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I’m tired of all this nonsense about beauty being only skin deep. That’s deep enough. What do you want—an adorable pancreas?

Jean Kerr 1961

Premenstrual syndrome (PMS) is defined as a group of physical, psychological and behavioural changes that begin 2–14 days before menstruation and are relieved immediately the menstrual flow begins.1

These symptoms occur in the luteal phase of the menstrual cycle yet the pathogenesis of PMS is still uncertain. Among the proposed causes are pyridoxine deficiency, excess prostaglandin production and increased aldosterone production in the luteal phase.1 However, PMS is most probably related to enhanced sensitivity to progestogen with an underlying serotonin deficiency.2

Key facts and checkpoints

  • PMS increases in incidence after 30 years, with a peak incidence in the 30–40 years age group.

  • PMS also occurs in the 45–50 years age group, when it may alternate with menopausal symptoms, causing clinical confusion.3

  • The symptoms of PMS decrease in severity just before and during menstruation.

  • The symptoms cannot be explained by the presence of various psychological or psychiatric disorders.

  • The severe form of PMS is classified in the Diagnostic and Statistical Manual of Mental Disorders (4th and 5th edns) as premenstrual dysphoric disorder (PMDD).


Up to 90% of women may experience premenstrual symptoms, which can vary from moderately severe in 20–40% of women to disabling in 2%.4 Interestingly, up to 15% of women can feel better premenstrually.5 Statistics from countries such as Sweden, the US and the UK indicate that up to 40% of women are significantly affected.5 About 5–10% of women experience such severe symptoms that PMS disrupts their quality of life.


Various aetiological factors have been identified as contributing to PMS.1

Predisposing factors:

  • mental illness

  • alcoholism

  • sexual abuse

  • family history

  • stress

Precipitating factors:

  • hysterectomy

  • tubal ligation

  • cessation of the OCP

Sustaining factors:

  • diet containing caffeine, alcohol, sugar

  • smoking

  • stress

  • sedentary lifestyle


Various symptoms from among the 150 reported are summarised in FIGURE 104.1.

FIGURE 104.1

Symptoms of premenstrual syndrome

The most common symptoms are depression 71%, irritability 56%, tiredness 35%, headache 33%, bloatedness 31%, breast tenderness 21%, tension 19% and aggression/violence 13%.6 Other important symptoms include weight gain, lowered performance, decreased libido and feeling out of control.

Classification of PMS

It is convenient to classify PMS in terms of severity of symptoms.3

  1. Mild: symptoms signal onset of menstruation. No medical advice sought or needed.

  2. Moderate: symptoms annoying but insufficient to interfere with function at home or ...

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