The worst of these health professionals regard PMS merely as a convenient excuse that women use. The truth of the matter is that severe PMS can threaten the personal, social and professional lives of sufferers and lead to domestic violence and suicide attempts.
It is the lack of a understanding of a condition that is at times difficult to diagnose, that makes some health professionals reluctant to recognise PMS. There may also be cultural and gender reasons why practitioners fail to recognise or accept the existence of PMS. This means that often inappropriate or no help is given to sufferers when the best thing to do in this situation would be to refer the patient to a practitioner with a greater understanding of the condition.
Q. What are the latest theories as to what causes PMS?
A. Although the underlying cause of PMS remains unknown, cyclical ovarian activity i.e. ovulation, appears to be an important factor. In the central nervous system, allopregnenalone (a chemical derived from natural progesterone), acts like a sedative, decreasing anxiety and irritability, by enhancing the function of GABA, the brain’s major inhibitory transmitter.
Also, oestrogen acts to improve mood by having a positive effect on serotonin levels, the brain's major stimulatory transmitter. PMS symptoms are associated with sharp decreases in circulating levels of oestrogen and progesterone. It is this change in hormone levels which takes place premenstrually, the fall in oestrogen and progesterone levels, which appears to trigger PMS. Supportive evidence for this mechanism comes from the fact that there appears to be an excess of depression post-natally and peri-menopausally when there is also a major change in these hormone levels.
Q. Why does it seem to be becoming more common?
A. One might speculate that the incidence of PMS is increasing because we live in increasingly stressful society where the pressures on the individual are becoming ever greater. The more likely explanation is that PMS is not actually becoming more common; it is that it is becoming increasingly recognised by patients and health professionals due to an improvement in awareness through greater coverage in the press, licensing of certain PMS preparations such as Prozac (an antidepressant) and Cyclogest (natural progesterone) and through work of organisations such as the National Society for Premenstrual Syndrome.
Q. How do you confirm the diagnosis?
A. The diagnosis of PMS is not always straightforward. It is important that a prospective symptom diary is given to the patient at the initial assessment. The patient is asked to prospectively document symptomatology over the following one to two cycles on a daily basis. At the next appointment the distribution and severity of symptoms through the menstrual cycle can then be assessed. Symptoms are graded according to their severity. The diaries are studied visually; for research purposes the data can be entered into a computer programme.
The one employed in our unit is called Trigg’s trend analysis, a programme originally devised for analysis of repetitive trends within industry. The programme gives both a qualitative description as to whether the trends are true PMS and a quantitative estimate of symptom severity. The two symptom patterns are discussed below:
Primary PMS
PMS symptoms leading up to menstruation but completely relieved when bleeding starts.
Secondary PMS
Only partial relief of PMS symptoms when bleeding starts with a background psychiatric problem.
Q. In your experience is the "Pill" an effective remedy?
A. Although prescribed by many practitioners because it is able to suppress ovulation and provides contraceptive cover, this treatment is largely ineffective when compared to placebo (dummy treatment). This is thought to be because a synthetic progestogen is given on a daily basis with the oestrogen in the pill.
This progestogen may cause PMS-type symptoms of its own accord. Also, it is possible for the PMS symptoms to resurge during the pill – free week, so if the pill is to be used, it should be used on a continuous basis. Some pills can actually make PMS symptoms worse.
Q. Is PMS linked to other conditions and does it run in families?
A. Premenstrual depression appears to be linked to two other times of increased depression related to hormonal changes. These are postnatal depression and climacteric depression These are the "triad of mood disorders." They often occur in the same vulnerable woman. For example, it is common to see a 45 year old woman with severe perimenopausal depression. She will say that she last felt well when she was pregnant 10 years ago. She then developed postnatal depression which lasted 6 - 9 months.
When the periods returned, the depression became cyclical. The PMS became worse with age and her 7 days of symptoms became 14 days of symptoms. Soon the cyclical depression became continuous and she was given antidepressants because she was still having periods and the perception was that she could not be have a hormonal cause. The depression is due to a change of hormone levels, either oestradiol or progesterone in susceptible women. Although there does appear to be a familial element of inheritance for PMS, a definite genetic link has not yet been established.
Q. Why is it a particular problem in women between the ages of 30 and 40?
A. The answer to this question is linked to that of the previous one. PMS can occur at any time in a woman's life from when the periods start to when they end at the menopause. However, because there is a progressive worsening of PMS postnatally the preponderance of severe PMS occurs in the fourth decade of life. Also, the menstrual cycle gets progressively shorter as women approach the menopause which leads to smaller gaps between periods and therefore proportionately a greater time is spent each cycle in the premenstrual phase.
Q. Does it improve after pregnancy?
A. Women are typically well in the latter half of pregnancy when oestrogen and progesterone levels are high and constant. After birth of the baby, postnatal depression can then be followed by a deterioration in premenstrual symptoms when the periods restart, because of the rapid changes in hormone levels.
Q. What does vitamin B6 do and how is it thought to work?
A. Vitamin B6, pyridoxine, is a factor in the pathway for synthesis of dopamine, a central nervous system stimulant. A recent summary of the data, published by Professor O'Brien's group in the British Medical Journal, has shown benefit over placebo for doses up to 100mg.
However, there are data of risks to the nervous system with high doses as evidenced by neurological side effects such as tingling in the fingers and care should be taken when prescribing to give the minimum dose required (usually 50mg daily).
Q. Are there any exciting developments in the pipeline?
A. Work is currently focussing on a number of areas.
In the basic science area, scientists are still trying to determine the specific trigger in the brain which makes some women more susceptible to PMS than others.
Improved ways of logging PMS symptoms are being developed to enable women to determine whether they are truly suffering from PMS and allowing them to take control of their symptoms. These electronic palm held diaries allow the logged information to be transferred directly to a computer database where the information can be analysed and the results used to either diagnose the PMS or to monitor progress whilst on treatment.
Studies are also underway to allow the licensing of oestrogen patches for the treatment of PMS although some practitioners, including our centre, are using these already in closely monitored patients. Some women are now using these patches with natural progesterone and the Mirena intrauterine systems.
It is hoped that Prozac will soon be licensed as a premenstrual phase only treatment rather than for continuous usage.
Finally, a new light emitting mask has been developed which seems to be showing some good results in reducing severity of premenstrual symptoms
Volunteers with severe PMS are always being sought to take part in these studies and anyone who is interested should write to the address below.
Volunteers for studies can write to the following address.
Dr Nicholas Panay
Research Fellow
The Psychoendocrine Clinic
Chelsea & Westminster Hospital
369 Fulham Road
London SW10 9NH
About the Author
Nick Panay BSc MRCOG MFFP is a Gynaecologist and Subspecialist in Reproductive Medicine. He is also Secretary of The National Association for Premenstrual Syndrome (NAPS). His main interests include PMS, gynaecological endocrinology, infertility, menopause and minimal access surgery.
His interest in PMS arose from work as a research fellow in the psychoendocrine clinic at The Chelsea and Westminster Hospital. He has set up numerous studies into the treatment of severe PMS many of which are currently ongoing. Through his work at clinic and also through NAPS, he hopes to increase understanding and awareness, amongst both the health profession and general public, of this poorly understood and treated condition.
