Premenstrual syndrome and dysmenorrhoea are two common causes of discomfort prior to and during the menstrual period. Although both these conditions are generally not life threatening, they are the most common cause of absenteeism in women from work and school. In both cases underlying causes which mimic the symptoms of either PMS or dysmenorrhoea must be ruled out and treated if necessary before an accurate diagnosis can be made.

Premenstrual syndrome and dysmenorrhoea are two common causes of discomfort prior to and during the menstrual period. Although both these conditions are generally not life threatening, they are the most common cause of absenteeism in women from work and school. In both cases underlying causes which mimic the symptoms of either PMS or dysmenorrhoea must be ruled out and treated if necessary before an accurate diagnosis can be made.

Premenstrual syndrome (PMS) Premenstrual syndrome (PMS) is a combination of emotional, physical, psychological and mood disturbances that occur after a woman’s ovulation and normally end with the onset of her menstrual flow. The most common mood-related symptoms include irritability, depression, over sensitivity and mood swings with alternating sadness and anger. The most common physical symptoms are fatigue, bloating, breast tenderness (mastalgia), acne and appetite changes with food cravings.

PMS remains an enigma because of the wide-ranging symptoms and the difficulty in making a firm diagnosis. Several theories have been made to explain the cause of PMS, but none of these have been proven and specific treatment for PMS still largely lacks a solid scientific basis. Some of the theories are described as follows:

• Sex hormones: PMS has been thought to be due to decreased production of sex hormones by the ovaries after ovulation.
• Neuro-transmitters: Alterations in sex hormone levels at around the time of ovulation are thought to affect certain brain chemicals that in turn bring about the mood changes of PMS. Specifically serotonin and tryptophan, which function as neuro-transmitters in the brain have been shown to have a profound effect on mood and emotion.
• Opioid peptides: These are substances possessing some properties of opiate narcotics but are not derived from opium. The concentrations of these compounds in the brain can fluctuate in response to the hormones produced by the ovaries and they are also known to affect mood.

Because of genetic differences some women can be more susceptible to these chemical changes in the brain and suffer more severe symptoms than others.

About 80% of women experience some symptoms of PMS, however only a minority (estimated at 10%) have severe PMS that impacts their work, relationships or lifestyle in a significant way.

Diagnosis of PMS can only be made if there is a symptom-free interval after the menstrual flow and prior to the next ovulation. If the symptoms persist throughout the cycle, then PMS may not be the proper diagnosis.

The most helpful diagnostic tool is the menstrual diary, which documents physical and emotional symptoms over a number of months. If the changes occur consistently around ovulation (midcycle, or 7 – 10 days into the menstrual cycle) and last until the menstrual flow begins, then PMS is probably the accurate diagnosis. It is however important to rule out any other conditions which mimic the symptoms of PMS.

Treatment of PMS varies and although some measures lack a solid scientific basis they do seem to help some women. General measures include dietary changes, exercise and emotional support from family and friends during the time of a woman’s cycle. Avoidance of salt before the menstrual period, reduction of caffeine intake, elimination of smoking, alcohol and refined sugars have all been recommended and may help the symptoms. Other dietary alterations include restricting the intake of animal fats, dairy products and calcium. Women have been encouraged to increase their intake of complex carbohydrates such as pasta and rice, magnesium and zinc, vitamins A, E and B6. While doses of vitamin B6 of 50mg once or twice daily can help relieve symptoms of PMS, excessive use of vitamin B6 is discouraged.

Medications used in the treatment of PMS include diuretics, painkillers, oral contraceptive pills, drugs that suppress ovarian function and antidepressants.

Diuretics are drugs that increase the rate of urine production and thereby eliminate excess fluid from the body tissues and bloating. These products should only be used under the supervision of a medical practitioner as they may have side effects with long-term use.

Analgesics or painkillers are commonly given for menstrual cramps, headaches and pelvic discomfort. The most effective group appear to be the non-steroidal antiinflammatory drugs such as ibuprofen (Nurofen® or Brufen®), naproxen (Naprosyn®) and mefenamic acid (Ponstan®)

Oral contraceptive pills are sometimes prescribed to stabilise hormone fluctuations. While approximately 25% of women taking oral contraceptives find improvement, 50% find no change and the remainder may even experience a worsening of symptoms.

The use of ovarian suppressants and anti-depressants should only be used in extreme cases and under the supervision of a medical practitioner.

Although drugs may be useful in treating mood disturbances and physical symptoms, it is often a combination of diet, medication and exercise that is needed to provide maximum relief from PMS. Exercise in particular improves general health and helps relieve nervous tension and anxiety. In addition exercise is believed to release endorphins which can be mood elevating.

Although there is no ‘cure’ for PMS at this time, there are many options in managing its signs and symptoms. The first priority should be an accurate diagnosis and assurance that there are no underlying causes or medical conditions. Proper diet, exercise and lifestyle changes can help and should be tried before resorting to over-the-counter drugs or prescription medication.

Dysmenorrhoea
Dysmenorrhoea, also known as menstrual cramps or painful menstruation is a common problem, affecting women in their reproductive years. Approximately 30 – 50% of all women, from teenagers to women in their 30’s suffer from dysmenorrhoea during their menstrual cycle. Although some pain during menstruation is normal, excessive pain is not. Dysmenorrhoea is then described as menstrual pain that is severe enough to limit a woman’s normal activity and requires medication. Two types of dysmenorrhoea are distinguished, namely:

• Primary dysmenorrhoea or spasmodic dysmenorrhoea, and
• Secondary dysmenorrhoea or con-congestive dysmenorrhoea.

Primary dysmenorrhoea is painful menstruation for which no organic or psychological cause can be found.
Primary spasmodic dysmenorrhoea is characterised by sharp pains that are caused by the uterine muscle contracting and tightening. Sharp pains are sometimes felt in the inner thighs of lower abdominal muscles and some sufferers report backache, bloating and tenderness of the breasts. Young women in their early teens to late twenties are the main sufferers of this kind of dysmenorrhoea and women who have never had children seem to be more prone to it. Childbirth often marks the end of these menstrual cramps. Primary dysmenorrhoea has been linked to imbalances in oestrogen and progesterone, the main hormones that interplay throughout the menstrual cycle.

Secondary dysmenorrhoea is painful menstruation for which an organic or psychosexual cause can be found. These causes include:

• endometrial polyps,
• fibroid tumours of the uterus,
• ovarian cysts,
• prolapse of the uterus,
• pelvic inflammatory disease or an infection of the uterus, and
• endometriosis.

Endometriosis is the main cause of secondary dysmenorrhoea but is often misdiagnosed as primary dysmenorrhoea. Endometriosis is caused by implantation and growth of the endometrium outside the uterus on any area in the pelvic cavity, including the fallopian tubes, ovaries and outer wall of the uterus. When these tissues bleed during the menstrual flow it results in inflammation and scarring. Pain during menstruation and during sexual intercourse is the main symptoms of endometriosis.

Secondary dysmenorrhoea is characterised by cramps that are usually felt more to one side and do not peak or subside as quickly as in primary dysmenorrhoea. The pain usually starts several days before menstruation and gradually increases in intensity as menstruation approaches. Other symptoms of secondary dysmenorrhoea include excessive menstrual bleeding and pelvic discomfort; fever, backache and vaginal discharge in the case of an infection and painful intercourse. Treatment for primary dysmenorrhoea focuses primarily on pain relief. This can be done with home treatments such as heating pads and massage or the use of over-the-counter drugs such as non-steroidal antiinflammatory agents (Nurofen®, Ponstan®). Prescription drugs that may be used include Naprosyn® or Synflex®. Oral contraceptives that regulate hormone levels may also be prescribed to relieve menstrual pain.

It is important that a patient suffering from dysmenorrhoea be referred to a medical practitioner when:

• Menstrual pain is so severe that it disrupts the patient’s life;
• Menstrual periods always hurt;
• Unexplained symptoms accompany painful menstruation;
• Bleeding is heavier than usual;
• The pain is primarily on one side.

If endometriosis is the cause, a gynaecologist should supervise the treatment. Primary dysmenorrhoea can only be diagnosed when other serious causes of pelvic pain have been ruled out. Patients should be informed of the symptoms of other more serious causes of secondary dysmenorrhoea and should be referred to a medical practitioner when necessary.

In conclusion, it is imperative that health care workers acknowledge the effects of PMS and dysmenorrhoea and recognise the fact that both disorders require assistance, consideration, patient education and possible pharmacological intervention.

REFERENCES:

1. Health 24.co.za: Premenstrual syndrome
2. Health 24.co.za: Dysmenorrhoea
3. Management of Premenstrual Syndrome. Medifile – drug information bulletin. South African Pharmaceutical Journal. Vol. 15. No. 4. May 2001
4. Pray W. S. PMS: A disorder that is diagnosable. The Journal of Modern Pharmacy. Vol.7. No.6. June 2000.