What is Premenstrual Syndrome (PMS)?

PMS, also known as premenstrual syndrome, is the collective name for the group of physical, psychological and behavioural symptoms we might experience in the luteal phase of the menstrual cycle (the two weeks between ovulation and our period). There are thought to be over 150 symptoms of PMS, ranging from bloating and acne, to confusion and aggression. They disrupt the way we normally feel and function, interfering with work, school, relationships and general day-to-day life. Symptoms typically resolve a few days after we get our period.

The exact cause of PMS is unknown. It’s thought that there are many different factors that come into play. Many media outlets like to point the finger at hormones, but with most things, it’s not quite that simple.

Considering most of us go through a ‘standard’ 28-day menstrual cycle, if PMS was caused by hormones alone, we’d all have it, which isn’t the case.

The main factor is thought to be individuality - it’s thought that PMS is likely to be down to each person’s sensitivity to the steroid produced when progesterone is broken down. This steroid is called allopregnanolone. It affects GABA receptors which are associated with emotions such as anxiety, stress, and fear. It’s thought that people with PMS and PMDD are more sensitive to allopregnanolone than those who don’t have PMS or PMDD, and they may even have GABA receptors that respond differently to allopregnanolone than those who don’t have these conditions.

Other factors such as genetics, stress levels, and lifestyle also likely play a role. Read more about the causes of PMS and PMDD here.

It’s thought that around 75% of naturally cycling females get PMS. Because PMS is under-researched and underfunded, coupled with the fact that there’s no physical test for PMS (for example, a blood test), studies looking at the prevalence of PMS return different results; stats range from 32% to 90%. Regardless of the exact number, we do know that PMS is incredibly common, and you’re not alone in feeling its effects!

With over 150 symptoms of PMS, each person’s experience will be different. Further, the combination of symptoms each person experiences will likely change each month, so it can be very tricky to identify PMS as it presents differently each month. The following list covers the most common ones, but is not exhaustive. If you feel a physical or emotional change in the weeks preceding your period that disrupts your daily life, it could be a symptom of PMS.

Physical symptoms

Bloating: many people who experience PMS experience uncomfortable bloating or fluid retention during the luteal phase of the menstrual cycle. This can cause us to feel full, clothes to feel tighter around the waist, or we may experience an increase in how much we weigh. Read more on PMS and bloating here.

Breast and nipple tenderness: some people may experience breast and/or nipple tenderness, soreness, and/or swelling in the weeks before their period.

Headaches: PMS can also cause painful headaches or migraines. Headaches with PMS may be related to hormonal fluctuations or changes in blood flow to the brain. When particularly severe, these can become ‘menstrual migraines’, which may be accompanied by nausea, vomiting, and sensitivity to light and sound.

Cramps: menstrual cramps, despite the name, can occur pre-period and are a common symptom of PMS. Cramps occur when the uterus contracts, compressing blood vessels and reducing blood supply. When this happens, the uterus releases chemicals that trigger pain. This can be felt in your stomach, back, or thighs, and can range from mild to severe.

Fatigue: many people experience fatigue or low energy levels in the weeks leading up to their period. This can be exacerbated by disrupted sleep that many people experience in the luteal phase of their cycle.

Spots and acne: hormonal acne or spots are more likely to flare up during the luteal phase and clear up once your period has finished. This is due to the drop in oestrogen and progesterone just before your period, which triggers your sebaceous glands (oil-producing glands on your skin) to make more sebum (an oily substance). When too much is produced, we can get spots. Spots and acne can affect self-esteem, and our mental health can suffer as a result.

Psychological symptoms

Mood swings: mood swings can be anything from waking up in a great mood, and then feeling really low twenty minutes later, to being upset by something we wouldn’t normally be bothered by. People who experience PMS may find themselves feeling irritable, anxious, depressed, sad, or hopeless.

Irritability: irritability, or being annoyed easily, is a common symptom of PMS, which can be exacerbated by poor sleep.

Anxiety: anxiety is one of the most common symptoms of PMS. One study showed that up to 70% of people may feel anxious in the weeks leading up to their period.

Depression: PMS can also cause feelings of depression. This is a persistent feeling of sadness or loss of interest that affects the way we think, feel, or behave. During the menstrual cycle, a drop in serotonin levels (the happy hormone) can cause us to feel down or depressed. It’s important to note that for some people, PMS exacerbates already existing mental health conditions like depression. Some reports state that up to 50% of people seeking treatment for PMS may already have depression or anxiety. If you or someone you know is experiencing severe PMS anxiety each month, or any other symptoms that are significantly affecting your quality of life, it’s important to seek help from a GP. If you’re having suicidal thoughts and are worried you may act on them, you should call 999, go to A&E or contact The Samaritans.

Behavioural symptoms

Trouble sleeping: some people find they have trouble sleeping during the luteal phase. This can be due to the hormonal changes we experience during the luteal phase, and/or the addition of other PMS/PMDD symptoms disrupting our sleep. As progesterone is known to raise internal body temperature, scientists believe this increase can prevent us from falling asleep and can cause sleep disturbances. Stress levels, cramps, and pain can also keep us up/wake us at night, worsening our sleep quality.

Change in libido: during our luteal phase our libido typically drops. This is because oestrogen and testosterone (which increase our libido) are low during the luteal phase. Conversely, some people may find they want sex more during PMS as the pleasure derived can reduce the severity of symptoms such as low mood and stress.

Not everyone will experience these symptoms, and the severity and duration of such can vary widely from person to person. People may experience different symptoms from month to month or during certain times in their life, such as periods of high stress, or after pregnancy.

There is no exact timing for when PMS symptoms will occur. However, they typically occur one to two weeks before our period. This is called the luteal phase of the menstrual cycle, and is the time between ovulation and the start of the menstrual bleed (the period). For many people, PMS symptoms are at their worst in the days leading up to the start of their period and tend to improve or disappear once menstruation begins. In terms of age, PMS can start as early as puberty, when we first get our period, up until menopause, when they stop. However, it’s most common to start seeing the symptoms in our early 20s.

Currently, PMS is diagnosed by your GP after you’ve evidenced that you experience PMS symptoms one to two weeks before your period, consistently for two months, that affect your daily life and subside once you get your period. If you think you have PMS, start noting down the symptoms you experience, when they happen, and how bad they feel. Take this record to your GP who can discuss diagnosis and treatment options to help manage your PMS. If you need advice about talking to a healthcare professional about PMS, read our article on talking to your GP about PMS here.

If you are experiencing severe PMS symptoms that significantly affect your quality of life, you may have PMDD (premenstrual dysphoric disease). Do not wait to seek medical advice if you are feeling affected by PMS or PMDD.

Depending on what your PMS symptoms are, there’s a wide range of options that can help ease them and allow you to go about daily life. It’s important to speak with a qualified healthcare provider who can give you professional advice. Together, you can work out what works best for you. We typically split them into three groups: medical, non-medical, lifestyle.

Medical

Over-the-counter pain relief: in the UK, you can buy paracetamol or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen to relieve PMS cramps, headaches, breast pain, and other types of pain associated with PMS, without a prescription.

Hormonal medical treatments:

Pill: according to the NHS, some people find their PMS symptoms are relieved by taking the combined contraceptive pill. One progesterone-only contraceptive pill (which contains drospirenone - a specific type of progesterone) has been shown to improve severe PMS symptoms when taken continuously (speak to your GP about how to do this safely). The pill may be a good choice if you also need contraception.

Patches: oestrogen hormone patches or gel can improve the physical and psychological symptoms of PMS.

GnRH analogues: gonadotrophin-releasing hormone (GnRH) analogues suppress ovarian hormone production, and are usually only recommended to people with severe PMS symptoms when other treatments haven’t worked.

Non-hormonal medical treatment: healthcare professionals may recommend selective serotonin reuptake inhibitors (SSRIs) or serotonin-noradrenaline reuptake inhibitors (SNRIs) for reducing PMS symptoms. These can provide rapid relief in as little as three days. Diuretics (water pills) such as spironolactone may help with physical symptoms of PMS such as bloating.

Psychological support and therapy: for PMS symptoms that are psychological or psychosomatic, cognitive behavioural therapy (CBT) has been shown to help, and may be offered as a treatment option. CBT aims to address our thoughts, feelings, and physical sensations altogether, with the aim of reducing negative ones that can trap us in a bad cycle.

Surgical treatment: if none of the above treatments is successful, and PMS is severely affecting your quality of life, a healthcare provider may suggest surgery. This is considered the only ‘cure’ for PMS and may either involve removal of the ovaries (‘bilateral oophorectomy’) or removal of the ovaries, uterus, fallopian tubes, and cervix. Your doctor will advise which is best for you depending on how you react to specific progesterones. As this removes the ovaries and eggs, no more oestrogen can be released, inducing surgical menopause. Hormone replacement therapy (HRT) may subsequently be recommended depending on your age.

Alternative therapies

When the following are used alongside conventional medicine, it's considered ‘complementary’ therapy. When they’re used instead of conventional medicine, it's considered ‘alternative’ therapy.

Acupuncture, aromatherapy, chiropractic, reflexology and traditional Chinese medicine (TCM) have all been shown to reduce symptoms such as stress, anxiety, bloating, low mood, and more. For more information on complementary therapies, read our article here.

Supplements: taking supplements has been shown to be helpful for many people. Supplements containing calcium, vitamin D, magnesium, vitamin B6, and vitex agnus-castus (a herb known as Chasteberry), ginkgo biloba and evening primrose oil help ease symptoms for some people. Always seek medical advice before starting complementary therapy, especially if you are pregnant, breastfeeding or taking other medication.

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Lifestyle

One of the first things your healthcare provider may suggest is making changes to your daily routine, such as doing more exercise, eating a healthy, balanced diet, and trying to reduce and manage stress. It’s tough to make lots of changes at once, so try making one change first, and then starting on the next.

Exercise: trials show that all types of exercise including cardio (walking, running, boxing, swimming, cycling, etc.), yoga, and pilates can significantly decrease severity of PMS symptoms.

Diet: including calcium-, iron-, zinc- and/or vitamin D-rich foods or supplements in your diet can help ease PMS symptoms. If you’re unsure about adding these to your diet, consult a healthcare professional first. For more information on supplements, read our article on PMS and supplements here. 

‍Stress: if possible, reducing our exposure to stressful circumstances just before, during and after a period could help ease PMS symptoms in the current and next cycle. Yoga, meditation, breathwork and spending time in nature have all been shown to have a calming effect on the mind.