Premenstrual Syndrome - Dr. Senai Aksoy

Premenstrual Syndrome

Premenstrual Syndrome (LES) is a relatively simple condition to diagnose and treat. Premenstrual Syndrome (PLS) usually begins to manifest between the ages of 25 and 35 and recurs during every premenstrual period. Women whose symptoms are quite severe also experience what is referred to as Premenstrual Emotional Disorder (PAD). In both LES and PAD, the symptoms decrease markedly with the onset of menstruation.

While 85% of menstruating women state that they experience premenstrual syndrome more than once in their lives, 2% to 10% complain of symptoms that reduce their capacity and affect their daily lives. Although it is claimed that LES has more than 200 symptoms, hypersensitivity, tension, and emotional disturbance are the most common and most influential symptoms.

Symptoms of Premenstrual Syndrome

It is possible to divide the symptoms of LES into three. Behavioural, psychological, and physical.

  • Behavioural Symptoms: Tiredness, insomnia, dizziness, change in sexual interest, overeating or craving for certain foods.
  • Psychological Symptoms: Temper tantrums, depressed mood, crying, anxiety, tension, mood lability, difficulty concentrating, forgetfulness, restlessness, feeling lonely, lack of self-confidence.
  • Physical Symptoms: Headache, breast tenderness and swelling, back pain, abdominal pain and swelling, weight gain, water retention, nausea, and muscle and joint pain.

Causes of LES

Although the causes are unknown, they may be complex and based on many factors. The effects of hormones on this issue are not very clear. However, when ovulation was suppressed, symptoms improved.

Changes in hormone levels may affect central neurotransmitters such as serotonin. However, fluctuations in sex hormone levels are normal in women with LES. Evidence has shown that this disorder is associated with increased sensitivity to progesterone in women with underlying serotonin problems. But this mechanism cannot explain all cases because some patients do not respond to treatment with SSRI group antidepressant drugs. Prostaglandin problems related to the inability to convert linoleic acid to prostaglandin precursors may be associated with LES. Genetic factors may also play a role in LES development because the incidence of LES in both siblings is twice as common in identical twins as in fraternal twins.

LES Diagnosis

The American Society of Obstetrics and Gynecology (ACOG) recommends using the following diagnostic criteria. Patients who complain of severe emotional disorder symptoms and significant dysfunctions can be evaluated with PAD criteria.

Diagnostic Criteria For Premenstrual Emotional Disorder (PAD)

Criterion 1: At least 5 of the following symptoms (at least one of the symptoms is one of the criteria 1 – 2 – 3 – 4) in the last week of the luteal phase (period after ovulation) in the previous year’s menstruation, these symptoms are follicular decreased with the onset of the first phase (the period before ovulation) and disappeared within one week following the onset of menstruation.

  • Depressed mood, feelings of hopelessness, and self-deprecating thoughts.
  • Marked anxiety, tension, and a feeling of being “on edge”.
  • Marked mood swings (suddenly feeling sad, crying, or overreacting to rejection).
  • Marked and persistent anger and increased conflicts in relationships.
  • Loss of interest in routine activities (school, work, friends, hobbies).
  • Personal (subjective) opinion of difficulty concentrating.
  • Drowsiness, fatigue, and marked loss of energy.
  • Marked appetite changes, overeating, or craving certain foods.
  • Excessive sleeping or insomnia.
  • Personal (subjective) view of being crushed or losing control.

Other physical symptoms (for example, breast swelling or tenderness, headaches, joint or muscle pain, swelling sensation or weight gain).

Note: In menstruating women, While the “luteal phase” refers to the time between ovulation and the onset of menstruation, the “follicular phase” begins with the menses. In nonmenstrual women (women who have had a hysterectomy), it may be necessary to monitor hormone levels to detect the luteal and follicular phases.

Criterion 2: The disorder interferes with work/school life or other daily social relationships or activities (e.g., avoiding social activities, decreased productivity or work/school performance).

Criterion 3: Discomfort and distress; major depression is not aggravated by another disorder such as panic disorder, dysthymic disorders, or personality disorder.

Daily assessments must confirm criteria 1, 2 and 3 for at least two consecutive months.

LES and PAD can only be diagnosed after various physical and psychological disorders have been ruled out. LES should also be distinguished from simple premenstrual symptoms (e.g., swelling and breast tenderness) that do not affect daily life and are experienced during the natural ovulation process. The presence of three criteria is very important for confirming the diagnosis of LES. These symptoms are experienced continuously and repeatedly, only in the luteal phase of menstruation, limiting functions, and affecting life.

When LES or PAD is suspected, patients are asked to monitor daily signs for several months. With the help of this daily follow-up, the variability of periodic symptoms can be followed, and it can be determined that some women have non-luteal symptoms.

LES Treatment

LES treatment aims to improve or eliminate symptoms, reduce the effects of the symptoms seen on activities and relationships, and keep the side effects of treatment at a minimum. Although many treatment options exist, few of them have been proven effective in controlled trials.

Initially, all patients with LES should start with a drug-free treatment. Drug therapy can only be considered in patients with persistent LES symptoms and patients who meet the criteria for LES.

The application of surgical treatment (removal of the uterus and ovaries in general) is a controversial issue. Because it is an irreversible application and brings some risks with it, surgical treatment can only be applied in patients who do not respond to other treatments and who have other gynaecological findings to support the decision for such surgery.

Non-drug (Non-pharmacological) Treatment

The content of drug-free treatment of LES includes patient education, supportive therapy, and recommending behaviour changes. It was observed that women who were educated about LES’s biological basis and symptoms were less affected by the symptoms and experienced less anxiety.

Using the daily symptoms chart allows patients to plan some behavioural or life changes to control symptoms.

Sleep problems manifested as insomnia or excessive sleepiness are frequently seen in women with LES. It is recommended to provide regular bedtime and wake-up times, especially during the luteal phase.

Restricting the use of salt helps to reduce the symptoms of fluid retention, swelling and chest swelling.

  • Caffeine is associated with premenstrual tension/sensitivity and insomnia, so it is important to limit caffeine intake during this period.
  • Performing non-heavy aerobic/yoga exercises also reduce pain complaints.
  • The effectiveness of the use of vitamins (A, E, and B6), magnesium, multivitamin/mineral supplements, and evening primrose oil in terms of dietary support in patients with LES was evaluated. Vitamin E is among the potential treatment tools of LES due to its minimal harm, antioxidant effect and positive experimental results. Experiments with vitamins A and B did not sufficiently support the same findings.
  • It has been observed in experiments that intake of calcium carbonate at doses of 1200mg/day helped improve swelling symptoms. While ACOG recommends calcium intake, it does not recommend magnesium supplementation.

The effects of evening primrose oil, a prostaglandin precursor, have not yet been supported by experiments. However, some women have reported that it is good for breast tenderness.


Before deciding on drug treatment, other methods should have been tried for at least three months. If symptoms do not improve satisfactorily, drug therapy is considered. The treatment is tailored to the individual, taking into account the patient’s needs and other medical conditions.

  • Over-the-counter Medications: Most over-the-counter medications include moderate-strength diuretics (diuretics), prostaglandin inhibitors, and antihistamine treatments. However, the doctor’s advice should be taken when using these drugs in combination. Because in such cases, some active ingredients may be taken too little, and some may overdose. If the patient will use non-prescription drugs, choosing a product containing a single active ingredient (for example, vitamins or painkillers) should be preferred.
  • Psychotropic Drugs: Due to the effects of serotonin on LES and PAD, the use of SSRI group antidepressant drugs can be considered in patients with severe LES or PAD. However, the doctor will decide by considering the side effects of these drugs, such as insomnia, fatigue, dizziness, headache, and sexual dysfunction. The use of anxiolytic drugs should not be preferred due to the risk of addiction. Although some positive effects of other psychotropic drugs (e.g., bupropion, tricyclic antidepressants, and lithium) are observed, they should not be preferred because of their side effects that can outweigh their benefits.
  • Diuretics: Spironolactone (Aldactone) is an aldosterone antagonist similar to steroid hormones and is the only diuretic type effective in relieving LES effects such as breast tenderness and fluid retention.
  • Prostaglandin Inhibitors: Nonsteroidal anti-inflammatory drugs effectively treat dysmenorrhea (e.g., naproxen sodium). In particular, naproxen sodium relieves physical distress and relieves headaches; however, it should be used with caution by the doctor if the patient has gastrointestinal problems.
  • Medicines Used to Change the Menstrual Cycle: The effects of using gonadotropin-releasing hormones, estrogen and progesterone on LES and PAD have been investigated, but their benefits are limited.
  • Oral Contraceptive Use: Although it is frequently used in LES treatment, there is not enough evidence that its effects are permanent. The use of monophasic drugs is the right choice, as the benefits may be due to the estrogen component it contains. Contraceptives (birth control pills) can increase some effects while reducing swelling, headaches, abdominal pain and breast tenderness. Feedback from patients showed that patients using these drugs had fewer physical complaints. However, these drugs do not have a positive effect on mood.
  • Synthetic Progesterone-like Drugs (e.g., Medroxyprogesterone Acetate): We see that the use of progesterone is more common in the past. Paradoxically, some evidence indicates that progesterone causes some of LES’s physical and psychological effects. The use of progesterone is generally used for abdominal swelling and pain, nausea, chest pain and menstrual irregularities. However, a symptom-reducing effect of progesterone could not be proven in 14 controlled trials.

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