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No woman should risk job, relationships or peace of mind because of PMS

Almost every woman who ovulates experiences premenstrual changes she recognizes as an impending period. For many, those changes, which may include breast tenderness, bloating or food cravings may be annoying, but they don't cause a significant problem. About half of my patients have some PMS symptoms, and of those, about 10 percent experience symptoms serious enough to disrupt their lives. Three to 5 percent of patients have very severe symptoms.

Charting very helpful in establishing diagnosis
When I started in practice a couple of decades ago, women who complained of PMS were often pooh-poohed, and the symptoms were attributed to being "all in your head." Fortunately, we know better now, although we still don't know precisely what causes PMS. Despite years of research into things such as the possibility of hormonal imbalances or vitamin and mineral deficiencies, we still don't know the cause and we have no physical test for PMS.

That's why I've found charting to be so useful. I give my patients who report PMS-like symptoms a chart that lists 13 symptoms that include both physical and psychological symptoms—such as irritability, bloating, breast tenderness and relationship problems. I ask them to track whether they have severe, moderate, mild or no symptoms in each category for each day for a couple of months.

Ruling out other causes
This chart may help reveal that another condition such as depression, endocrine disorders, diabetes, etc., is the real cause of a woman's symptoms. Even though symptoms of these other conditions may worsen during the second two weeks of a woman's cycle, unless the symptoms are restricted to that time and abate when her period starts, PMS is not causing them. In such cases, we treat the underlying condition first, which could eliminate the need for premenstrual therapy.

I've found that the very act of charting can help a woman feel in more control of her symptoms. It can also help her plan challenging or stressful activities, and it can help her family and friends be more understanding and less demanding when her period approaches.

Treatment options
Once we've established PMS as the cause of discomfort, I talk with my patients about their options. Every woman, whether disturbed by premenstrual symptoms or not, can benefit from good health habits, such as getting adequate sleep, consuming a healthful diet, exercising regularly and practicing stress management techniques.

For many of my patients, beginning an aerobic exercise program, cutting down on sweets and salt and getting a good night's sleep mark the beginning of the end of PMS. One of my patients discovered the more she ran, the less PMS she had. Today's she's postmenopausal, but still runs marathons.

I also encourage women with painful breasts to cut down on caffeine and try the herb, evening primrose oil, which relieves this symptom for many women. Calcium and vitamin B6 may also help other symptoms. Most women can benefit from taking 1,000 milligrams (mg) of calcium daily. Aim for a total calcium intake of 1,200 mg per day, and be sure you take the supplements along with food so they're properly absorbed.

One hundred milligrams of vitamin B6 may relieve a wide range of symptoms, including depression. I would caution women that taking more than 100 mg of B6 can be toxic, so track how much you take carefully.

PMDD: the most debilitating form of PMS
Sometimes these lifestyle changes and/or supplements can eliminate or reduce symptoms sufficiently to make all the difference in a woman's life, but when such changes do not provide sufficient relief, the patient may be suffering from premenstrual dysphoric disorder, or PMDD, the most severe form of PMS.

For 3 to 5 percent of patients, symptoms are more extensive and highly debilitating, involving emotional as well as physical disturbances that can make it difficult, if not impossible, for them to cope with tasks and stresses that they handle readily during the rest of the month.

For these women, remedies such as antidepressant and anti-anxiety drugs can help. Serotonin-enhancing antidepressants, such as Sarafem, which is a low-dose form of fluoxetine (Prozac^®), taken during the last two weeks of a woman's cycle can make a huge difference.

It's interesting to note that women who take these medications for depression generally don't notice a difference in their symptoms for several weeks, whereas a woman with PMDD sees a change within a day or two. Depression and PMDD are two separate diseases, and I think it's helpful to differentiate the medications used to treat them with two different names even though they are the same chemically.

The serotonin selective reuptake inhibitors (SSRIs) represent a real advance in our treatment of women with severe PMS. No woman should have to risk her job, relationships or peace of mind because of premenstrual disturbances.

Dr. Minkin is an attending gynecologist/obstetrician at Yale-New Haven Hospital and a clinical professor in obstetrics and gynecology at the Yale School of Medicine. She is a partner of the Gynecology and Infertility Group with offices in New Haven, Guilford and Essex.