When you hear the three letters P-M-S, odds are your gut reaction is a four-letter word. The typical perception is, if you have premenstrual syndrome (PMS), you become a bloated, emotional mess for a few days every month. While that may be accurate for some people, it doesn’t capture the true range of premenstrual experiences — and there is much more to PMS than the stereotypical pool of bad symptoms (1).
PMS is a cultural catch-all for everything from eating a whole tub of ice cream to discrediting women in places of power. PMS is given unfounded weight to validate certain behaviors and make people victims of their biology. In reality, the premenstrual experience varies dramatically from person to person, ranging from one or two mild complaints to several near-debilitating symptoms.
At Clue, we are creating a tool that can be used to help people learn about their bodies and dispel myths and misinformation about the menstrual cycle. PMS is one of the biggest misconstructions.
Let’s clarify what we mean when we say PMS. We’ll start by busting the main myths around the topic.
Myth #1: All women have PMS.
This myth comes from the popular mistake to attribute any symptoms occurring before the period directly to PMS. In truth, dealing with premenstrual symptoms does not necessarily equate to PMS.
Premenstrual syndrome is a medical diagnosis (ICD-9-CM 625.4 or ICD-10-N94.3) of multiple premenstrual symptoms that have a significant negative effect on a person’s life (2). Premenstrual symptoms of low to moderate intensity that do not have a significant negative effect on a person’s life are not considered PMS from a medical perspective.
Scientific reports are somewhat inconclusive and very confusing in reporting percentages of individuals actually affected by PMS, and often refrain to “some sort of PMS” (8–19). Many of the estimated 95% of individuals who report having “some sort of PMS” are actually experiencing premenstrual symptoms. For example, a headache happening a few days before a person’s period every cycle may not have a significant negative impact on their day-to-day functioning, and therefore may just constitute a mild premenstrual symptom. However, a recurrent experience of depression, insomnia and extreme fatigue, on the other hand, might significantly impact someone’s well-being and therefore meet the criteria for PMS or even premenstrual dysphoric disease (PMDD) (11, 13, 20, 21).
Fact #1: The experience of premenstrual symptoms
is not the same as premenstrual syndrome.
Myth #2: The premenstrual phase is all about bad moods.
Science supports that the premenstrual experience is not inherently negative for everyone, despite what culture, society and media suggest. The way we’re taught culturally and talk socially about the premenstrual experience affects how we identify with it ourselves (22).
It is important to note that current research has primarily connected negative moods to our biology (3–5, 19, 23). This research has deduced a linear relationship between biology and behavior, and failed to fit PMS experience within the socio-cultural context (24).
Dr. Sarah Romans of the University of Otago in New Zealand showed that many of the medical studies supporting this idea suffered from major methodological errors. In many cases, research participants were asked about their mood but were given a list to choose from that only included negative options. Romans states “this limits a complete description of premenstrual mood experiences… If only negative mood is studied, it will erroneously be concluded to be the only direction in which mood varies”(1).
Without clear scientific evidence, why is the idea of negative premenstrual mood so pervasive? In her review, Dr. Romans looked into how various cultures affect perceptions of menstruation. She shares evidence that people who are socialized to expect a negative premenstrual experience are primed to report more problems, citing many studies demonstrating negative attitudes towards the cycle with long histories in the U.S. and beyond (1).
Dr. Diana Taylor, Professor Emeritus of Family Healthcare Nursing in the School of Nursing UCSF commented on participants whose studies including positive mood choices stating “It wasn’t that their periods had become altogether blissful experiences” rather, they “had simply begun to notice the positive effects their cycles had on their lives.”
The cultural processing of this becomes more evident when we look at how the premenstrual experience manifests around the world. In her book, Dr. Taylor discusses a study from the 1970s looking at the incidence of PMS in the U.S., Japan, Nigeria, Turkey, Greece and the Apache nation, where large cultural variations in the premenstrual experience were discovered. Why the significant variation?
PMS is not a one-size-fits all experience, rather, each person’s experience is filtered through social and cultural beliefs that influence how they process symptoms.
Dr. Taylor explains that while the premenstrual experience varies from culture to culture, this variation also reminds us that the the term “premenstrual syndrome” is a medically constructed label, and has no equivalent in many parts of the world. To put it another way — while premenstrual symptoms occur more or less universally, negative mood doesn’t.
Fact #2: Bad moods and the premenstrual experience
do not go hand in hand for everyone.
Myth #3: Bad moods in your premenstrual phase can be blamed exclusively on hormone fluctuations.
Hormones play a major role in an individual’s menstrual cycle (25), but aren’t the only reason for bad premenstrual moods. Overall mental and physical health have a greater impact on mood than menstrual cycle phase.
Participants of a recent study (27) tracked daily mood and health data over six months to test a commonly stated fact amongst researchers that the premenstrual phase is the source of depressed, irritable moods and mood swings (14, 19, 28, 29). The study tracked both positive and negative moods, collected data from every cycle phase (not just the premenstrual phase) and followed several consecutive menstrual cycles.
The conclusion was surprising; data did not support the idea of a negative mood prevailing in the premenstrual phase. Most importantly, Sarah Roman’s group found that social support, physical health and perceived stress were more significant as predictors of daily mood than menstrual cycle phase. “This suggests that a nuanced approach to the causes of a woman’s mood variability should consider the quality of her social relationships and her physical health before considering her reproductive function” (27).
Note: Hormones may be the cause of premenstrual syndrome for some people. Lower levels of estradiol in the premenstrual phase may cause decreased levels of serotonin (“The Confidence Molecule”) and dampened mood (26).
Fact #3: Physical and emotional health have a greater
impact on your daily mood than your menstrual cycle.
What is PMS, really?
PMS is a cluster of physical, behavioral and emotional changes in the time before menstruation that recur with most or all menstrual cycles and negatively affect a person’s normal life (30). However, there’s complexity to many aspects of this basic definition, as clear PMS diagnoses often morph into diagnoses of “some sort of PMS” (8, 10–19). Your premenstrual symptoms may change over your reproductive lifespan and fluctuate in intensity from cycle to cycle — for example, mild cramps as a teenager sometimes give way to a more intense symptom cluster in adulthood (31).
To make a clinical diagnosis of PMS, your doctor will consider the number, type and severity of your symptoms. Approaching your premenstrual symptoms with this in mind is helpful in assessing your own experience.
Symptom number: Over 150 symptoms have been attributed to PMS in literature. Some explanations of PMS will list individual symptoms (e.g. crying spells, social withdrawal, and confusion) while other definitions provide symptom clusters (e.g. pain/discomfort, somatic/cognitive, behavioral/functional, and mood-related). At least one symptom needs to be “severe” to fit the diagnosis, although someone with PMS may experience as many as 10 symptoms in a particular cycle (2).
Timing and duration: By definition, premenstrual symptoms occur in the luteal phase (that’s the second half of your cycle, from ovulation to the start of the period). Symptoms must resolve at the beginning of or a couple days into the period. If symptoms are experienced outside of the luteal phase or throughout the entire cycle, they are not strictly premenstrual symptoms and may indicate a different issue. Severe symptoms may last several days or for most of the luteal phase, whereas low to moderate symptoms may only last one to two days (2).
Severity: This is based on personal observation. You are your own compass, and judging the severity of your premenstrual symptoms is an exercise of checking in with your personal well-being. Researchers and doctors studying PMS have developed different scales to better calculate symptoms in an objective way. In her work, Dr. Diana Taylor uses the following scale and asks patients to rank each symptom they experience on a daily basis according to:
0 — Absent
1 — Mild
2 — Moderate
3 — Severe
4 — Extreme (2)
PMDD and PMM
Premenstrual dysphoric disorder, or PMDD, is a more recent entry into the medical lexicon. PMDD, like PMS, is a diagnostic label given when the experience of premenstrual symptoms is very severe. PMDD has its own set of diagnostic criteria of symptom type, duration and severity. Take note: the existence of PMDD is controversial. Some scientists contend that classifying severe PMS as a psychiatric disorder is a dangerous precedent, and that PMDD was created to justify a new pharmaceutical market and representative of the over-medicalization of women’s reproductive biology (32). Whatever we name this extreme form of PMS, studies estimate the prevalence to be 1–8% (2).
Premenstrual magnification, or PMM, is the worsening of an existing condition in the luteal phase and/or during menstruation. Depression, anxiety, panic disorders, irritable bowel syndrome, asthma, migraine, seizure disorder, allergies and chronic fatigue syndrome may all be premenstrually magnified. Symptoms of premenstrually magnified conditions may appear as or overlap with premenstrual symptoms and may be mistakenly identified as such. However, the persistence of symptoms throughout the cycle (not just in the luteal phase) help differentiate premenstrual magnification from true premenstrual symptoms (33).
What does PMS mean for you?
What comes to mind when you think about PMS now? (We hope it isn’t the common “that time of the month” reaction.)
PMS is a medical diagnosis given by doctors after considering the number, type and severity of someone’s premenstrual symptoms. Before that conversation can happen, a person must first record and report the characteristics of their premenstrual symptom pattern to their doctor. You can determine your pattern of premenstrual symptoms by carefully tracking your cycle.
Symptom tracking can be valuable even if you don’t feel the need to have a conversation with your doctor about PMS. Getting familiar with your premenstrual symptom pattern can be useful for letting you know where you are in your cycle, helping you plan ahead to mitigate uncomfortable symptoms like diarrhea (34), and identifying triggers that exacerbate symptoms and/or selecting relief strategies.
Important guidelines for tracking are:
- Record data every day as you experience it. This stands in contrast to recalling how you felt several days ago, which can be less accurate.
- Track for several (not just one) complete menstrual cycles. This will help capture cycle-to-cycle variation.
- Track data in every cycle phase, not just the premenstrual phase. If you only collect data in one phase, it will not be possible to compare and then conclude that one phase is different from another.
- Record both positive and negative symptoms.
- Provide life context. Include notes about stress, skin problems, diet, relationships, etc. because your cycle is just one of many things that can affect you and your well-being (27).
Once you’ve tracked several cycles of data, it’s time to evaluate. Here are the basic steps:
Visualize your premenstrual phase: Count back 14 days before each period began. That span of time, from ovulation to the start of your period, is roughly your luteal phase. Many cycle tracking apps, including Clue, will identify this phase for you.
Look for patterns: Do any symptoms regularly come up in the premenstrual phase? Or are they distributed throughout your cycle? You might be surprised to learn that the constipation or mood swings you thought only occurred premenstrually are actually happening throughout your cycle.
Assess severity: Are any symptoms severe enough to impact your life in some way? Missing work or school, conflicts with people in your life or a need to medicate symptoms may indicate a moderate/severe case of PMS.
Completing these steps will provide you with an understanding of your own premenstrual symptoms, and this is powerful information to help you make decisions. Whether your next step is buying a heating pad for the cramps or talking to your healthcare provider about managing symptoms, tracking is an essential first step to taking control and understanding your body.
Healthcare is rapidly evolving. We’re becoming increasingly curious about all facets of our health and are taking measures into our own hands (literally). People no longer accept one-size-fits-all treatments or generalized judgments from gender-based biology. It’s time to take a personalized, science-based perspective on PMS rather than follow the current cultural projections of what it means to be a “woman” with a cycle.
References:
1. Romans S, Clarkson R, Einstein G, Petrovic M, Stewart D. Mood and the menstrual cycle: a review of prospective data studies. Gend Med. 2012;9(5):361–84.
2. Taylor DCS. Taking Back the Month: A Personalized Solution for Managing PMS and Enhancing Your Health, Chapter 1: The Puzzle of PMS. : New York, NY. The Berkley Publishing Group 2002.
3. Chrisler JC, Caplan P. The strange case of Dr. Jekyll and Ms. Hyde: how PMS became a cultural phenomenon and a psychiatric disorder. Annu Rev Sex Res. 2002;13:274–306.
4. Dye L, Blundell JE. Menstrual cycle and appetite control: implications for weight regulation. Hum Reprod. 1997;12(6):1142–51.
5. Evans SM, Levin FR. Response to alcohol in women: role of the menstrual cycle and a family history of alcoholism. Drug Alcohol Depend. 2011;114(1):18–30.
6. Michell AR. Changes of sodium appetite during the estrous cycle of sheep. Physiol Behav. 1975;14(2):223–6.
7. Tucci SA, Murphy LE, Boyland EJ, Halford JC. [Influence of premenstrual syndrome and oral contraceptive effects on food choice during the follicular and luteal phase of the menstrual cycle]. Endocrinol Nutr. 2009;56(4):170–5.
8. Cheng SH, Sun ZJ, Lee IH, Shih CC, Chen KC, Lin SH, et al. Perception of premenstrual syndrome and attitude of evaluations of work performance among incoming university female students. Biomed J. 2015;38(2):167–72.
9. Zaafrane F, Faleh R, Melki W, Sakouhi M, Gaha L. [An overview of premenstrual syndrome]. J Gynecol Obstet Biol Reprod (Paris). 2007;36(7):642–52.
10. Warner P, Bancroft J. Factors related to self-reporting of the pre-menstrual syndrome. Br J Psychiatry. 1990;157:249–60.
11. Wallenstein GV, Blaisdell-Gross B, Gajria K, Guo A, Hagan M, Kornstein SG, et al. Development and validation of the Premenstrual Symptoms Impact Survey (PMSIS): a disease-specific quality of life assessment tool. J Womens Health (Larchmt). 2008;17(3):439–50.
12. Ugarriza DN, Klingner S, O’Brien S. Premenstrual syndrome: diagnosis and intervention. Nurse Pract. 1998;23(9):40, 5, 9–52 passim.
13. Tschudin S, Bertea PC, Zemp E. Prevalence and predictors of premenstrual syndrome and premenstrual dysphoric disorder in a population-based sample. Arch Womens Ment Health. 2010;13(6):485–94.
14. Rapkin AJ, Mikacich JA. Premenstrual syndrome and premenstrual dysphoric disorder in adolescents. Curr Opin Obstet Gynecol. 2008;20(5):455–63.
15. Rapkin AJ, Mikacich JA. Premenstrual syndrome in adolescents: diagnosis and treatment. Pediatr Endocrinol Rev. 2006;3 Suppl 1:132–7.
16. Nisar N, Zehra N, Haider G, Munir AA, Sohoo NA. Frequency, intensity and impact of premenstrual syndrome in medical students. J Coll Physicians Surg Pak. 2008;18(8):481–4.
17. Kraemer GR, Kraemer RR. Premenstrual syndrome: diagnosis and treatment experiences. J Womens Health. 1998;7(7):893–907.
18. Gurevich M. Rethinking the label: who benefits from the PMS construct? Women Health. 1995;23(2):67–98.
19. Frackiewicz EJ, Shiovitz TM. Evaluation and management of premenstrual syndrome and premenstrual dysphoric disorder. J Am Pharm Assoc (Wash). 2001;41(3):437–47.
20. Yang M, Gricar JA, Maruish ME, Hagan MA, Kornstein SG, Wallenstein GV. Interpreting Premenstrual Symptoms Impact Survey scores using outcomes in health-related quality of life and sexual drive impact. J Reprod Med. 2010;55(1–2):41–8.
21. Rapkin AJ, Mikacich JA. Premenstrual dysphoric disorder and severe premenstrual syndrome in adolescents. Paediatr Drugs. 2013;15(3):191–202.
22. Hamblin J. TheAtlantic [Internet]2012.
23. Bernsted L, Luggin R, Petersson B. Psychosocial considerations of the premenstrual syndrome. Acta Psychiatr Scand. 1984;69(6):455–60.
24. Walker A. Theory and methodology in premenstrual syndrome research. Soc Sci Med. 1995;41(6):793–800.
25. Roos J, Johnson S, Weddell S, Godehardt E, Schiffner J, Freundl G, et al. Monitoring the menstrual cycle: Comparison of urinary and serum reproductive hormones referenced to true ovulation. Eur J Contracept Reprod Health Care. 2015:1–13.
26. Kikuchi H, Nakatani Y, Seki Y, Yu X, Sekiyama T, Sato-Suzuki I, et al. Decreased blood serotonin in the premenstrual phase enhances negative mood in healthy women. J Psychosom Obstet Gynaecol. 2010;31(2):83–9.
27. Romans SE, Kreindler D, Asllani E, Einstein G, Laredo S, Levitt A, et al. Mood and the menstrual cycle. Psychother Psychosom. 2013;82(1):53–60.
28. Jarvis CI, Lynch AM, Morin AK. Management strategies for premenstrual syndrome/premenstrual dysphoric disorder. Ann Pharmacother. 2008;42(7):967–78.
29. Lauersen NH. Recognition and treatment of premenstrual syndrome. Nurse Pract. 1985;10(3):11–2, 5, 8–20 passim.
30. Premenstrual syndrome (PMS). In: Gymecologists TACoOa, editor.
31. Taylor DCS. Taking Back the Month: A Personalized Solution for Managing PMS and Enhancing Your Health, Chapter 2: The Ages and Stages of PMS.: New York, NY. The Berkley Publishing Group 2002.
32. Daw J. Is PMDD real? : American Psychological Association; 2002.
33. Taylor D. Perimenstrual Symptoms and Syndromes: Guidelines for Symptom Management and Self Care. Johns Hopkins Advanced Studies in Medicine; 2005.
34. Heitkemper MM, Cain KC, Jarrett ME, Burr RL, Hertig V, Bond EF. Symptoms across the menstrual cycle in women with irritable bowel syndrome. Am J Gastroenterol. 2003;98(2):420–30.
