Premenstrual Syndrome Explained

Premenstrual Syndrome


Premenstrual syndrome is described as a variety of physical, Psychological and cognitive symptoms which occur regularly and cyclically during the luteal phase of the menstrual cycle and disappear after the commitment of menstruation. This paper will look at the history, the different theories on the pathogenesis of PMS, treatment and management. And finally, we will look at how it is diagnosed.


PMS was first described by Robert Frank in 1931, after noticing high levels of estrogen which he called premenstrual tension. Frank theorized that the sauce of the condition was hormonal, frank’s prescription of this condition was complete radiation and removal of the ovaries. Katharina Dalton later in 1953 co-wrote a paper that introduced the name premenstrual syndrome, and according to her, PMS was responsible the decreased productivity. In 1981 while serving as a defence doctor, she testified for the murder trial where the woman was cleared because she was able to show that the accused suffered from PMS. That case brought to light the syndrome after years of telling the woman that it was all in their head (Kumar et al. 2014).

Normal physiology

Menstruation has three main phases each with varying levels of hormones that are released, the first one is the follicular stage. Estrogens and progesterone start out at there lowest levels, follicular stimulating hormones levels rise, causes stimulation and maturity of the follicles. Also, production of estrogen by the ovaries causes the levels to rise while maintaining progesterone levels remain at constant. In the Ovulation stage which happens at day 14, there is a surge in the luteinizing hormone. Between 14 and 28, the follicles raptures and turn into corpus luteum, the corpus luteum then secrets progesterone and estrogen in readiness for implantation. If fertilization happens, the fertilized egg attaches to the layer of the blood vessels that supply nutrients to the developing placenta. If fertilization does not happen the corpus luteum disintegrates progesterone and estrogens levels fall, the blood vessel lining is shed off, and menstruation begins (Meera S. Beharry, 2015).

Description (Pathology)

Doyle et al. (2015) describe PMS as a group of symptoms that happens during the luteal phase of the menstrual cycle and is of unknown origin. They theorize that the symptoms you see PMS during the luteal phase might be due to suppression of the immune system. (Sanders et al., 1983) in contrast, found a relationship between PMS and ovarian sex hormones. (Walsh et al.2015) Also reported that the general census is that the ovarian cycle plays a part in the symptoms you see during PMS. This is because there are no symptoms of PMS before puberty, during pregnancy and after menopause. Sex hormones like GnRH and LH play a part, evident in the fact the symptoms of PMS go away when being treated with GnRH (Rapkin et al.2014). Sex steroids easily pass through the blood-brain barrier, the sex steroid receptors can be found in some places including and not limited to the amygdala and hypothalamus. (Kumar et al. 2014) Recently theorized that progesterone is broken down to Allopregnanolone and pregnenolone in the brain. These stimulate the gamma-Aminobutyric acid (GABAa) which is associated with mood changes.

The by-products of progesterone break down, pregnenolone and allopregnanolone further produce anxiolytic, which has sedative effects. However, at lower levels, these can cause anxiety, negative mood and aggression.  The GABA receptors become less sensitive to allopregnanolone after exposure to high concentrations. In so doing they increase the symptoms that are experienced during the luteal phase of menstruation. Also, serotogenic activity in the brain is also affected by progesterone and estrogen.  Evident by the fact, selective serotonin reuptake inhibitors have shown to help with the symptoms of PMS. Progesterone increases monoamine oxidase, which reduces the availability of hydroxytrytamine. High levels of hydrotrytamine results in depressed moods. Estrogen has ant depressive effect in that it increases the break down of MAO. MAO then increases the availability of free tryptophan in the brain which enhances serotonin transports. (Monash University, 2011) Found that, at the start of PMS women tend to have an increased sensitivity to Luteinizing hormone at the corpus luteum. Other possible causes of PMS are lack of poor diet, over-consumption of alcohol and low levels of vitamins (Cunningham et al, 2009).

Treloar et al. (2002) found a genetic basis to the symptoms that are experienced during PMS, this is based on 720 twin pairs.  This is supported by (Sharma, Kansal, & Chopra, 2013) when they investigated the phenotypic variation in the gene TAS2R38. The study found that females who tested PTC bitter at lower levels had low levels of PMS while females that only tested at higher levels had higher levels of PMS. A severe form of PMS is Premenstrual dystrophic disorder, PMDD has more severe symptoms than PMS. Individual with PMDD present a marked increase in depression, anger and anxiety about a week before menstruation and stops after (Sharma, Kensal & Chopra, 2013). How it stats is still and mystery, research has also found that it is also related to hormonal imbalance during the luteal stage of the menstrual cycle.

Other hormonal imbalances that have been reported are thyroid indices, also study on women with PMS have found a deviation from the normal secretion. Numerous studies have shown that at least 20% of adolescents at any point will suffer from moderate to sever forms of PMDs that may affect there daily functioning. Statistics show that about 3-8% of woman suffer from PMDD in the world and about 30% of women with normal cycle. Finally, Lang (1998) found women that women that had severe forms of PMS had histories of physical or sexual abuse. They found this was probably due to the deregulation of the stress response system.



There is no set way currently used to diagnose PMS, as the hormone levels remain constant during this period, the royal college of obstetrics and gynaecology have given the following guidelines. Diagnosis of PMS is usually done through accurate charting of the symptoms over two months. An individual should record daily the presence of symptoms especially during the luteal phase of menstruation (Walsh et al.2015). The symptoms have to stop when the menstruation starts, these guidelines have not changed since 2000. There are over 100 symptoms that women show when they have PMS or PMDD, the most common ones are; Insomnia, bloated stomach, depression or anxiety, headaches and back pain. People at risk of PMS are women between the age of 20 and early 40’s, have at least one child and a history of depression in the family (Andrea J. Rapkin, 2013).

Treatment and Therapy

When Robert Frank first described PMS in 1931, he used to treat women with radiation. Over the years as we have known more about the PMS, treatment as changed as well. When a woman is found to have PMS treatment is done step by step depending on how severe the symptoms are. According to the royal college of obstetrics and gynaecology, the first step is to try non-pharmacological methods. (Schellenberg 2001) In a controlled study showed a 52% improvement in PMS symptoms when women where on an extract of Agnus castus fruit, however, this cannot be trusted because of the size sample of the study. Ayres et al. (2010) In a randomized, double-blinded and crossover study on 36 women that used St Johns wort found mixed results.  Found that in the first cycle the study found an improvement in Mood, insomnia and confusion while in the second cycle the study showed no improvement in moodiness, confusion and insomnia this is supported by (Ambrosini et al., 2013). Who also found pain-related symptoms to have improved in women with milder forms of PMS.

Other non-pharmacological methods that are used are; cognitive behavioural therapies that address stress management relaxation and assertive training.  Also, exercise helps with the symptoms of PMS. For example, Pilates and other stretching techniques help reduce stress and improve general mood through the production of serotonin (State Government of Victoria, 2015). Also, adopting a healthy eating lifestyle has shown to help in the management of PMS. Finally, another triple twin study found that wheat germ products can be used to control the symptoms of PMS, this is due to the presence of B6, E, calcium and magnesium (Abdollahifard et al. 2014). In addition to the point (Kues et al. 2014), is currently conducting a study on the effectiveness of Internet-based behavioural therapy.

Pharmacological therapy

Pharmacological drugs like selective serotonin reuptake inhibitors provide more sustained but less rapid improvement of PMS. SSRI’s are currently being used in Australia as the first line of therapy in individuals with severe forms of PMS (Verma et al. 2014). If the SSRIs do not work anti-anxiety drugs like benzodiazepines can be prescribed, potential dependence on the drug may happen (Marjoribanks Jane. 2013). Pituitary-ovarian axis drugs also known as oral contraceptives were used with minimal effect. These kinds of medication are approved for use in America but not in the UK. In Australia and New Zeeland, newer contraceptives with drospirenone and ethinyl estradiol have shown to have a positive effect on the symptoms of PMS. Especially when they are given for 24 hours (Bakhshiani et al.2014).  The main side effect of this medication is venous thrombosis which is why it is not suitable all women.

Hormone therapy is used if SSRI’s do not work, several randomized studies have shown gonadotropin-releasing hormone improves symptoms of PMS (Nevette et al. 2013). SSRI’s Work by reducing the levels of estradiol and progesterone which in turn stops the maturation cycle. However, GnRH should be used only for short-term and must be reserved for individuals with the severe form of PMS. This is because it may induce vagina atrophy, eliminate ovulation and caused an increase in cardiovascular diseases. In Australia, it is recommended that treatment without add- back therapy should only be continued for 6 months. If women have receiving add-back therapy for a long time, their bone and mineral density should be monitored (Welsh et al. 2015).

Terry (2012) showed that the use of estrogen also improves the symptoms of PMS, although receiving unopposed estrogen will require progesterone otherwise you risk the development endometrial hyperplasia. In severe cases and as a last resort a hysterectomy and bilateral Salpingo-oophorectomy when done has shown to have a positive effect on both mood and physical symptoms. Analgesics such as NASIDS have shown to reduce the physical symptoms of PMS. Finally, (Murshid, 2011) reported that dopamine agonist is effective in dealing tender swelling breasts because it increases the production of thyrotropin.  Also, diuretics, which can be given during the luteal phase help reduce bloating and tender breast (Harvey, 2012). Side effects of these medications are a headache, lethargy and can severely affect the potassium levels in the blood which in turn can affect the electrolyte levels.  Ongoing assessment is important, if a woman has not responded to any of the pharmacological drugs, then they should be assessed for psychiatric disorders (Walsh et al.2015).

Complications and cultural issues

If left untreated PMS can cause the following complications; the first major one anxiety can manifest as feelings of tension women with PMS. This usually happens 2 weeks before and gets worse in the days leading to menstruation. Women report an overpowering feeling of anxiety, but with nothing to attach the anxiety and aggression too. If this continual it can affect a person’s relationships and work. The second major complication that may happen is depression that can also hinder a women way of life during that time of the months. That can affect a woman’s work and possibly impact on relationships with others. Ussher et al, (2014) reported that there are also cultural issues that play a part in either worsening the symptoms of PMS and reducing it.

For example, a study that was done in Canada and New Zeeland found that PMS among many women and men is still considered as a myth, suggesting that its all in their head. The reason they gave was up until the latter part of the twentieth century talking about PMS was not acceptable. This might have caused women to develop negative feelings about Menses. However, when the study was analyzed by the National healthy services (2012) in the UK, they advised the results be read with caution. Because the researchers used different techniques in assessing the moods of women (Bazian, 2012). (Magnoni et al. 2013) Conducted a study on the perception of PMS among men aged between the age of 19 and 21. It found that the men who had knowledge of what PMS were more likely to understand that changes that happen during that time of the month.


  • We have had a look at the normal process of the woman’s cycle, the differing views on the pathogenesis of PMS/PMDD.
  • we do not know how exactly PMS comes about, however, nearly all the current research agrees on the fact that PMS/ PMDD has a hormonal element to its aetiology.
  • Treatment of PMS is done on a step by step basis; the first line of treatment is through the use of behavioural management tactics to reduce stress.
  • If that does not work then we would move to pharmacological agents, the first medications used are SSRI. If this does not work hormone therapy should be considered, Hysterectomy is used as last resort and in worst cases.


This is a bachelor degree level paper, there are any errors we apologise, send us an email and we will make the changes.



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