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Premenstrual Syndrome (PMS)

By

JoAnn V. Pinkerton

, MD, University of Virginia Health System

Last full review/revision Feb 2021| Content last modified Feb 2021
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Premenstrual syndrome (PMS) is a group of physical and psychologic symptoms that start several days before and usually end a few hours after a menstrual period begins. Premenstrual dysphoric disorder is a form of PMS in which symptoms are so severe that they interfere with work, social activities, or relationships.

  • PMS includes any combination of the following: becoming irritable, anxious, moody, or depressed or having headaches or sore, swollen breasts.

  • Doctors base the diagnosis on symptoms, which are usually recorded daily by the woman.

  • Consuming less sugar, salt, and caffeine and exercising may help relieve symptoms, as does taking certain supplements, pain relievers, birth control pills (sometimes), or antidepressants.

Because so many symptoms, such as a bad mood, irritability, bloating, and breast tenderness, have been ascribed to PMS, defining and identifying PMS can be difficult.

About 20 to 50% of women of childbearing age have PMS. About 5% have a severe form of PMS called premenstrual dysphoric disorder.

PMS may occur partly because of the following:

  • Estrogen and progesterone levels fluctuate during the menstrual cycle. Some women are more sensitive to these fluctuations.

  • Some women may have a genetic make-up that makes them more susceptible to PMS.

  • Serotonin levels tend to be lower in women with PMS. Serotonin is a substance that helps nerve cells communicate (a neurotransmitter) and is thought to help regulate mood.

  • A deficiency of magnesium or calcium may contribute.

The fluctuations in estrogen and progesterone may affect other hormones, such as aldosterone, which helps regulate salt and water balance. Excess aldosterone can cause fluid retention and bloating.

Symptoms of PMS

The type and intensity of PMS symptoms vary from woman to woman and from month to month in the same woman. The various physical and psychologic symptoms of PMS can temporarily upset a woman’s life.

Symptoms may begin a few hours up to about 10 days before a menstrual period, and they often disappear completely a few hours after the period begins. During the years before menopause (called perimenopause), women may have symptoms that persist through and after the menstrual period. Symptoms may become more severe during stress or during perimenopause. The symptoms of PMS may be followed each month by a painful period (cramps, or dysmenorrhea), particularly in adolescents.

The most common symptoms are irritability, anxiety, agitation, anger, insomnia, difficulty concentrating, lethargy, depression, and severe fatigue. Women may feel bloated and temporarily gain weight. Breasts may feel full and be painful. Women may have a sense of heaviness or pressure in the lower abdomen.

Other disorders may worsen while PMS symptoms are occurring. They include the following:

  • Seizure disorders, with more seizures than usual

  • Connective tissue disorders, such as systemic lupus erythematosus (SLE, or lupus) or rheumatoid arthritis, with flare-ups

  • Respiratory disorders, such as allergies and congestion of the nose and airways

  • Migraines

  • Mood disorders, such as depression or anxiety

  • Sleep disturbances, such as sleeping too much or not sleeping enough

Mood disorders can cause similar symptoms, and those symptoms may worsen just before a menstrual period, even in women who do not have PMS or premenstrual dysphoric disorder.

In premenstrual dysphoric disorder, premenstrual symptoms are so severe that they interfere with work, social activities, or relationships. Interest in daily activities is greatly reduced, and some women may even become suicidal. Symptoms occur regularly before menstrual periods start and end when or shortly after periods start. Women may lose interest in their usual activities and have suicidal thoughts.

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Symptoms That Can Occur in Premenstrual Syndrome (PMS)

Physical

  • Awareness of heartbeats (palpitations)

  • Backache

  • Bloating

  • Breast fullness and pain

  • Changes in appetite and cravings for certain foods

  • Constipation

  • Cramps, heaviness, or pressure in the lower abdomen

  • Dizziness, including vertigo

  • Easy bruising

  • Fainting

  • Fatigue

  • Headaches

  • Hot flashes

  • Insomnia, including difficulty falling or staying asleep at night

  • Joint and muscle pain

  • Lack of energy

  • Nausea and vomiting

  • Pins-and-needles sensations in the hands and feet

  • Skin problems, such as acne and localized scratch dermatitis

  • Swelling of hands and feet

  • Weight gain

Psychologic

  • Agitation

  • Anxiety

  • Confusion

  • Crying spells

  • Depression

  • Difficulty concentrating

  • Emotional hypersensitivity

  • Forgetfulness or memory loss

  • Irritability

  • Mood swings or worsening of mood disorders that are already present

  • Nervousness

  • Short temper

  • Social withdrawal

Diagnosis of PMS

  • For PMS, a doctor's evaluation

  • For premenstrual dysphoric disorder, specific guidelines

The diagnosis of PMS is based on symptoms. To identify PMS, doctors ask a woman to keep a daily record of her symptoms. This record helps the woman be aware of changes in her body and moods and helps doctors identify any regular symptoms and determine what treatment is best.

If women have symptoms of depression, they may be given standardized tests for depression or be referred to a mental health care practitioner. However, doctors can usually distinguish PMS or premenstrual dysphoric disorder from mood disorders based on factors such as the timing of symptoms. If the symptoms disappear soon after the menstrual period begins, they are probably caused by PMS or premenstrual dysphoric disorder.

Premenstrual dysphoric disorder

Premenstrual dysphoric disorder cannot be diagnosed until a woman has recorded her symptoms for at least two menstrual cycles. Doctors base the diagnosis on specific guidelines. The guidelines state that women must have a total of at least five of the symptoms that often occur in women with PMS (with at least one from each of the two lists below).

The symptoms must include at least one of the following:

  • Having changeable moods (for example, suddenly feeling sad and tearful)

  • Being very irritable or angry or having more conflicts with other people

  • Feeling very depressed or hopeless or being very critical of self

  • Feeling anxious, tense, or on edge

The symptoms must also include at least one of the following:

  • A decreased interest in usual activities

  • Difficulty concentrating

  • Low energy or fatigue

  • Noticeable changes in appetite, overeating, or specific food cravings

  • Problems sleeping (having problems going to or staying asleep or sleeping too much)

  • Feelings of being overwhelmed or out of control

  • Physical symptoms that often occur in women with PMS (such as tender breasts)

Also, the symptoms must have occurred for most of the previous 12 months, and they must be severe enough to interfere with daily activities and function.

Treatment of PMS

  • General measures

  • Sometimes drugs, including hormones and/or antidepressants

PMS may be difficult to treat. No single treatment is effective for all women, and few woman have complete relief with any single type of treatment.

General measures

Women can try the following to help relieve PMS symptoms:

  • Getting enough rest and sleep (at least 7 hours each night)

  • Exercising regularly, which may help lessen bloating as well as irritability, anxiety, and insomnia (yoga and Tai Chi help some women)

  • Using stress reduction techniques (meditation or relaxation exercises)

  • Avoiding stressful activities

  • Consuming more protein and less sugar and caffeine (including that in chocolate)

  • Consuming more fruits, vegetables, milk, complex carbohydrates (for example, in breads, pastas, beans, and root vegetables), high-fiber foods, low-fat meats, and foods high in calcium and vitamin D

  • Consuming less salt, which often reduces fluid retention and relieves bloating

  • Avoiding certain foods and drinks (such as cola, coffee, hot dogs, potato chips, and canned foods)

Certain dietary supplements may lessen PMS symptoms to some degree. These supplements include chasteberry extract from the agnus castus fruit, vitamin B6, and vitamin E. Women should talk to their doctor before they take any supplements, especially vitamin B6, which may be harmful if taken in high doses. Nerve damage is possible with as little as 200 milligrams of vitamin B6 a day.

Did You Know...

  • Taking birth control pills sometimes relieves symptoms but sometimes makes them worse, particularly in the first 6 weeks after starting.

Drugs

Taking nonsteroidal anti-inflammatory drugs (NSAIDs) may help relieve headaches, pain due to abdominal cramps, and joint pain. To decrease the intensity of headaches or cramps, women can start taking NSAIDs a few days before their period starts.

Hormone therapy may help. Options include the following:

  • Birth control pills

  • Progesterone vaginal suppositories

  • Progesterone pills

  • Injection of a long-acting progestin (a synthetic form of the female hormone progesterone) every 2 or 3 months

Oral contraceptives that result in shorter menstrual periods or that increase the interval between periods to as much as 3 months may help some women.

Women who have more severe PMS symptoms or premenstrual dysphoric disorder may benefit from taking antidepressants such as citalopram, fluoxetine, paroxetine, or sertraline. These drugs are used to prevent symptoms, and to be effective, they should be taken daily before symptoms begin or, for some women with PMS, taken daily the 2 weeks before menstrual periods begin. Taking these drugs after symptoms begin usually does not relieve symptoms. These drugs are most effective in reducing irritability, depression, and some other symptoms of PMS. Brexanolone, given intravenously, is now available for treatment of postpartum depression specifically, and may be particularly helpful if oral drugs are ineffective.

If fluid retention is a problem, doctors may prescribe the diuretic spironolactone (which helps the kidneys eliminate salt and water from the body).

Doctors may ask a woman to continue keeping a record of her symptoms so that they can judge the effectiveness of PMS treatment.

For women who have premenstrual dysphoric disorder that persists despite other treatments, a gonadotropin-releasing hormone (GnRH) agonist (such as leuprolide or goserelin), given by injection, may help relieve symptoms. GnRH agonists are a synthetic form of a hormone produced by the body. GnRH agonists cause the ovaries to produce less estrogen and progesterone. Thus, they help control the rapid fluctuations in hormone levels that occur before menstrual periods and that contribute to symptoms. Women are usually also given estrogen plus a progestin, taken in a low dose by mouth or a patch.

Researchers continue to evaluate other drugs as possible treatments for PMS and premenstrual dysphoric disorder.

Surgery

As a last resort for women who have severe symptoms that cannot be controlled with other treatments, doctors may offer surgery. Removing the ovaries eliminates menstrual cycles and thus eliminates PMS symptoms. However, removing the ovaries has the same effects as menopause, including increasing the risk of osteoporosis and other problems associated with menopause. To lessen or prevent some of these effects, doctors typically suggest that these women take hormone therapy that contains estrogen and a progestin or progesterone until they reach the average age for menopause (about age 51).

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