June 25, 2001 -- For 10 years, Los Angeles resident Vicky O'Toole experienced severe cramping, bloating, and nausea related to her period.
"Doctors kept telling me it was just PMS, but finally I learned I had endometriosis," a condition in which uterine tissue grows abnormally outside the uterus, she says. "I kept a careful list of all my symptoms for two months, and when they occurred. That convinced my doctor to listen to me. I hope other women will realize these symptoms can be a sign of significant illness. Discuss them seriously with your doctor, and be sure to get a thorough exam."
Alexander Shifrin, MD, agrees.
When patients arrive in his office saying they experience premenstrual syndrome, he first asks them to fill out a detailed questionnaire about their symptoms, including exactly what the symptoms feel like and when they occur. Then he takes a medical history, with a focus on previous obstetrical, gynecological, neurological, and psychological issues. Finally, he does a thorough physical exam.
"You want to rule out anatomical abnormalities such as fibroids and, of course, a disease such as endometriosis, which can masquerade as PMS. It is particularly important to look at the patient as a whole person, not just focus on gynecological symptoms," says Shifrin, an ob-gyn, associate director of residency programs at Long Island College Hospital in Brooklyn, and assistant clinical professor at the State University of New York-Brooklyn.
Look at Your Lifestyle
Once serious disease has been ruled out, the next step is to try some simple lifestyle changes. For many women, eliciting the relaxation response will control PMS, according to Alice Domar, PhD, director of the Mind/Body Center for Women's Health in Boston and author of Self-Nurture: Learning to Care for Yourself as Effectively as You Care for Everyone Else. Several different methods can be effective, she says, including progressive muscle relaxation, meditation, yoga, and guided imagery.
"Ten years ago, we did a randomized, controlled, prospective study of women with severe PMS," Domar says. Those who simply listened to a relaxation tape 20 minutes a day had a 57% reduction in both physical and psychological symptoms. In that study we used a tape that combines diaphragmatic breathing, breath-focused meditation, and mental images of walking along a mountain stream."
Many physicians believe dietary changes will do a great deal to lessen PMS symptoms. Steven Goldstein, MD, says severe salt restriction during the second half of the menstrual cycle is often helpful. It's not enough to stop using the saltshaker, he emphasizes. You have to check the labels on all sorts of prepared foods, and be aware of the high sodium content in many dishes when you eat out.
"I've had patients come back to me and say, 'I hate your guts. My diet is bland as hell -- but it does make a difference in my PMS symptoms,'" says Goldstein, professor of obstetrics and gynecology at New York University School of Medicine. He also recommends a moderate dose of water-soluble, time-release vitamin B-6.
Different women may benefit from different programs, says Steven Rosenzweig, MD. But in his experience, it is generally helpful to take a stepwise approach and begin with the quality of diet, exercise, and rest.
"Your diet should balance carbohydrates, proteins, and fat at each meal. Emphasize whole grains, natural oils rather than margarine and saturated fats, and vegetable sources of protein. If you follow this sort of diet, many of the mood swings and energy issues associated with PMS can be solved," says Rosenzweig, director of the Center for Integrative Medicine at Thomas Jefferson University Hospital in Philadelphia.
It's extremely important to follow a lifestyle with a natural rhythm of rest and activity. Get an appropriate amount of sleep, and pursue some form of daily exercise followed by the relaxation response. "This will improve the quality of sleep at night and often reduces the total sleep requirement," he says.
And as Rosenzweig cannot resist mentioning, this sort of diet and exercise program has health-promoting effects that extend far beyond control of PMS.
He recommends a good multivitamin, the full range of B vitamins (not just B-6), and often extra magnesium.
"Women with a predisposition to PMS symptoms often tend to have low magnesium stores. But the single most effective supplements, in my opinion, are evening primrose oil and flaxseed oil," he says. While women's needs vary, a usual starting dose would be about 1,000 mg of each per day.
In addition, you can find specially formulated dietary supplements designed to combat PMS. Judith Wurtman, PhD, developed PMS Escape, a powdered drink mix containing a mixture of carbohydrates and vitamins.
"We know the changes in mood and appetite that characterize PMS are related to changes in the amount of serotonin in the brain, says Wurtman, a researcher at the Massachusetts Institute of Technology and director of the TRIAD Weight Management Center at McLean Hospital in Boston. "PMS Escape helps raise serotonin levels in the brain for about four to five hours. It works faster than food, and you only use it on the days you have symptoms."
Suppose you try diet and lifestyle changes but nothing seems to help? First, take a closer look at your personal pattern of symptoms. If you have classic PMS, you'll notice that you start to feel better as soon as your period begins. If you fit that definition, this means your symptoms are clearly cycle-related. In that case, Goldstein says, cycle suppression using birth control pills will alleviate many if not all of your symptoms.
What About Sarafem?
If you watch TV an average amount, you've already seen the ads for Sarafem, those pink and lavender capsules designed to ease premenstrual depression and mood swings. Sarafem is actually a low dose of the antidepressant Prozac, repackaged with a new look and name. It's not supposed to be used for garden-variety PMS. Sarafem is prescribed only for premenstrual dysphoric disorder (PMDD).
"This condition was only recently included in the DSM-IV, the manual of psychiatric disorders," says Shifrin. "This is a huge advance."
"In this syndrome the patient's primary complaint is severe depression, anxiety, irritability, and mood swings, while PMS is characterized by more physical symptoms," says Jean Endicott, PhD, director of the Premenstrual Evaluation Unit at Columbia Presbyterian Medical Center, in New York City. "The second diagnostic criteria for PMDD is the presence of severe symptoms leading to psychosocial impairment."
She estimates 3% to 8% of women with regular menstrual cycles have clinically significant symptoms that meet the criteria for PMDD, while about 60% have PMS.
You can't walk into a doctor's office, say you have bad periods, and walk out with a prescription for Sarafem, Endicott explains. Instead, your doctor will ask you to keep careful records for two menstrual cycles, charting your symptoms and when they occur. The main reason is that is many women who seek help for a PMS problem turn out to have depression and mood swings throughout the month, although it gets worse premenstrually. "If that's the case, their diagnosis and treatment will be different."
Sarafem can be useful for the rare patients who fit the definition of PMDD, physicians say. "For the handful of patients who experience extreme discomfort and are incapacitated, Sarafem does seem to be a useful alternative. It's a half-strength dose of the lowest dose of Prozac. If I select my patients carefully the response to Sarafem is almost uniformly successful," Goldstein says. "However, it is only suitable for a small percentage of people. You want to try other alternatives first."
Rosenzweig agrees. "After you've tried supportive therapies such as lifestyle changes and mind/body methods, if the patient is still distressed and in need of more help, they should be evaluated to see whether Sarafem could help them. Diet and the relaxation response and Sarafem aren't an "either-or" choice. In some patients they may all work together to alleviate premenstrual symptoms."