Premenstrual syndrome (PMS) refers to the variation of physical and mood symptoms that appear during the last one or two weeks of the menstrual cycle and disappear by the end of a full flow of menses. This is a diagnosis used by Ob-Gyns and primary care physicians. Psychiatrists and other mental health workers tend to use the diagnosis term of premenstrual dysphoric disorder (PMDD) to describe a specific set of mood symptoms that are also present the week before menses and remit a few days after the start of menses and also interfere with social or role functioning. Is there any difference between the two or do they represent the same entity? Most doctors believe these two terms refer to the same clinical entity.
A recent educational series from the Association of Professors of Obstetrics and Gynecology, Ling FW, Mortola JF, Pariser SF st al.: Premenstrual syndrome and premenstrual dysphoric disorder: Scope, diagnosis, and treatment. 1998 Pragmaton, Chicago IL., looked at the components that go in to each of these diagnoses.
How common is PMS?
Up to 80% of women have cyclic symptoms associated with their menses but only about 3-5% have symptoms so severe that it interferes with work, school, usual activities or relationships. The average onset is 26 years of age with symptoms often becoming worse over time. Other mental health problems and diagnoses are often associated with PMS and PMDD, especially major and minor depression.
What are some of the actual symptoms of PMS and PMDD?
PMS looks more at physical symptoms such as bloating, weight gain, breast tenderness, swelling of hands and feet, aches and pains, poor concentration, sleep disturbance, appetite change, and psychologic discomfort. Premenstrual dysphoric disorder has as part of its definition, symptoms such as depressed mood or dysphoria, anxiety or tension, emotional lability, irritability, decreased interest in usual activities, concentration difficulties, marked lack of energy, marked change in appetite, overeating or food cravings, sleepiness or insomnia, and feeling overwhelmed.What other diagnoses can be confused with PMS and PMDD?
The differential diagnosis includes:Many times it is extremely difficult to rule out a premenstrual exacerbation of another mood or physical disease versus a primary diagnosis of PMS or PMDD, or even the possible combination of both a medical or psychologic disorder and PMS.
What causes PMS?
There is moderate evidence to support the theory that premenstrual symptoms are caused primarily by changes in brain chemicals that transmit between nerves and cells (neurotransmitters) brought about by cyclical fluctuations in ovarian hormones. PMS does not occur before menarche, during pregnancy and after menopause, either natural or surgical.
Is PMS hereditary?
Current research indicates that there is a possible genetic factor in the development of PMS and may explain as high as 35% of symptoms. Several studies of twins indicate a higher incidence of PMS symptoms in identical female twins versus non-identical female twins. Family environment may also play a role in that a high prevalence of a history of sexual abuse has been found in women seeking treatment for PMS.What can I do to see if I have PMS?
You need to see your doctor to make sure none of the other problems are confusing the symptoms. The doctor will probably check your thyroid studies (TSH), blood sugar for diabetes, blood count for anemia and evaluate your history and physical findings to rule out automimmune disease, vascular disease, seizures and endometriosis among others. The doctor may want you to take some psychometric written tests to see if depression, anxiety or even panic disorder are playing a role in your symptoms.
The hallmark of PMS diagnosis is prospective symptom charting. Without it, the diagnosis of PMS cannot be accurately made. The reason for this is that retrospective recall has almost always been found to be markedly different from prospective charting. While you may think there is a one-to-one variation of symptoms with your menstrual cycle, prospective charting often shows that symptoms are present all of the time and represent basically a mood disorder more than just PMS. That mood disorder is where treatment needs to be directed. The doctor will give you a chart to track the severity of some of your symptoms over one or two months. There needs to be at least a week that is symptom free in the first part of your menstrual cycle in order to diagnose PMS.
What are some of the possible treatments for PMS?
The best treatments are often the simplest. Dietary change can help dramatically. Discontinuance of all caffeine containing products, drinks and over-the-counter medications. A low carbohydrate diet, especially avoiding any simple sugars and only sparingly having complex carbohydrates is beneficial. Calcium supplements (1200 mg/day) also have been shown to help. Vitamin B6 (pyridoxine) has contradictory evidence of its efficacy and progesterone treatment used in the past has been shown to be no better than placebo.
Common prescription medicines used are included in the table below:
| Class of drug | Medicine | Dose |
|---|---|---|
| Antidepressants | fluoxetine (Prozac®) | 20 mg/day |
| sertraline (Zoloft®) | 50-150 mg/day | |
| paroxetine (Paxil®) | 10-30 mg/day | |
| clomipramine (Anafranil®) | 25-75 mg/day (14 days before menses) | |
| Antianxiety | alprazolam (Xanax®) | 1-2 ug/day (6-14 days before menses) |
| buspirone (Buspar®) | 25-60 mg/day (12 days before menses) | |
| Ovulation suppression | GnRH agonist Lupron® | 3.75 - 7.5 mg/monthly I.M. |
| GnRH agonist Buserelin | 400-900 ug/day intranasal | |
| Danazol (Danocrine®) | 200-400 mg/day at onset symptoms |
New categories of drugs have recently become available for the prevention of osteoporosis without all of the uterine and breast tissue stimulation effects of normal postmenopausal estrogen replacement therapy (ERT). These new drugs, selective estrogen receptor modulators (SERMs), are important for women because a woman's lifetime relative risk of hip fracture is equal to the development of breast, uterine and ovarian cancer combined. Also, only 20 to 30% of women who are prescribed ERT remain on it for over a year. The biggest reason they stop it is because of irregular uterine bleeding and because of the side effects from the progestin therapy needed to counteract the endometrial effect of estrogen alone. The biggest reason women never start on ERT or never fill their prescriptions is fear of breast cancer.
A recent review article, Goldstein SR: Selective estrogen receptor modulators: A new category of therapeutic agents for extending the health of postmenopausal women. Am J Obstet Gynecol 1998;179:1479- 84. has given us the material to answer some questions that women have about ERT.
If I need estrogen for the control of hot flashes and vaginal dryness, will any of the new medications help that without increasing my risk for breast cancer?
No. In general these specialized estrogens either make hot flashes worse (tamoxifen) or no real improvement (raloxifene). Neither of them help with vaginal dryness either, so lubrication or topical estrogens may be needed for this problem.
If I have a family history of heart disease, which medications are best for me?
Right now, only estrogen (conjugated estrogens, estradiol) has been studied and shown to decrease the new occurrence of heart disease. If you already have heart disease, estrogens may be associated with more adverse events when treatment is first started. Tamoxifen and raloxifene (Evista®) both lower total cholesterol and low density lipoproteins, but they do not increase the good cholesterol, high density lipoproteins. We do not know yet if they will prevent the new occurrence of heart disease. It is unlikely, however, they will cause heart disease.
Can I prevent osteoporosis and heart problems without increasing my risk for breast cancer or uterine cancer?
Raloxifene (Evista®) does not cause tissue proliferation in either the breast or the uterus as opposed to tamoxifen which seems to prevent breast cancer but causes endometrial cancer in up to 4% of women on long term use. They both help prevent osteoporosis.
If I already have osteoporosis can I use these new drugs?
These compounds prevent osteoporosis but the data is not yet in on treatment of osteoporosis. Right now either estrogens or the bisphosphonate, Fosamax® are recommended for osteoporosis treatment. If the side effects of the Fosamax® (stomach upset) are too great or estrogens are contraindicated, raloxifene (Evista®) should be a good substitute.
What are the side effects I can expect from the new selective estrogens?
Raloxifene may cause some leg cramps, but it also has a lower incidence of breast pain and abnormal uterine bleeding compared to estrogen and progestin hormone replacement therapy. If a woman is on tamoxifen for breast cancer, besides endometrial cancer, hot flashes get worse and polyps and hyperplasia of the endometrium can cause abnormal bleeding.
Which osteoporosis preventatives affect what?
| Medication | Main Use | Tissue Effect |
|---|---|---|
| estrogens Premarin® Estratab® Estrace® |
menopausal symptoms heart disease prevention | breast cancer - may stimulate or promote cholesterol - lowers LDL and raises HDL heart disease - lowers incidence of new occurrence endometrium - stimulates hyperplasia |
| tamoxifen Nolvadex® | breast cancer treatment and preventative | breast cancer - decreases,
prevents cholesterol - lowers LDL heart disease - unknown endometrium - stimulates bleeding and cancer |
| raloxifene Evista® |
osteoporosis prevention when unable or unwilling to take estrogen | breast cancer - possible treatment and
preventative but not tested cholesterol - lowers LDL heart disease - unknown endometrium - no stimulation |
| alendronate Fosamax® (not a selective estrogen) |
osteoporosis treatment | breast cancer - no known
effect cholesterol - no effect heart disease - no known effect endometrium - no known effect |
For more information on this subject on the net:
A recent set of symposium papers on the emerging role of estrogen and androgen therapy in the postmenopausal women was published in the Journal of Reproductive Medicine. There were several articles and from Vermeulen A:Plasma androgens in women. J Reprod Med 1998; 43:725-33I was able to extract a few general facts along with my personal interpretations:
| Observation | Implication |
|---|---|
| testosterone levels after removal of the ovaries are about 50% of the level of women who underwent natural menopause | women who have ovaries removed surgically need more testosterone supplementation than women who undergo natural menopause |
| estrogen levels are equally low in women who have had oophorectomy and women who have undergone natural menopause | the postmenopausal ovary doesn't manufacture estrogens of any significance |
| other androgens (androstendione, DHEA) made by the adrenal gland decrease slowly with age so that in women over age 70 they are 20% of the levels at age 20 | androgen decline is an aging process and adds to acute changes at menopause or surgical ovarian removal |
| androgens are naturally converted to estrogens by the body and the rate of conversion increases with age | the body uses natural or supplemented androgens as a source of estrogen |
| in postmenopausal women who have pain with sexual relations, estrogen improves sexual satisfaction, but in postmenopausal women without pain during sex, estrogens do not improve sexual satisfaction or sexual functioning | if vaginal dryness is present, estrogens will help sexual functioning, probably by reducing pain |
| androgen supplementation after menopause has been shown to have a positive affect on sexual desire (libido), arousal, fantasies, satisfaction, pleasure, orgasm and relevancy | androgen supplementation should be added to estrogen replacement in any women who has any symptoms or complaints of decreased sexual functioning or overall wellbeing |
| in order to get sexual mood benefits from androgens, blood levels need to be restored to upper normal levels for premenopausal women | through supplementation, levels of testosterone 1.4- 1.6 nmol/L (40-50 ng/dL) and DHEA -S -- 6-8umol/L (200-300ug/dL) are desireable if there are no signs of androgen excess (acne, increased hair growth, voice deepening, and temporal balding) |
Another basic tenet came from these articles. It is that
relief of any of the symptoms such as hot flashes, sweats, sexual
libido, vagianl dryness, is incomplete with any hormonal regimen.
Some women, 25-35%, will continue to have major symptoms and
most women who get relief will not get total relief, only about
2/3's of their symptoms.
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The Viagra (sildenafil) treatment of male erectile dysfunction will be a pharmaceutical event for the history books. This is a drug that effectively treats a male's inability to achieve or maintain an erection sufficient for satisfactory sexual performance. Is it a widespread problem? It is estimated that 39% of men 40 years of age and 67% of men 70 years of age have this problem.
A recent collaborative study looked at the efficacy of this treatment--Goldstein I et al.: Oral sildenafil in the treatment of erectile dysfunction. N Engl J Med 1998;338:1397- 1404. Various dose regimens were used, but overall in men, it improved erectile function (equivalent to the arousal phase in women with clitoral swelling and vascular swelling) by almost 100%. It improved orgasmic function by about 20% and it had ZERO effect on sexual desire. The overall intercourse satisfaction increased by 100%. The major side effects increased as dose increased and were predominantly headache, flushing (both about 20-30%) and stomach upset (about 10%). Interestingly the side effects were only a small proportion of the reasons for discontinuing the study (7-15%, at different doses, stopped participating in the study).
Why should we write about this at Woman's Diagnostic Cyber? Because there will be a significant impact on women whose partners use Viagra. There will be more frequent demands for sexual intercourse which may or may not be welcome. Many women who are menopausal report a decreased sexual desire even if they are on estrogen replacement therapy. If women are having any vaginal dryness, they may fear pain with sexual relations and that certainly turns off libido. Even if women are on estrogen replacment and have good vaginal lubrication, if they are having vaginal intercourse less frequently than once per two weeks, they will have loss of vaginal elasticity that can cause discomfort or pain when they first start to increase the frequency of sexual relations.
Sexual desire is a very complex subject-- see previous news:
There are many different components to possible sexual desire barriers.
The list could probably go on and on with different problems that will demand different solutions or treatments. I predict that this Viagra epidemic will cause epidemics in women:
On the up side, there will be many more relationships in which
the intimacy happiness level goes up. That is good!
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Have you or someone you know ever had a panic attack over being alone, having to go to a public or social function or just plain being afraid of a certain situation? Have you ever had a major life trauma, accident, rape etc. and seemed to adjust after a short while just to have some emotional anxiety creep up later? You may wonder if this is a serious mental health problem or just a life event with which you have to cope. Many women don't necessarily want to see a psychiatrist to find out, but their primary care physicans aren't always aware of the many different mental health classifications that specialists have defined.
An excellent diagnostic web site, Internet Mental Health, has been created by Dr Phillip W. Long, a Canadian psychiatrist. On this site, http://www.mentalhealth.com, he gives the diagnostic criteria for almost 60 of the most common psychiatric disorders. In addition to the descriptive diagnostic criteria, self-diagnosis modules are available so you can answer questions to see if you have a specific diagnosis. Its important to know that you do or do not qualify for a mental health diagnosis. Many of these conditions benefit from treatment.
The following table illustrates just the anxiety, eating and mood disorders that are in the site:
| Anxiety Disorders | Panic Disorder |
| Agoraphobia (Generalized Phobia) | |
| Social Phobia | |
| Specific Phobia | |
| Obsessive-Compulsive Disorder | |
| Posttraumatic Stress Disorder | |
| Generalized Anxiety Disorder | |
| Acute Stress Disorder | |
| Eating Disorders | Anorexia Nervosa (self-imposed starvation) |
| Bulimia Nervosa (binge eating and dieting) | |
| Mood Disorders | Major Depressive Disorder (unipolar depression) |
| Bipolar I Disorder | |
| Bipolar II Disorder | |
| Cyclothymic Disorder |
Estrogens or more specifically, the lack of them, can worsen some of these conditions. For example agoraphobia which is a fear of going out in public places, can be aggravated by low estrogen levels and improves with estrogen therapy.
If a woman mentions to her doctor that she has a decreased desire for sex, she may receive an evasive statement or answer. It is a complex subject with many causes, not always well understood by many physicians. Sexual desire, or libido as it is sometimes called, is influenced by our own health, environmental circumstances and the behavior of our partner and others. Dr. L. Barbach recently wrote a review article that pointed out the many contributors to this problem, Barbach L. Loss of sexual desire. Menopause Management 1998;7(1):10-14.
Physical causes are often responsible. Fatigue, whether due to stress, to physical work or even sleep deficit from childcare or hot flashes, is a common cause of decreased libido. Physical muscle or joint pain, pain with intercourse and urinary incontinence may also interfere with desire for sexual relations. In this case, fear of pain or embarassment works as a supressive force. Decreased estrogen at the time of menopause may cause the vaginal skin to become thin, dry and painful with the friction of intercourse. The opening to the vagina may loose elasticity and be painful with penetration. Estrogen replacement medication can relieve many of the vaginal symptoms and even stop the hot flashes which cause sleep disturbance, but in spite of this, there still is some loss of sexual desire at the time of menopause.
Many medications that women take can have sexual side effects. Antidepressant medicines can decrease sexual desire above and beyond the effect that the depression itself has. Pain drugs such as opiates block testosterone synthesis and decrease sexual response. Antihypertensive medications notoriously affect sexual response in men and are thought to have a lesser but real effect in women also.
A woman's sexual interaction with her partner can affect desire. If the partner loses desire due to physical fatigue, medications or any reasons, a woman may unconsciously suppress her own desire. If she feels unattractive or anxious or even critical of her partner's lovemaking skills, sex is naturally avoided. Any barriers to communication about a couple's sexual relationship can create dissatisfaction. Past sexual abuse or rape trauma may lie dormant for years and only surface when a woman is safely involved in a committed relationship.
In spite of all the possible causes that can affect sexual desire, the most frequent cause of libido decrease among women is her non-sexual relationship with her partner. Problems over power struggles, resentment, feelings of being unimportant or just plain anger about past behavior can occur at any stage in a couple's life and are often the most common causes of decreased sexual desire. Marital problems frequently come to the surface at midlife.
With all of the above complex interactions, its understandable how the statement "I don't seem to care for sex as much as I used to" puts up a red flag to the physician about the amount of time that problem is going to take. A desireable response might be: "Decreased sexual desire is a complex problem that we will need to take time to investigate. Perhaps we could schedule another appointment for a longer time period so I can give this the attention it deserves."