Women who have premenstrual syndrome (PMS) experience a variety of physical and emotional symptoms that occur each month from 2 to 14 days before their menstrual cycle. The symptoms usually disappear once the cycle begins. PMS may begin at any age and ends after menopause. Approximately 75 percent of women experience PMS to some degree, with 20 to 50 percent finding that symptoms disrupt their daily activities, and 3 to 5 percent becoming incapacitated.

PMS is often accompanied by the following signs and symptoms.

• Abnormal bloating and weight gain
• Breast swelling, tenderness
• Mood swings
• Depression and anxiety
• Skin disorders
• Changes in appetite, food cravings
• Changes in interest in sex
• Headaches, backaches, cramps
• Inability to concentrate, loss of interest in usual activities, confusion

While the exact cause of PMS is unknown, the most popular theories include hormonal changes (estrogen excess or progesterone deficiency), hypoglycemia (low blood sugar), vitamin B₆ deficiency, abnormal metabolism of prostaglandin (hormone-like substances), excessive fluid retention, and endorphin (a substance in the brain that provides pain relief) withdrawal.

Women with a history of the following conditions are at a higher-than-average risk for having PMS.

• Dysmenorrhea (painful menstruation)
• Depressive, mood, anxiety, or bipolar disorders (family history, too)
• Postpartum depression or psychotic episodes
• High stress

If you are experiencing symptoms associated with PMS, you should see your health care provider. He or she can help make a diagnosis and guide you in determining which treatment or combination of therapies will work best for you.

You'll need to chart your symptoms and their severity daily for one to two months. Your provider will take a detailed history of symptoms, do a physical and gynecologic examination to rule out other medical conditions, and conduct a psychosocial evaluation. Certain laboratory and imaging studies may be used, such as a Pap smear, complete blood count, chemistry screen, fasting blood glucose test, and thyroid studies.

Reducing stress, increasing exercise, and making dietary changes around the time of menstruation can prevent PMS symptoms from worsening.

Preventive measures and, in some cases, drug therapy, are most often used for treating PMS.

Your provider may prescribe the following medications.

• Diuretics, for bloating and water retention
• Analgesics, for headaches and cramps
• Beta-blockers and calcium-channel blockers, to prevent the onset of migraine headaches
• Prostaglandin inhibitors for painful menstruation
• Spironolactone for skin conditions
• Medications that block ovulation
• Bromocriptine for breast soreness
• Anti-anxiety medications
• Antidepressants
• Progesterone, for relief of symptoms

Women who are planning to become pregnant should avoid medications such as prostaglandin inhibitors, diuretics, spironolactone, and danazol.

Women whose symptoms are severe and do not respond to treatment may need to undergo a hysterectomy, including removal of the ovaries, followed by estrogen replacement therapy.

A comprehensive treatment plan for PMS may include a range of complementary and alternative therapies.

Decreasing or avoiding caffeine (including chocolate), saturated fats, sugar, salt, dairy, meat, poultry, and alcohol can help reduce the intensity and duration of symptoms. Nutritional deficiencies may be addressed with these supplements.

• Vitamin B₆ (100 to 200 mg a day) with B-complex (50 to 100 mg a day)
• Magnesium (400 mg a day)
• Vitamin E (400 to 600 IU a day), especially with breast tenderness
• Essential fatty acids: omega-3 and omega-6 (3,000 to 4,000 mg a day for three months, then decrease dose by 1,000 mg every two months)
• Chromium (250 mcg one to two times per day) to reduce sugar cravings

Herbal remedies may be helpful in alleviating symptoms. The following herbs should be used in combination, either as tincture (60 drops three times a day or tea (1 cup three to four times a day):

• Chaste tree (Vitex agnus castus) (175 mg a day)
• Black cohosh (Cimicifuga racemosa) (100 to 600 mg a day)
• Valerian (Valeriana officinalis) (150 to 300 mg one to four times a day, or before bed for insomnia) or kava kava (Piper methysticum) (200 mg one to four times a day, or before bed). Reduce dose of either herb if drowsiness occurs.
• Milk thistle (Silybum marianum) (200 to 600 mg a day)
• Dandelion (Taraxacum officinale) root and/or leaves as a tea or tincture can be used as a diuretic. If you have liver problems, consult with an experienced practitioner before using dandelion.
• St. John's wort (Hypericum perforatum) (300 mg two to three times per day) for depression associated with PMS. Must be taken consistently throughout the month; direct sun exposure may cause rashes in some people.

Herbs are generally available as dried extracts (pills, capsules, or tablets), teas, or tinctures (alcohol extraction, unless otherwise noted). Dose for teas is 1 heaping tsp./cup water steeped for 10 minutes (roots need 20 minutes). For PMS, teas or tinctures are preferred.

There have been few studies examining the effectiveness of specific homeopathic remedies. Professional homeopaths, however, may recommend one or more of the following treatments for PMS based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

• Chamomilla — for intense menstrual pain; this remedy is most appropriate for individuals who are extremely irritable, angry, and have frequent mood swings
• Cimicifuga — for feelings of hysteria, frustration, and being overwhelmed; this remedy is most appropriate for individuals who have labor-type pains that migrate from one side of the body to the other and may involve the back or even sciatic nerve (the largest nerve in the body; extends from the lower back down through the legs and knees)
• Colocynthis — for cramps that are relieved by bending forward, abdominal massage, and warmth (such as a heating pad); this remedy is most appropriate for individuals who are extremely irritable and restless
• Ignatia — for emotional symptoms such as grief, panic, and mood swings; this remedy is most appropriate for individuals who feel particularly vulnerable
• Lachesis — for individuals who tend to be annoyed, caustic, talkative, and envious and whose pain and bloating is worse on the left side; symptoms tend to worsen upon awakening in the morning and with exposure to heat or light pressure; symptoms improve dramatically when menstruation begins
• Lycopodium — for bloating with backaches and gas that are the worst during early evening and in warm weather
• Magnesia phos — for sharp cramps that are relieved by bending forward, abdominal massage, and warmth (such as a heating pad), but are worsened by cold air
• Nux vomica — for individuals who are extremely irritable, confrontational, and feel nauseous
• Pulsatilla — for irregular periods with cramps, bloating, and/or mood swings as the predominant symptoms; an appropriate candidate for Pulsatilla is gentle and yielding but clingy and cries easily; may have nausea and water retention that is aggravated by heat
• Sepia — for bloating, mood swings, constipation, drowsiness, and irritability

Although scientific evidence regarding the use of acupuncture for PMS is lacking, this condition is frequently treated by acupuncturists. Acupuncturists treat people with PMS based on an individualized assessment of the excesses and deficiencies of qi located in various meridians. In the case of PMS, a qi deficiency is usually detected in the liver and/or spleen meridians. Many treatments include moxibustion (a technique in which the herb mugwort is burned over specific acupuncture points), and qualified practitioners may also recommend herbal treatment or dietary modifications.

Some studies suggest that chiropractic spinal manipulation may be effective for women with PMS. Women with PMS have been found to have a higher rate of spine-related problems (such as tenderness and muscle weakness) than those who do not have PMS. In one study, researchers found that women with PMS experience a significant decrease in symptoms after receiving spinal manipulation and soft tissue therapy compared to those who do not receive the chiropractic treatment. The researchers note that these effects may be short-lived and that monthly chiropractic treatment would probably be needed to maintain these positive results.

Severe PMS can disrupt a woman's life. Psychological and emotional support as well as treatment of the physical symptoms may help.

Ongoing follow-up and regular evaluations are necessary.

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