premenstrual syndrome

Definition

Premenstrual syndrome (PMS) refers to symptoms that occur between ovulation and the onset of menstruation. The symptoms include both physical symptoms, such as breast tenderness, back pain, abdominal cramps, headache, and changes in appetite, as well as psychological symptoms of anxiety, depression, and unrest. Severe forms of this syndrome are referred to as premenstrual dysphoric disorder (PMDD). These symptoms may be related to hormones and emotional disorders.

Description

Approximately 75% of all menstruating women experience some symptoms that occur before or during menstruation. PMS encompasses symptoms severe enough to interfere with daily life. About 3–5% of women experience the more severe PMDD. These symptoms can last 4–10 days and can have a substantial impact on a woman's life.

The reason some women get severe PMS while others have none is not understood. PMS symptoms usually begin at about age 20-30 years. The disease may run in families and is also more prone to occur in women with a history of psychological problems. Overall however, it is difficult to predict who is most at risk for PMS.

— Cindy L. A. Jones, PhD

The first ‘modern’ account of premenstrual tension (PMT) was published in a medical journal in 1931. Feelings of tension, self-deprecation, and even severe depression experienced by women in the 7-10 days preceding menstruation were accurately described. By the 1950s the list of symptoms reported by women in the premenstrual period had increased, and there was a growing realization that so-called ‘tension’ was just one aspect of the problems. In a paper published in 1953 the term ‘premenstrual syndrome’ was introduced to encompass the extending list of symptoms. The name eventually stuck, and the problem is now often referred to as PMS.

The symptoms of PMS include not only anxiety, irritability, and depression but also constipation, food cravings, sleep problems, tiredness, and a feeling of bloatedness, particularly in the abdominal area (due to water retention). These are just a few of the common complaints, and in fact it has been mooted that when all reported symptoms of PMS are added up the total can reach the unbelievable number of 160.

The incidence of PMS ranges from 5% to 95% according to different surveys which have been undertaken. For example, in a survey by Woman's Own magazine in 1993, nine out of ten women claimed to suffer from at least some of the symptoms. A study in the early 1980s by the World Health Organization reported that the incidence of premenstrual mood changes varied between 23% amongst Sudanese women to 73% amongst Muslim women in the then Yugoslavia. Thus one is left with the conclusion that women can and do suffer from PMS irrespective of culture and society. However, such a wide variation in the estimated incidence can either fuel the sceptics or suggest that not suffering from PMS is abnormal. In whatever way it is viewed, it is quite clear that many women do experience symptoms associated with their changing hormone levels during their menstrual cycle, and there is now growing awareness that symptoms described by patients as PMS are not always limited to the premenstrual period; they can extend into the menstrual period itself.

The causes of PMS remain unknown. It is generally believed that symptoms result from the waning hormone secretions from the ovaries as the corpus luteum begins to degenerate towards the end of the menstrual cycle. At this stage concentrations of progesterone and oestrogen in the circulating blood decline, and this is thought to precipitate the various symptoms. How the loss of these hormone secretions results in the physical, behavioural, and psychological symptoms ranging, for example, from abdominal bloating to food cravings and lethargy remains unknown, as does the question as to why some women should suffer from PMS while others do not. Theories have been proposed regarding the ratio of oestrogen to progesterone secretions or the absolute concentrations of these hormones, but these have not been consistently validated. More likely, the cause is an individual's response to her changing hormone secretions, which may be exacerbated by social and/or cultural influences.

There is no doubt that sex hormones can influence brain function. It has long been recognized that they can affect the neurotransmitters which transmit neural signals within the brain, and also the receptors on nerve cells which recognize these neurochemicals. Recent work has suggested that the specific receptors for serotonin (otherwise known as 5-hydroxy-tryptamine) are increased by oestrogens but decline when secretions of this hormone are reduced. A deficiency of this same neurotransmitter, or a loss of its receptors, has also been linked with food cravings. Thus it is possible that many of the symptoms of PMS may be caused by the loss of hormone secretions and a consequent reduction in some aspects of brain chemistry. It follows that treatment of symptoms with drugs that can increase serotonin activity, including vitamin B₆, can alleviate the symptoms of PMS.

However, the question still remains: can PMS be defined as a pathological condition or is it a ‘normal’ consequence of changing hormone secretions? In this respect it is interesting to note that women who are prone to suffer depression are more likely to suffer from PMS than those who do not. Perhaps one should consider that whether or not one suffers from PMS will very much depend on the ‘background’ of brain chemistry against which the hormones (or lack of them) are working.

— Saffron Whitehead

Bibliography

• Dalton, K. and Holton, D. (1994). PMS. Harper Collins, London

See also menstrual cycle.

As many as 90 per cent of women suffer from premenstrual tension (also known as premenstrual stress and premenstrual syndrome). The disruptive emotional and physical symptoms (including appetite changes, irritability, and headaches) that precede menstruation may last up to two weeks or longer. The symptoms vary considerably in intensity from very mild and barely perceptible, to so severe that work and domestic harmony are threatened. Physical changes associated with premenstrual tension are an increase in breast size, increased fluid retention with associated weight gain, abdominal distension, and an increase in skin pigmentation.

There appears to be no single cause of PMT, but it is probably linked to a hormonal imbalance (such as lack of progesterone during the second half of the menstrual cycle). Some experts suggest that nutritional deficiencies can disrupt the body's delicate hormonal balance. These include a lack of gamma-linoleic acid (GLA), vitamins, and minerals (such as zinc, magnesium, and vitamin B₆). There is, however, no conclusive evidence that supplements of these nutrients have any beneficial effects, and there is a risk of toxicity if doses higher than 50 mg per day of vitamin B₆ are taken. Other factors (alcohol, stress, ageing, a diet high in saturated fats, and viral infections) may also precipitate PMT. Sufferers are generally advised to reduce their intake of saturated fats and salty foods, increase their consumption of fruit and green vegetables, and drink plenty of fluids during attacks; even if this has no effect on PMT, the dietary changes should improve overall health.

Some gynaecologists believe that fatigue can cause PMT and recommend that women rest before a period is due. However, moderate exercise significantly reduces the severity of premenstrual symptoms in many women. In addition to improving fitness, regular aerobic training can reduce feelings of depression and anxiety.

A condition that occurs within 10 days before menstruation and ends soon after menstruation begins. The most common physical and psychological symptoms may include fatigue, heightened appetite, lack of coordination, headache, bloating or cramping of the abdomen, pain in the joints or back, pressure or pain in the breasts, depression, apprehension, and inappropriately aggressive behavior.

Definition

Premenstrual syndrome (PMS) refers to a compilation of over 150 symptoms that occur between ovulation and the onset of menstruation. The symptoms include both physical symptoms, such as breast tenderness, back pain, abdominal cramps, headache, and changes in appetite; behavioral symptoms such as clumsiness, poor concentration, and sleep problems; as well as psychological symptoms of anxiety, irritability, depression, and unrest. Severe forms of this syndrome are referred to as premenstrual dysphoric disorder (PMDD). These symptoms may be related to hormonal imbalances and emotional disorders.

Description

Between 40-75% of all menstruating women experience symptoms that occur before or during menstruation. PMS encompasses a wide range of symptoms, some as minor as appetite change or others so severe that they may interfere with daily life. Some women experience a beneficial increase in their sexual libido. Only 3-7% of women experience the much more severe premenstrual dysphoric disorder (PMDD). These symptoms can last 4-10 days and can have a substantial impact on a woman.

The reason some women get severe PMS while others have little or none is not understood. PMS symptoms usually begin at puberty and last until menopause. Women more sensitive to hormonal change may experience PMS more than others. Stress is also a huge contributor and the relief of tension often lessens the other symptoms as well. Overall however, it is difficult to predict who is most at risk for PMS.

Causes & Symptoms

Because PMS is restricted to the second half of a woman's menstrual cycle, after ovulation, it is thought that hormones play a role. During a woman's monthly menstrual cycle, which lasts from 24-35 days, hormone levels change. The hormone estrogen gradually rises during the first half of a woman's cycle, the pre-ovulatory phase, and falls dramatically at ovulation. After ovulation, the post-ovulatory phase, progesterone levels gradually increase until menstruation occurs. Both estrogen and progesterone are secreted by the ovaries, which are responsible for producing the eggs. The main role of these hormones is to cause thickening of the lining of the uterus (endometrium). However, estrogen and progesterone also affect other parts of the body, including the brain. In the brain and nervous system, estrogen can affect the levels of neurotransmitters, such as serotonin. Serotonin has long been known to have an effect on emotions, as well as eating behavior. It is thought that when estrogen levels go down during the post-ovulatory phase of the menstrual cycle, decreases in serotonin levels follow. Whether these changes in estrogen, progesterone, and serotonin are responsible for the emotional aspects of PMS is not known with certainty. However, most researchers agree that the chemical transmission of signals in the brain and nervous system is in some way related to PMS. This is supported by the fact that the times following childbirth and menopause are also associated with both depression and low estrogen levels.

Nutritional deficiencies, food allergies, and hypoglycemia have been linked with PMS. A diet deficient in essential fatty acids, zinc, magnesium, and vitamin B₆ may affect estrogen and progesterone production and their balance in the body.

Over 150 symptoms for PMS have been identified. These include physical, behavioral, and emotional aspects that range from mild to severe. The physical symptoms include bloating, headaches, food cravings, abdominal cramps, headaches, tension, fatigue, acne, muscle aches, and breast tenderness. Behavioral symptoms may include insomnia, lack of concentration, and clumsiness. Emotional aspects include mood swings, irritability, and depression.

Diagnosis

The best way to diagnose PMS is to review a detailed diary of a woman's symptoms for several months. PMS is diagnosed by the presence of physical, psychological, and behavioral symptoms that are cyclic and occur in association with the premenstrual period of time. PMDD, which is far less common, was officially recognized as a disease in 1987. Its diagnosis depends on the presence of at least five symptoms related to mood that disappear within a few days of menstruation. These symptoms must interfere with normal functions and activities of the individual.

Treatment

There are many treatments for PMS and PMDD depending on the symptoms and their severity. Hypnotherapy, spiritual healing, color therapy, reflexology, Ayurvedic medicine, Chinese herbalism, acupuncture, acupressure, aromatherapy, herbal treatment, Naturopathic treatment, and homeopathy are all therapies that have been used to treat PMS.

Vitamins and Minerals

Some women find relief with the use of vitamin and mineral supplements. Magnesium can reduce the fluid retention that causes bloating, while calcium may decrease both irritability and bloating. Magnesium and calcium also help relax smooth muscles, which may reduce cramping. Recent studies indicate that calcium supplements can reduce premenstrual complaints by nearly half. Vitamin E reduces breast tenderness, nervous tension, fatigue, and insomnia. Vitamin B₆ decreases fluid retention, fatigue, irritability, and mood swings. Vitamin B₅ supports the adrenal glands and may help reduce fatigue.

Phytoestrogens and Natural Progesterone

The Mexican wild yam, Dioscorea villosa, contains a substance that may be converted to progesterone in the body. Because this substance is readily absorbed through the skin, it can be found as an ingredient in many skin creams. (Some products also have natural progesterone added to them.) Some herbalists believe that these products can have a progesterone-like effect on the body and decrease some of the symptoms of PMS.

The most important way to alter hormone levels may be by eating more phytoestrogens. These plant-derived compounds have an effect similar to estrogen in the body. One of the richest sources of phytoestrogens is soy products, such as tofu. Additionally, many supplements can be found that contain black cohosh (Cimicifuga racemosa) or dong quai (Angelica sinensis), which are herbs high in phytoestrogens. Red clover (Trifolium pratense), alfalfa (Medicago sativa), licorice (Glycyrrhiza glabra), hops (Humulus lupulus), and legumes are also high in phytoestrogens. Increasing the consumption of phytoestrogens is also associated with decreased risks of osteoporosis, cancer, and heart disease.

Herbal Treatment

Herbal treatment has been used to treat many symptoms of PMS. Herbs to alleviate cramps include angelica root, cramp bark, kava kava, red raspberry, black haw, and rosemary. Black cohosh, peppermint, strawberry leaf, and valerian root have been used to decrease mood swings. Dandelion, couch grass, and hawthorn are effective diuretic herbs used to reduce bloating and swelling. Burdock root and red clover are liver cleansing herbs that can be useful in eliminating excess estrogen from the system. Herbs to balance hormones include blessed thistle, dong quai, false unicorn root, fennel seed, sarsparilla root, and squaw vine. Feverfew may be effective for migraine headaches.

Many herbs may be beneficial as a natural antidepressant. St. John's wort (Hypericum perforatum) has stood up to scientific trials as an effective antidepressant. As with the standard antidepressants, however, it must be taken continuously and does not show an effect until used for four to six weeks. There are also herbs, such as skullcap (Scutellaria lateriflora) and kava kava (Piper methysticum), that can relieve the anxiety and irritability that often accompany depression. An advantage of these herbs is that they can be taken when symptoms occur rather than continually. Chaste-berry tree (Vitex agnus-castus), in addition to helping rebalance estrogen and progesterone in the body, may also relieve the anxiety and depression associated with PMS.

Aromatherapy

Aromatherapy oils can be a useful adjunct treatment for PMS. Lavender oil reduces headaches, cramps, and painful breasts. Chamomile and sandalwood oils may be used to relieve stress and tension. Premenstrual fatigue may be remedied by geranium, bergamot, and rosemary oils.

Homeopathy

A number of homeopathic remedies may be applied in the treatment of PMS, depending upon the individual's symptoms. Natrum muriaticum may be the appropriate remedy when irritability, lack of self-confidence, depression, anxiety, and headaches are present. Sepia may be given when PMS is accompanied by stress, weepiness, and to calm nerves. Symptoms of indifference, panic attacks, anger, tension, hair loss, sugar cravings, and a reduced sex drive may indicate that Kali carbonicum may be the appropriate remedy.

Allopathic Treatment

Allopathic treatments available include over-thecounter anti-inflammatory drugs such as ibuprofen or acetominophen, antidepressant drugs, hormone treatment, or (only in extreme cases) surgery to remove the ovaries. Anti-inflammatory drugs are useful in reducing headaches, muscle aches, and cramping. One recommendation is to begin taking the anti-inflammatory one to two days before the onset of cramps. Doing so will block the cramp-causing hormones, prostaglandins, and may prevent any nausea, vomiting, and diarrhea associated with PMS. Hormone treatment usually involves oral contraceptives. This treatment used to prevent ovulation and the changes in hormones that accompany ovulation. Recent studies, however, indicate that hormone treatment has little effect over placebo.

Antidepressants

Antidepressants prescribed for PMS include sertra-line (Zoloft), fluoxetine (Prozac), and paroxetine (Paxil). They are termed selective serotonin reuptake inhibitors (SSRIs) and act by indirectly increasing the brain serotonin levels, thus stabilizing emotions. Some doctors prescribe antidepressant treatment for PMS throughout the cycle, while others direct patients to take the drug only during the latter half of the cycle. Antidepressants should be avoided by women wanting to become pregnant. Side effects of sertraline were found to include nausea, diarrhea, and decreased libido.

Expected Results

The prognosis for women with both PMS and PMDD is good. Most women experience relief from symptoms when treated.

Prevention

Maintaining a good diet, one low in sugars, salt, fats, alcohol, and caffeine, and high in phytoestrogens and complex carbohydrates, may prevent some of the symptoms of PMS. Consumption of more complex carbohydrates may relieve PMS symptoms since carbohydrates drop seratonin levels as they raise insulin levels. For instance, two cups of cereal or a cup of pasta has enough carbohydrate to effectively increase serotonin levels. Carbohydrates also provide steady levels of blood sugar and act to stabilize one's mood. One recommendation is to eat 100 calories of complex carbohydrates every three hours beginning one week before menstruation. Complex carbohydrates include whole wheat bread and pasta, brown rice, and whole grain foods. Caution should be taken due to the fact that a high carbohydrate diet causes water retention, which in turn is a symptom of PMS.

Women should try to exercise three times a week, keep in generally good health, and maintain a positive self image. Because PMS is often associated with stress, avoidance of stress or developing better means to deal with stress can be important. Relaxation techniques, meditation, and yoga practice can aid in stress reduction.

Resources

Books

The Burton Goldberg Group. Alternative Medicine: The Definitive Guide. Fife, WA: Future Medicine Publishing, 1999.

Periodicals

Gold, Judith. "Premenstrual Dysphoric Disorder: What's That?" Journal of the American Medical Association 278 (September 24, 1997): 1024-1026.

Hochwald, Lambeth. "Get with the Program. (PMS and Menstrual Care)." Natural Health (January/February 1997): 54-56.

Steiner, M. "Premenstrual Syndromes." Annual Review of Medicine 48 (1997): 447-455.

[Article by: Jennifer Wurges]

Definition

Premenstrual syndrome (PMS) refers to symptoms that occur between ovulation and the onset of menstruation. The symptoms include both physical symptoms, such as breast tenderness, back pain, abdominal cramps, headache, and changes in appetite, and psychological symptoms of anxiety, depression, and unrest. Severe forms of this syndrome are referred to as premenstrual dysphoric disorder (PMDD). These symptoms may be related to hormones and emotional disorders.

Description

Approximately 75 percent of all menstruating women experience some symptoms that occur before or during menstruation. PMS encompasses symptoms severe enough to interfere with daily life. About 3 to 7 percent of women experience the more severe PMDD. These symptoms can last four to ten days and can have a substantial impact on a woman's life. The reason some women get severe PMS while others have none was as of 2004, not understood.

Demographics

Not really a characteristic of adolescent girls, PMS symptoms usually begin between ages 20 and 30 years. The disease may run in families and is also more prone to occur in women with a history of psychological problems. Overall however, it is difficult to predict who is most at risk for PMS.

Causes and Symptoms

Because PMS is restricted to the second half of a woman's menstrual cycle, after ovulation, it is thought that hormones play a role. During a woman's monthly menstrual cycle, which lasts 24 to 35 days, hormone levels change. The hormone estrogen gradually rises during the first half of a woman's cycle, the preovulatory phase, and falls dramatically at ovulation. After ovulation, the postovulatory phase, progesterone levels gradually increase until menstruation occurs. Both estrogen and progesterone are secreted by the ovaries, which are responsible for producing the eggs. The main role of these hormones is to cause thickening of the lining of the uterus (endometrium). However, estrogen and progesterone also affect other parts of the body, including the brain. In the brain and nervous system, estrogen can affect the levels of neurotransmitters, such as serotonin. Serotonin has long been known to have an effect on emotions, as well as eating behavior. It is thought that when estrogen levels go down during the postovulatory phase of the menstrual cycle, decreases in serotonin levels follow. Whether these changes in estrogen, progesterone, and serotonin are responsible for the emotional aspects of PMS was not, as of 2004, known with certainty. However, most researchers agree that the chemical transmission of signals in the brain and nervous system are in some way related to PMS. This belief is supported by the fact that the times following childbirth and menopause are also associated with both depression and low estrogen levels.

Symptoms for PMS are varied and many, including both physical and emotional aspects that range from mild to severe. The physical symptoms include: bloating, headaches, food cravings, abdominal cramps, headaches, tension, and breast tenderness. Emotional aspects include mood swings, irritability, and depression.

When to Call the Doctor

A physician or other healthcare provider should be called whenever a woman experiences symptoms of PMS that exceed her ability to cope.

Diagnosis

The best way to diagnose PMS is to review a detailed diary of a woman's symptoms for several months. PMS is diagnosed by the presence of physical, psychological, and behavioral symptoms that are cyclic and occur in association with the premenstrual period of time. PMDD, which is far less common, was officially recognized as a disease in 1987. Its diagnosis depends on the presence of at least five symptoms related to mood that disappear within a few days of menstruation. These symptoms must interfere with normal functions and activities of the individual. The diagnosis of PMDD has caused controversy connected to the concern that it may be used against women, labeling them as being impaired by their menstrual cycles.

Treatment

There are many treatments for PMS and PMDD depending on the symptoms and their severity. For mild cases, treatment includes vitamins, diuretics, and pain relievers. Vitamins E and B6 may decrease breast tenderness and help with fatigue and mood swings in some women. Diuretics work for some women. For more severe cases and for PMDD, treatments available include antidepressant drugs, hormone treatment, or (only in extreme cases) surgery to remove the ovaries. Hormone treatment usually involves oral contraceptives. This treatment, as well as removal of the ovaries, is used to prevent ovulation and the changes in hormones that accompany ovulation. Some studies in the early 2000s, however, indicate that hormone treatment has little effect over placebo.

Antidepressants

The most progress in the treatment of PMS and PMDD has been through the use of antidepressant drugs. The most effective of these are sertraline (Zoloft), fluoxetine (Prozac), and paroxetine (Paxil). They are termed selective serotonin reuptake inhibitors (SSRIs) and act by indirectly increasing the brain serotonin levels, thus stabilizing emotions. Some doctors prescribe antidepressant treatment for PMS throughout the cycle, while others direct women to take the drug only during the latter half of the cycle. Antidepressants should be avoided by women who want to become pregnant. Sertraline appears to significantly improve productivity, social activities, and relationships compared. Side effects of sertraline were found to include nausea, diarrhea, and decreased libido.

There are alternative treatments that can both affect serotonin and hormone responses, as well as affect some of the physical symptoms of PMS.

Vitamins and Minerals

Some women find relief with the use of vitamin and mineral supplements. Magnesium can reduce the fluid retention that causes bloating, while calcium may decrease both irritability and bloating. Magnesium and calcium also help relax smooth muscles, and this may reduce cramping. Vitamin E may reduce breast tenderness, nervous tension, fatigue, and insomnia. Vitamin B6 may decrease fluid retention, fatigue, irritability, and mood swings. Vitamin B5 supports the adrenal glands and may help reduce fatigue.

Phytoestrogens and Natural Progesterone

The Mexican wild yam (Dioscorea villosa) contains a substance that may be converted to progesterone in the body. Because this substance is readily absorbed through the skin, it can be found as an ingredient in many skin creams. (Some products also have natural progesterone added to them.) Some herbalists believe that these products can have a progesterone-like effect on the body and decrease some of the symptoms of PMS.

The most important way to alter hormone levels may be by eating more phytoestrogens. These plant-derived compounds have an effect similar to estrogen in the body. One of the richest sources of phytoestrogens is soy products, such as tofu. Additionally, many supplements can be found that contain black cohosh (Cimicifugaracemosa) or dong quai (Angelica sinensis), which are herbs high in phytoestrogens. Red clover (Trifolium pratense), alfalfa (Medicago sativa), licorice (Glycyrrhiza glabra), hops (Humulus lupulus), and legumes are also high in phytoestrogens. Increasing the consumption of phytoestrogens is also associated with decreased risks of osteoporosis, cancer, and heart disease.

Antidepressant Alternatives

Many antidepressants act by increasing serotonin levels. An alternative means of achieving this result is to eat more carbohydrates. For instance, two cups of cereal or a cup of pasta have enough carbohydrates to effectively increase serotonin levels. An herb known as St. John's wort (Hypericum perforatum) has stood up to scientific trials as an effective antidepressant. As with the standard antidepressants, however, it must be taken continuously and does not show an effect until used for four to six weeks. There are also herbs, such as skullcap (Scutellaria lateriflora) and kava (Piper methysticum), that can relieve the anxiety and irritability that often accompany depression. An advantage of these herbs is that they can be taken when symptoms occur rather than continually. Chaste tree (Vitex agnus-castus) in addition to helping rebalance estrogen and progesterone in the body, also may relieve the anxiety and depression associated with PMS.

Prognosis

The prognosis for women with both PMS and PMDD is good. Most women who are treated for these disorders do well.

Prevention

Maintaining a good diet, one low in sugars and fats and high in phytoestrogens and complex carbohydrates, may prevent some of the symptoms of PMS. Women should try to exercise three times a week and keep in generally good health. Because PMS is often associated with stress, avoidance of stress or developing better means to deal with stress can be important.

Nutritional Concerns

Consuming foods, such as soy products, that are good sources of phytoestrogens may provide relief of PMS symptoms. In general, eating a balanced diet is beneficial.

Parental Concerns

Parents should be aware of the symptoms of PMS in their adolescent daughters. The condition is uncommon but can occur in women under the age of 20.

Resources

Books

Carr, Bruce R., and Karen D. Bradshaw. "Disturbances of Menstruation and Other Common Gynecologic Complaints in Women." In Harrison's Principles of Internal Medicine, 15th ed. Edited by Eugene Braunwald et al. New York: McGraw-Hill, 2001, pp. 295–6.

Jenkins, Renee R. "Menstrual Problems." In Nelson Textbook of Pediatrics, 17th ed. Edited by Richard E. Behrman et al. Philadelphia: Saunders, 2003, pp. 667–70.

Moe, Barbara. PMS (Premenstrual Syndrome). New York: Rosen Publishing Group, 2002.

Premenstrual Syndrome: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. San Diego, CA: Icon Group International, 2004.

Rebar, Robert W., and Gregory E. Erickson. "Menstrual Cycle and Fertility." In Cecil Textbook of Medicine, 22nd ed. Edited by Lee Goldman et al. Philadelphia: Saunders, 2003, pp. 1513–20.

Periodicals

Dell, D. L. "Premenstrual Syndrome, Premenstrual Dysphoric Disorder, and Premenstrual Exacerbation of Another Disorder." Clinical Obstetrics and Gynecology 47, no. 3 (2004): 568–75.

Derman, O., et al. "Premenstrual syndrome and associated symptoms in adolescent girls." European Journal of Obstetrics, Gynecology and Reproductive Biology 116, no. 2 (2004): 201–6.

Johnson, S. R., et al. "Premenstrual syndrome, premenstrual dysphoric disorder, and beyond: a clinical primer for practitioners." Obstetrics and Gynecology 104, no. 4 (2004): 845–59.

Organizations

American Society for Reproductive Medicine. 1209 Montgomery Highway, Birmingham, AL 35216–2809. Web site: www.asrm.com.

Web Sites

"Menstruation." National Library of Medicine. Available online at www.nlm.nih.gov/medlineplus/menstruation.html (accessed January 8, 2005).

"PMS: What You Can Do to Ease Your Symptoms." American Academy of Family Physicians. Available online at (accessed January 8, 2005).

"Premenstrual Syndrome." Mayo Clinic. Available online at www.mayoclinic.com/invoke.cfm?id=DS00134 (accessed January 8, 2005).

"Premenstrual Syndrome." The National Women's Health Information Center. Available online at www.4woman.gov/faq/pms.htm (accessed January 8, 2005).

"Premenstrual Syndrome." University of Pennsylvania Health System. Available online at www.obgyn.upenn.edu/pms/pms.html (accessed January 8, 2005).

[Article by: L. Fleming Fallon, Jr., MD, DrPH]

For more information on premenstrual syndrome, visit Britannica.com.

Associated with the retention of water and salts in the tissues for up to a week before the onset of menstruation, the symptoms of PMS include irritability, fatigue, emotional distress, and sometimes depression.

Pregnant mare's serum.