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Premenstrual Syndrome: Causes & Symptoms, Risk Factors & Investigations

More than 85% of women have one or more physical or emotional disorders during menstrual cycle between ovulation (when the egg is released from the ovary, around the 14th day of cycle) and the first day of menstruation. These disorders are known as premenstrual symptoms.Premenstrual Syndrome

When they interfere with the woman`s ability of perform her normal duties and relate with her surroundings, these disorders fall into the so-called premenstrual syndrome. While some women start to have these problems around 20 years old, other ones don`t have them until 30 years.

Premenstrual syndrome, or PMS, may have a fluctuated evolution with improvements and worsening of symptoms during the woman`s reproductive period, and the patient can experience worsen symptoms close to the perimenopause period (the end of 3rd or 4th decade of life).

We can talk about this syndrome only in women who experience ovarian cysts. The ones who don`t ovulate (due to the presence of a pregnancy, menopause or administration of birth control pills) don`t suffer of these disorders. However, lots of them have symptoms related to the hormone levels in the blood.


PMS and its more severe form, known as premenstrual dysphoric syndrome, are close related to the endocrine system (hormonal) which produces hormones involved in the menstrual cycle. Because in women there`s a complex hormonal system, experts aren`t yet able to say that they know all the details of the series of events which trigger this syndrome.

The only direct known cause is the one genetically inherited, because it was noticed that most women who show this syndrome have relatives who suffer of the same symptoms.

As the symptoms are heterogeneous (they don`t occur equally in all the patients), the same can be said about the involved factors in triggering the syndrome:

  • The increased level of aldosterone (a hormone secreted by the adrenal gland); this phenomenon is normal after ovulation and causes fluid retention, weight gain, breast swelling and headache in some women, but not all of them.
  • Excess of prolactin (hormone produced by the pituitary gland), which interfere with ovulation and causes irregular periods.
  • Use of insufficient serotonin (a neurotransmitter), which causes the anxiety and depression; experts confirm that lots of women with PMS who have mood disorders are too sensitive to normal changes of levels of estrogen and progesterone during the menstrual cycle,  which results in insufficient use of serotonin mentioned above.
  • Low levels of endorphins (hormones produced by the pituitary gland), which accentuates the depression and sensitivity to pain.
  • Prostaglandins (substances secreted by all cells), which causes breast swelling, fluid retention, cramps, headaches, depression and irritability.
  • Insulin sensitivity, which normally changes during premenstrual period, can lead to low levels of blood sugar (hypoglycemia), and some experts consider that this may be a cause of premenstrual syndrome.

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Premenstrual symptoms are normally encountered during the menstrual cycle, this phenomenon being present at over 85% of women at some point in life. If the patient doesn`t have exaggerate consecutive reactions to hormonal changes during the menstrual cycle, it`s possible for her to have a poor symptomatology or no symptoms at all.

These symptoms vary considerably from one woman to another and from one menstrual cycle to another, and they may have a variable intensity – from mild to severe. Some women consider that the symptoms worsen under emotional stress. From the 150 possible signs of this syndrome, the most frequent are:

Physical Symptoms

  • Breasts tenderness and swelling.
  • Fluid retention, bloating, weight gain.
  • Change in bowel habits.
  • Acne (pimples).
  • Leakage when breasts or nipples are pressed (this should be checked by a doctor).
  • Excessive food cravings (especially for sweets or salty foods).
  • Fatigue, lack of energy.
  • Low libido.
  • Headache, pain in breasts, muscles or joints, back pain (especially lower back pain before the first day of menstruation.)

Behavioral Symptoms

  • Aggressivity.
  • Withdrawn attitude from family and friends.

Emotional Symptoms

  • Depression, sadness or despair.
  • Fury, irritability.
  • Anxiety.
  • Mood changes.
  • Inability of concentration, decreased attention.

By definition, PMS occurs during the luteal period (between ovulation and the onset of menstrual bleeding). They may occur during the entire above described period or only for a short period of time during ovulation or the first few days after birth. The woman notice the severity of the symptoms, the way they vary from one month to another and that they appear or disappear without a clear cause.

Severe Symptoms

In case that the patient suffers severe mood changes, bad depression and anxiety of high intensity (with or without mental problems), we can assume that she suffers of premenstrual dysphoric syndrome. The symptoms of this disorder improve within 3 days of menstruation and it affects 8% of women. These symptoms are:

  • Depression, anxiety, bipolar disorder (mental disorder characterized by depression alternating with anger), schizophrenia and eating disorders.
  • Endometriosis (diseases characterized by the increase, development and functioning of endometrial tissue in a different location than the normal one – outside of the uterus).
  • Headache in the form of migraines.
  • Convulsions.
  • Irritable bowel syndrome (disorder characterized by alternating episodes of diarrhea accompanied by cramps and periods of constipation).
  • Asthma.
  • Chronic fatigue syndrome.
  • Allergies.
  • Anemia.
  • Thyroid diseases.

Other medical conditions can cause symptoms that are found in the premenstrual syndrome as well, and this thing is extremely important in terms of therapy. The best method for the patient to detect if the symptoms are caused by this syndrome is to find out when ovulation occurs and remember this moment. Then she can keep track (a calendar would work) by writing down these symptoms and the days when the period appears.

The cleanest way to find out when ovulation occurs is the one performed by monitoring cervical mucus, basal body temperature and levels of luteinizing hormone. It was believed that ovulation occurs 14 days before menstruation, meaning in the 15th day of a menstrual cycle of 28 days, but recent studies suggested that this moment varies from one woman to another and from one month to another.

Pathophysiogenetic Mechanism

Premenstrual syndrome is closely linked to changes in the endocrine system between ovulation and the first day of the menstrual cycle. Contrary to general opinion, ovulation and PMS don`t start 2 weeks before menstruation. The day of ovulation varies a lot from woman to woman and from one month to the next, averaging somewhere between day 10 and 22 of the menstrual cycle. Women with irregular cycles have even greater variability in terms of the onset of ovulation and the occurrence of PMS.

Any hormonal changes may cause premenstrual syndrome, thus explaining the great variability of the possible symptomatology that accompanies this syndrome. In the production of the egg and the preparation of the body for a possible pregnancy are involved hormones produced by the hypothalamus, pituitary gland, thyroid gland, adrenal gland and ovaries, while they send messages through chemical substances, to each other and to the rest of the organism. These signals – hormones and neurotransmitters – can influence mood, energy reserves, ability to focus, body weight, fluid levels in the body and perception of pain. If a small portion of this complex hormonal system doesn`t work properly, then the entire system is affected and there are frequently different combinations of symptoms associated with PMS.

While most women experience the onset of premenstrual syndrome at around 20 years of age, women most often complain of symptoms around 30 years. Women in the late 30s and early 40s, who have hormonal changes and normal ovulation, may accuse mood-related, emotional and physical signs that might be similar to premenstrual syndrome and premenstrual dysphoric syndrome. After menopause, when the hormonal level is low and without important fluctuations, women stop suffering from PMS.

Postmenopausal women receiving hormonal supplements and women taking birth control pills might also experience PMS.

Although the exact cause of the syndrome isn`t known, some factors that predispose to this medical condition could be identified.

Risk Factors

Risk factors that cannot be controlled are:

  • Family members who already had this syndrome.
  • Deficiency of vitamin B6, calcium and magnesium.
  • Varicose veins (the syndrome is more common in the 3rd decade and the symptoms are also more aggressive).
  • Anomalies of mental disorder, anxiety or depression. There are an important risk factor for the development of premenstrual dysphoric syndrome.

Risk factors that can be controlled are:

  • Sedentary lifestyle (lack of physical exercise).
  • Stress.
  • Excessive caffeine.
  • Poor diet.

Specialized Consultation

A lot of women suffer of PMS, and the specialist consultation is recommended in the following cases:

  • The symptoms affect the lifestyle and the ability of the patient to perform the usual routine.
  • The symptoms seem to be out of control.
  • The symptoms don`t respond to ambulatory treatment.
  • Significant symptoms (like depression, anxiety, irritability, mood disorders) don`t improve in a few days after the onset of menstruation.

Watchful waiting

If the symptoms appear constantly a few months in a row, ambulatory treatment will be approached, and many women have noted that making minor lifestyle changes has dramatically improved their symptoms.

If the ambulatory treatment has no results and the symptoms affect your lifestyle significantly, it`s recommended to schedule a doctor appointment 3 months from the time when you took the decision. Many experts will ask the patient to write a “diary” for at least 2 months before they can establish the diagnosis of PMS.

The diary should keep track of the following:

  • The symptoms and their severity.
  • The days when the signs occur.
  • Date of ovulation (if the patient can specify the date).
  • When menstruation occurs.

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Recommended Doctors

Generally speaking, a family doctor can diagnose and treat PMS, but if he isn`t familiar with the medical condition, a consultation can be recommended to diagnose and treat the condition.

Experts who are able to diagnose and treat PMS are:

  • The general practitioner.
  • The family doctor.
  • The internist.
  • Gynecologist.

If the symptoms are severe, a gynecological consultation is recommended to prepare a treatment plan. If the symptoms are more of a emotional or behavioral nature, or if the diagnosis is premenstrual dysphoria syndrome, then it may be extremely useful to work with a psychiatrist or psychologist.


There is no special analysis to diagnose PMS. The diagnosis is based on the patient`s history and on the “diary” of 2 to 3 menstrual cycles that record daily signs, menstruation days and ovulation days if possible. Because it`s extremely important for your doctor to exclude other illnesses that are manifested by similar symptoms, it might require more than one consultation for each individual patient.

Throid-stimulating hormone (TSH) is recommended to evaluate the thyroid function, because the disorders of this gland (treatable disorders) can mimic PMS.

The diagnosis of PMS can be even more difficult when the woman suffers from other medical conditions that also worsen during the second period of the menstrual cycle.

  • Although there are some clear criteria of diagnosis for PMS, its symptoms are mixed with that of other conditions.
  • All symptoms should be evaluated and treated.

It`s important for the patient to determine if the symptoms are specific to PMS, so that the doctor can decide the optimal treatment.

By definition, premenstrual syndrome and premenstrual dysphoria syndrome occur only between ovulation and the onset of menstruation.

It was believed that menstruation took place 14 days before menstruation, meaning in the 15th day of a 28-day menstrual cycle, but recent studies suggested that the time varies greatly from woman to woman, and from month to another. Women with irregular menstrual cycles have even greater variability of ovulation time.

The most sensitive way to find out when ovulation occurs is by monitoring the levels of cervical mucus, basal body temperature and luteinized hormone (LH).

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