For a small number of women, the days before the start of a period can be dreadful.

What is pre-menstrual syndrome?
The vast majority of women who continue to have periods experience some kind of physical or psychological change in the days before their period begins. For most women the symptoms are mild and do not interfere with their domestic or work activities. However, for a small proportion of women their symptoms are so severe that they dread this time of the month.

There are over 100 recognised symptoms that may be due to PMS but, fortunately, most women experience only a handful of problems. The most common symptoms are:

irritability

mood swings

losing one's temper easily

loss of confidence

crying for no particular reason

aggression

poor concentration

tiredness

breast tenderness

abdominal swelling or bloating

weight gain

swollen ankles

headaches and possibly migraine.

None of these symptoms are exclusive to PMS and can be symptoms of other illnesses such as depression, hyperthyroidism (overactive thyroid gland) or hypothyroidism (underactive thyroid gland). However, the symptoms of PMS have a fairly consistent relationship with the start and finish of a woman's periods.

How does a woman know if she has PMS?
While blood tests and urine tests are helpful in making sure that a woman does not have another cause for her PMS symptoms, there is no laboratory test that can diagnose PMS. The diagnosis of the condition is based upon the type of symptoms (typically those mentioned above) and when they occur. Most women with PMS notice a gradual worsening of their symptoms during the week running up to their period, with a rapid or gradual disappearance of symptoms when their period starts. This is not always the case and, sometimes, symptoms can persist during the period or even for one or two days after it has finished.

The diagnosis of PMS can only be made by keeping a diary of the symptoms and their severity. This should be kept for three consecutive months. A diagnosis of PMS is usually only made if there are 10 consecutive symptom-free days each month.

What causes PMS?
It is not known what causes PMS. Most doctors believe that it is somehow linked to the fluctuating levels of female hormones experienced after ovulation. These may directly cause some of the physical symptoms of PMS such as bloating. PMS sufferers may have a lower level of a certain chemical in their brain (serotonin), which may explain some of the non-physical symptoms such as irritability, depression and mood swings.

PMS is not caused by any underlying abnormality with the woman's pelvic organs nor is it caused by a hormone deficiency.

Understanding PMS is the first step to conquering the illness.

When should a woman seek treatment?
Recognising that her symptoms are due to PMS is an important first step. For the majority of women the symptoms are only a minor inconvenience which they can recognise, anticipate and deal with themselves. These women may seek reassurance from their doctor but no specific treatment is necessary.

However, for a minority of women, their PMS is serious enough to affect their work, daily life and their relationships. It is advisable that these women see their GP to discuss their problems, possibly with a view to some treatment.

What treatments are available?
Confirming the diagnosis and talking through the issues is the first step. There are very many treatments for PMS, most of which have some short-term benefit but few provide relief for longer than a few months. The reason for this is the 'placebo effect'. A placebo is a treatment that is actually ineffective but has the psychological effect of making the patient feel better. It is well recognised that patients with most illnesses (PMS included) will notice an improvement with a placebo treatment, at least in the beginning. To demonstrate that a treatment is better than a placebo requires careful scientific study. Not all PMS treatments have been subjected to proper evaluation in this way.

A visit to the woman's GP is usually the first step if she is being troubled with PMS. It may be helpful when you make the appointment to explain that you want to discuss PMS as your GP may wish to set some additional time aside to discuss your symptoms. Other sources of help might include a Well-Woman Clinic or a Family Planning Clinic. Severe cases, or cases which have not responded to simple treatments might be referred to a gynaecologist or a psychiatrist with a particular interest in treating severe PMS.

Treatment will depend upon the nature of the symptoms and their severity. For many women, simple changes to their diet and lifestyle, reducing alcohol and caffeine intake and cutting down on cigarettes will make the monthly symptoms more bearable. Your GP can give you guidance in this. A suitable diet sheet is available via the National Association for Premenstrual Syndrome (NAPS) at www.pms.org.uk.

Tablet treatments vary in their actions and their effectiveness. The following are often tried in PMS.

Non-hormonal treatments

Vitamin B6 This is also known as pyridoxine. It is commonly recommended for mood swings and irritability. There is some scientific support for its use for mild symptoms but it is important not to take it in too high a dose. It is advisable to consult your doctor before starting treatment.

Evening primrose oil (EPO)
Capsules of EPO are often helpful in alleviating pre-menstrual breast pain.

Bromocriptine and cabergoline
These medicines are useful if pre-menstrual breast pain is a major symptom. They are only available on prescription.

Diuretics (water tablets)
These may give relief from ankle swelling. They will not relieve abdominal bloating, which is not caused by fluid retention but by relaxation and distension of the muscle in the wall of the bowel. They are prescribed by a doctor and should only be taken for a few days each month in the lowest of doses.

Antidepressants
There is much enthusiasm for the use of a class of antidepressants called SSRIs (eg Prozac) in the treatment of severe PMS where the symptoms are mostly depression, mood swings, irritability, etc. The results of treatment are often dramatic and are supported by scientific studies. Side effects can sometimes be a problem. Discussion with a GP, gynaecologist or psychiatrist is essential before starting treatment.

Hormonal preparations

Progestogens This is a group of hormones that is taken for 10 to 14 days before the beginning of the period. Progestogens are widely prescribed and have relatively few side effects. It was once thought that PMS was due to a lack of progestogen in the woman's bloodstream but it is now recognised that this is not the case. Some women do gain short-term relief of mild symptoms with progestogens but most scientific studies do not support their use.

Combined oral contraceptive (COC) pill
This is often prescribed in PMS, especially if contraception is required. It is believed to help by stopping ovulation and reducing the body's natural fluctuations in the hormones thought to be responsible for PMS. Unfortunately, some women actually find that the COC gives them PMS because of the hormones contained in the pill. Although it is logical to use the COC pill in PMS, there is little scientific evidence to support its use. It is available by free prescription.

Danazol
This is a synthetic hormone based on the male hormone testosterone. Its use in PMS is supported by scientific studies but it has a number of side effects, which means that it is suitable for use in low doses only and will not be tolerated by all women. It is available by prescription only. A woman must not become pregnant while taking this medication.

Oestrogen patches and implants
By giving a woman extra oestrogen (one of the female hormones) in this way, it can suppress ovulation and reduce the naturally occurring hormone fluctuations. There is scientific evidence to support its use in PMS. Available on prescription, usually after consultation with a gynaecologist.

LHRH analogues (GnRH analogues) such as Zoladex, Prostap and Synarel
These are potent medicines used by gynaecologists for a number of conditions. They temporarily switch off a woman's ovaries, which usually gives relief from PMS within two months. They are expensive and are only suitable for short-term use (up to six months). LHRH analogues may be used to confirm the diagnosis of PMS and to help guide the woman and her gynaecologist towards considering surgery or not. They are used only in severe and difficult-to-treat cases.

Mirena intra-uterine system (IUS)
This device is, in fact, a contraceptive coil, which is placed inside the uterus (womb), that releases a small dose of progestogen hormone into the body. Most women experience a reduction in the heaviness and duration of their periods and some say that it improves their PMS. It may be combined with an oestrogen patch or implant.

Surgery
For a small minority of women, surgical removal of the ovaries is the only measure that will allow them to continue a normal existence free of PMS. This is a major step to be considered very carefully by the woman, her GP and gynaecologist. Removing the womb only (hysterectomy) may not improve PMS. Once the ovaries are removed, a woman must be prepared to take hormone replacement therapy (HRT) until at least the age of 50.

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