Premenstrual Syndrome

September, 2006

Definition of the Problem
Premenstrual Syndrome (PMS) refers to a cyclic group of symptoms, both physical and psychological, that can affect a woman in the days or weeks prior to the monthly onset of her period ("menses"). The pain that can accompany menstruation is called dysmenorrhea.

Primary dysmenorrhea is the “normal” uterine contractions that occur during menses; its exact cause is unknown, but hormones probably play a primary role. Secondary dysmenorrhea is the result of an underlying condition (infection, inflammation, or other disorder).

Scope and Cost of the Problem
According to the American Academy of Obstetricians and Gynecologists, up to 85% of women have one or more symptoms of Premenstrual Syndrome. About 5-10% of women report being debilitated by severe symptoms (ACOG, 2000). This equates to approximately 2.5 million American women. Some of the more intrusive symptoms include pain, headache, tension, mood swings, depression, and fatigue.

Absenteeism due to the severity of PMS and menstrual pain is “underappreciated” (Harlow and Park, 1997) and is a leading cause of absenteeism for women under thirty (Daugherty, undated). One-third of women affected by dymenorrhea have an average of 9.6 days of bedrest and lost productivity annually (Kjerulff, Erickson, and Langenberg, 1996). A 2002 study estimated that heavy bleeding alone contributed to a 6.9% reduction in annual employment (Cote, Jacobs, and Cumming, 2002), while a 1984 study reported the annual indirect costs of dysmenorrhea at $2 billion in lost productivity, and 600 million lost work hours (Dawood, 1984).

Dysmenorrhea and PMS are usually treated with either over-the-counter or prescription diuretics ("water pills" to reduce water retention) and NSAIDS (for pain). Oral contraceptives or prostaglandin inhibitors (both available only by prescription) are treatments for primary dysmenorrhea.

Medications to regulate other hormone production are sometimes used. Severe psychological symptoms often respond to anti-depressants. All of these treatments vary in effectiveness from woman to woman. Calcium/ magnesium supplements are clinically proven effective. Lifestyle modifications (diet, sleep, and exercise) are often effective in relieving symptoms.

Mind-Body Therapies
A recent review of the literature published in the American Journal of Obstetrics and Gynecology confirmed that women with PMS and PMDD widely use complementary and alternative medicine, and that there is “substantial evidence of efficacy” for mind-body approaches to these conditions (Girman, Lee, and Kligler, 2003).

One such approach is Cognitive Behavioral Therapy. A 2002 study of 108 women showed that Cognitive Behavioral Therapy was as effective as fluoxetine in the treatment of PMDD, and that CBT was associated with better maintenance of treatment effects than was the prescriptive (Hunter, Ussher, et al, 2002).

Studies also support the use of the mind-body therapies relaxation and guided imagery for PMS and menstrual pain. In one study, women who participated in a regular relaxation program reported a significant 58% improvement in their severe premenstrual symptoms (Goodale, Domar, and Benson, 1990).

Another study showed the effectiveness of relaxation training, either alone or combined with imagery, in reducing resting time for women with spasms of cramping (Amodei, Nelson, et al, 1987). Not only does relaxation help with menstrual pain and discomfort, but it is also effective in reducing absenteeism. These beneficial effects were long-lasting (Quillen and Denney, 1982).

While mind-body interventions can positively affect menstrual distress, they can also affect cycle rhythmicity. In addition to significantly decreasing perceived distress scores, women in a guided imagery study were also able to lengthen their cycles (Groer and Ohnesorge, 1993).

Using guided imagery to reduce the severity of PMS and menstrual pain can lead to increased comfort and decreased absenteeism, without the cost and potential undesirable side effects of some medications.

[no authors listed] ACOG Issues Guidelines on Diagnosis and Treatment of PMS. American College of Obstetricians and Gynecologists. Press Release. March 31, 2000. Qtd on: News Rx. Women’s Health Weekly. May 6, 2000.
Accessed September, 2005.

Amodei N, Nelson RO, Jarrett RB, Sigmon S. Psychological treatments of dysmenorrhea: differential effectiveness for spasmodics and congestives. J Behav Ther Exp Psychiatry. 1987 Jun;18(2):95-103.

Cote I, Jacobs P, Cumming D. Work loss associated with increased menstrual loss in the United States. Obstet Gynecol 2002;100:683–7. Qtd in: Braunstein JB, Hausfeld J, Hausfeld J, London A. Economics of Reducing Menstruation With Trimonthly-Cycle Oral Contraceptive Therapy: Comparison With Standard-Cycle Regimens. Obstetrics & Gynecology. 2003;102:699-708.

Daugherty JE. Dysmenorrhea. Griffith’s: 5 Minute Clinical Consult – A Reference for Clinicians, Mark R. Dambro, M.D., ed. Undated.
Accessed September, 2006.

Dawood MY. Ibuprofen and dysmenorrhea. American Journal of Medicine. 1984 77:87-94.

Girman A, Lee R, Kligler B. An integrative medicine approach to premenstrual syndrome. Am J Obstet Gynecol. 2003 May;188(5):S56-65

Goodale IL, Domar AD, Benson H. Alleviation of premenstrual syndrome symptoms with the relaxation response. Obstetrics and Gynecology. 1990 Apr; 75 (4): 649-55.

Groer M, Ohnesorge C. Menstrual-cycle lengthening and reduction in premenstrual distress through guided imagery. J Holist Nurs. 1993 Sep;11(3):286-94.

Harlow SD, Park M. A longitudinal study of the risk factors for the occurrence, duration and severity of menstrual cramps in a cohort of college women. Br J Obstet Gynaecol. 1997 104:386.

Hunter MS, Ussher JM, Browne SJ, Cariss M, Jelley R, Katz M. A randomized comparison of psychological (cognitive behavior therapy), medical (fluoxetine) and combined treatment for women with premenstrual dysphoric disorder. J Psychosom Obstet Gynaecol. 2002 Sep;23(3):193-9.

Kjerulff KH, Erickson BA, Langenberg PW. Chronic gynecological conditions reported by US women: Findings from the National Health Interview Survey, 1984 to 1992. Am J Public Health. 1996;86:195–9. Qtd in: Braunstein JB, Hausfeld J, Hausfeld J, London A. Economics of Reducing Menstruation With Trimonthly-Cycle Oral Contraceptive Therapy: Comparison With Standard-Cycle Regimens. Obstetrics & Gynecology. 2003;102:699-708.

Quillen MA, Denney DR. Self-control of dysmenorrheic symptoms through pain management training. J Behav Ther Exp Psychiatry. 1982 Jun;13(2):123-30.