Why am I so upset before menses? Battling PMS

Here is an abstract from what may be called a symptom diary:

“March 1: Menstruation begins. As usual, a slight tummy ache on first day.

“March 16: Getting tired. Insomnia last night. No appetite today. Tummy feels bloated.

“March 20: Feeling miserable. Forgetful. Breasts are painful. Tearful for no reason.

“March 22: Unable to concentrate. Feeling anxious and panicky.

“March 23: having loose stools. Breast tenderness getting worse. Upset with colleague. Feeling depressed.

“March 29: Menstruation starts again. No more negative feelings. No more breast pain.”

This account is by F, 23 and single, who had been instructed to chart her symptoms daily for three months. The physical and emotional symptoms fluctuated in intensity and timing but they were cyclical, occurring one to two weeks before menstruation and disappearing soon after.

Some of the symptom were debilitating and caused disruptions in F’s lifestyle. After excluding other psychiatric conditions, she was diagnosed as having premenstrual syndrome (PMS).

women's clinic

Common Symptoms PMS

PMS is a mixture of physical and emotional symptoms linked to the menstrual cycle. It is common, affecting about 75 per cent of females of reproductive age. It occurs mostly in teenagers and women in their early 20s.

Common physical symptoms are abdominal distention, headaches and breast tenderness. Psychological symptoms include fatigue, forgetfulness, poor concentration, irritability and depression.

To confirm the diagnosis, the patient has to chart her symptoms daily. These emerge about two weeks preceding menses and resolve completely when menstruation starts. In pregnancy and menopause, when menstrual cycles are absent, patients are completely symptom-free.

While symptoms may be particularly intense in some months, they may only be slightly noticeable in others. For most women, symptoms are not severe enough to affect their daily routines and activities but in a small proportion of women (about 5 per cent), they can be severe and disabling.

The exact cause of PMS is still unknown. Recent research indicates that women vulnerable to premenstrual mood changes do not have abnormal levels of hormones or disturbances in hormonal regulation.

It is probably a result of the brain’s sensitivity to normal cyclical hormonal changes. There is an abnormal transmission of serotonin, a brain chemical that plays a crucial role in mood regulation. This may explain why symptoms such as irritability, moodiness or depression, sleep problems and food cravings are associated with PMS.

During our counselling sessions, I gave F relevant information about her condition. This is important in PMS management as studies find that women educated about its biological basis have an increased sense of control over and relief of the symptoms.

F kept a symptom diary. This helped her to identify the triggers and timings of symptoms so that behavioural intervention could be implemented. Psychotherapy, using behavioural cognitive therapy and stress management, may also ameliorate or eliminate symptoms.

In addition, F kept to a structured sleep schedule with consisted sleeping and waking times during the second half of menstrual cycles. This was to ensure that she had adequate rest as sleep disturbances would affect her mood.

She was advised to exercise regularly in gym. Women with PMS who did aerobic exercises reported fewer symptoms.

F was encouraged to eat healthy, balanced diet rich in fruit, vegetables and wholegrain carbohydrates. This promotes good health and a sense of well-being. Dietary changes were suggested, including salt restriction to minimize bloating, fluid retention and breast swelling and tenderness

She was also told to avoid caffeine to reduce irritability and insomnia. Evening primrose oil supplements were added although there is no general consensus on their benefits.

After two months of these lifestyle adjustments, F’s physical symptoms improved although emotionally, she still had occasional panic attacks and depression. I prescribed a small dosage of Zoloft during second half of her cycle.

This is a psychiatric drug from the group Selective Serotonin Reuptake Inhibitors. Numerous double-blind, randomized studies support its effectiveness. F responded very well to the drug and is now on her way to recovery.

Dr Peter Chew is a highly experienced Gynae Doctor based in Gleneagles Hospital, Singapore. If you require gynaecology or fertility treatment services, feel free to make an appointment with us.