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D.K is a 34 year old woman with premenstrual symptoms that have become quite bothersome to her and those around her. She told me she’s always had some difficulty with abdominal bloating, swelling of her hands and feet, irritability, breast tenderness, and headaches during the two or three days preceeding her periods, but recently these symptoms have gotten much worse. Once her period begins, the symptoms disappear and she has no trouble at all until the next menstrual flow is about to begin. In her teenage years, she was started on birth control pills, and those provided some relief from her symptoms. She stopped the birth control pills in her mid-twenties, in order to have children. She had three of them and breast fed each of them for 6-12 months. Following her last delivery two years ago, she had a tubal ligation. Her exam was normal, and I asked her a number of questions, focused on three issues:
1. Do her symptoms occur with most of her periods?
2. Are her symptoms limited to the late luteal phase of her cycle? In other words, does she ever have these symptoms at other times?
3. Are the symptoms severe enough to interfere with some normal activities or social interaction?
It is of diagnostic importance that the symptoms be repetetive and predictable. While this reliable patient had not maintained a calendar or diary of symptoms, she was quite sure of the cyclic occurrence of these symptoms regularly over the last year. Some physicians require a prospective recording of symptoms before accepting the diagnosis of PMS, but I think with a reliable patient who is quite sure of the pattern of typical PMS symptoms, there is no need to prolong her misery by making her keep a 3-month calendar to document her symptoms. It is also of diagnostic importance that she not have any of these symptoms at other times. Migraine headaches, for example, may worsen both in frequency and intensity with the menstrual cycle. It does the migraine patient no good to lable her symptoms as PMS when she actually has migraines all the time…it’s just that they get worse around her menstrual flow. The same can be said about such mood disorders as depression and anxiety. These patients are depressed or anxious pretty much all the time, but their symptoms get much worse around their menstrual flows. They will respond best to anti-anxiety or anti-depressant therapy.
Probably most women will notice at least some “PMS symptoms” around the time of their menstrual periods. For most of these women, the very mild symptoms are easily tolerable or respond to such interventions as dietary modification, oral analgesics, exercise or tolerance. It is not helpful to label all women with any PMS symptoms as suffering from Premenstrual Syndrome. Instead, we should reserve that diagnosis for those in whom the symptoms are severe enough to interfere with their normal activities. As physicians, I believe we need to distinguish between patients experiencing normal but annoying PMS symptoms, and those whose normal activities are impaired by their symptoms. We have a wealth of medical interventions that can be helpful to both those patients, but I think the intensity of the intervention should match the severity of the problem.
PMS symptoms occur in the 5 days before menses, and are relieved by menses. The symptoms are severe enough to cause some identifiable impairment in the patient’s functioning. The types of symptoms that women with PMS report include:
• Depression
• Angry outbursts
• Irritability
• Anxiety
• Confusion
• Social Withdrawal
• Breast Tenderness
• Abdominal Bloating
• Headache
• Swelling of arms, legs, feet hands, wrists or ankles.
In the case of D.K., I explained that she is suffering from PMS, just like she did when she was a teenager. I discussed the fact that the birth control pills she took were a very effective treatment of PMS in her, and kept her symptom-free until she stopped them to have her children. But each time she became pregnant, and continuing until she stopped nursing, her menstrual cycles were suppressed, and so the pregnancies provided her good relief from her symptoms.
Her PMS resumed seriously in the last year because she had stopped breastfeeding her youngest, allowing her menstrual cycles to resume. But this time, she wasn’t taking birth control pills, but was relying on her tubal ligation for contraception. In this situation, her PMS symptoms roared back.
I recommended she resume birth control pills, which had given her very good results in the past. As a non-smoker with no risk factors, she could safely take birth control pills until menopause, at which time the PMS would naturally abate. It was important, though, to make sure that the birth control pills I prescribed were strong enough to consistently suppress ovarian function. Many newer birth control pills are effective at preventing pregnancy, but are not strong enough to consistently suppress ovarian function. If she were to take one of these weaker birth control pills, her PMS symptoms will not improve and may get worse, both in severity and duration. So I made sure to pick a strong one, with levonorgestrel as the progestin, a strong, long half-life progestin that was in her previous birth control pill. I suggested Portia, a very good generic birth control pill with an excellent track record of suppressing ovarian function.
There are other interventions that can be useful in treating PMS, but none as effective as a strong, low-dose birth control pill. Among these other interventions are:
• Non-steroidal anti-inflammatory drugs
• SSRI’s
• Spironolactone
• Vitamins
• More sleep
• Weight loss
• More exercise
• Less caffeine, alcohol, sugar and salt
I asked her to return for a followup visit in 3-6 months, but that I expected her symptoms to be largely resolved by the birth control pills, after she had been on them for at least 2 months.
