The PMS Blues: Understanding and Treating Premenstrual Syndrome
October 10, 1986 - Boston Globe / Living Arts - Alexis Beck

The past 20 years of Beth's 39 years have been disrupted by a nightmarish biological struggle. For the past two weeks every month, this marketing professional, who is also a wife and mother of two teen-age boys, was afflicted with debilitating headaches, insatiable cravings for chocolate and chips, an uncomfortable 7 to 10 pound weight gain and extreme mood swings, from depression to rage.

Beth, who asked that her last name not be used, is a victim of premenstrual syndrome, or PMS. "I felt completely out of control of my life. I just wanted to hide," she said during an emotional conversation in her suburban home. "I really put my husband through the wringer. I would want him to hold me, and as soon as he did, I'd push him away. I would shut myself in the bedroom and tell him to stay out. As the years passed and things got worse, I finally asked him to commit me - I thought I was losing my mind."

Then she would get her period, and two days later, "I would feel like myself," she said. But she made no connection between her symptoms and her menstrual cycle.

"We have no precise definition for PMS, nor do we really know what causes it," said Dr. Michelle Harrison, a PMS, nationally recognized Cambridge-based physician whose practice is devoted exclusively to the diagnosis and treatment of PMS.

"Although many theories have been suggested, none are universally upon, and none appear to be true for all women with PMS." Harrison continued. One popular theory links the problem to a deficiency of progesterone, the hormone that prepares a woman's body for pregnancy approximately every 28 days. According to Dr. Katharina Dalton, a British gynecologist whose 30 years of pioneering work first alerted the medical community to the realties of PMS, an estrogen excess, or a relatively high estrogen-to-progesterone ratio, is the culprit.

Harrison, however, is partial to a neurologically based theory. She believes a problem occurs in the hypothalamus, the area in the brain's center where myriad functions of the neurologic and endocrine systems are regulated - for example, ovulation and the production of estrogen and progesterone, blood glucose levels and appetite control.

Other possible explanations include excessive secretion of prolactin, a pituitary hormone: hypoglycemia (low blood sugar): fluid retention: and a vitamin B6 or magnesium deficiency.

Another theory, held by a minority of skeptics, is that PMS doesn't exist, that it is all in the head. This belief is behind the frequent, if inappropriate, prescription of drugs like Valium and Elavil, and behind the patronizing treatment by physicians that many women report.

"A purely psychiatric diagnosis of PMS feeds into the belief that women are crazy." Emphasizes Harrison. "A purely physical diagnosis suggests that women are at the mercy of their hormones. And neither is true."

Last July, the American Psychiatric Association officially decided that PMS would no longer be included on its list of recognized mental disorders. A more narrow diagnosis, "periluteal phase dysphoric disorder," will instead be included in a special appendix. What is PMS?

PMS is the cluster of symptoms that appears 2 to 14 days before the onset of a menstrual period.

The most common physical symptoms include a bloated feeling, weight gain, breast tenderness, headache, increased appetite (usually for sweet and/or salty foods), fatigue, poor coordination, changes in bowel habits (constipation or diarrhea), and a particular sensitivity to the effects of alcohol.

The psychologically based symptoms range from irritability, anxiety and depression to an inability to concentrate, significant mood swings, crying jags and suicidal impulses.

Some women have such mild symptoms that they hardly notice that the occasional headache or desire for chocolate always occurs during the same week of the month. Other women, unfortunately, can't help but notice. For them, the days or weeks before their periods are a descent into physical or emotional misery.

Distinct premenstrual symptoms usually first appear when a woman is in her 20's. Some believe a hormonal upheaval is at the bottom of it all, the sort of upheaval that occurs at puberty, for example. The interruption or cessation of menstrual cycle, whether naturally, surgically or chemically (e.g. pregnancy, tubal ligation or using an oral contraceptive) can also trigger PMS in a previously symptom-free woman. Its incidence and severity generally increase with age, with women between 35 and 45 usually having the most difficult time.

"At one time or another approximately 85 to 90 percent of women will experience some symptoms during one or more menstrual cycles," explains Harrison. According to Dalton, 40 percent of women have PMS at any given point in time on a fairly regular basis, and 5 to 10 percent seek medical attention because the symptoms are severe enough to interfere with their lives.

Because of the broad spectrum of symptoms and the number of body systems involved, PMS can elude all but the expert.

In her quest for relief over the years, Beth sought all kinds of advice and therapies, but her PMS went unrecognized and persisted: she tried birth control pills, which only exacerbated her symptoms: diuretics: beta blockers for her headaches, which left her so sleepy she couldn't work: and psychotherapy. Finally, during an appointment with her company's in-house physician, whose help she sought four months ago for her excruciating headaches, she found the answer.

Since that time, Beth has all but eliminated her symptoms through a change in diet, daily exercise and a regimen of vitamins.

DIANGOSIS
Among the many differing symptoms and etiological opinions, there is one unifying feature of PMS that allows it to be identified, contends Dalton. It is the timing of the symptoms. Most experts agree that PMS is identified not by which symptoms occur, but by when they occur. It is best recognized by the presence of symptoms that develop or substantially worsen following ovulation and during the two weeks before menstruation, and by the dramatic disappearance of symptoms when menstruation starts. Also, when PMS is a problem, there is at least one symptom-free week following menstruation. Even once this set of conditions is satisfied, actually diagnosing the syndrome is still difficult. There is no reliable chemical, physical or psychological tests upon which the medical practitioner can base his opinion. Therefore, Harrison cautions, "It is absolutely critical that any possible underlying disorder by ruled out before the diagnosis of PMS is made. Different problems require different treatments, and the underlying condition, if there is one, must be treated first." Disorders that might cause symptoms resembling PMS include endometriosis, a seizure disorder, a pituitary tumor, hypothyroidism and chronic depression. Many of the experts contacted agreed that charting is a primary diagnostic tool and represents the best means so far of demonstrating which symptoms are premenstrual and which occur at other times in the menstrual cycle. This means keeping a record for two to three months of what symptoms occur throughout the month, when they occur and when menstruation begins and ends.

TREATMENT
Because the cause of PMS is undetermined, no ideal treatment has been formulated. Different practitioners use different combinations of the treatment methods and drugs accepted. And some experts say that validating the reality of the syndrome can be the most important component of treatment. On treatment methods, there are three schools of thought: lifestyle change, vitamin therapy and drug or hormonal therapy. According to nutritionist Connie Roberts, nutrition is the best defense against PMS. Roberts, coordinator of the nutrition consultation service at Brigham and Women's Hospital in Boston, has spent the last several years researching and administering the dietary treatment of PMS. She recommends the following program: Sum Increase complex carbohydrates like whole-grain breads and cereals, pastas, potatoes, rice and fruit, and eliminate the simple sugars, or "junk food."

• Eat six small meals per day with no more than three hours between ingestions, without increasing the usual calories.
• Avoid caffeine, including decaffeinated coffees, teas (except herbal), chocolate, colas, and the painkillers and cold preparations that commonly contain it. (These recommendations help keep blood glucose on an even keel to reduce food cravings, fatigue and mood swings.)
• Cut back on saturated fats (red meats, whole milk dairy products, butter and processed foods containing coconut and palm oils).
• Modify sodium intake since sodium holds fluids in the body, which can exacerbate bloating, breast tenderness and emotional symptoms.
• Eat naturally rich sources of vitamin B6 and magnesium (leafy green vegetables, whole grains, seeds and nuts) as well as potassium (broccoli, winter squash, potatoes, bananas, oranges, lentils).

Exercise can reduce the severity of PMS by improving the body's ability to tolerate stress and pain, since exercising brings the naturally tranquilizing effect of endorphin release. It can also reduce body fat, thus lowering the body's estrogen production. Experts agree that it should be aerobic (brisk walking in fine). Last at least 45 uninterrupted minutes, and be pleasurable.

Vitamin B6 at doses of 200 to 500 milligrams per day has been reported to relieve symptoms of depression and bloating for some women. "Together with a proper diet and exercise regimen, I have seen fairly good results with it," says Dr. Alan Altman, A Brookline gynecologist.

In response to the research that indicates potential neurological side effects from B6 therapy, Altman, says, "the problems arose with doses of 2,000 mg or more and when it was taken without any other B vitamins. As long as 500mg daily is not exceeded and the patients balances it with other B vitamins by taking a standard over-the-counter B complex supplement, I am comfortable with this approach."

Somewhat more questionable is the oil extracted from the evening primrose plant, a North American wildflower.

Freda Romero, a nurse specialist at the Women's Division of Health Resources in Brookline, who see every PMS patient at the clinic, generally recommends it on a trial basis only. "If it's going to work, it takes about two month for its effects to be felt, and sometimes the benefits don't last much longer." It's available in capsule from without a prescription in health food stores and some pharmacies, but Romero cautions that there can be side effects like skin irritation and gastric irritation when taken without food. Women who are prone to alcohol-induces headaches should avoid it.

The most controversial treatment is perhaps the method of last resort - progesterone. While not approved by the Food and Drug Administration for PMS use, nor proven more effective than placebos in clinical trials, some practitioners prescribe it and some patients feel they can't live without it.

Gina is one of those women. "Progesterone gave me my life back," says this 27-year-old entertainment industry executive who prefer to be anonymous.

Gina battled her symptoms 22 of the 34 days of her cycle. Fatigue was the most overwhelming symptom. During an eight-hour workday, she would fall asleep at her desk. Once home, she would immediately fall into bed to stay for the next 14 hours.

Progesterone therapy has been used in England since 1948 where it is government approved. It has been available in this country since 1981, but only two companies distribute it. On an average, a woman will spend $125 per month for an n effective dosage.

"When it works, progesterone seems to prevent or alleviate symptoms so that the woman feels like herself," said Harrison, "and when it works well, it provides relief within an hour two. Getting the dosage right is tricky though: it may range from 200 to 4,000 mg per day."

"The efficacy rates and long term effects are not yet clear, added Harrison, who has each patient sign a release form that clearly states the possible side effects as well as the controversial nature of the treatment, which is available by prescription only."...

The American Council on Science and Health warns women seeking treatment of PMS to be skeptical of clinics or practitioners who claim no failures, who base their diagnosis on blood, urine or hair test, who promote a "secret formula," who charge excessively high prices (the average cost in the Boston area is between $150 and $300, which includes the initial evaluation and physical, and the follow-up treatment and educational sessions once the diagnosis is confirmed) or who do not inform patients that treatment with progesterone, other steroid hormones and vitamins is experimental and some causes of unproven safety.