Premenstrual syndrome (PMS) – Symptoms and Treatment

Definition of the disease. Causes of the condition

Premenstrual syndrome, or PMS, is a complex of various physical and psychosocial disturbances in a woman that occur two weeks before menstruation and subside immediately after the onset of menstrual bleeding. PMS symptoms arise due to external and internal factors against the background of innate or acquired hormonal system instability. This condition significantly reduces not only a woman’s ability to work but also her quality of life, as it occurs during her peak social and professional activity period.
This syndrome begins to manifest before the start of the menstrual cycle, lasts for about two weeks, and ceases with the onset of menstrual bleeding. The frequency of PMS is 25-30% among healthy women, with half of the female population experiencing PMS symptoms in 50% of cases.
According to historical records, the ancient Roman physician Galen (2nd century AD) is considered the first scientist to study PMS. He associated painful sensations in women before menstruation with the phases of the moon. The scientific basis for PMS was first provided by English gynecologist R. Frank in 1931. He formulated, systematized, and explained a series of reasons for periodically occurring mental and physical disorders in women.
PMS, along with arterial hypertension, obesity, Alzheimer’s disease, and chronic fatigue syndrome, is considered a disease of civilization. It primarily affects women living in urban areas and engaged in intellectual work. This is due to regular stress, which adversely affects a woman’s psyche.
Main risk factors for developing PMS:

  • Residing in large cities;
  • Belonging to the Caucasian race;
  • Intellectual work;
  • Late pregnancy and childbirth – after 35 years;
  • Hereditary predisposition – presence of PMS symptoms in the mother or sister;
  • Stress;
  • Excessive number of pregnancies and childbirth – more than 3-5;
  • Artificial abortions and spontaneous miscarriages;
  • Postpartum depression and preeclampsia – late toxemia;
  • Gynecological surgeries and inflammatory diseases of the female reproductive organs: adenomyosis (proliferation of the uterine endometrium), adnexitis (inflammation of the uterine appendages), oophoritis (inflammation of the ovaries), endometritis (inflammation of the uterus);
  • Cranial and brain injuries;
  • Poor nutrition – junk food (fast food, food additives, preservatives), malnutrition, etc.;
  • Lack of a rational work and rest regime;
  • Endocrine system disorders – diabetes mellitus, hypothyroidism;
  • Insufficient physical activity;
  • Smoking – women who started smoking in adolescence are most susceptible to PMS.

Symptoms of Premenstrual Syndrome

The symptoms of PMS are numerous and can be divided into psychological and physical (somatic) categories.

Psychological symptoms include:

  • Tension, anxiety, fatigue.
  • Emotional instability.
  • Dysphoria – gloomy irritability, feeling of hostility towards others.
  • Depression.
  • Aggressiveness.
  • Impaired coordination of movements.
  • Problems with attention concentration.

In severe cases, suicidal attempts, lethargy (sluggishness, lethargy, fatigue), insomnia, taste perversions, thirst, appetite disturbance up to anorexia or bulimia, and changes in sexual behavior may occur.

Physical disturbances may manifest as tenderness and swelling of the mammary glands, migraine-like headaches, leg swelling, abdominal bloating, sensation of excess weight, muscle weakness, back pain, pelvic and joint pain.

Severe PMS symptoms may include:

  • Signs of arthritis – joint swelling and pain.
  • Skin manifestations – hives, acne, pigmentation on the torso and face, itching, seborrhea.
  • Constipation.
  • Increased urinary frequency.
  • Nausea, vomiting.

The symptoms of PMS are so diverse that diagnosis relies not on symptom assessment but on the cyclic nature of their appearance before menstruation and cessation after it. Therefore, only physical and psychological manifestations that cyclically occur exclusively during the luteal phase (between ovulation and the onset of menstruation), disappear with the onset of menstrual bleeding, and are absent for at least a week after it can be interpreted as PMS.

The duration of PMS reaches approximately 16 days, directly related to the duration of the luteal phase. The most pronounced symptoms of PMS develop just before menstruation. With the onset of menstrual bleeding, they quickly and completely cease.

Almost all women experience some manifestations of PMS; however, the true picture is observed only in 30-40% of cases. This should be taken into account when diagnosing PMS: changes in the female body should be pronounced and accompanied by impairment of physical activity and social interactions.

Classification and Stages of Premenstrual Syndrome Development

Depending on the symptomatology and severity of PMS, four clinical forms are distinguished:

  1. Neuro-psychic form – tearfulness, muscle weakness, apathy, depression, fatigue, irritability, insomnia, lethargy, aggressiveness, memory impairment, increased sensitivity to smells and sounds; in severe cases – suicidal attempts, feelings of melancholy, fear, anxiety, decreased libido.
  2. Edematous form – tenderness and swelling of the mammary glands, swelling of the hands, feet, and face, irritability, muscle weakness, abdominal bloating, skin itching, sweating, weight gain, urinary frequency changes, alterations in urine density in the general blood analysis.
  3. Cephalalgic form – migraine-like headaches, irritability, increased sensitivity to sounds and smells, nausea, vomiting, dizziness, impaired coordination of movements and attention, hyperesthesia – increased pain sensitivity.
  4. Crisis form – increased blood pressure, rapid pulse, tachycardia, feelings of fear, sweating. This form usually develops if PMS is left untreated.

Depending on the severity of premenstrual disturbances and the clinical symptomatology, four varieties of the syndrome are identified:

  • Premenstrual symptoms;
  • Premenstrual dysphoric disorders;
  • Proper PMS;
  • Premenstrual magnification – a complication of PMS.

According to the severity of PMS, it can be:

  • Mild – the appearance of 3-4 PMS symptoms 2-10 days before menstruation, with 1-2 symptoms being most pronounced;
  • Severe – the appearance of 5-12 PMS symptoms 3-14 days before menstruation, with 2-5 symptoms being most pronounced.

Stages of PMS development:

  1. Compensation stage – the presence of PMS symptoms during the second phase of the menstrual cycle and their disappearance with the onset of menstruation. Over time, the severity of clinical manifestations decreases.
  2. Sub-compensation stage – disappearance of PMS symptoms with the onset of menstruation, but their exacerbation as the disease progresses.
  3. Decompensation stage – presence of PMS symptoms before and after menstruation with a decrease in the remission period.

Complications of Premenstrual Syndrome

As complications of PMS, premenstrual magnification can be considered – worsening or exacerbation of physiological conditions present in the patient before menstruation begins. Such a course of the syndrome is called an atypical form of PMS.

Premenstrual magnification includes the following pathologies:

  1. Vegeto-dystrophic myocardiodystrophy – arrhythmias, chest pain, consciousness disturbances, etc.
  2. Hyperthermic ophthalmoplegic migraine – eye movement disorders (diplopia, ptosis, mydriasis) on the side of pain.
  3. Hypersomnic disease – increased sleepiness.
  4. Cyclical “allergic” reactions:
  • Ulcerative gingivitis – acute pain, bleeding from the gums;
  • Stomatitis – swelling, soreness, and redness of the oral mucosa, may be covered with a white or yellow coating;
  • Dermatitis – rash, itching, skin irritation, and cracks;
  • Bronchial asthma – shortness of breath, episodes of difficulty breathing, coughing fits, suffocation;
  • Iridocyclitis – eye pain radiating to the temporal and frontal areas and worsening at night, tearing, photophobia, protein deposits on the back surface of the cornea, changes in the color and pattern of the iris, pupil constriction, formation of posterior synechiae, vitreous opacity, changes in intraocular pressure, and decreased vision.

The appearance of these complications, especially “allergic” ones, is associated with disturbances in the functioning of the autonomic nervous system.

Diagnosis of Premenstrual Syndrome

In the initial stages of diagnosis, it is necessary to identify the cyclic nature of the syndrome’s manifestations and its correlation with the second phase of the menstrual cycle. However, if the menstrual cycle is irregular, it can be quite challenging to determine the cyclic nature of PMS symptoms.

The diagnosis of “PMS” is based on the results of a comprehensive medical examination and is confirmed using a menstrual chart. In this chart, the patient should independently note the presence and intensity of PMS clinical manifestations relative to the day of the menstrual cycle for 2-3 months. The maintenance of the menstrual chart is done under the supervision of a doctor, who evaluates the regularity of symptom appearance before menstruation and their disappearance afterward at the end of each month. Additionally, the patient needs to weigh themselves daily so that the doctor can diagnose true fluid retention in the body.

An important aspect of diagnosis is hormone testing: luteinizing hormone (LH), follicle-stimulating hormone (FSH), progesterone, free and total testosterone, dehydroepiandrosterone sulfate (DHEA-S). Functional tests are also conducted to assess the second phase of the menstrual cycle. They include an examination of cervical mucus, colposcopic examination of the cellular composition of vaginal smears, and measurement of vaginal basal temperature.

Sometimes pelvic organ ultrasound (USG) is prescribed. It is performed to indirectly assess the hormone-producing function of the ovaries based on the study of their morphological characteristics. To rule out organic pathology and diseases during pregnancy that mimic the clinic of PMS (neurological, cardiovascular, psychiatric, oncological), electrocardiography (ECG), electroencephalography (EEG), adrenal ultrasound, and skull X-ray are conducted.

In cases where diagnosis is challenging, it is advisable to involve allied specialists such as a psychiatrist, neurologist, psychotherapist, and therapist. This helps in excluding the diagnosis of “PMS.”

Treatment of Premenstrual Syndrome

The development of treatment regimens for patients with PMS should be tailored to the specific characteristics of each case. However, essential components of treatment for all forms of premenstrual disorders include:

  • Normalization of work and rest regimen with moderate physical exercise.
  • Rational balanced nutrition, including a fractionated low-calorie diet enriched with thiamine (vitamin B6), carotene (vitamin A), tocopheryl acetate (vitamin E), ascorbic acid (vitamin C), minerals, polyunsaturated fatty acids, etc.

Given the high prevalence of inflammatory diseases of the female reproductive organs in patients with PMS, the main treatment is prescribed after identifying foci of infection and their treatment.

Psychotherapy is a highly effective primary approach in the treatment of PMS. It involves confidential conversation with the patient and explanation of the nature of the disease. Psychotherapy is particularly effective in cases of mild PMS. During treatment, it is desirable to involve the patient’s partner to alleviate growing tension and misunderstanding.

Since PMS is accompanied by an imbalance in the endocrine status, hormone therapy should be included in the treatment regimen. When choosing drugs, pregnancy planning should be considered. For example, for patients with PMS who plan to conceive, the treatment regimen includes Duphaston, which is taken from the 16th to the 25th day of the menstrual cycle for six months. In other cases, combined oral contraceptives (COC) are prescribed to be taken in contraceptive mode for three months.

The diversity of premenstrual disorders is associated with the involvement of prostaglandins in the pathological process. Therefore, nonsteroidal anti-inflammatory drugs (NSAIDs) such as diclofenac, ibuprofen, etc., should be included in the comprehensive therapy of different forms of premenstrual disorders. They help relieve pain occurring before and during menstruation.

Given the significant role of stress factors in the development mechanism of premenstrual disorders, the prescription of anti-stress therapy is advisable. It includes the intake of adaptogens, multivitamins, autogenic training, aromatherapy, manual and water massage, vacuum therapy, and water procedures.

Patients with elevated prolactin levels in the blood are prescribed dopaminergic drugs (Dostinex). For such patients, ovulation is usually disrupted against the background of stress. Therefore, contraceptive methods should not be used in their treatment. Instead, Duphaston is prescribed for six months to correct hormonal imbalances in the second phase of the menstrual cycle.

The treatment of PMS should continue for three menstrual cycles. This is an approximate duration, and treatment may last longer depending on individual body characteristics.

In cases of extremely severe PMS, bilateral ovariectomy may be performed, resulting in the irreversible cessation of ovarian function. After this procedure, menstrual cycles cease, along with the disappearance of PMS symptoms. Hormone therapy is indicated for operated patients until the age of 51, which is the usual age of onset of menopause.

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