I’ve heard the jokes, seen the cards……and also met the women for whom it’s no laughing matter. I’m referring to PMS and PMDD, Premenstrual Syndrome and Premenstrual Dysphoric Disorder. While it is thought that up to 90% of women experience mild physical and/or emotional symptoms in the days preceding menstruation, there are some for whom the symptoms are severe enough to adversely impact quality of life.
PMS, which is estimated to impact up to 30% of women of child-bearing age, is characterized by a combination of physical and emotional symptoms. This may include (but is not limited to) bloating, headaches, fatigue, gastrointestinal disturbances, breast tenderness, depression, irritability, anxiety, and insomnia. An additional 5-6% of women are considered to have PMDD, in which the symptoms are more pronounced than with PMS and lead to significant challenges.
For a definitive diagnosis to be made, it is important for a woman to track her symptoms over the course of two to three consecutive menstrual cycles. A daily diary should include not just the actual symptoms, but their severity, as well as note the actual days of bleeding. PMS/PMDD is diagnosed if symptoms are found to occur within the window of five days before menstruation until four days after the start of menses. Additionally, these symptoms must be reported as negatively impacting the quality of life. What is key in both PMS/PMDD is that there must be symptom-free days, most notably in the period of time preceding ovulation. An online symptom diary chart is available.
While self-diagnosis is common, it is important to have a comprehensive evaluation with a qualified health care provider. Many other medical conditions can cause symptoms that mimic or overlap with PMS/PMDD, including thyroid and blood sugar abnormalities, vitamin deficiencies, chronic fatigue syndrome, irritable bowel, and others. Additionally, some experts estimate that almost 50% of women with PMS/PMDD also have either depression or anxiety. That is why it is essential to have a symptom diary to aid in clearly assessing when a woman is experiencing which symptoms, so as to best understand what is happening and then to most appropriately tailor therapeutic strategies.
Is relief from PMS/PMDD possible? Or are women left with just having to wait until menopause occurs for symptoms to disappear? In my experience, I find that many women can experience a noticeable improvement in the intensity of their symptoms, resulting in better quality of life. With mild to moderate symptoms, intervention most often begins with attention to lifestyle measures. These include regular aerobic exercise, good sleep hygiene, and various relaxation measures such as massage, biofeedback, and meditation. Some women try supplemental calcium, vitamins, and/or other supplements. Certain dietary strategies, including increasing complex carbohydrates, avoidance of salt, refined sugar, alcohol and caffeine, and eating frequent small meals may prove helpful. Women may also benefit from counseling in areas of better self-care, including boundary setting. It is fair to give these strategies a trial of several months before evaluating efficacy. In the event that a woman does not find these measures to sufficiently improve her quality of life, or if her symptoms are more severe, it is possible to try various medications. There are a variety of options, ranging from therapies to treat specific physical symptoms such as bloating, to hormonal regulation, to cyclic use of certain anti-depressants.
For those for whom PMS/PMDD is not a part of their frame of reference, it can be hard to understand, and therefore be sympathetic, with women who struggle. That lack of understanding can result in minimizing or outright dismissal of these symptoms. Women may be told, “It’s all in your head,” or in a similarly unhelpful fashion, “Just deal with it.” All women deserve adequate support if either PMS or PMDD is thought to be present. And that must begin with being believed. I firmly endorse the right of each human to be heard when there is a concern, and to be listened to and validated in a safe and confidential environment. That is certainly my goal as a nurse practitioner who has the honor of working with women.
One researcher noted that over the course of her lifetime, a woman has approximately 400-500 menstrual cycles. If she is consistently having adverse symptoms a half to full week each month, it is estimated she will spend the equivalent of four to ten years of her life experiencing PMS/PMDD. Do we have a definitive understanding of the exact physiologic cause of PMS/PMDD? No. But that does not mean we don’t have reason for hope…….and help to offer.
Barbara Evans, WHNP-BC is a board certified women’s health care nurse practitioner at Windham Family Practice, a department of Brattleboro Memorial Hospital.