Emmanuel K. Essel, M. D.
Obstetrician Gynecologist
5040 Oberlin Avenue
Lorain, OH 44053
Telephone: 216 960-0644




Premenstrual Syndrome - Is It Real?

Ms. Amy Smith sat before her gynecologist with tears in her eyes and sobbed.
"What's wrong Amy?," asked Dr. James Dodd.  "I'm a Jekyll and Hyde.  I'm the
most likable person but just before my period I'm a different individual.
My kids refuse to come near me.  My husband balks at having anything to do
with me and I scare my coworkers.  Please doctor, do something or else I'll
lose my job, family and friends."  Ms. Smith is the typical distressed woman
whom many physicians see daily in their offices asking for help.


Premenstrual syndrome (PMS) is a very common condition affecting about 5-40%
of American women and provokes disruption in their relationship with the
people they care most about.  It causes social, psychological and economic
problems.  PMS also presents as a challenge to health care providers of women.
It is a real illness that occurs two weeks before the period.  The usual
physical and mental responses to normal levels of ovarian hormones during
the 14 days before the period are exaggerated.  This results in repetitive
occurrence of such symptoms as irritability, depression, fatigue, bloating,
breast tenderness and headaches.

 


The cause of PMS is unknown.  Controversy exists about whether it is a
mental disease, a disease related to the cultural background of the patient
or a menstrually related condition.  In July 1994, the Economist Magazine
reported that the British Psychological Society in April 1993 said  PMS did
not exist.  It was the Society's view that it is a psychological problem
"more determined by psychology and culture than hormones.'' A study
sponsored by the WHO in 1981 found PMS symptoms in 23% Indonesian women and
79% among Yugoslavian women.  The theory being that in cultures where women
talk about PMS the disease is more common.

The American Psychiatrist Association (APA) thinks PMS is a depressive
condition that occurs before a woman's period.  They have recommended that
PMS be defined as a depressive symptom in their Diagnostic and Statistical
Manual.  The APA  calls PMS a "premenstrual dysphoric disorder."
In spite of the controversy, medical researchers are aware of its
relationship to the menstrual cycle.  For example, removing both ovaries
improves the symptoms.  Drugs used to suppress ovarian function also have
been found to improve PMS.  Some patients who have lost their ovarian
function and receive monthly estrogen and progesterone develop PMS symptoms.
Current knowledge seems to point to disturbance in chemical messengers that
transmit information between nerve cells. This disturbance may lead to
decrease in serotonin, a mood elevating chemical in the brain. 

 



Ms. Smith, as expected wanted instant relief of her symptoms.  Though her
symptoms suggested PMS, the diagnosis cannot be based on her current
history.  Unlike other ailments, physical examination or laboratory tests
don't help in the diagnosis of PMS.  The diagnosis will involve Ms. Smith
recording for two months her symptoms and their severity on a scale of one
to ten.  This way, her physician would establish the relationship of the
complaints to her menstrual period.

There are two groups of symptoms that may be obvious after Ms. Smith
completes the chart, namely emotional and physical.  The emotional
manifestation may include depression, angry outbursts, irritability,
confusion, social withdrawal and fatigue.  The physical symptoms include
breast pain, abdominal bloating, headaches and swollen legs.

The chart of Ms. Smith should show at least one emotional and a physical
symptom during each of the two weeks before her periods if she has PMS.  She
should also be relieved of her symptoms four days after her period without
recurrence until a fortnight before her next period.

 


The symptoms should be present without her taking any drugs, alcohol or
hormones and they should be severe enough to disrupt her lifestyle.
Ms. smith's chart may show primary PMS, secondary PMS or other symptoms
unrelated to the menstrual cycle wrongly attributed to PMS.

Primary PMS:
 This is the classic PMS that occurs about two weeks before the
period.  The symptoms are more than what most women would consider as normal
menstrually related symptoms that do not cause them any problems.

Secondary PMS:
 Ms. Smith will have menstrually related symptoms throughout
the menstrual cycle that become worse about two weeks before her period. 
Non menstrually related symptoms:
 These complaints would occur throughout
the month but wont get worse before the periods. 
Once Dr. Dodd reviews the chart, he will exclude other medical conditions
like menopause and underactive thyroid disease. He may then refer Ms. Smith
to a Psychiatrist if there are depressive symptoms occurring throughout the
month.



There is no single treatment that can improve all the symptoms involved with
PMS.  A single physical symptom such as breast pain, headache, swelling and
abdominal pain is treated with a specific drug.  Emotional symptoms related
to Primary PMS are treated with antidepressants.  If the symptoms occur
throughout the cycle and get worse before the period, the patient may
receive antidepressants daily.
 
Modification of Amy's behavior and lifestyle is important.  Dr. Dodd would
encourage her to exercise regularly and reduce the amount of caffeine as
well as sugar in her diet. Other foods and beverages may be taken in
moderation and certain vitamins prescribed.  She would also learn stress
reduction exercises.
 
Many women affected by PMS learn from their physicians, partners or friends
that "it's not real, it's the hand of nature and all women should learn to
bear it," or they are ridiculed as complaining too much.  Some women have
difficulty parenting or do poorly at work or school. Others have increased
social isolation or legal difficulties from PMS or depression. Women who
think they may be affected by PMS should seek help from their physicians
because help is available. It is a real disease.







.

Manny Essel