Management of Premenstrual Syndrome

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Premenstrual syndrome (PMS) refers to the range of physical and emotional symptoms that many women experience in the lead-up to menstruation (the period). Most menstruating women are affected, with symptoms ranging from relatively mild to severe. Women aged between 30 and 40 years appear to be at most risk.

Since the cause remains unknown, PMS can’t be cured or prevented. However, it can be successfully managed with appropriate self-care and a range of different treatments. Consult with your doctor before starting any PMS treatment program.

Keeping a PMS diary

There are more than 150 recognised PMS symptoms, and PMS differs from one woman to the next. Common symptoms include irritability, moodiness, fluid retention, breast tenderness and food cravings. There are no specific tests for PMS, so diagnosis depends on ruling out other possible causes.

In most cases, you can identify PMS by keeping a symptoms diary. Include the details of your menstrual cycle  for example, the first and last days of your menstrual period and any ovulation symptoms. Keep this diary for at least three menstrual cycles.

If your symptoms are due to PMS, the following pattern should occur:

Symptoms are experienced in the two weeks before your period starts.

Symptoms resolve with the period.

Once the period is over, you experience at least seven days with no symptoms

Symptoms start to return about mid-cycle or in the week before your period starts.

If symptoms continue throughout the menstrual cycle without change, PMS is probably not the cause  see your doctor for further investigation.

PMS management

PMS can be successfully managed with lifestyle changes, dietary modifications, supplements and medications. You may have to experiment to find the balance of treatments that works best for you. It’s a good idea to continue your PMS diary and record any symptoms while you trial the remedies. Be sure to consult with your doctor.

Lifestyle changes

Recommended lifestyle changes include:

Exercise regularly, at least three times a week – try to exercise daily in the premenstrual period.

Don’t smoke.

Cut back on caffeine and alcohol in the two weeks before menstruation.

Ensure that you get enough sleep.

Manage your stress in whatever way works for you – for example counselling, Tai Chi or meditation, walking or gardening.

Dietary changes

Women experiencing PMS symptoms crave high fat and high sugar foods like chocolate, biscuits and icecream. They usually increase their food intake by about 20 per cent. You can manage your weight and help reduce your PMS symptoms by making a few dietary changes, including:

Eat smaller meals more often for example, have six ‘mini-meals’ instead of three main meals.

Reduce your intake of salty foods.

Include more fresh fruits and vegetables and wholegrain foods in your daily diet.

Boost your dairy food intake, but switch to reduced fat or non-fat versions.

Don’t keep high fat and high

sugar foods in the house.

Make sure you always have tasty and healthy snack alternatives on hand.

Record your food choices in your PMS diary – charting your food intake may help you become more aware of high fat and high sugar snacking.


Check with your doctor before taking any type of supplement. Complementary therapies should be viewed as a medicine and should be treated with the same respect.

Supplements that have been shown to help reduce PMS symptoms include:

Calcium: about 1,200mg per day of calcium carbonate can reduce PMS symptoms by half. You need to take these supplements for at least three cycles before you may notice an improvement.

Magnesium: about 200mg per day of magnesium can reduce PMS-related bloating, fluid retention and breast tenderness by 40 per cent. You need to take these supplements for at least two cycles before you may notice any improvement. Food sources of magnesium include nuts, legumes, whole grains, dark green vegetables, seafood (oysters), and meats.

Chaste tree: a study showed that the herbal supplement chaste tree (also known as chaste berry, or vitex agnus castus) reduces PMS symptoms by half. It has been shown in some studies to reduce symptoms of irritability, mood swings, anger, headache and breast fullness. This herbal treatment needs to be taken for at least three months and should only be prescribed by qualified herbalists.

Vitamin E: about 400 units of vitamin E per day may reduce breast tenderness. Vitamin E taken with selenium supplement of 25–50 micrograms daily may be beneficial. High doses of selenium can cause toxicity and should not exceed 100 micrograms per day.

Evening primrose oil: Gamma-linoleic acid (GLA) is the active agent found in evening primrose oil. Much like mefenamic acid, GLA blocks prostaglandin synthesis, resulting in decreased breast tenderness, bloating, and weight gain. The standard dose is 3 grams per day, and it should be started less than 1 week before the onset of your period. This agent is available without a prescription at health food stores and certain pharmacies. A review of the studies on evening primrose oil, however, showed no proven effect on the symptoms of PMS.

Ginkgo biloba: Shown to reduce the symptom of breast pain but not other PMS symptoms.

Vitamin B6 (pyridoxine): evidence is mixed about the effectiveness of vitamin B6 supplements. High doses of vitamin B6 are toxic to the nervous system. Use with caution and avoid long-term use.

Other supplements: Black cohosh, and dandelion are anecdotally thought to reduce PMS symptoms. However, their effects have not been established. There are some concerns that black cohosh may harm the liver in some individuals. Always consult your doctor before taking any supplement, including herbal supplements.

St John’s Wort: is a mood stabiliser and has been shown to improve mood. This supplement may interact with other medications so always check with your doctor before taking St John’s Wort.

Medical treatments

There is no cure for PMS. If lifestyle changes and supplements do not work, there is also a range of hormone treatments and medications available to help you manage your symptoms.

Hormonal treatments

The aim of hormone treatment is to suppress ovulation and reduce the hormones of the premenstrual phase. Many different hormone therapies have been trialled for PMS:

The combined oral contraceptive pill: ‘the pill’ may relieve premenstrual symptoms. The monophasic pill is preferable, where all the hormone tablets are the same dose. Studies show mixed results. A pill-free interval of 3–4 days seems to give better results.

Oestrogen therapy: high-dose non-oral oestrogen to inhibit ovulation has been effective. The oestrogen is given either as a patch or an implant. Unless the woman has had a hysterectomy, progesterone-like therapy will also be needed. This may cause side effects similar to PMS.

GnRH agonists: these medications are usually prescribed as a treatment for endometriosis or fibroids and are used for a maximum of six months. They stop ovulation and periods, creating a temporary menopause. Tibolone is often added to relieve menopause-like symptoms. Hormones: Hormones such as nafarelin (Synarel) and leuprolide (Lupron) prevent your body from releasing eggs and undergoing a menstrual cycle. Therefore, if you take these medications, you will not ovulate and will not menstruate. This treatment eliminates PMS symptoms in more than half of all women receiving it. These hormones are like birth control pills in that they suppress the menstrual cycle, but the cycle returns when they are stopped. However, women taking the birth control pill still bleed every month. Women on this therapy have no periods at all. However, most contraceptive pills and patches can be used in a continuous fashion to reduce or eliminate withdrawal bleeding. 

Mirena IUD: this IUD (intra uterine device) releases a low-dose progesterone-like hormone, which may suppress ovulation and reduce symptoms in some women.

Danazol: this medication may also stop ovulation and reduce PMS, but has significant side effects.

Depo-Provera: this injectable contraceptive stops ovulation and may relieve PMS symptoms. Side effects may include irregular bleeding and mood changes.

Bilateral salpingo-oophorectomy: removing both ovaries can abolish PMS but can also lead to menopause and severe menopausal symptoms if oestrogen and progesterone-like treatment is not given after the operation.


There are a number of medications that have been trialled for PMS:

Anti-anxiety drugs: Benzodiazepines are drugs that decrease anxiety by depressing the central nervous system. Alprazolam (Xanax) is a member of this class. It can be effective in treating the anxiety associated with premenstrual syndrome. You may feel drowsy if you take this type of medicine. Benzodiazepines can be addictive.

Antidepressants: Fluoxetine (Sarafem, also known as Prozac), sertraline (Zoloft), and paroxetine (Paxil) are medicines that help the body increase the activity of serotonin, a brain chemical that has been shown to be low in some women with PMS . Clinical trials show that they effectively treat mood symptoms such as depression, anxiety, and anger. However, other symptoms of PMS, such as tiredness and decreased sexual drive, may not improve or may become worse on these drugs.

Anti-inflammatories: These drugs prevent the body from producing prostaglandins, which have been suggested as a cause of PMS. Reducing the amount of prostaglandins in the body may eliminate many of the inflammatory symptoms of PMS such as menstrual cramps, breast pain, headache, swelling, and other discomforts. Several types of anti-inflammatory agents are used for PMS. Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended initially, and there are several that may be purchased without a prescription. COX-2 inhibitors are a new type of NSAID that must be obtained with a prescription. These are longer-acting than most NSAIDs and have less risk of causing stomach discomfort or ulcers.

NSAIDs include the following medicines. 

Diclofenac (Cataflam, Voltaren)

Ibuprofen (Motrin)

Ketoprofen (Orudis)

Meclofenamate (Meclomen)

Mefenamic acid (Ponstel)

Naproxen (Aleve, Naprosyn)

Diuretics: Diuretics (commonly called water pills) are drugs that help the body to shed excess water through the kidneys. These medicines significantly help reduce the weight gain, breast swelling, pain and bloating associated with PMS. Metolazone (Mykrox, Zaroxolyn) and spironolactone (Aldactone) are 2 commonly used diuretics.

Many of these treatments can have side effects, so make sure you are well informed about them before you and your doctor decide on your treatment.

Complementary therapies

Many women feel they benefit from a variety of natural therapies, although a lack of controlled studies means there is no clear evidence of their benefits.

Options include:

Cognitive behavioural relaxation therapy: uses one or a variety of relaxation techniques to relieve psychological and/or physical symptoms.

Complementary therapies: such as acupuncture or naturopathy.


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