Health visitors, counsellors, and nurses as well as GPs should be aware of PMS and how it may be affecting their patients. Primary care team members, because of their knowledge of an individual woman and her circumstances, are ideally placed to help her work out whether PMS is the main cause of her distress or whether other factors in her life are actually to blame.
PMS is a problem that is best dealt with by empowering the woman to do as much as she can to help herself and collaborate positively in evaluating any medical treatments prescribed.

Women coming to the surgery with PMS need time to work out what the problems and solutions are and so a number of appointments may be necessary. The initial consultation should seek to establish a therapeutic relationship, identify the woman’s complaints and begin to prioritize the difficulties.

History

Assessment starts with the history of the main troublesome symptoms, the timing in the menstrual cycle, the severity, and the impact on the woman and those around her. Ask her why she is seeking help now. There may have been a crisis, an unmanageable extra stressor, or she may have heard about a new treatment that she would like to try. She will not have the definitions of PMS to hand and so may rely on magazine articles, a friend’s suggestion, or a scan of the Internet to prompt her presentation. As many as half of women who present complaining of PMS do not have cyclical symptoms after diary keeping so another label needs to be found, and guidance towards a more useful focus. Unfortunately, many women come already certain of their diagnosis and do not want to contemplate an alternative. This may be because they fear the stigma of depression or relationship difficulties and are not confident about solutions to such issues.

Social and relationship context

Women often feel responsible for the emotional well-being of those around them. They blame themselves when things go wrong and look for internal reasons for social and relationship problems. It may be easier to blame the hormones than confront the misery of an absent partner or wayward children. Some social problems are intractable but can be borne except when further strained by premenstrual symptoms.

Cultural norms, expectations and fears

Many women cannot deal with their own anger and are very upset about irritable outbursts, especially when directed at ‘innocent victims’ such as their small children. A typical example of this might be as follows: a woman is overwhelmed with guilt and depression because of an irritable outburst with partner or children. She is appalled at her behaviour and seeks an explanation that allows her to retain her image of herself as self-controlled and loving and reject the side of herself that becomes angry or demanding because it is not how women should behave, even if the anger is justified. She may describe herself as ‘Jekyll and Hyde’ and does not accept her different reactions as part of normality but instead feels out of control and therefore ill. The most frequent fear is that this represents ‘madness’ and PMS offers a hormonal explanation that avoids this conclusion. Reassurance about her sanity and the role of stress may allow exploration of psychological factors.

Previous treatments

The patient may be very familiar with her PMS and better versed in the options for treatment than her professional adviser. She may have already tried a number of strategies and have strong views about the next step. A history of past treatments and the outcomes will enable rational and acceptable choices for the future.
Past medical history

PMS is a chronic disorder and a history of gynaecological events, previous illnesses, psychological and other will help put PMS in the context of the woman’s previous experience of health and illness.

Daily symptom diary keeping

A clear history of PMS is useful in planning treatment but research has shown that women are rather poor at remembering the detail of fluctuating symptoms and tend to attribute negative symptoms to PMS premenstrually and to external events post-menstrually. Thus a daily symptom diary can provide further information about timing and circumstances that enables better definition and management of the situation. It may indicate a pattern of symptoms that confirms PMS, but if it does not then the woman herself will be the first to speculate on alternative explanations. The chart is also valuable in determining whether advice or treatment is helping and the woman should be encouraged to keep it for several months. Knowing in some detail how she is likely to feel at particular times of the cycle gives the woman some sense of the predictability of her symptoms and allows her to plan for the difficult times. It is very helpful to make allowances for PMS, and many women have benefited from fairly simple rearrangements to their schedules of work and other activities to reduce the stress during premenstrual days.

Education, understanding and support

Talking to her GP, health visitor, or practice nurse may open the door for a woman to talk to others such as her partner, family, friends, or colleagues. This means that problems are brought out into the open rather than the woman feeling isolated or ‘going round the bend’. A woman can learn more about her body, about normal functions of her female self, and what might be abnormal. Talking to others can also reveal a wealth of remedies and strategies for dealing with PMS. Many women spend their time looking after others and an important part of the strategy to combat PMS is for the woman to look at her needs and to nurture herself.

General health promotion and review of health status

A check on general health is useful. Health promotion is worthwhile for all and the evidence for such advice lies in the broader epidemiological studies on the value of low fat, high fibre diet, exercise and the dangers of smoking and excess alcohol. A person will probably be fitter and able to deal better with stress if eating a balanced ˜healthy™ diet and incorporating some form of exercise and relaxation into her lifestyle.

It is also possible that women are more sensitive to changes in blood sugar levels in the premenstrual days, resulting in feelings of weakness, fatigue, and carbohydrate cravings. Careful attention to diet can help, eating frequent small protein-rich meals, particularly if the woman tends to skip meals or eat sugary snacks. It is well worth looking at caffeine intake, since caffeine can increase levels of anxiety and irritability. Many people drink more tea and coffee than they realize and cutting down or cutting these drinks out completely can be helpful. Alcohol consumption may influence PMS. Many women drink more alcohol in response to PMS but excessive intake can make symptoms worse.

There may be links between smoking and premenstrual symptoms and cutting down or stopping smoking is part of general health advice. Exercise can help many of the physical and emotional symptoms of PMS, including tiredness, anxiety, irritability, and bloating. If breast tenderness is a problem, a well-fitting sports bra may help. Learning simple relaxation techniques or meditation can help too. Isolation and lack of control over life’s demands is known to be stressful. Encouraging fun, time with friends, personal time, and regular sleep can reduce dysphoria and anxiety and give a sense of control.

One of the most distressing symptoms of PMS is aggressive irritability, which women say affects their activities and relationships. Although in our culture women are generally brought up to be more passive and nurturing than men, it is possible that PMS may bring out real anger about real problems in an otherwise easy-going woman. She and those around her may perceive this as irritability and dismiss the underlying problems, which need to be explored. The premenstrual days may not be the best time to tackle problems that are making her angry, but this is not a reason for ignoring them.

This assessment illustrates the importance of taking a holistic approach to PMS and looking at every woman’s circumstances, particularly before embarking on medical treatments. It is important to remind women that good habits of life are best practised in the ‘good’ weeks, as it is much more difficult to start when things are already overwhelming. Books on PMS are available with sections on diet, relaxation and exercise (Sanders 1985; Duckworth 1990; Harrison 1991). There is a useful address for women’s health at the end of the chapter. If no women’s health group is run in the surgery, there may be a local group to which women can be referred.

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Despite some views that PMS is a complaint of â neurotic women, there is no consistent relationship between women’s personalities and PMS. There do, however, appear to be links between PMS and general psychological health. Women who are psychiatrically ill may experience more, and more severe, premenstrual psychological symptoms than psychologically healthy women. Women with PMS are more likely to have had a depressive illness in the past and more likely to have had postnatal depression (Halbreight 1996). Recently, interest has focused on PMS in perimenopausal women. During the time leading up to the menopause, PMS can become more severe and blur into the menopause. It is possible that some women are more vulnerable than others to hormonal fluctuations and are therefore at risk of problems with PMS, the menopause, and a mild form of postnatal depression and so require extra support at these times.

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With information, patience, and encouragement, women can work out ways to understand and manage their symptoms and this may include seeking medical advice from their general practitioner (GP).
Definition Many women notice change in their emotional and physical feelings during the menstrual cycle. While for the majority such changes are acceptable, for others they are distressing. These distressing premenstrual changes are now described as ‘premenstrual syndromeâ€^TM rather than ‘premenstrual tensionâ€^TM, in recognition of the variable nature of the symptoms, which may not always include tension. The definition of PMS has been fraught with problems, since the type of symptoms and their severity can vary enormously both between women and between cycles for individual women. There are a number of definitions of PMS available. O’Brien (1990) gives a widely accepted example:

a disorder of non-specific somatic, psychological or behavioural symptoms recurring in the premenstrual phase of the menstrual cycle. Symptoms must resolve completely by the end of menstruation leaving a symptom-free week. The symptoms should be of sufficient severity to produce social, family or occupational disruption. Symptoms must have occurred in at least four of the six previous menstrual cycles.

He does not specify which symptoms, because these can be so variable. More than 150 symptoms have been described, but the commonest include: low mood, irritability, anxiety, tension, clumsiness, poor memory, food craving, sleep disturbance, bloating, breast tenderness, abdominal pain, back ache, weight gain, fatigue. Some women notice only mood changes, others only physical symptoms, but it is more common for both to be experienced together. There are no specific symptom clusters and individual women tend to report their own unique combination of symptoms. However, most of the women looking for help have a predominance of psychological symptoms because these interfere most with relationships in everyday life.

Recently, a severe premenstrual syndrome with predominantly mood symptoms has been defined in the appendix of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM IV, 1994), called ‘premenstrual dysphoric disorderâ€^TM (PMDD). Operational criteria have been described so that research into this severe condition can be more consistent. Epidemiological data using these criteria reveal a subgroup of women with a disorder that is very like an affective disorder and which may be best treated as one. This has allowed women with the most disabling pattern of PMS symptoms to be researched specifically, with encouraging results for all sufferers. While being yet another medical label for women, this may be helpful with regard to management approaches.

Distressing changes may start up to 14 days before menstruation, although it is more common for the symptoms to last for up to a week, and disappear at or shortly after the start of menstrual bleeding. Many women say that the severity varies from cycle to cycle, depending on general life events and stresses. Until the timing in relation to menstruation is established, PMS can be confused with more general problems such as anxiety or depression, and may be misdiagnosed or mistreated. Hence, the first step in diagnosis is careful and regular symptom recording to establish the nature and timing of the problems. Women should be asked to complete menstrual charts, recording their moods and other symptoms for at least two cycles.

Some women complain of symptoms that seem to be related to the menstrual cycle but wax and wane at other times in the cycle, e.g. at ovulation. Some definitions allow such variations, e.g. Magos (1990):

distressing physical, psychological and behavioural symptoms not caused by organic disease which regularly recur during the same phase of the menstrual cycle and which significantly regress or disappear during the remainder of the cycle.

Again it is crucial to establish the pattern by prospective daily symptom diary kept over several cycles

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The sequence of hormone events occurring in the menstrual cycle during which ovulation takes place is shown in Fig 1.1. At menstruation, plasma levels of the anterior pituitary hormone, follicle-stimulating hormone (FSH), are already rising, stimulating the growth of several Graafian follicles within the ovary. In general, the end result of this follicular development is (usually) one mature follicle and ovum. The developing follicle produces increasing amounts of oestrogens, notably oestradiol. As levels of oestradiol begin to rise early in the follicular phase of the cycle, production of FSH is suppressed  by negative feedback but oestradiol levels continue to increase over the next few days until a critical level is reached. Here, by positive feedback it triggers the anterior pituitary to release about 24 hours later a surge of luteinizing hormone (LH) with levels up to 50 IU/l and to a lesser extent FSH with levels up to 15 IU/l; such levels only occur for one day. Ovulation follows the onset of the LH surge within about 34—36 hours and the ruptured ovarian follicle develops into the corpus luteum which secretes both oestradiol and progesterone in the second half or luteal phase of the cycle. Levels of both oestradiol and progesterone therefore rise after ovulation, reaching peak levels between days 18 and 22 of a 28-day cycle. In the last few days of the cycle, if pregnancy has not occurred, the corpus luteum degenerates and oestradiol and progesterone levels fall before menstruation ensues. Plasma levels of progesterone can be measured to assess ovulation and levels greater than 16 nmol/l on days 18—22 are indicatory. The time period from the LH surge to menses is consistently close to 14 days but may vary normally from 12 to 17 days. However, variability in cycle length among women is principally due to varying number of days required for follicular growth and development in the follicular phase. Menstrual bleeding can occur both in ovulatory and anovulatory cycles. In the latter the ovary produces enough oestrogen to stimulate endometrial growth and bleeding occurs when oestrogen levels fall. Bleeding in anovulatory cycles tends to be irregular, painless and heavy. In the past decade it has been found that ovarian follicles also produce peptide hormones such as inhibin and activin, which inhibit and stimulate FSH production, respectively. While these peptides are not measured routinely, they may be in specialized centres.

Endometrial events

The process of menstruation is poorly understood and it is not really known why women should bleed at all since it does not seem to fulfil any biological function. It only occurs in a restricted number of species: humans and most subhuman primates. Consequently, scientific understanding of the physiological mechanisms involved in the process of menstruation is based on animal as well as human data. Endometrium undergoes growth, degeneration and regression prior to menstruation and bleeding occurs from endometrial blood vessels, especially spiral arterioles. In most species that menstruate, endometrial arterioles are unusual in that they are profusely coiled as they run through the endometrium and also change throughout the menstrual cycle. Endometrial vessels have the unique property of undergoing benign angiogenesis (growth) during each menstrual cycle; otherwise this process is restricted to neoplasia and tissue injury. While this process is clearly  under the control of ovarian steroids, endometrial endothelium lacks steroid receptors. These are present on endometrial epithelium and stromal cells, which produce angiogenic polypeptides, which then act on the endothelium. These arterioles undergo profound vasoconstriction which starts 4—24 hours before menstruation and lasts until the end of menstrual bleeding. Bleeding results from relaxation of individual blood vessels and then ceases as they constrict. If constriction did not occur, it could not unreasonably be expected that women would bleed to death at the menarche. Another phenomenon that occurs during menstruation is myometrial contraction. The myometrium contracts throughout the menstrual cycle and there is increased activity during menstruation especially in women with primary dysmenorrhoea.

Of the pathways thought to play a major role in abnormal menstruation, the evidence for altered eicosanoid biosynthesis is compelling. Prostaglandins have the capacity to affect both haemostasis and myometrial contractility. Very high levels of prostaglandins are found in uterine tissues and menstrual blood. Prostaglandin levels are further increased in women with menorrhagia and dysmenorrhoea and clinically inhibitors of prostaglandin biosynthesis are effective in these disorders. In menorrhagia there is also additional evidence of an altered responsiveness to the vasodilator prostaglandin E2. Increased concentrations of prostaglandin E2 receptors are present in myometrium collected from women with excessive bleeding. In dysmenorrhoea the leukotriene pathway allied to prostaglandins has also been implicated in that higher levels of leukotrienes are present in endometrium of dysmenorrhoeic women. Finally, increased endometrial fibrinolysis has been implicated in menorrhagia leading to the use of antifibrinolytic agents.

Variation in menstrual blood loss The amount of blood loss at each menstruation has been measured in several population studies. In several hundred women not complaining of any menstrual problems, objective measurement of menstrual blood loss (MBL) shows a skewed distribution with the mean of about 35 ml and the 90th percentile of 80 ml. MBL is considered excessive if greater than 80 ml: without treatment, such a loss leads to iron deficiency anaemia and constitutes objective menorrhagia (Fig 1.2). Blood losses up to 1600 ml have been measured in some women. Despite variation in the total amount of blood lost, 90% is lost within the first 3 days, fitting in with patientsâ€^TM description of a tap being turned on and off.

Variation in cycle length and duration of menstruation

Cyclical vaginal bleeding is known to occur at well defined intervals from the menarche to the menopause. Since ancient times it was shown that the length of the menstrual cycle, i.e. from day 1 of one period to day 1 of the next, approximated to the phases of the moon. The Greek ‘menâ€^TM means month. Women in many cultures refer to their periods as the moon and some women believe they are actually caused by the moon! Not surprisingly, the 28-day cycle has become the symbol of health and normality in relation to reproductive function and women begin to worry that something is wrong if their menstrual cycle deviates from this 28-day ‘normâ€^TM. Furthermore, medications to induce artificial cycles, such as the oral contraceptive and hormone replacement, are also generally geared to producing 28-day ‘idealâ€^TM cycles. It therefore leads to women seeking medical treatment to regulate periods if cycles become either short or long.

It is important that women should be informed that there is a large degree of variability in cycle length that is compatible with good health.Variability in cycle length was best evaluated in the classical study of Vollman (1977). The famous 28-day cycle happens to be the commonest cycle length recorded (Fig 1.3), but only just, and then in only 12.4% of cycles documented. Cycle length changes with age, forming a U-shaped curve from the menarche to the menopause. Mean cycle length drops from 35 days at age 12 to a minimum of 27 days at age 43, rising to 52 days at age 55 years with an enormous range of cycle length.

Clearly, there is a wide variation in normal cycle length, especially in the first few years after the menarche and in the years preceding the menopause. It is important that normal biological variation be recognized by both women and their doctors so that they do not become obsessed by the 28-day ‘idealâ€^TM
Similarly, there are also misconceptions about duration of menstruation. In a series of 321 women in Oxford, average duration of menstruation was found to be 5—6 days (Fig 1.4, from Rees, unpublished observations). Furthermore, there was no difference in duration of menstruation between women with normal blood loss and objective menorrhagia.

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Menstruation has had magical and mythical connotations since ancient times. In many prehistoric cultures and up to the Middle Ages, the uterus was considered as a separate creature with autonomous rights. It was regarded by some as a type of wild beast roaming through the woman’s body and endangering her life. Pliny noted that while menstrual blood cured epilepsy, gout, malaria and boils, it also caused iron to rust and copper to turn green. Menstruation has been considered to be a taboo subject. The word ‘tabuâ€^TM comes from the Polynesian where it means menstruation as well as things that are both sacred and unclean. In various cultures, women have been prohibited from preparing food, tending plants and having any contact with men; and have been banished to menstrual huts. In our own society, mothers may still tell their daughters not to bath, wash their hair or undertake physical exercise during menstruation. These attitudes have no doubt contributed to the relatively recent development of effective sanitary protection, with commercial tampons only being introduced in the 1920s.

As a result of these myths, it is not surprising that it can be difficult for women to distinguish between normal and abnormal menstruation. The purpose of this chapter is to try and suggest which symptomatology, as usually presented to the general practitioner, might indicate the need for further appropriate investigation and treatment either at a primary care level or by the specialist. It is probably best when discussing menstrual disorders with patients to use simple descriptive English terms such as heavy or painful periods rather than take refuge behind school-boy classical Greek. For instance polymenometrorrhagia literally means frequent month womb rushing out rather than frequent heavy irregular periods.

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What if, long before you’d heard about collagen injections or dermabrasion, you discovered more about how people age? If you could “see” what’s really going on under your skin’s surface, you would be able to strengthen your beauty and vitality from the inside out—repairing, rebuilding, and even preventing the signs of wear and tear from showing up too soon. You could see what causes weight to come on so insidiously, why veins break into unsightly tattoos, and why our bones weaken as we slump into old age. You would take into your own hands a new measure of control.

If you were able to look deep inside the cells of your body, you would see how they vary greatly in size and shape, and how their unique design allows each one to carry out a specific job. Muscle cells allow you to move as they contract and relax. Nerve cells transmit messages. Liver cells eliminate toxins and regulate body chemistry. Red blood cells transport oxygen in and carbon dioxide out. Pancreas cells make and replace hormones. It’s a complex, ever-changing universe. Despite its particular task, however, each cell is constructed according to the same basic pattern. Underneath a protective membrane lies a jellylike substance called cytoplasm, which houses the cell’s nucleus and all of your chromosomes, each composed of the DNA blueprint that makes you who you are. As hormones, fuel, and nutrients move in and out of the porous cell membrane, all the vital chemical reactions that build and maintain your body take place.

A look inside this intricate world would show you just how fragile your cells are and, more important, how nearly everything you do affects their functioning. You would see how they are assaulted by pollutants you breathe in; how they are defended by certain vitamins and minerals; how they stand up to cigarette smoke and alcohol; and, most important, why some cells deteriorate and others thrive, maintaining their youthful robustness. What does this have to do with how you look? Understanding what makes a cell flourish gives you the power to make it happen, and your body is more receptive than you probably think. Your eyes, your cheeks, your neck—every part of your body—show the care you’ve taken to hold the aging process at arm’s length.

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They take on extra electrons or develop unstable electron orbits of their own. As free radicals, the potential of these unstable oxygen molecules to wreak havoc is enormous. In a lightning-quick fraction of a second, they can demolish any other molecules that get in their way, including your DNA.

This never-ending process destroys minuscule amounts of your body over time, much like crashing waves hitting rocks along a coastline. Whether your body holds up like granite or crumbles like clay depends greatly on what materials you have used in your own cellular construction.

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Selenium exists naturally in soil and passes into the roots of grains and vegetables, nourishing the plant as it grows and protecting your body after you eat it. Notice the word whole grains. Four slices of whole wheat bread hold nearly 50 micrograms of selenium. If you choose white bread instead, you’ll cut that figure nearly in half, to a mere 28 micrograms.

As grains are refined to produce white flour, the mineralrich outer fiber coating is discarded, along with the selenium that was ready to protect you. So whole grain products are not just more satisfying; they really are much better for you. Vitamin E. Found in the natural oils of beans, vegetables, fruits, and nuts, as well as in the grains of wheat in your bread, vitamin E is a potent antioxidant that nestles within your cell membranes, lying in wait until free radicals come along to threaten it. Instead of attacking your delicate cells, free radicals end up attacking vitamin E. Like swords hitting sturdy shields, the assault is severe, but the damage is minimal. With all of the positive publicity vitamin E has received in recent years, some people have gotten carried away by taking very high doses of it in supplement form. The truth is, you’ll get all you need by eating a nice variety of the foods listed in the table on page 7. What’s more, vitamin E actually recycles itself. With a little help from your body’s supply of vitamin C, it defends your cells over and over again.

Carotenoids. Think carrots, sweet potatoes, pumpkins, and other orange vegetables. Add them to your diet and you’ll gain yet another measure of defense against free-radical damage from betacarotene—

the best-known member of the carotenoid family—and its six hundred or so cousins. Delivered to your bloodstream and then to your cells, beta-carotene cloaks them in a protective layer that helps them live longer. Like vitamin E, beta-carotene takes up its post within the cell membrane, repelling invading free radicals.

While carotenoids are particularly concentrated in orange vegetables, they are also found in green and yellow vegetables. There is a cousin of beta-carotene you should get to know, named lycopene. It has an odd name, but you already know it very well. It provides the red color in a tomato, just as beta-carotene gives its orange color to a carrot or a sweet potato. Slice open a watermelon. Guess where that bright red color comes from? Lycopene may not be as famous as beta-carotene, but it is actually one of the most plentiful carotenoids in your body. It powerfully neutralizes free radicals and has gained popularity among cancer researchers for dramatically cutting cancer risk.

Take a fresh look at the produce aisle. You’ll spot nature’s palette that has beta-carotene here, lycopene there—not for looks, but for providing strong protection throughout a plant’s growing process. When you bring these foods into your diet, their protection enters your skin and all your other body tissues.

The beauty of a diet rich in grains, vegetables, fruits, and legumes is that it provides your body with a rich supply of nutrients for knocking out free radicals and countless other pollutants— without spending a fortune on supplements or thinking in terms of “milligrams” or “recommended daily allowances.” Whole, natural foods supply a generous bounty of potent vitamins, minerals, and other protectors for vitality and wellness. Think of Mother Nature as the original Avon lady. When it comes to your healthy good looks, she delivers like no one else can.

Vitamin C. When you drink your morning glass of orange juice, you may think only of its cold-fighting power, but there’s a lot more to vitamin C than that. Not only does vitamin C work as a powerful antiaging nutrient, making the collagen that strengthens muscles, bones, and skin, it also helps regulate our moods and psychological functions.

All day long, and even at night as you sleep, free radicals form in your bloodstream. Vitamin C is your blood’s number one bodyguard and night watchman, eradicating free radicals with ease. It moves in and out of your cells, joints, brain, spinal cord, and even into your eyes to seek out and destroy free radicals. Eating vitamin C–rich foods such as broccoli, Brussels sprouts, grapefruit, strawberries, and, of course, oranges and other citrus fruits, will send free radicals and their aging effects packing. Without vegetables and fruits in your diet each day, your defenses will be down.

By now you might feel as if you have to be a chemist to understand all these cell-protecting compounds, but it’s actually easier than you think. When you bring home brightly colored vegetables and fruits, along with whole grain breads and cereals, their vitamin E, beta-carotene, lycopene, and selenium automatically enter your cell membranes, while their vitamin C goes to work patrolling your bloodstream. They will defend you against free radicals, slowing down the toll of time.

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