms closely, with the help of their health care professional, for signs that their condition is getting worse or that they are becoming suicidal, especially when they first start therapy or when their dose is increased or decreased.
- Anti-anxiety medications such as alprazolam (Xanax) are sometimes prescribed when anxiety is the main symptom associated with PMS or PMDD. These drugs can be taken during the 14 days between ovulation and menstruation (the luteal phase) when symptoms occur (rather than daily). Dependence and serious withdrawal reactions can occur with Xanax, so its dosage and discontinuation should be carefully monitored.
- Calcium supplements (1,000 to 1,200 mg daily). Additional calcium in any form may help relieve some PMS symptoms. Low-fat dairy products (milk, yogurt and cheese) are a primary source of calcium, but you can also gain calcium from the following:
- Tofu and other soy products
- Rice milk
- Dark greens, like turnip greens
- Green or red cabbage (raw)
- Salmon and sardines
- Exercise. Regular exercise can also help relieve and possibly prevent PMS symptoms. You will get the greatest benefits if you exercise for at least 30 minutes, at least five days a week. But even taking a 20- to 30-minute walk three times a week can improve your mood.
- Chasteberry. The extract of the fruit of the chasteberry tree is shown to be a safe and effective treatment for PMS. This therapy is used primarily outside the United States. It may be obtained over the counter, but the dose and purity may be uncertain.
In addition, there's some evidence that some nutritional supplements such as vitamin E, magnesium and vitamin B-6 may help ease symptoms of PMS. Discuss these and other strategies with your health care professional before taking any dietary supplement.
There is no single treatment that works well for every woman who experiences PMS. Typically, it's wise to try the most conservative treatment options first, which include lifestyle changes such as modifying your diet and exercising more. Discuss your symptoms with your health care professional if strategies you've tried don't work, so he or she can recommend other treatment options.
Can premenstrual syndrome (PMS) be prevented? Many women report benefits from a variety of lifestyle change including dietary changes, exercise and stress management. Dietary changes may include:
- Increasing calcium intake.
- Decreasing consumption of refined sugar.
- Decreasing or avoiding caffeine and nicotine, which act as stimulants and can increase tension and anxiety as well as interfere with sleep patterns. For some women, the severity of PMS symptoms increases as caffeine consumption increases.
- Decreasing alcohol consumption, which can act as a depressant. If you experience PMS, you may have an increased sensitivity to alcohol premenstrually.
- Decreasing salt intake and increasing water consumption to avoid water retention and bloating.
- Avoiding sodas, which may contain high levels of caffeine, salt, sugar and/or artificial sweeteners.
- Drinking natural diuretics, such as herbal teas.
Ironically, some PMS symptoms, such as mood swings, irritability, bloating, hunger, carbohydrate cravings and fatigue, may lead you to consume foods that aggravate the condition.
Premenstrually, you may crave either refined sugar (usually combined with chocolate) or fat (combined with salt). Generally, foods high in refined sugars and fat temporarily raise energy levels. But within several hours or less, as your body metabolizes these foods, you may "crash," meaning you'll feel worse than before you ate them. Foods high in sugar content can also leave you feeling jittery.
To alleviate mood swings and fatigue, try adding more high-quality, complex carbohydrates to your diet such as:
- Whole grain breads, pastas and cereals
- Potatoes (white or sweet)
- Rice (preferably brown or wild)
- Fresh vegetables, particularly corn and legumes, such as peas, chickpeas and lentils
- Fresh fruits
These complex carbohydrates help keep blood sugar levels even while providing your body with a long-lasting source of energy.
It's not uncommon for your appetite to increase just before your period begins. To combat the munchies and extra weight gain, try eating smaller, low-fat healthful meals using the food choices listed above.
Make sure you include adequate calcium in your diet; calcium may help prevent irritability, anxiety and other PMS symptoms. Good sources of calcium include:
- Low-fat milk and milk products like yogurt, ice cream and cheese
- Dark greens (like turnip greens)
- Green or red cabbage (raw)
- Cooked collards
- Salmon and sardines
- Soy products, such as tofu and soy milk
- Calcium-fortified orange and grapefruit juices
Another good way to prevent PMS symptoms is through regular exercise in the form of aerobic activities such as brisk walking, jogging, biking or swimming. You will get the greatest benefits from exercise if you do it for at least 30 minutes, five or more days a week. But even taking a 20- to 30-minute walk three times a week can:
- Increase endorphin and serotonin production, brain chemicals that may help decrease pain and discomfort and improve mood, respectively
- Decrease stress and anxiety
- Increase REM sleep
Other lifestyle changes that will help you control PMS include:
- Sleeping consistent hours
- Establishing a bedtime routine to help cue body and mind for sleeping
- Keeping a PMS symptom checklist, also called a menstrual cycle diary, to identify when symptoms and which symptoms occur so you can be prepared for them
Facts to Know
- An estimated 75 percent of women of childbearing age experience premenstrual symptoms ranging from very mild to very severe.
- Approximately 3 to 8 percent of women experience premenstrual symptoms severe enough to disrupt their daily function and meet criteria for premenstrual dysphoric disorder (PMDD)––a severe form of PMS.
- Taking additional calcium in any form may help improve or even prevent PMS symptoms. Ideally, increase daily amounts of low-fat dairy products and other calcium-containing foods to reach the 1,000 to 1,200 mg of calcium daily health care professionals recommend. If you have trouble reaching this goal from your diet alone, consider using over-the counter calcium supplements.
- Symptoms of PMS may get worse with age.
- If you experience PMS, you may experience an increased sensitivity to alcohol premenstrually.
- Some evidence suggests that women who are vulnerable to depressive illness, panic disorder or other psychiatric or chronic medical disorders may be particularly susceptible to PMS.
- Strategies for PMS symptom relief include medication, dietary changes, exercise and stress management.
- Dietary changes to relieve PMS symptoms include increasing daily amounts of dietary or supplemental calcium, drinking more water and adding more complex carbohydrates (fruits, vegetables and grains) to your meals. Decreasing foods in your diet that contain refined sugar, limiting or avoiding caffeine and nicotine, decreasing alcohol consumption, decreasing salt intake and avoiding sodas may also help.
- Some of the PMS symptoms you may experience, such as mood swings, irritability, bloating, hunger, carbohydrate cravings and fatigue, may lead you to consume high-fat foods and/or foods high in refined sugar, which actually aggravate these symptoms. Try to avoid them.
- Even women who have had hysterectomies can have symptoms of PMS if at least one functional ovary is left intact following the hysterectomy.
Questions to Ask
Review the following Questions to Ask about premenstrual syndrome (PMS) so you're prepared to discuss this important health issue with your health care professional.
- What causes PMS?
- Are my symptoms characteristic of PMS?
- What other illnesses could be causing these symptoms?
- Which tests, if any, should I have to rule out other illnesses?
- How is PMS treated?
- What treatment may work best for me?
- I've heard that not getting enough calcium can cause PMS. How can I add calcium to my diet?
- What's premenstrual dysphoric disorder (PMDD)?
- How do you treat PMDD?
- What exactly is premenstrual syndrome (PMS)?
There are more than 150 documented symptoms of PMS, but the number of symptoms seen in the vast majority of patients is much more limited. Some of the most common PMS symptoms include bloating, fatigue, sudden mood swings, irritability, anxiety, depression, weight gain, headaches, joint and muscle aches, food cravings and fluid retention. To be considered PMS symptoms, they must occur exclusively in the last 14 days of your menstrual cycle (usually about five to seven days before your period begins). True PMS symptoms tend to increase in severity as the cycle progresses and are relieved within a few days after the start of the menstrual flow. Cramps are not considered a symptom of PMS, but they are common in women with PMS.
- What causes PMS?
PMS appears to be caused by a sensitivity to the normal rising and falling levels of the hormones estrogen and progesterone, which may influence brain chemicals, including serotonin, a substance that has a strong affect on mood. It's not clear why some women develop PMS or PMDD and others do not, but researchers suspect that some women are more sensitive than others to changes in hormone levels.
- How is PMS diagnosed?
There is no single laboratory test for PMS, but one of the most common ways to diagnosis PMS is by keeping a daily checklist, chart or "menstrual cycle diary" that tracks when your premenstrual symptoms occur for a few consecutive months. Your health care professional should rule out other disorders or diseases that mimic or are identical to the symptoms caused by PMS before diagnosing you with the condition. Other conditions include but are not limited to thyroid disorders, depression, endocrine abnormalities, menopause, heart problems, allergies and low blood sugar. Laboratory tests, personal and family medical histories and a physical exam are part of the diagnostic process.
- Is PMS treatable?
Yes! Many women experience some relief from PMS symptoms if they make diet and lifestyle changes, particularly increasing consumption of calcium, complex carbohydrates (fruits, vegetables, grains and beans) and water, and decreasing caffeine, alcohol, salt and refined sugar intake. Regular exercise and sleep may also help relieve symptoms. Certain medications can provide relief.
- When does PMS typically appear?
PMS symptoms can appear any time between puberty and menopause, though the most common age for PMS to start to become a problem is during your late 20s to mid-30s.
- Will my PMS symptoms get better as I age?
Probably not until you reach menopause. In some women, symptoms of PMS worsen with age and stress. Even women who have had hysterectomies can have PMS if at least one functional ovary is left intact following the hysterectomy. Once you reach menopause, your PMS symptoms will end with the end of menstruation.
- If I regularly take the recommended steps to relieve my PMS symptoms, how long before I may see results?
It may take two to three months to experience relief from PMS symptoms. If you don't see any improvements by then, check with your health care professional for a new action plan.
- Are menstrual cramps a symptom of PMS?
Cramps are not considered a symptom of PMS, although they may occur in women who have PMS. Called dysmenorrhea, cramps typically begin just before (24 to 48 hours) the onset of menstruation and disappear by the end of flow.
- Lifestyle changes for PMS sufferers
Some of the lifestyles changes recommended to treat premenstrual syndrome (PMS) may also be useful in preventing symptoms. Perform aerobic activity such as brisk walking, jogging, biking or swimming for a minimum of two hours and 30 minutes of moderate-intensity exercise, or one hour and 15 minutes of vigorous-intensity exercise, or a combination of moderate-intensity and vigorous-intensity activity. Couple this with muscle strengthening exercise at least two days a week. Some women benefit from eating a balanced diet (with increased whole grains, vegetables, fruit, and decreased or no salt, sugar, alcohol and caffeine). It's also important to manage stress and get adequate rest; the body may have different sleep requirements at different times during the menstrual cycle.
- Eating right to fight PMS
To reduce your PMS symptoms, spread your normal caloric intake over three small meals and three small snacks per day, and avoid going for long periods of time without eating. Avoid or wean yourself off caffeine. Caffeine can worsen breast tenderness, and many women report that irritability and headaches decrease when they cut their caffeine intake. Reducing salt intake can relieve fluid retention. Snack suggestions: Plain yogurt; unsalted nuts, seeds and popcorn; whole-wheat bread with peanut butter; pumpkin or banana bread; graham crackers; unsalted whole-grain crackers; bran or oatmeal muffins; raw vegetables; and raw or dried fruits.
- Calcium can help alleviate PMS symptoms
If you suffer from the physical and psychological symptoms typical in premenstrual syndrome (PMS), calcium may help solve your problem. In one study, women who took 600 mg of calcium twice a day experienced fewer PMS symptoms than women who took a placebo. Calcium can be obtained through the diet or in the form of nutritional supplements or antacids. Remember to talk to your health care professional before taking calcium supplements.
- Medications for PMS
If a healthy diet, regular exercise and calcium supplements fail to improve mood swings or other emotional symptoms of PMS, you may want to talk to your health care professional about a serotonin reuptake inhibitor (SSRI) antidepressant medication. Other prescription medications sometimes prescribed for severe PMS include gonadotropin-releasing hormone (GnRH) agonist treatments that suppress estrogen production and oral contraceptives. A type of "combination" oral contraceptive containing drospirenone, a progestin, and ethinyl estradiol, a form of estrogen, is FDA approved for both the prevention of pregnancy and for the emotional and physical symptoms associated with PMDD. However, these contraceptives (Yaz, Beyaz and Safyral) should only be used to treat PMDD if you choose to use them for birth control because other forms of treatment don't carry the same risks as oral contraceptives. Other oral contraceptives, such as Lybrel, can be taken continuously with no inactive interval to relieve PMS or PMDD. Oral contraceptives are not recommended for women who smoke because of increased cardiovascular risks. Be sure to ask your health care professional about short- and long-term side effects of any medications recommended to relieve symptoms of PMS and PMDD.
- Is it PMS or PMDD?
If your premenstrual symptoms are bothersome, you may have PMS. If the symptoms are primarily emotional or behavioral and are severe enough to interfere significantly with work or relationships, you may have a more serious form of PMS, premenstrual dysphoric disorder (PMDD), which affects about 3 to 8 percent of women of childbearing age. PMDD symptoms can include a markedly depressed mood, severe anxiety or tension and wild mood shifts, as well as significant physical symptoms. However, severe mood-related symptoms are key to PMDD. If you suspect you have PMDD or PMS, consult your health care professional.
Organizations and Support
For information and support on coping with Premenstrual Syndrome, please see the recommended organizations, books and Spanish-language resources listed below.
American College of Obstetricians and Gynecologists (ACOG)
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
MGH Center for Women's Mental Health
Address: Perinatal and Reproductive Psychiatry Program Simches Research Builiding
185 Cambridge St Suite 2200
Boston, MA 02114
National Family Planning and Reproductive Health Association (NFPRHA)
Address: 1627 K Street, NW, 12th Floor
Washington, DC 20006
A Gynecologist's Second Opinion
by William H. Parker and Rachel L. Parker
Bitchin' in the Kitchen: The PMS Survival Cookbook
by Jennifer Evans
Curing PMS Naturally with Chinese Medicine
by Bob Flaws
Natural Medicine for PMS
by Deborah R. Mitchell
Once a Month: Understanding and Treating PMS
by Katharina Dalton
PMS & Perimenopause Sourcebook: A Guide to the Emotional, Mental, and Physical Patterns of a Woman's Life
by Lori Futterman and John E. Jones
PMS Relief: Natural Approaches to Treating Symptoms
by J. Marshall
PMS: Women Tell Women How to Control Premenstrual Syndrome
by Stephanie Degraff Bender and Kathleen Kelleher
Self-Help for Premenstrual Syndrome
by Marla Ahlgrimm R.Ph.
SOS for PMS: Whole Food Solutions for Premenstrual Syndrome
by Lissa Deangelis and Molly Siple
Medline Plus: Premenstrual Syndrome
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
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