A very common but frustrating condition of which I see a great deal in the office is premenstrual syndrome. Its effects can range from minor annoyance all the way through to severe mood changes and suicidal thoughts.

What is PMS?

PMS is a condition characterized by the appearance of physical and emotional symptoms during the second half ( luteal phase) of the menstrual cycle. Hormonal changes can trigger disruptive symptoms in a significant percentage of women during all or part of the two weeks leading up to menstruation. Symptoms tend to taper off at the start of or during menstruation. The woman then is symptom free for the next two weeks until ovulation occurs and symptoms begin again. PMS may vary from month to month with some cycles much better than others. However on the average PMS tends to get worse each year unless the woman institutes treatment or hormone levels change and she stops ovulating. Up to 40 percent of women suffer from PMS. The term PMS tends to be used by Gynecologists while psychiatrists have named the same syndrome Late Luteal Phase Dysphoric Disorder.

Signs and Symptoms of PMS

More than 150 symptoms have been associated with PMS. Symptoms may be both physical and emotional. The most commonly seen are:

  • Feeling “out-of-control”
  • Anxiety
  • Irritability
  • Depression
  • Crying spells
  • Panic attacks
  • Feelings of hostility and anger
  • Decreased concentration
  • Decreased work or social performance
  • Bloating
  • Clumsiness
  • Fatigue
  • Food cravings ( especially chocolate, sweets or salty foods)
  • Fluid retention
  • Headaches
  • Heart palpitations
  • Weight gain

PMS is characterized by its regularity and its link to menstrual cycles. PMS tends to be triggered by changes in hormones. Women with PMS often confuse their symptoms with early menopause. PMS is often confused with depression. However depression occurs throughout the month and may in fact worsen prior to a period whereas with PMS there are usually two good weeks out of the month . The symptoms of PMS often improve with pregnancy. The sufferer often has a period of increased activity prior to the onset of the worst symptoms. At this time her mood may be elevated, she may function with very little sleep, and may perform activities like cleaning the house.

Causes of PMS

The exact cause of PMS is not known. PMS may result from changes in chemicals in the brain. Hormonal changes also play some role. PMS does not appear to be caused by abnormal levels of hormones  but it certainly can worsen or be triggered by fluctuations of hormones which have a wide normal range. However suppression of ovarian hormone levels is associated with the elimination or improvement of PMS in many women. There are no lab or diagnostic tests to diagnose PMS. The diagnosis is made by history.

Treating P.M.S.

The treatment of PMS can be divided into life style changes, dietary changes, vitamin and natural products and medical treatments.

Lifestyle Changes

  • Regular aerobic exercise– at least 20 minutes a day four times a week. Daily would be even better. Walking, jogging, swimming, cycling and dancing.
  • Use some form of stress reduction such as meditation, visualization, yoga, drawing, music or keeping a journal.
  • Use some form of physical relaxation such as taking a hot tub, massage or acupuncture.

Dietary Changes

  • Eat 5 or 6 small meals a day, instead of three large ones.
  • Fresh fruits and pasta are critical. These should make up to two-thirds of your diet each day when you are suffering from PMS.
  • Caffeine is fatal. Avoid it at all cost. Caffeine makes PMS much worse. Caffeine is found in coffee, tea, cola and chocolate.
  • Giving in to food cravings will make you worse. Usual cravings are for chocolate, sweets or salty foods. Just because you crave these foods does not mean you need them! When you get these cravings substitute fresh fruit or pasta instead and you will be much improved.
  • Alcohol will make you feel worse. Many women drink alcohol because they are feeling so badly but it only worsens PMS.

Vitamins and Natural Products

  • Vitamins and Natural Products
  • Vitamin B6 100 mg every day of the month increasing to one hundred mg. Twice a day when symptoms of PMS occur.
  • Vitamin E 400 international units (IU) a day.
  • Vitamin C 1,000 mg a day.
  • Magnesium 300 mg a day.
  • A good multivitamin would contain all the above and the only addition would be the extra 100 milligrams of vitamin B6 when PMS was occurring.
  • Recent studies have shown that 1200 mg of elemental calcium a day will reduce PMS considerably. In a recent research study, Tums Extra Strength tablets, each containing 300 mg of calcium, were used one tablet four times a day with meals. There was significant improvement of PMS.
  • I have not found oil of evening Primrose to be helpful; much better is Flax Seed oil taken daily before PMS occurs and two or three times a day after PMS onsets.
  • If depression is a feature of PMS, then St. John’s Wort can be very helpful. St. John’s Wort should be treated as an anti-depressant medication even though it is a natural product. It should not be used in conjunction with other antidepressants. St. John’s Wort often causes fewer side effects than antidepressants. The usual dose is 0.3% Hypericin ( the active component of St. John’s Wort), 300 mg. two or three times daily, starting a few days before the onset of PMS symptoms.
  • Milk Thistle has also been shown to be useful in a dose of 100 mg twice a day starting a few days before PMS symptoms occur.

Medical Treatments

In some women there appears to be a decrease in functioning progesterone, according to the theories of Dr. Kathrina Dalton. Therefore some women benefit from the use of progesterone taken in the second half of the cycle.

Remember that progesterone is very different from progestins such as Provera. Real progesterone is identical to the progesterone that the ovaries produce, whereas progestins are synthetic and may have undesirable side effects. Progesterone is available in capsules ( one brand being Prometrium) which can be taken in 100 to 200 mg doses. They should be taken on an empty stomach and at bedtime. The reason for taking progesterone a bedtime is that it can make you sleepy. Progesterone is also available as a gel, rectal suppositories and as a cream. Absorption of the cream is not as predictable as the tablets.

Medications which can affect the mood and emotion have also proven to be of use in PMS. These drugs include fluoxetine ( Prozac), alprazolam (Xanax and buspirone ( BuSpar). I reserve the use of these as pharmacologic agents to patients who have not responded to milder treatments. The difficulty using these medications for more than a few months is that the basic hormonal problem is not being addressed.


PMS is real and has a hormonal basis. Women with PMS do not choose to have the mood changes nor can they will them away. Usually a program made up of lifestyle changes, dietary modifications and vitamins improves things a great deal. The individual treatment plan needs to be customized to suit each specific woman.

The first place to start is to eliminate all caffeine. Caffeine withdrawal may lead to a severe headache for week and a total lack of energy but the end result is worth while.

Women need to avoid the food cravings for chocolate, sweets and salty foods. In their place they need to substitute complex carbohydrate such as pasta and fresh fruit.

The first vitamin to add is 100 mg of vitamin B6 everyday increasing to 100 mg twice a day during the time of the month when the woman suffers from PMS.

Increased exercise levels are beneficial. This simple program leads to improvement. If the benefits are not great enough then consider adding some of the other treatments already mentioned.

Greater awareness that there is a medical basis for PMS and greater tolerance for women suffering from it, will improve many women’s lives.