Premenstrual Syndrome (PMS)

	Topic Overview
	Health Tools
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When To Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Home Treatment
	Medications
	Surgery
	Other Treatment
	Other Places To Get Help
	Related Information
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What is premenstrual syndrome (PMS)?

Up to 85% of women normally have one or more troubling physical and emotional symptoms between the time they ovulate and the first days of their menstrual period.¹ These are called premenstrual symptoms. When premenstrual symptoms interfere with your relationships or responsibilities, they are called premenstrual syndrome (PMS).

While some women first have PMS in their teens or 20s, others don't until their 30s. PMS can come and go during your reproductive years. You may find that your symptoms get worse as you approach perimenopause, in your late 30s or 40s.

PMS occurs only in women who ovulate during their monthly menstrual cycle . Women who do not ovulate—because of pregnancy, menopause, or taking birth control pills—do not have premenstrual symptoms. However, many do have similar hormone-related symptoms.

What causes PMS?

PMS is linked to changes in the endocrine system, which makes hormones that control the menstrual cycle. The female endocrine system is complex. This is why medical experts don't fully understand the chain of events that causes premenstrual symptoms to be severe in some women and not in others.

The one direct cause that is known to affect some women is genetic: many women with PMS have a close family member with a history of PMS.¹

What are typical premenstrual symptoms?

PMS consists of a wide variety of physical, emotional, and behavioral symptoms. Symptoms vary greatly from woman to woman and can range from mild to severe.

Common physical symptoms include breast swelling and tenderness, bloating, water retention, weight gain, acne, food cravings, sleep changes, lack of energy, reduced sexual desire, and pain, such as headaches, migraines, aching joints or muscles, cramps, and low back pain.

Common emotional symptoms include depression, sadness, hopelessness, anger, irritability, anxiety, and mood swings. Many women also notice that they feel less alert and less able to concentrate.

Common behavioral symptoms include withdrawal from family and friends, and physical or verbal aggression.

If you have severe emotional and/or behavioral symptoms (with or without physical symptoms) between ovulation and the first days of your period, you may have premenstrual dysphoric disorder (PMDD). In contrast to PMS, PMDD affects only 3% to 8% of women.²

How is PMS diagnosed?

No single test can diagnose PMS. Diagnosis is usually based on a 2- or 3-month menstrual diary that records your daily symptoms and how severe they are, the days you menstruate, and when you ovulate (if known). However, your health professional will also consider your medical history and physical examination results. It's important to rule out other conditions that have PMS-like symptoms, such as thyroid problems.

How is it treated?

Although there is no cure for PMS, most women can improve their symptoms with simple lifestyle and dietary changes. After a few cycles, you will likely notice improvement from getting enough magnesium and vitamin B₆, extra calcium, and regular moderate exercise, and eating a balanced diet. It's equally important to avoid smoking, as well as too much caffeine, alcohol, chocolate, and salt. For pain, use nonsteroidal anti-inflammatory drugs (NSAIDs)—these are effective because they block pain-producing prostaglandins, which tend to increase during the premenstrual period.

If home treatment measures don't bring enough relief, talk to your health professional about additional treatment.

• If bloating is your primary symptom, ask your health professional about a diuretic, such as spironolactone.
• For moderate to severe PMS, serotonin reuptake inhibitors (SSRI) are often the first-choice treatment. An SSRI can improve both physical and emotional symptoms. Most women gain relief by taking a low dose either continuously or only during their premenstrual days.³
• For moderate to severe PMS or PMDD there is one type of birth control pill that helps many women. It is sold as YAZ and Yasmin, with drospirenone. (YAZ is very low-estrogen, and Yasmin is low-estrogen.) The drospirenone has a unique hormone action, and acts like a water pill (diuretic).⁴ YAZ has been approved by the U.S. Food and Drug Administration for treating PMDD symptoms.

If you try an SSRI but find it ineffective, it's a good idea to try another type of SSRI before moving on to a different class of medication, such as a benzodiazepine for anxiety (which can become addictive) or most types of birth control pills (which may help or may make symptoms worse).

In rare and otherwise untreatable cases, severe PMS can be treated by completely suppressing the ovaries' function. However, this creates a condition similar to menopause, with unpleasant symptoms of its own and an increased risk of osteoporosis because of low estrogen production.

If you are using medication for PMS symptoms, be sure to use one or more highly effective birth control methods. Some of these treatments can cause birth defects when taken during early pregnancy.

Frequently Asked Questions

Health tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	Should I try an SSRI for premenstrual syndrome (PMS)?

Premenstrual syndrome (PMS) and the more severe form, premenstrual dysphoric disorder (PMDD), are linked to changes in the endocrine system, which produces hormones that control the menstrual cycle. Because the female endocrine system is so complex, medical experts don't fully understand the chain of events that causes PMS in some women and not others.

The one direct cause that is known to affect some women is genetic—many women with PMS have a close family member with a history of PMS.¹

Just as your combination of PMS symptoms is slightly different from another woman's, so is the mix of factors underlying your symptoms. Changes in the endocrine system that cause PMS symptoms can include:

• Increased aldosterone (a hormone from the adrenal gland). This is normal after ovulation. Aldosterone causes fluid retention, weight gain, breast swelling, and headaches in some women but not others.⁵
• Too much prolactin (a hormone from the pituitary gland), which can interfere with ovulation and cause irregular cycles and breast tenderness.⁵
• The brain's underuse of the neurotransmitter serotonin, which is known to cause anxiety and depression. Experts theorize that many women with PMS mood problems are sensitive to normal premenstrual changes in estrogen and progesterone (from the ovaries). This sensitivity may trigger a problem with the brain's use of serotonin.⁶
• Decreased endorphins (hormones from the pituitary gland), which may increase pain and depression in some women.⁵
• Prostaglandins (chemicals made by all body cells), which are linked to breast pain, fluid retention, cramping, headaches, irritability, and depression.⁵
• Sensitivity to insulin, which is thought to be common during the premenstrual time following ovulation. This sensitivity can lead to episodes of low blood sugar, which some researchers think may trigger premenstrual symptoms.⁵

Premenstrual symptoms are a natural part of the menstrual cycle, affecting over 85% of women at some time during their lives.⁷ If your body doesn't react strongly to its monthly hormonal changes, you probably have mild premenstrual symptoms or none at all. However, if you have one or more mild to moderate premenstrual symptoms that disrupt your work, relationships with others, or sense of well-being, you are said to have premenstrual syndrome (PMS).

PMS symptoms vary greatly from woman to woman and cycle to cycle, and can range from mild to severe. Some women note that their symptoms are worse during times of increased emotional or physical stress. Of the more than 150 symptoms that have been linked to PMS, the most common are listed below.

Physical symptoms include:

• Breast swelling and tenderness.
• Bloating, water retention, weight gain.
• Changes in bowel habits.
• Acne.
• Nipple discharge when nipples or breasts are pressed. (Any leakage that spontaneously happens when you aren't pressing on the nipple should be checked by a health professional.)
• Food cravings, especially for sweet or salty foods.
• Sleep pattern changes.
• Fatigue, lack of energy.
• Decreased sexual desire.
• Pain. Common complaints include headaches or migraines, breast tenderness, aching muscles and joints, or cramps and low back pain prior to menstrual bleeding.

Behavioral symptoms include:

• Aggression.
• Withdrawal from family and friends.

Emotional and cognitive symptoms include:

• Depression, sadness, hopelessness.
• Anger, irritability.
• Anxiety.
• Mood swings.
• Decreased alertness, inability to concentrate.

By definition, premenstrual symptoms only occur during the luteal phase, between ovulation and the start of menstrual bleeding, or soon after. Premenstrual symptoms can occur during the entire luteal phase or can appear briefly during ovulation, in the days leading up to menstrual bleeding, or both. You may notice that the severity and pattern of your PMS symptoms varies from month to month. You may also stop or start having PMS symptoms for no clear reason.

Severe symptoms

If you have severe premenstrual mood swings, depression, irritability, or anxiety (with or without physical symptoms), you are said to have premenstrual dysphoric disorder (PMDD). Symptoms generally subside within the first 3 days of menstrual bleeding. This severe type of PMS affects up to 8% of women.⁸ Women with PMDD symptoms tend to report that they:

• Have negative behavior and feelings of hopelessness.
• Feel guilt and shame.
• Feel they have lost control over their lives.
• Believe they are mentally ill and fear the stigma of mental illness.
• Have poor job performance or missed workdays during the premenstrual period.
• Feel distanced from family and friends.

Premenstrual worsening of other conditions

You may notice that symptoms of other medical conditions get worse between ovulation and the first day of menstrual bleeding—this is called menstrual magnification. The conditions most affected are:⁷

• Mental health problems, such as depression, anxiety disorders, bipolar disorder, schizophrenia, and eating disorders.
• Endometriosis.
• Migraine headaches.
• Seizure disorders.
• Irritable bowel syndrome (IBS).
• Asthma.
• Chronic fatigue syndrome.
• Allergies.
• Anemia.⁹
• Thyroid disease.⁹

Are my symptoms truly premenstrual, starting after I ovulate?

What seems like PMS can sometimes be caused by another condition. It's important to know, because your treatment options will be different if your symptoms aren't actually linked to premenstrual hormone changes. The best way to learn whether your symptoms are premenstrual is to know when you ovulate (the day you ovulate is the start of your premenstrual phase). Keep track of ovulation days, a daily record of your symptoms, and menstrual bleeding days in a menstrual diary (What is a PDF document?).

You can most accurately pinpoint your ovulation day by monitoring your cervical mucus, your basal body temperature (BBT), and your luteinizing hormone (LH) changes with an ovulation test.¹⁰ Traditionally, ovulation was thought to happen 14 days before the next menstrual period, or on day 15 of a 28-day cycle. However, recent research suggests that ovulation dates vary widely from woman to woman and from month to month.¹¹

Premenstrual syndrome (PMS) is linked to normal changes in your endocrine system that start when you ovulate, lasting up to the first days of your menstrual period. Contrary to popular belief, ovulation and PMS symptoms don't necessarily start 2 weeks before your period. The day of ovulation varies widely from woman to woman, ranging in one study from day 10 to day 22 of a monthly menstrual cycle.¹¹ Women with irregular cycles have an even greater range of possible ovulation and premenstrual days.

Any number of hormone changes can cause premenstrual symptoms—this accounts for the many types of symptoms that women have after ovulation. As your hypothalamus, pituitary gland, thyroid gland, adrenal glands, and ovaries work together to produce an egg (ovum) and prepare your body for a possible pregnancy, they send out chemical signals to each another and the rest of your body. These signals—in the form of hormones and brain chemicals, or neurotransmitters—can affect your mood, energy level, ability to think clearly, body fluid and weight, and pain perception. If one part of the endocrine system isn't working right, the rest of the system is affected, often causing a combination of premenstrual symptoms.

Although most women first experience PMS in their mid-20s, PMS becomes even more common among women in their 30s.⁹ Among women in their late 30s and early 40s (who have erratic periods, ovulation, and hormone changes), unpredictable physical, emotional, and mood-related perimenopausal symptoms can be similar to PMS and premenstrual dysphoric disorder (PMDD).⁸ After menopause, when hormones are low and no longer fluctuating, women do not have PMS.

If you take estrogen and/or progestin for birth control or for hormone replacement after menopause, you can also have PMS-like symptoms.

Although the cause of premenstrual syndrome (PMS) is poorly understood, a number of risk factors have been noted among women with PMS.

Risk factors for PMS that you cannot control include:

• A family history of premenstrual syndrome (PMS).
• Vitamin B₆, calcium, or magnesium deficiency.⁵
• Age. PMS becomes increasingly common as women age through their 30s, and symptoms sometimes get worse over time.⁹
• Previous anxiety, depression, or other mental health problems. This is a significant risk factor for developing premenstrual dysphoric disorder (PMDD).⁸

Risk factors that you can control include:

• Lack of exercise.
• High stress.
• High caffeine intake.
• Poor diet.

Many women have premenstrual syndrome (PMS) either before or during their menstrual periods. If you have severe symptoms, you may wonder whether you need to see your health professional for symptom treatment.

Call your health professional if:

• PMS symptoms regularly disrupt your life and keep you from doing your regular activities.
• You feel out of control because of PMS symptoms.
• PMS symptoms do not respond to home treatment.
• Significant PMS symptoms (such as depression, anxiety, irritability, crying, or mood swings) do not end after a couple of days of your menstrual period.

Watchful Waiting

If PMS symptoms consistently occur for several months in a row, try home treatment measures. Many women find that making small changes in their lifestyle significantly improves their symptoms.

If home treatment does not improve your symptoms and they are severely disrupting your life, make an appointment for 3 months from now to see your health professional. Many health professionals will want you to complete a menstrual diary for at least two menstrual cycles before they can diagnose and treat PMS.

If you think you have PMS, keep track of the following in a menstrual diary (What is a PDF document?).

• Your symptoms and their severity
• Dates when symptoms occur
• Days that you ovulate (if you can tell when this happens)
• Days when you have your menstrual period

Who To See

Generally, your primary health professional can diagnose and treat premenstrual syndrome (PMS). If your health professional is not familiar with PMS, he or she can refer you to one who is.

Health professionals who can diagnose and treat PMS include:

• Nurse practitioners.
• Physician assistants.
• General practitioners.
• Family medicine doctors.
• Internists with training in women's health care.
• Gynecologists.

If you have severe PMS, you may need to consult a gynecologist to help develop a treatment plan. If your symptoms are mainly emotional or behavioral, or you have been diagnosed with premenstrual dysphoric disorder (PMDD), working with a psychiatrist or psychologist may help you find ways to manage your symptoms.

To prepare for your appointment, see the topic Making the Most of Your Appointment

No single test can diagnose premenstrual syndrome (PMS). A diagnosis of PMS or the more severe form, premenstrual dysphoric disorder (PMDD), is usually based on a medical history and a two- or three-cycle menstrual diary that records daily symptoms, menstruation days, and ovulation days, if possible. Because it's important for your health professional to rule out other conditions that cause PMS-like symptoms, it may take more than one visit to diagnose your symptoms. See an example of a menstrual diary (What is a PDF document?).

Because treatable thyroid problems sometimes cause PMS-like symptoms, you may have a thyroid-stimulating hormone (TSH) blood test to make sure that your thyroid gland is working properly.

Diagnosing PMS may be difficult when a woman has another condition that is made worse during the last 2 weeks of her menstrual cycle .

• Although there are clearcut criteria for diagnosing premenstrual syndrome, PMS-like symptoms often blend in with those of other conditions.
• All symptoms need to be evaluated and treated.

Knowing whether your symptoms are premenstrual helps you and your health professional decide on the best treatment for you. By definition, PMS and PMDD occur only during the phase between ovulation and the start of menstrual bleeding. Traditionally, ovulation was thought to happen 14 days before the next menstrual period, or on day 15 of a 28-day cycle. However, recent research suggests that ovulation dates vary widely from woman to woman and from month to month.¹¹ Women with irregular cycles have a wide range of possible ovulation days.

You can most accurately pinpoint your ovulation day by monitoring your cervical mucus, your basal body temperature, and your luteinizing hormone (LH) changes.¹⁰

Up to 85% of women normally have one or more troubling physical and emotional symptoms between the time they ovulate and the first days of their menstrual period.¹ These are called premenstrual symptoms. When premenstrual symptoms interfere with your relationships or responsibilities, they are called premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD), a severe form of PMS.

Although PMS cannot be cured, you do have a number of lifestyle and medication choices that can reduce your symptoms and improve your quality of life.

Basic PMS treatment

Experts recommend that all women with PMS start by keeping a menstrual diary, making lifestyle changes, and using home treatment measures.⁷ After a few menstrual cycles, you should notice some improvement in symptoms. Whether or not you then decide to add medication treatment, be sure to continue helping your body weather its premenstrual days by:

• Taking daily calcium [1200 mg] and vitamin B₆ [50 mg to 100 mg]. Both of these nutrients affect the hormone-producing endocrine system. Calcium is strongly linked to PMS symptoms and relief.⁸ Although research and expert opinions are mixed, daily vitamin B₆ is thought to improve PMS depression and physical symptoms.¹²
• Reducing your caffeine, refined sugar, and sodium intake, at least during the premenstrual phase of your cycle. These substances are linked to emotional and physical PMS symptoms, such as insomnia, tension and anxiety, food cravings, pain, and bloating.⁸
• Getting regular exercise. Exercise is proven to reduce depression.⁸ Women often report that exercise helps relieve tension, pain, and mood-related PMS symptoms.
• Reducing stress. While stress is not a cause of PMS, it may make your symptoms worse. In turn, coping with stress can be more difficult during the premenstrual period.⁷
• Using nonprescription medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), for headache, joint or muscle pain, or cramps. NSAIDs work best when taken before and continued at regular dosage intervals throughout the premenstrual pain period. For some women, this continues into the first days of menstrual bleeding, to relieve painful cramps.

See an example of a menstrual diary (What is a PDF document?).

Additional treatments for PMS

If you still have moderate to severe symptoms after two or three cycles of healthy lifestyle and home treatment measures, talk your health professional about further treatment options. Consider the following for specific symptoms.

All physical and mood-related symptoms

The selective serotonin reuptake inhibitor (SSRI) class of antidepressants is often the first-choice medication for moderate to severe premenstrual symptoms, including aggression, depression, anxiety, and physical symptoms. Most women gain relief by taking an SSRI either continuously or only during their premenstrual days.³ If you try an SSRI but find it ineffective, it's a good idea to try another type of SSRI before moving on to another class of medication. For more information, see:

Should I try an SSRI medication for PMS symptoms?

The U.S. Food and Drug Administration (FDA) has sent out a warning on the SSRI Paxil (paroxetine). Taking this medicine in the first 12 weeks of pregnancy may increase your chance of having a baby with a birth defect.

The birth control pill with estrogen and drospirenone is another treatment option for moderate to severe PMS or PMDD. This pill is sold as YAZ (very low-estrogen) or Yasmin (low-estrogen). The drospirenone improves severe physical and emotional symptoms in 1 in 8 women. It has a unique hormone action, and also acts like a water pill (diuretic).⁴ YAZ has been approved by the U.S. Food and Drug Administration for treating PMDD symptoms.

Bloating or breast tenderness

• Spironolactone, taken during the premenstrual phase, works as a diuretic and effectively reduces bloating and breast tenderness.¹
• Drospirenone, in the birth control pill called YAZ or Yasmin, acts like spironolactone. It relieves bloating, breast tenderness. In some women, it also relieves other emotional and physical PMS symptoms.⁴
• Daily vitamin E (400 IU), taken during the premenstrual phase, is a recognized treatment for breast tenderness.¹
• Evening primrose oil contains essential fatty acids that may offer mild relief of breast tenderness.¹

For more information about complementary, alternative, and supplement therapies for PMS, see the Other Treatment section of this topic.

Other hormonal, sedative, or surgical treatments for severe PMS

The goal of hormonal and surgical treatments is to stop a part of the hormonal (endocrine) system that is linked to premenstrual symptoms. These treatments are not commonly used to treat PMS symptoms, either because they are now known to be ineffective or because they have severe side effects.

• Birth control pills (estrogen-progestin) are widely prescribed for PMS but are no longer recommended by experts in the field as a first-choice treatment.^{1, 3} Recent research has shown that birth control pills are not consistently effective for PMS. Although they may improve bloating, headache, abdominal pain, and breast tenderness for some women, other women report that they have worse symptoms or they develop mood problems. Birth control pills are known to be ineffective for treating mood symptoms.⁷Estrogen alone may offer some benefit for some women, but when taken without progestin, it increases the risk of uterine (endometrial) cancer.
• Progestin has been used in the past for PMS but is now proven to be ineffective or to actually make physical and emotional symptoms worse.¹
• Danazol (Danocrine) is a synthetic male hormone that can relieve breast pain by decreasing estrogen production. It isn't often prescribed because it can't be used long-term and causes weight gain, depression, deepening of the voice, smaller breasts, and cholesterol problems.
• Benzodiazepine treatment with alprazolam (Xanax) is occasionally used for PMS-related anxiety. It depresses the central nervous system, loses effectiveness over time, and can be addictive. Because long-term use can be complicated by withdrawal and life-threatening symptoms, this medication is only recommended for a few days' use when other treatments have been ineffective.
• Bromocriptine (Parlodel) can relieve breast pain by reducing prolactin production. However, it isn't often prescribed because side effects are common, including nausea and vomiting, headache, cramps, and fatigue. A lowered dose can reduce side effects.
• Gonadotropin-releasing hormone agonists (GnRH-a) are a last-resort treatment for severe PMDD symptoms. Although a GnRH-a does control PMS by "shutting down" the ovaries, the tradeoff is that it is causes menopausal symptoms such as hot flashes and vaginal dryness.
• Surgery to remove the ovaries (oophorectomy) is a rarely used, controversial treatment, because it is irreversibly causes early menopause. Menopause symptoms caused by surgery, such as hot flashes, depression, and insomnia, are often more severe than those of natural menopause.

What To Think About

No single therapy is effective for all women. You and your health professional may have to try more than one type of treatment before finding the right choice for you.

You cannot prevent premenstrual syndrome (PMS), but you can take measures to reduce your risk of having severe premenstrual symptoms by:

• Taking daily calcium (1200 mg) and vitamin B₆ (50 mg to 100 mg). Calcium is strongly linked to PMS symptoms and relief.⁸ Although research and expert opinions are mixed, daily vitamin B₆ is thought to improve PMS depression and physical symptoms.¹²
• Getting regular exercise, which increases natural brain chemicals (endorphins) that reduce pain and provide a feeling of well-being.
• Eating a balanced diet that helps keep your blood sugar levels stable. Eat small meals with complex carbohydrates, whole grains, protein, fruits, and vegetables. Avoid refined sugar, as well as excessive fats, salt, and alcohol.
• Reducing stress with time management practices, enough rest, and relaxation techniques.
• Limiting the amount of caffeine in your diet.
• Quitting smoking, if you smoke.

For as long as you have a menstrual cycle and ovulate, your hormone-producing endocrine system has powerful, cyclic effects on your body. If you have symptoms that are or may be premenstrual syndrome (PMS), use the following home treatment measures as initial and ongoing treatment.

• Keep a menstrual diary. By recording your symptoms, their severity, and the days when you have your period and ovulate, you can identify patterns in your cycle and plan the best treatment with your health professional. You can also use your menstrual diary to plan ahead for, prevent or reduce, and better cope with your premenstrual symptoms. Whenever possible, plan to take extra good physical and emotional care of yourself during your premenstrual days. It's also useful to let people close to you know when your more trying days will be. See an example of a menstrual diary (What is a PDF document?).
• Begin or maintain a moderate exercise schedule (30 minutes, 4 to 5 times weekly). Exercise is proven to reduce depression.⁸ Women often report that exercise helps relieve tension, pain, and mood-related PMS symptoms.
• Take daily calcium (1200 mg) and vitamin B₆ (50 mg to 100 mg). Calcium is strongly linked to PMS symptoms and relief.⁸ Although research and expert opinions are mixed, daily vitamin B₆ is thought to improve PMS depression and physical symptoms.¹²
• Follow a sensible and balanced diet that provides the recommended levels of vitamins and nutrients.
• Use a nonsteroidal anti-inflammatory drug (NSAID) to reduce PMS pain. NSAIDs relieve premenstrual and menstrual pain and reduce menstrual bleeding. They reduce inflammation, which is from increased prostaglandin production during the premenstrual period. NSAIDs work best when taken before and continued at regular dosage intervals throughout the premenstrual pain period. For some women, this continues into the first days of menstrual bleeding, to relieve painful cramps. If you have regular cycles, start taking an NSAID 1 to 2 days before you expect pain to start.
• Avoid or eliminate unhealthy habits, such as smoking or having too much caffeine, alcohol, chocolate, or salt.
• Reduce stress in your life.
• Create a support system. Join a support group of women who are managing their PMS or premenstrual dysphoric disorder (PMDD). With your loved ones, plan ahead for ways to reduce the demands and stress placed on you, as well as the amount of stress that your premenstrual symptoms place on them.
• Wear a more supportive bra, such as a sports bra, if your breasts are tender during your premenstrual days.

These self-care measures can help you figure out which changes are most useful in relieving your PMS symptoms. It may be best to:

• Try one or two techniques at a time, instead of all of them at once. This will allow you to identify the most helpful techniques.
• Try the technique for two to three menstrual cycles. Some techniques may require more than one cycle to be helpful.
• Stop using a technique if you have tried it for 2 or 3 months and it doesn't seem to be helping. (However, if it is improving other parts of your life, you might want to keep doing it even if it isn't reducing your PMS symptoms.)

Troubling physical and emotional symptoms that occur between the time you ovulate and the first days of your menstrual period are called premenstrual symptoms. When premenstrual symptoms interfere with your relationships or responsibilities, they are called premenstrual syndrome (PMS). When premenstrual emotional symptoms or aggression are severe, they are called premenstrual dysphoric disorder (PMDD).

If you have moderate to severe premenstrual symptoms that continue despite home treatment and lifestyle changes, talk to your health professional about using medication. Most medications for PMS affect some part of the hormone-producing endocrine system with the goal of blocking or increasing a certain chemical process that may be causing symptoms. There is no known medication that can "cure" PMS.

The most commonly used medications for PMS are nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and selective serotonin reuptake inhibitors (SSRIs) for mood-related symptoms. There is also a newer kind of birth control pill, sold as YAZ and Yasmin, that helps with PMDD symptoms. YAZ has been approved by the U.S. Food and Drug Administration for treating PMDD symptoms. These medications are well proven and have a low risk of severe side effects.

Should I try an SSRI medication for PMS symptoms?

Medication Choices

Pain relievers (nonsteroidal anti-inflammatory drugs [NSAIDs])

• Naproxen, ibuprofen, or mefenamic acid (such as Aleve, Motrin, Advil, or Ponstel). NSAIDs relieve premenstrual and menstrual pain and reduce menstrual bleeding. They reduce inflammation, which is from increased prostaglandin production during the premenstrual period. NSAIDs work best when taken before and continued at regular dosage intervals throughout the premenstrual pain period. For some women, this continues into the first days of menstrual bleeding, to relieve painful cramps. If you have regular cycles, start taking an NSAID 1 to 2 days before you expect pain to start.

NSAIDs greatly improve premenstrual and menstrual pain. But, NSAIDs do not relieve breast tenderness.¹ They also do not relieve emotional PMS symptoms.

Selective serotonin reuptake inhibitors (SSRIs) to treat mood-related and physical symptoms

• Fluoxetine, paroxetine, sertraline, fluvoxamine, or citalopram (such as Prozac, Sarafem, Paxil, Zoloft, Luvox, or Celexa). These medications improve the brain's use of the neurotransmitter serotonin, relieving depression, anxiety, irritability, aggression, and physical symptoms in many women with PMS and PMDD. They are effective either when taken during the premenstrual weeks only or when taken continuously.

Diuretic to treat water retention and weight gain

• Spironolactone (Aldactone). When taken during the premenstrual weeks, this diuretic reduces bloating and breast tenderness by blocking the body's use of the hormone aldosterone.¹
• Drospirenone, in the birth control pill called Yasmin, acts like a water pill (diuretic). It relieves bloating and breast tenderness. In some women, it also relieves other emotional and physical PMS symptoms.⁴

Benzodiazepine to treat anxiety

• Alprazolam (such as Xanax) is only recommended for a few days' use when other treatments have been ineffective. It depresses the central nervous system, loses effectiveness over time, and can be addictive. Long-term use can be complicated by withdrawal or life-threatening symptoms.

Hormonal treatments

• There is one birth control pill with estrogen and drospirenone (sold as YAZ and Yasmin) that can help with moderate to severe PMS or PMDD. YAZ is very low-estrogen, and Yasmin is low-estrogen. The drospirenone improves severe physical and emotional symptoms in 1 in 8 women. It has a unique hormone action, and also acts like a water pill (diuretic).⁴ YAZ has been approved by the U.S. Food and Drug Administration for treating PMDD symptoms.
• Other types of birth control pills (estrogen-progestin) are widely prescribed for PMS, but experts in the field no longer recommend these as a first-choice treatment.^{1, 3} Research has shown that birth control pills are ineffective or problematic for many women with PMS. Although they may improve bloating, headache, abdominal pain, and breast tenderness for some women, other women report that they have worse symptoms or they develop mood problems. Birth control pills are known to be ineffective for treating mood symptoms.⁷Estrogen alone may offer some benefit for some women, but when taken without progestin, it increases the risk of uterine (endometrial) cancer.
• Progestin (progesterone) has been used in the past for PMS but is now proven to be ineffective or to actually make physical and emotional symptoms worse.¹

For more information about birth control pills and progestin, see the topic Birth Control.

Additional hormone treatments

• Danazol (Danocrine), a synthetic male hormone, can relieve breast pain by decreasing estrogen production. It isn't often prescribed because it can't be used long-term without causing weight gain, depression, deepening of the voice, smaller breasts, and cholesterol problems.
• Gonadotropin-releasing hormone agonist (GnRH-a) (such as Lupron Depot, Synarel, or Zoladex). A GnRH-a is a last-resort treatment for severe PMDD symptoms. Although a GnRH-a does control PMS by "shutting down" the ovaries, the tradeoff is that it is causes menopausal symptoms such as hot flashes and vaginal dryness.

Other antidepressants

• Tricyclic antidepressants (such as Elavil, Anafranil, or Tofranil) are not as well studied as SSRIs for PMS and are generally less favored because of their possible side effects. However, they do improve severe depression and insomnia for some women.

Other medications

• Bromocriptine (Parlodel) can relieve breast pain by reducing prolactin production. However, it isn't often prescribed because side effects are common, including nausea and vomiting, headache, cramps, and fatigue. A lowered dose can reduce side effects.
• Propranolol (Inderal) is effective in most women with PMS symptoms of headache or migraine.¹³ Propranolol is a beta-blocker type of medication that is most commonly used to treat heart-related conditions.

What To Think About

Using your menstrual diary, show your health professional which symptoms are the most bothersome to you. He or she can then recommend treatment that focuses on relieving your worst symptoms. See an example of a menstrual diary (What is a PDF document?).

If you are considering medication treatment, it may be helpful to think about and discuss some of the following questions with your health professional:

How effective has the medication been for other women?

Some medications and dietary supplements have been shown to be effective in relieving symptoms of PMS. Other medications used to treat PMS have been shown to be no more effective than a "sugar pill" (placebo). Some of these medications, such as progesterone, may be recommended. However, it is better to use medications, vitamins, or minerals that studies have shown to be effective. You may also want to think about the cost of a medication that may or may not work.

What are the medication's side effects?

The side effects of some medications may be just as unpleasant as your PMS symptoms. For example, gonadotropin-releasing hormone agonists (GnRH-a) and danazol have significant adverse side effects. In other cases, the relief from symptoms that a medication gives may far outweigh any side effects it causes.

How often will you have to take the medication?

Some medications must be taken every day, but others may only be taken when your symptoms are present. If your symptoms are not severe and do not last long, you may not think the benefits of medication treatment are worth taking the medication every day.

FDA Advisories. The U.S. Food and Drug Administration (FDA) has issued:

• An advisory on antidepressant medicines and the risk of suicide. The FDA does not recommend that people stop using these medicines. Instead, a person taking an SSRI should be watched for any warning signs of suicide. This is especially important at the beginning of treatment or when doses are changed.
• A warning about the antidepressants Paxil and Paxil CR and birth defects. Taking these medicines in the first 12 weeks of pregnancy may increase your chance of having a baby with a birth defect.

In the past, some women with premenstrual dysphoric disorder (PMDD), the severe form of premenstrual syndrome, were treated with surgical removal of the ovaries (oophorectomy) and the uterus (hysterectomy). Without functioning ovaries, a woman's body doesn't make eggs, estrogen, and progesterone and no longer has a menstrual cycle.

Surgical removal of the ovaries for PMDD is highly controversial and rarely done.⁷ It is only considered if a woman meets all of the following criteria:

• PMS symptoms are severe and regularly disrupt her quality of life.
• She has no future plans to have biological children, and she is many years away from natural menopause.
• Symptoms improve with the use of medications that produce a condition similar to menopause (such as danazol or a gonadotropin-releasing hormone agonist [GnRH-a]). However, even if symptoms improve during danazol or a GnRH-a treatment, it is possible that the medication is not the reason for the improvement.
• All other treatments have failed.
• All or most of the symptoms are directly related to PMDD. Other problems, such as psychological or nonmedical problems in her life or environment, do not appear to contribute to the symptoms.

Although oophorectomy ends premenstrual symptoms, it also leads to early menopause and perimenopausal symptoms that tend to be more severe than those of natural menopause. Early menopause also increases the risk of osteoporosis because low estrogen leads to bone density loss. Because of this, women with no ovaries are advised to take estrogen (HRT or ERT) at least until menopausal age to protect against bone loss.

• Estrogen-progestin hormone replacement therapy (HRT) is used when the ovaries but not the uterus are removed, to reduce the risk of estrogen-related uterine (endometrial) cancer.
• Estrogen replacement therapy (ERT) is used after both the ovaries and uterus are removed. (Additional progestin isn't necessary to protect against uterine cancer when there is no uterus present.)

Surgery also has risks related to the procedure or anesthesia. For more information, see the topic Hysterectomy.

Although premenstrual syndrome (PMS) cannot be cured, you do have a number of lifestyle, medication, and other treatment choices that can reduce your symptoms and improve your quality of life. Although most of the therapies listed below are not considered standard treatment for PMS, you may find one or more of them helpful in relieving some of your symptoms. In general, these treatments are safe and well tolerated.

Other Treatment Choices

Complementary or alternative therapies

• Relaxation methods, including relaxation exercises, roll breathing, yoga, and massage therapy.
• Bright light therapy. Small studies of bright light therapy suggest that exposure to cool-white fluorescent light in the mornings and evenings on days when PMS symptoms are present may reduce the severity of your symptoms.²
• Sleep deprivation therapy. Though not widely studied, limiting the amount of sleep you get for one night during your premenstrual phase may improve PMS or PMDD depression. After sleeping only 3 to 4 hours at the beginning or end of one night, women with PMDD have shown improved mood, especially after one recovery night of sleep.¹⁴ This is thought to be linked to a change in circadian rhythms, which seem to be abnormal in women with PMDD.¹⁵

Vitamin and mineral supplements often recommended for home treatment of PMS and PMDD

These supplements are commonly recommended for PMS home treatment:

• Calcium. This mineral affects the hormone-producing endocrine system. Calcium is strongly linked to PMS symptoms and relief.⁸ A high level of calcium intake [1200 mg], broken up into three doses per day, may improve your negative moods and reduce fluid retention and pain. Calcium has the added advantage of reducing the risk of osteoporosis.
• Magnesium. Some women with PMS have been found to have low magnesium levels, which are linked to abnormal levels of chemicals (prostaglandins) that increase pain and inflammation. Two or more months of daily magnesium has been shown to reduce premenstrual bloating (water retention).¹⁶ Magnesium is also likely to improve premenstrual pain and may improve negative mood.¹²
• Vitamin B6 (pyridoxine). This vitamin affects the endocrine system and helps the body use magnesium. Although research and expert opinions are mixed, daily vitamin B₆ is likely to improve PMS depression and physical symptoms.^{12, 3} Take no more than 100 mg daily to avoid toxic effects on the nervous system.
• Vitamin E. Taken during the premenstrual phase, this vitamin supplement is a recognized treatment for breast tenderness.¹ It may also reduce mood and physical symptoms.³ Improvement in weight gain, anxiety, headaches, sweet cravings, depression, insomnia, and low energy are possible.

Other mineral or herbal therapies sometimes used for PMS

• Zinc. Zinc may help improve PMS-related acne.
• Vitex (agnus-castus, or chasteberry). Although vitex's action on the body isn't well understood, it does seem to change hormone levels that affect ovulation and estrogen production.¹² Studies have shown that vitex reduces irritability, anger, breast tenderness, bloating, cramping, and headaches.⁵ Possible side effects include nausea, gastrointestinal upset, and malaise.¹²
• Ginkgo biloba. Ginkgo may reduce breast tenderness, bloating, and weight gain.⁵ More study is necessary before ginkgo can be considered a proven PMS treatment.
• Black cohosh. One study has shown that black cohosh relieves PMS symptoms of anxiety, tension, and depression.⁵
• Evening primrose (Oenothera biennis). The oil of evening primrose is a rich source of gamma-linolenic acid (GLA), an essential fatty acid, which is thought to affect prostaglandin effects, such as pain, on the body. It may offer mild relief of breast tenderness.¹ However, most studies have not shown that evening primrose relieves PMS symptoms.^{5, 12}

What To Think About

You can buy vitamin and mineral supplements and herbal remedies in drugstores, grocery stores, or health food stores.

When trying an alternative therapy for PMS or PMDD, first try those that are most known to be effective. Try a therapy for two to three menstrual cycles: to be helpful, some therapies may require use for more than one cycle.

As with all supplements, it is important to follow the directions on the supplement label. Do not exceed the maximum dose. If you are trying to become pregnant but want some relief from your PMS symptoms, discuss using nutritional supplements and herbal remedies with your health professional. Certain supplements and remedies have side effects that should be avoided if you are trying to become pregnant.

Pamphlet

• Anxiety
• Birth Control
• Depression
• Fitness
• Menopause and Perimenopause
• Stress Management

Citations

1. Dickerson LM, et al. (2003). Premenstrual syndrome. American Family Physician, 76(8): 1743–1752.

2. Steiner M, Born L (2000). Diagnosis and treatment of premenstrual dysphoric disorder: An update. International Clinical Psychopharmacology, 15(Suppl 3): S5–S17.

3. Bhatia SC, Bhatia SK (2002). Diagnosis and treatment of premenstrual dysphoric disorder. American Family Physician, 66(7): 1253–1254.

4. Yonkers KA, et al. (2005). Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder. Obstetrics and Gynecology, 106(3): 492–501.

5. Dog TL (2001). Integrative treatments for premenstrual syndrome. Alternative Therapies in Health and Medicine, 7(5): 32–39.

6. Halbreich U, et al. (2002). Efficacy of intermittent, luteal phase sertraline treatment of premenstrual dysphoric disorder. Obstetrics and Gynecology, 100(6): 1219–1229.

7. Davis AJ, Johnson SR (2000). Premenstrual syndrome. ACOG Practice Bulletin No. 15, pp. 1–9. Washington, DC: American College of Obstetricians and Gynecologists.

8. Grady-Weliky TA (2003). Premenstrual dysphoric disorder. New England Journal of Medicine, 348(5): 433–437.

9. Arias R (2002). Premenstrual syndrome. In DR Mishell et al., eds., Management of Common Problems in Obstetrics and Gynecology, 4th ed., pp. 253–255. Malden, MA: Blackwell.

10. Stanford JB, et al. (2002). Timing intercourse to achieve pregnancy: Current evidence. Obstetrics and Gynecology, 100(6): 1333–1341.

11. Wilcox AJ, et al. (2000). The timing of the "fertile window" in the menstrual cycle: Day-specific estimates from a prospective study. BMJ, 321(7271): 1259–1262.

12. Girman A, et al. (2003). An integrative medicine approach to premenstrual syndrome. American Journal of Obstetrics and Gynecology, 188(5, Suppl): S56–S65.

13. Diegoli MSC, et al. (1998). A double-blind trial of four medications to treat severe premenstrual syndrome. International Journal of Gynecology and Obstetrics, 62(1): 63–67.

14. Parry BL, et al. (1995). Early versus late partial sleep deprivation in patients with premenstrual dysphoric disorder and normal comparison subjects. American Journal of Psychiatry, 152(3): 404–412.

15. Parry BL, et al. (1997). Temperature circadian rhythms during the menstrual cycle and sleep deprivation in premenstrual dysphoric disorder and normal comparison subjects. Journal of Biological Rhythms, 12(1): 34–46.

16. Walker AF, et al. (1998). Magnesium supplementation alleviates premenstrual symptoms of fluid retention. Journal of Women's Health, 7(9): 1157–1165.

Author:	Kathe Gallagher, MSW	Last Updated June 19, 2006
Medical Review:	Renée M. Crichlow, MD - Family Medicine Deborah A. Penava, BA, MD, FRCSC, MPH - Obstetrics and Gynecology
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