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Menstrual Cramps, PMS, and other Monthly Challenges for Women

One very common consequence of normal menstrual periods is uterine cramping or dysmenorrhea. While many women over 40 were told as teenagers that this is "all in your head", we now know that this is really all in your uterus:  dysmenorrhea is a result of increased prostaglandin production immediately before and during menses.  Mild to moderate cramping is considered normal and is usually easily treated with ibuprofen or other over-the-counter anti-inflammatory medicines.  Using oral contraceptives, using the contraceptive patch, and practicing regular aerobic exercise may also reduce dysmenorrhea.  Using an intrauterine device (IUD) for contraception may increase menstrual cramping.  Women with moderate to severe menstrual cramping may have a medical problem such as endometriosis or fibroids and should be evaluated by their physicians. 

While dysmenorrhea is a very common menstrual symptom, it is not part of premenstrual symdrome or PMS.  PMS is a chronic, cyclic mood disorder distinguished by a set of physical, psychological and emotional symptoms that affects approximately four out of 10 women of childbearing age in the second half of their menstrual cycle.  While the exact cause of PMS symptoms is not known, many physicians attribute them to fluctuations in female hormone levels or other bodily chemicals. PMS is often the brunt of jokes and is rarely taken seriously, even by the women who have it. It has been blamed for unpredictable, unexplainable, and unacceptable behaviors in women from moodiness to murder. While up to four out of ten women under 50 have reported symptoms of PMS, relatively few are actually affected by its closely related, but much more severe condition, premenstrual dysphoric disorder (PMDD).

PMS symptoms appear to be most troubling in women who smoke, have stressful lives, rarely exercise, get insufficient sleep, or who have a poor diet. In fact, PMS symptoms may be triggered or worsened by a high intake of caffeine, alcohol, salt, red meat or sugary foods (especially chocolate). . .despite the fact that many women with PMS have cravings for these substances (especially chocolate). In some women, the use of oral contraceptives has worsened or produced symptoms of PMS; in other women, however, starting or switching birth control pills has reduced or eliminated PMS symptoms.

Women between ages 25 and 34 are more than twice as likely to experience PMS than those between ages 35 and 44, although some women report that their PMS symptoms increase in the perimenopausal years (the 2 to 10 years before menopause). The good news is that PMS disappears once menopause is established, although many women describe going through menopause as having "constant PMS"!

In recent years, there has been some controversy in the medical community about the definition of PMS. This is because premenstrual discomfort is fairly common among women of childbearing age, affecting about 3 out of 4 of all menstruating women, making it quite "normal". However, fewer than 8 women out of 100 have premenstrual symptoms that are severe enough to disrupt their personal relationships or interfere with their normal daily activities. Some doctors feel that this latter criterion is essential to make the diagnosis of "true PMS". Other physicians feel that whether or not a woman has PMS or simply "menstrual discomfort" is based upon the woman's subjective view of her own circumstances. If PMS symptoms are significant enough to disrupt a woman's relationships or her normal daily activities, treatment is available and should be considered. 

Bloating is a common and uncomfortable menstrual symptom, with or without PMS. In addition to menses, other bloating triggers include eating certain foods (sugar, starches, salt); drinking too much alcohol (amount differs for different women; usually just two or more drinks can do it); being sedentary; lengthy travel or prolonged sitting for any reason; and certain medicines (e.g. hormone replacement therapy, progesterone, antihistamines, aspirin, antidepressants, and antibiotics).  Bloating results from water retention, which in many women is influenced by the hormonal changes of our menstrual cycle.  Some women document weight changes of 3-6 pounds before and after their cycle. This is water weight.  Ironically, treatment tips include drinking more water, not less, as well as reducing sugar, starches and salt before and during menses.  Exercise may also help. Also, be sure to get an adequate calcium intake. Studies show that women who aren't getting enough calcium are more likely to experience bloating than women who do. Premenopausal women need 1,200 mg of calcium per day; postmenopausal women need 1,500 mg/day if you have passed menopause. Getting an adequate amount of daily calcium has also been shown to reduce other symptoms of PMS as well.

In some women, birth control pills may contribute to menstrual bloating, but some pills may reduce bloating (e.g. Yasmin, which contains a progestin with diuretic properties). Bloating is not always menstrually related, however. Women who have bloating that lasts longer than their periods should consult their physicians, particularly if they have other symptoms such as lower abdominal pain or discomfort, back pain, weight loss and fatigue.

Birth control pills are often prescribed to treat menstrual irregularities, regulate heavy periods, and even to reduce symptoms of dysmenorrhea or PMS. They could have been called the "menstrual regulation pills" instead. However, birth control pills are also associated with period problems of their own, especially if a woman taking them misses pills or otherwise takes them incorrectly. Breakthrough bleeding (unpredictable, irregular, light bleeding in mid cycle) is the most common menstrual abnormality with "the Pill"; this often resolves without intervention within 3 months. If it doesn't, a different Pill is often the solution. Post pill amenorrhea is another complication of birth control pill usage. Of all of the menstrual irregularities, no single condition causes women more stress than a late period. The most common cause of  "late" period is pregnancy; the second most common cause is worrying about (or hoping to have) pregnancy. Other causes of late periods are usually due to other stressors, although a late period may be the first sign of amenorrhea. Losing (or gaining) a significant amount of weight may also cause menstrual irregularities. Amenorrhea may also be caused by anorexia (or other eating disorders), excessive exercise, chemotherapy or radiation, or premature ovarian failure (menopause before the age of 40 for any reason).

Many women have headaches as part of their PMS symptoms, but having menstrual migraine, a migraine headache occurring within the six days before menses, is not normal. It is common, however: of the 18 million women estimated to be migraine sufferers in the US, approximately two-thirds experience menstrual migraine. While many women mistakenly associate these headaches as part of premenstrual syndrome (PMS), they are migraines and may be effectively treated or prevented. However, migraine headaches of this type are typically the most severe and least likely to respond to treatment.

In some women, taking low-dose birth control pills may reduce the frequency of menstrual migraine; however, some women may actually experience an increased effect when they try this treatment. Progestin-only birth control pills may also be helpful.

While there are numerous prescription and over-the-counter treatments for migraine, prevention is often the best bet. Try to identify any triggers for your migraines and avoid them. Practice healthy lifestyle habits such as getting adequate sleep and balanced nutrition. Keep a headache diary and bring it with you to consult a headache specialist who can review any medications you may have already tried and offer some new options. If your medication is not helping despite taking it according to the instructions, speak with your physician about the possibility of taking a medicine prophylactically to prevent your migraines altogether.

Created: 6/27/2005  -  Donnica Moore, M.D.

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