Onset and Cause of Premenstrual Syndrome

Frederick R. Jelovsek MD, MS

"Is it common after the birth of a baby (first year not right after) to experience severe moodiness, depression, and anger during or right before a period?"

"I am 30 and have no previous medical problems." Anon

Moodiness, depression and anger for several days before a menses can be normal for some women but many would label it as premenstrual syndrome (PMS). Not everyone is aware that breast tenderness and menstrual cramps are not PMS symptoms although they do vary with the menstrual cycle. Most women (80%) have some sort of cyclical symptoms associated with their menses but only about 3-5% have symptoms severe enough to be labelled as PMS. Some authors have tried to divide this into 3 severity stages: low level symptoms, PMS (regular or standard) symptoms, and premenstrual magnification (severe) symptoms (1, 2, 3). The 5% of women who have severe symptoms, or premenstrual magnification, are the ones usually included in large studies about PMS.

What you describe, however, is a change for you; it is not what you were used to as your normal menstrual physiology before pregnancy. This is not uncommon, i.e., to note that the new onset of these mood symptoms coincides with an event such as delivery. It is hard to know if what you are experiencing would be considered low level symptoms or regular PMS symptoms.

Common Premenstrual Syndrome Questions

Can any pregnancy or delivery events cause premenstrual symptoms to start?

As far as we know, there is nothing about pregnancy, labor, or delivery that can change the uterus or ovaries so that there is a different hormonal environment with ovulation. Even though a woman may associate the new onset of symptoms with a delivery or even surgery, there is no evidence that these events are causative. The increased stress associated with life and living changes that stem from these events is a better explanation for any increase in premenstrual mood symptoms noted.

To answer your question directly if it is common to develop the symptoms you experience, the answer is "no". It does happen sometimes, however. When it does, you may need to consider it as the new onset of PMS or it may just be increased stress that seems to exceed the limits of coping during the height of menstrual hormones. In order to answer whether you have ongoing stress or depression that just worsens premenstrual, you will need to keep a prospective menstrual calendar. That is the only way to diagnose PMS. If you have an elevation of irritability or depression in the first half of the cycle, even though it gets worse in the 2nd half, you should be checked out to see if you have underlying anxiety disorder or depression by testing yourself in the first 2 weeks of your cycle.

Do hormone levels cause PMS symptoms?

Premenstrual syndrome does not occur in women before menarche (start of menses), after menopause or without ovulation. It takes ovulatory menstrual cycles to have PMS. An ovulatory cycle has slightly higher estrogen and massively higher progesterone levels in the two weeks before a menses than the two weeks after a menses. Just before menses, estrogen and progesterone levels start to drop but most women have symptoms of PMS if they have any at all, when the estrogen and progesterone levels are still high. There is some debate as to whether progesterone causes or relieves PMS symptoms, but the consensus seems to be that progesterone and synthetic progestins can cause PMS types of mood symptoms. Since progesterone and progestins can also relieve symptoms it seems best not to prejudge its role in treatment. It is interesting that anti progesterone drugs (RU-486) do not make the symptoms go away.

Studies have looked at whether the hormones in the luteal phase are at different levels in women with and without PMS. Essentially they found no differences in estrogen and progesterone levels. Cortisol, which is a stress hormone is lower in women with severe PMS symptoms but this is more likely an effect than a cause, i.e., the stress hormone has been depleted by the stress. Thyroid hormone has been looked at and except for the about 5% incidence of hypothyroidism found in women presenting for PMS, abnormal thyroid function has not been found to be associated with premenstrual syndrome.

What is the best treatment for premenstrual mood symptoms?

Caffeine is known to worsen any anxiety state so it makes sense to recommend discontinuing all caffeine containing beverages and products. Even the amount of caffeine in tea seems to have an effect.

Alcohol has also been shown to aggravate PMS symptoms rather than just be a response to the increased stress of PMS. Following a no alcohol intake program makes sense for women with PMS.

In addition to discontinuing all caffeine and alcohol, there are other lifestyle changes and over-the-counter treatments available. The non prescription medicines, diet and alternative medical therapies shown to be of benefit for premenstrual syndrome include:

• Vitamin B-6 up to 100 mg/day
• Calcium 1000 mg/day (calcium carbonate)
• Magnesium (Mg) 200 mg/day as MgO 
• Naproxen sodium 550 mg twice a day (eg, Alleve®)
• Exercise - conditioning and aerobic 
• Low fat, vegetarian diet 
• Reflexology of the hand, food and ear has also been shown to benefit premenstrual syndrome.

What prescription medicines have been shown to be effective treatment for PMS?

The following table indicates those drugs that have been tested in randomized trials and found to be more effective than placebo in reducing the intensity of premenstrual symptoms. Prescription drugs should be considered a last resort and only if all of the non prescription treatments have been tried as well as lifestyle changes.

While all of the above are effective, fluoxetine (Prozac®) may have slightly less side effects and be slightly more efficacious in reducing symptoms.

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