Helping Your Clients Understand and Manage Premenstrual Syndrome

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UPDATED August 2015

Premenstrual Syndrome (PMS) is characterized by a set of hormonal changes that trigger disruptive physical and emotional symptoms in women for up to two weeks prior to the onset of menstruation. Premenstrual symptoms usually taper off with menstruation and women remain symptom-free until the two weeks (mid-cycle) or so prior to their next menstrual period.

Mild to severe disruptive symptoms brought on by hormonal shifts prior to the onset of menses occur in an estimated 40 million women. More than 5 million require medication for marked mood and behavioral changes. The symptoms of PMS vary from woman to woman and from cycle to cycle, with intensity ranging from mild to moderate to incapacitating. Researchers estimate that about 20 to 40 percent of women who have PMS experience symptoms that make life difficult; another 2.5 to 5 percent report that their PMS is debilitating.

More than 150 symptoms of both physical and emotional origin have been associated with PMS. The most common physical symptoms include headache, migraine, fluid retention, abdominal cramping, fatigue, food cravings and breast tenderness. Common emotional symptoms include uncontrollable crying spells, anxiety, anger, irritability, depression, panic attacks and poor concentration. Symptoms may vary from month to month and there can even be symptom-free months.

Hormonal levels play a key role in PMS. The hormone estrogen begins to rise following menstruation and peaks around mid-cycle, or at ovulation. If pregnancy does not occur, estrogen levels rapidly decline following ovulation and then rise again just before the onset of menstruation. Since estrogen tends to attract fluids in the body, bloating usually occurs during estrogen peaks. In addition, blood sugar reduction and salt retention occur during estrogen peaks. The hormone progesterone is produced by the corpus luteum after ovulation and is purported to balance the effects of an increased level of estrogen. Some experts believe that high levels of stress yield high levels of cortisol, which blocks the progesterone from reaching its receptors. This equates to a predominance of estrogen in relation to progesterone.

Researchers are pursuing clues to explain what may cause the susceptibility to PMS in some women, but not in others. One possibility now being investigated is genetic differences in the sensitivity of receptors and related messenger systems that relay sex hormone signals within cells. Other clues include possible differences in patients’ histories of other mood disorders or in serotonin function.

There is no single diagnostic test for PMS. Tests may rule out other conditions in women who experience severe symptoms, though emotional and physical changes in sync with a woman’s menstrual cycle are usually a telltale sign.

A daily diary kept over the period of two to three months is one of the best tools to begin to identify and rate the severity of premenstrual symptoms. Begin by making two lists: the first includes three to five of the most acute physical symptoms and the second includes three to five of the most acute emotional symptoms prevalent during the two weeks prior to menstruation. On a daily basis, rate each symptom in both categories on a scale of 0 -10 (0 indicating no symptom; 10 indicating the most severe). Average each category daily and write the respective numbers on a calendar for that day. Keep track and note on the same calendar dates of ovulation and when menstruation begins. Doing this for several months provides an overview of when symptoms occur in relation to ovulation and menstruation, as well as their severity. Taking this information to a medical doctor can eliminate many unnecessary tests as well as provide valuable information leading to appropriate medical treatment.

Treating Symptoms Associated with PMS

Many experts recommend a multi-faceted approach for treatment of symptoms associated with PMS. The first line of treatment includes lifestyle modifications that can effectively reduce symptoms. Treatment includes:

Diet – General guidelines for a healthy diet are recommended overall with elimination or reduction of the intake of caffeine, alcohol, sugar and salt during the 14 days prior to menses. Also a 2000 study reported that women who followed a low-fat vegetarian diet for two menstrual cycles experienced less pain and bloating and a shorter duration of premenstrual symptoms than those who ate meat. More than one study reported less menstrual pain with a higher intake of omega-3 fatty acids. Omega-3’s are found in oily fish such as salmon, mackerel and tuna.Studies have shown that increasing complex carbohydrates is helpful for PMS. Carbohydrates increase blood levels of tryptophan, an amino acid that converts to serotonin, the brain chemical important for feelings of well-being. Whole grains and vegetables are preferred over simple carbohydrates such as sugar and starch – heavy foods, such as pastas, baked goods, white-flour products and potatoes.

Vitamins – According to British researchers, taking 50 milligrams of vitamin B6 daily may be effective in relieving the symptoms of PMS, including depression. The researchers reviewed nine published trials in which vitamin B6 was compared with (an inactive) placebo in more than 900 women with PMS. Doses of vitamin B6, up to 100 milligrams daily, were significantly better than placebo in relieving overall premenstrual symptoms and in relieving depression associated with PMS.Other vitamins and minerals that have been found to help relieve some PMS symptoms include the following: Folic acid (400 mg); Calcium with Vitamin D (1200 mg/day for women over 50); Magnesium (400 mg); Vitamin E (400 IU).

Exercise – Aerobic exercise, say the experts, increases endorphins and improves mood. In one study, women who jogged an average of 12 miles a week for six months experienced reduced PMS symptoms while a comparable group of women who remained sedentary did not improve their symptoms. A 30-minute walk, bicycle ride, swim or other aerobic activity every day is also beneficial to improve overall health and alleviate certain symptoms such as fatigue and a depressed mood. Yoga is helpful in that it regulates breathing, releases muscle tension and reduces stress – all of which can improve PMS symptom severity.

Massage and Bodywork – Research conducted by William Flocco and Dr. Terry Oleson in England found that foot, hand and ear reflexology reduced PMS symptoms by 46 percent during eight weeks of reflexology treatments. A reduction of symptoms continued for eight weeks following the treatments in 42 percent of participants and reflexology had none of the side effects of drugs used in other studies.Tiffany Field of the Miami Touch Research Institute conducted a study that substantiates the successful use of massage as an effective long-term aid for pain reduction and water retention, a short-term aid for decreasing anxiety and improving mood, and an overall benefit for women with premenstrual dysphoric disorder (PMDD), a severe form of PMS. Results indicated that the massage therapy group experienced a decrease in anxiety, depression, perceived pain and an overall reduction in PMS symptoms, including pain and water retention.

Alternative Therapies – Acupuncture was found to be effective in alleviating the triple-warmer spleen imbalance associated with PMS when Spleen 6 and 10 were needled. The combination of Large Intestine 4 and Spleen 8 is also used to ease PMS pain. Acupressure on these points is also effective. Aromatherapy relieves menstrual cramps with essential oils of chamomile, lavender, marjoram and melissa. For depression associated with PMS clary sage is excellent, but neroli, jasmine and ylang-ylang may be just as effective. If water retention is a concern use grapefruit, carrot seed and juniper. Some women report relief from PMS symptoms with the use of herbs such as ginkgo, ginger, chasteberry, evening primrose oil and St. John’s wort.

For best results, incorporate these lifestyle changes and track symptoms on a calendar for at least three to six months to get an accurate overall picture of the condition. If symptoms persist or become more severe, Premenstrual Dysphoric Disorder (PMDD) may need to be addressed. In PMDD, emotional symptoms such as antisocial behavior, depression, anxiety, persistent anger, rage and irritability interfere with relationships at home and at work. Physically, PMDD is accompanied by headaches, joint and muscular pain, bloating and breast tenderness that regularly interfere with daily activities, often causing absenteeism from work and social events.

Consultation with a physician may be appropriate in severe cases of PMDD, as antidepressants may be helpful in alleviating the emotional symptoms associated with this disorder. Initially, antidepressants known as serotonin-reuptake inhibitors (SSRIs) are taken only during the PMS phase. If this regimen fails to soften PMDD symptoms, daily doses of SSRI’s can be administered. Progesterone therapy, either in a topical cream or orally ingested has gained wide acceptance by physicians as a treatment for PMS. Progesterone seems to be particularly helpful in controlling the emotional symptoms of PMS such as anxiety and mood swings.

As a natural alternative to medication, massage therapy was found to be helpful with some symptoms associated with PMDD. In one study, twenty-four women with PMDD were randomly assigned to a massage therapy or a relaxation therapy group. The massage group showed a decrease in anxiety, depressed mood and pain immediately after the first and last massage sessions. The longer term effects of massage therapy included a reduction in pain and water retention and overall menstrual distress.

Massage therapists are in the unique position to both educate and advocate for their female clients who are in the throes of PMDD or PMS. Your support, through gentle touch of hand and heart, will go a long way in helping them navigate this rocky terrain successfully. As your clients take steps to manage their PMS by making the necessary lifestyle changes and seeking alternative and, if necessary, conventional therapies, their sense of self-awareness and empowerment will be strengthened.

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