by Howard J. Osofsky, M.D., Ph.D.
Although pre-menstrual tension was first described in 1931. only in recent years has there been growing interest by the medical profession in the topic of pre-menstrual symptoms. Perhaps related in part to the feminist movement and to women’s insistence on better care for themselves, more women have openly described symptoms to their physicians and they, in turn, have become more cognizant that these problems are not to be lightly dismissed. Adding further impetus to interest in this area have been publications by the British doctor, Katharina Dalton, who has advocated progesterone therapy for PMS. In recent years, both in England and in the United States, there have been court cases in which PMS was claimed as a defense for acts of violence; based on consultations that I and others have had, the incidence of such cases is likely to grow. Under any circumstances, the area is an important one and deserves careful attention.
Pre-menstrual tension, pre- menstrual syndrome, pre-menstrual symptoms, pre-menstrual changes – many investigators have used different names to describe these symptom complexes. Because of the variety and varying intensity of symptoms along with clustering of certain symptoms, a number of investigators prefer to use the term, “Pre-Menstrual Syndromes.” Various reports estimate that between twenty and ninety percent of women of child- bearing age have some PMS and that somewhere between three and fifteen percent have severe cases.
Physical symptoms include: swelling; weight gain; feeling bloated or fat; pain in the breasts; craving of certain foods such as sweets, salty foods, or alcohol; acne; and allergy symptoms. Some women develop severe headaches, and in our experience, some individuals may develop seizures that appear related to the menstrual cycle. I’ve seen, on occasion, teenage patients with learning disabilities whose difficulties seemed worse pre-menstrually. Psychologically, women frequently describe feeling empty, angry, irritable, nervous, depressed or having a sense of things being unreal. Although more women describe decreased energy levels and less interest in sex, some have more energy and increased sexual desire. Infrequently, women have noted hallucinations in relationship to their menstrual cycles, or a worsening of psychiatric symptoms may be present with a number of different pictures. Some disorders appear aligned to the cycle: major mood symptoms including depression; elation and suicidal tendencies; psychosis; seizures, and severe bulemia (uncontrollable eating often accompanied by vomiting). Some patients describe symptoms that occur only in relationship to the cycle; some have had psychiatric symptoms that have been treated with improvement but who have exacerbations related to the cycle; others have symptoms that are present to a lesser extent in general, but appear to increase in severity pre-menstrually, and still other women have initially severe symptoms pre-menstrually which then generalize through the remainder of their cycle.
As I mentioned, there are questions of whether, on rare occasion, violence can be linked to the menstrual cycle. A number of women whom I’ve seen have described episodes of throwing chairs or other furniture, and recently I’ve been contacted about women who feel that episodes of child abuse or other severe violence are linked to their menstrual cycle.
The more common pre-menstrual symptoms appear to be age related, increasing to a peak incidence in the 30s and 40’s. However, this age relationship doesn’t hold as well for very severe symptoms. For example, I’ve seen teenagers with prior learning disabilities and uncontrollable rage who were successfully treated and whose symptoms then recurred with the onset of their periods. Similarly, I’ve seen women with bulemia, seizures, psychotic symptoms, and severe depression or other mood changes that appear related to their menstrual cycle but not to their age. In some women symptoms may be incapacitating, resulting in loss of friends, jobs, and marriages, and at times necessitating hospitalization.
Although I’m pleased with renewed interest in PMS, I must also admit some concern. I fear that what started off as a legitimate outgrowth of consumers’ wishes for better care could result in women receiving poorly-developed treatment with medications that could have potentially harmful side effects. However, even with the more apparently safe medications, such as progesterone. I have some worries. Although progesterone appears to have relatively few serious side effects, I remember that in the 1950s Diethylstilbestrol was thought to be a relatively innocuous drug and now we’re dealing with significant complications in children whose mothers were exposed to DES during pregnancy. I worry, too, that issues (that in part emerged from genuine concerns of women) could be inappropriately used, in some cases, to question women’sjudgment and ability to hold decision-making positions. Although pre-menstrual symptoms are common and, in rare cases, there may be episodes of severe dysfunction, there is no evidence to suggest that women in general cannot make thoughtful decisions or hold major positions at any time of their menstrual cycle.
I strongly recommend that women with significant symptoms who feel in need of treatment receive adequate evaluations. Recently at an NIMH Conference, it was recommended that women keep careful prospective daily records of their symptoms for a period of three months to ascertain, carefully, the pattern of their symptoms and the possible links between symptoms and menstrual cycle. When women keep careful calendars, they sometimes find that symptoms either improve considerably or are not readily linked to the menstrual cycle. Sometimes improvement is related to women recognizing stressors that may trigger the symptoms, dietary patterns that may influence their symptoms, and exercise-related issues that may also be involved. They may find they can treat themselves or that they need only minimal help from their doctors.
Where symptoms are clearly related to the menstrual cycle, I recommend diligent medical, endocrine, and psychological assessments before the initiation of treatment. A number of treatment regimens have been prescribed including vitamins, diuretics, anti-spasmodics, progesterone, birth control pills, bromocriptine, prostaglandin inhibitors, cortisone, antidepressants, and lithium to name but a few. To date, most of the studies carried out have been poorly designed with inadequate followup, and results of good studies have not substantiated the efficacy of any one form of treatment for all women.
In specific, although there is currently much enthusiasm for natural progesterone, results of studies to date are not as conclusively positive as proponents would suggest. Birth control pills, another popular treatment, appear to stabilize symptoms for some women, but for others their symptoms may worsen. At present, a number of studies are under way to test the efficacy of different drug regimens and to explore the possibility of neuro-endocrine components to the symptoms: for example, whether a woman might have a vulnerable neuro-endocrine system or whether her system might react in a particular way to various stressors. In addition, I’ve been impressed, as others have, that a significant number of women with severe symptoms have psychological pressures or underlying stressful situations in their environment. Although hormonal and other medical factors are worthy of treatment, these other underlying difficulties should also be treated.
In summary, I believe that the Pre-Menstrual Syndromes are an important and long-neglected subject. Meaningful research needs to be conducted to understand this syndrome better and to identify various causes and appropriate treatment strategies. At present, I strongly advise women who need treatment go to respected professionals or clinics where adequate evaluations are carried out, where careful approaches to treatment are employed, and where followup is an integral part of the treatment plan. I emphasize the importance of prospective monitoring of the symptoms where possible, and an evaluation that addresses medical, endocrine, and psychological factors. Currently, we have established a Clearing House for research and clinical data concerning PMS at the Menninger Foundation and are willing to help patients or treaters in planning and carrying out appropriate evaluations and treatment. For more information, feel free to contact me at the Menninger Foundation. Box 829, Topeka, Kansas, 66601 or by phone at (913) 273-7500. ext. 5717.