Obstetric & Gynaecology Malaysia


Premenstrual syndrome (PMS) refers to a group of physical and behavioral symptoms that occur in a cyclic pattern during the second half of the menstrual cycle. Premenstrual dysphoric disorder (PMDD) is the severe form of PMS. Common symptoms include anger, irritability, depression, and internal tension that are severe enough to interfere with daily activities.

Mild PMS is common, affecting up to 75% of women with regular menstrual cycles; PMDD affects only 5% of women. This condition can affect women of any socioeconomic, cultural, or ethnic background.

PMDD is usually a chronic condition and can have a serious impact on a woman's quality of life. Fortunately, a variety of treatments and self-care measures can effectively control the symptoms in most women.

Tissues throughout the body are sensitive to hormone levels that change throughout a woman's menstrual cycle. Studies suggest that rising and falling levels of hormones (eg, estrogen and progesterone) may also influence chemicals in the brain, including a substance called serotonin, which affects mood.

However, it is not clear why some women develop premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD) and others do not. Levels of estrogen and progesterone are similar in women with and without these conditions. The most likely explanation, based upon several studies, is that women who develop PMDD are highly sensitive to normal changes in hormone levels.

The most common symptoms of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are fatigue, bloating, irritability, depression, and anxiety. Other symptoms include the

●Sadness, hopelessness, or feelings of worthlessness

●Tension, anxiety, or "edginess"

●Variable moods with frequent tearfulness

●Persistent irritability, anger, and conflict with family, coworkers, or friends

●Decreased interest in usual activities

●Difficulty concentrating

●Fatigue, lethargy, or lack of energy

●Changes in appetite, which may include binge eating or craving certain foods

●Excessive sleeping or difficulty sleeping

●Feelings of being overwhelmed or out of control

●Breast tenderness or swelling, headaches, joint or muscle pain, weight gain

Disorders that mimic PMS and PMDD

Other conditions have symptoms that are similar to those of PMS and PMDD, including depression, anxiety disorders, bipolar disorder, and perimenopause (the four- to five-year period before menopause).

Women with underlying depression often feel better during or after menses, but their symptoms do not resolve completely. On the other hand, women with PMS or PMDD have a complete resolution of symptoms when their menses begin. Some women who think they have PMS or PMDD actually have depression or an anxiety disorder.

There are other medical disorders that worsen before or during menstruation, such as migraines; chronic fatigue syndrome /myalgic encephalomyelitis ; myofascial pelvic pain syndrome, interstitial cystitis/ painful bladder pain; or irritable bowel syndrome. A careful medical history should be able to distinguish among these disorders. It is also possible for a woman to have PMDD in addition to another medical condition.

There is no single test that can diagnose premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). The symptoms must occur only during the second half (luteal phase) of the menstrual cycle, most often during the five to seven days before the menstrual period, and there must be physical as well as behavioral symptoms. In women with PMS or PMDD, these symptoms should not be present between days 4 through 12 of a 28-day menstrual cycle.

Blood tests are not necessary to diagnose PMS or PMDD. A blood count may be recommended to screen for other medical conditions that cause fatigue, such as anemia. Thyroid function tests can detect hypothyroidism (an underactive thyroid gland) or hyperthyroidism (an overactive thyroid gland), both of which have similar signs and symptoms to PMS and PMDD.

Recording symptoms on a regular basis with menstrual app or diary for two full menstrual cycles is helpful


Conservative treatments for premenstrual syndrome (PMS) may be recommended first, including regular exercise, relaxation techniques, and vitamin and mineral supplementation. These therapies relieve symptoms in some women and have few or no side effects. If these therapies do not bring sufficient relief, prescription medication can be considered as a second option.

Conservative treatments are also recommended for women with premenstrual dysphoric disorder (PMDD), along with a prescription medication.

Exercise – Exercise can help to reduce stress, tension, anxiety, and depression.

Relaxation therapy – PMS and PMDD can be worsened by stress, anxiety, depression, and other psychological conditions. Furthermore, living with PMS or PMDD can cause difficulties in interpersonal relationships, at work or school, and with general day-to-day living. Relaxation therapy can help to ease the stress and anxiety of daily life and may include techniques such as meditation, progressive muscle relaxation, self-hypnosis, or biofeedback.

●Vitamin and mineral supplements – Vitamin B1 200mg daily (Sulbutiamine, synthetic derivative of thiamine), Vitamin B6 up to 100 mg day, vitamin D3 800 unit daily, and vitamin E 400 unit daily with Calcium 600mg daily and Magnesium 200mg daily for 4 to 8 weeks trial might have a small benefit for women with mild PMS.

The most effective medications are.

Selective serotonin reuptake inhibitors (SSRIs) are a highly effective treatment for the symptoms of PMS and PMDD. The SSRIs include fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa), paroxetine (Paxil) and escitalopram (Lexapro).

Studies showed that SSRIs reduced the symptoms of PMDD significantly compared with placebo; between 60 and 75 % of women with PMDD improve with an SSRI. It may not be necessary to take the medication every day. Taking the SSRI only during the second half of the menstrual cycle may be sufficient.

Some women have sexual side effects with SSRIs. The most common sexual side effect is difficulty having an orgasm. 

SSRIs should be taken for at least two menstrual cycles to measure their benefit. Approximately 15 % of women do not experience relief with these drugs after two cycles, in which case an alternative treatment is recommended.

Oral contraceptive pills(OCP). Some women with PMS or PMDD get relief from their symptoms when they take a birth control pill. However, some women find that the birth control pill can aggravate their PMS symptoms and, in that case, they should move to an alternative treatment.

The pill can be taken continuously to avoid having a menstrual period. To do this, the woman takes all of the active pills in a pack and then opens a new pack; the placebo pills are discarded. In theory, taking the pill continuously prevents the usual cyclical hormone changes that could affect mood.

Gonadotropin-releasing hormone (GnRH) agonists (eg, leuprolide acetate or goserelin acetate) are a type of medication that causes the ovaries to temporarily stop making estrogen and progesterone. This causes a temporary menopause and improves the physical symptoms (eg, bloating) and irritability caused by PMS and PMDD. However, the medication results in extremely low estrogen levels, which causes severe hot flashes and bone loss over time. Therefore, in addition to the GnRH agonist, women are treated with low doses of estrogen and progesterone to stop hot flashes and to prevent bone loss. Although this treatment is very effective, it is complicated and expensive and is only used if other treatments do not work.

Several treatments are of no proven benefit in relieving the symptoms of PMS. These treatments include progesterone, other antidepressant drugs (tricyclic antidepressants and monoamine oxidase inhibitors), and lithium. There is also no proven benefit of several popular dietary supplements, including evening primrose oil, essential free fatty acids, and ginkgo biloba.