PMS

     Forty percent of women of childbearing age suffer from premenstrual syndrome, which can appear as early as puberty or as late as menopause. Onset generally follows some shock to the endocrine system, typically menarche (first menstruation), childbirth, tubal ligation, hysterectomy, going on or off oral contraceptives, or the advent of major life stress. PMS is generally hereditary, and symptoms can become worse with age.
     A neuro-endocrinopathy, meaning a hormone disorder originating in the brain, premenstrual syndrome can cause a wide variety of seemingly unrelated symptoms. Though difficult to diagnose because of this, the single consistency is that PMS usually has a cyclical pattern of symptoms. Symptoms can be highly variable with many combinations, ranging in severity from mild to moderate to incapacitating. Over a hundred symptoms have been observed, with each woman reporting her own unique set; but some of the most common include depression, lethargy, fatigue, irritability, unexplained anger, and a sense of being out of control, migraine or other headaches, sinus problems, edema, acne, compulsive eating, craving for sweet or salty food, joint pain, clumsiness, back pain, eye problems, weight gain, seizures, bowel disorders, suicidal thoughts or attempts, poor concentration, paranoia, crying, and violence.
     Diagnosis is not so much a matter of identifying certain sets of symptoms, but of identifying cyclical timing of the symptoms each month:

* Symptoms generally appear five to seven days before the onset of a period and subside with flow.
* Symptoms begin at ovulation (usually the fourteenth day of the cycle, or mid-cycle) and last two weeks or until menstrual flow begins.
* Symptoms begin at ovulation and last up to three weeks, until heavy flow begins or until a period is almost over.
* Symptoms appear for a few days at ovulation, subside temporarily, then reappear several days before flow begins.

     For three to eight percent of women, for whom PMS becomes a living nightmare, major medical intervention may be imperative. These women often feel out of control, unable to cope with daily life due to anxiety, depression, anger leading to aggression, and severe pain. It is believed that up to 40% of women may experience symptoms severe enough to disrupt their daily lives. Severe PMS can be treated as a progesterone imbalance with progesterone capsules or suppositories; and other severe symptoms may need to be treated seriously as well. Antidepressants and antianxiety agents are often appropriate for women with severe symptoms, and a diuretic is frequently helpful for severe fluid retention. In addition to prescription anti-inflammatory pain killers (NSAID’s), a physician may even prescribe narcotics for relief of pain and spasm.
     For most women, though, such medication may be overkill, their milder symptoms largely controllable by other means and prescription medications potentially causing more problems than they solve. The following general nonpharmacological measures are recommended by physicians to manage the milder symptoms most women experience. They may be helpful suggestions for your patients buying over-the-counter PMS remedies.

* Caffeine should be avoided at all times of the month, not just when experiencing PMS; for it tends to make symptoms worse. Coffee (even decaffeinated contains some caffeine), teas, colas, and anything else containing caffeine should be eliminated from the diet in favor of options that contain no caffeine.
* Chocolate is generally considered acceptable in small amounts in spite of cravings that may dictate large quantities. Chocolate contains caffeine, though, so unless it helps to feed a craving, it should probably be avoided.
* A well-balanced diet of at least four small meals a day can help to reduce abdominal cramps. Some physicians recommend six smaller meals instead of four. Intake of whole grains, vegetables, and fruit should be increased; while intake of salt, sugar, fats, and alcohol should be decreased. Increase dietary intake of calcium (skim milk, nonfat yogurt, collard greens, kale, calcium-fortified cereals and juices) and magnesium (spinach, other green, leafy vegetables and whole grain cereals). Though these measures can help during PMS, they can help more if adopted as lifestyle changes.
* Regular aerobic exercise is important, preferably a regular regimen that uses major muscle groups at least three times a week for periods of at least 20 minutes; but even a short brisk walk may help both physical and emotional symptoms on a bad day.
* Plenty of rest is essential. Recognize that the body may have very different temporary requirements to cope with the trauma of PMS. If it dictates that the patient remain awake at night, naps during the day can help to compensate. Whenever possible the patient should attempt to live with the schedule dictated by her PMS and not try to work against it.
* A positive attitude, however unlikely, can combat depression and anxiety. Patients should be encouraged to look on the bright side of things, recognizing the temporary nature of PMS.
* Major decisions may be better deferred to non-PMS days, when anxiety, depression, and irritability can influence such decisions negatively.
* Relaxation techniques like yoga, meditation, biofeedback, guided imagery, and self-hypnosis can be very helpful in coping with stress levels and even cramps.
* Remain aware that regardless of the fact that PMS is common joke material, it is very real and can be devastating and worse some months than others. Simply attempt to recognize its impact on physical and emotional well-being, and take care of temporary needs as they arise.
* PMS is predictable, so plan special occasions around inevitable symptoms.

OTC PRODUCTS FOR PMS
     In addition to the variety of over-the-counter products specifically designed help cope with symptoms, supplements of vitamin E, vitamin B6, calcium, magnesium, vitamin D, L-tyrosine, and L-lysine, have been shown to help many women to reduce the severity or duration of symptoms. Vitamin B6 has been shown to reduce bloating, produce some antidepressant effect, and help control carbohydrate cravings. Recommend a B-complex containing 50mg of B6, and suggest building up to 200mg to 500mg of B6 daily in a few months. Patients should also be encouraged to get 1500mg of calcium daily, preferably with vitamin D to facilitate utilization.
     Pain relievers containing acetaminophen (Tylenol and most generic “non-aspirin” pain relievers) can help pain and cramps; but the over-the-counter non-steroidal anti-inflammatory drugs (NSAID’s ) like aspirin, ibuprofen (Motrin IB, Nuprin, Advil, etc.), naproxen sodium (Aleve), and ketoprofen (Actron – discontinued in March of 1998), are generally more helpful, affecting prostaglandin levels to minimize cramps and reducing inflammation as well as pain.
     Some over-the-counter products contain one of these pain relievers in addition to a mild diuretic to help reduce fluid retention and/or an antihistamine to help reduce anxiety and/or to help one sleep. It may be a surprise with the strong recommendation that caffeine be avoided by PMS sufferers, but caffeine is occasionally included in such products to help minimize water retention, relieve fatigue, and enhance the pain-relieving effects of acetaminophen, or NSAID’s.

WARNINGS FOR THE PATIENT BUYING OTC PMS REMEDIES
* If such medications are needed for longer than ten days, a physician should be consulted for evaluation of symptoms.
* The antihistamines (pyrilamine maleate and diphenhydramine) can cause drowsiness that can be increased by drinking alcohol or taking other medications. In general, other antihistamines, sedatives, and anti-anxiety agents should be avoided. You should take extra care when driving or operating machinery because of the potential drowsiness; and these antihistamines can also exacerbate bronchial problems asthma, bronchitis, or emphysema by drying secretions and facilitating formation of mucous plugs.
* Ibuprofen can be irritating to the stomach, especially if taken regularly for long periods, and especially if the patient drinks alcohol. Those experiencing stomach upset or allergic reaction to aspirin or other NSAID’s may experience similar problems with ibuprofen and naproxen products.
* Acetaminophen can cause liver problems if the patient drinks alcohol in more than small amounts.
* When taking products that contain caffeine, additional caffeine from dietary sources can increase the nervousness, irritability, and sleeplessness that may already be problematic. It can cause tachycardia, hypertension, and exacerbate symptoms of GERD. Decongestants can exacerbate these same problems.
* Just like any other medication, these products should be kept out of the reach of children to avoid poisoning situations.
* A physician should be consulted before taking any of these medications during pregnancy or lactation.