Menstrual changes v PMS symptoms…

31 Aug 2018.

Differentiating ‘normal menstrual changes’ [1] from PMS (Premenstrual Syndrome) ‘symptoms’ is a big problem for patients, clinicians, and researchers [2]. There is no biological test that can be used to diagnose PMS and most symptoms rely on patient description e.g. pain, metabolic, or mood-related changes [3].

In fact, the latest clinical guidelines on PMS focus on the timing and severity of (apparently) ‘any’ symptoms:

It is the timing, rather than the types of symptoms, and the degree of impact on daily activity that supports a diagnosis of PMS. The character of symptoms in an individual patient does not influence the diagnosis… There is no limit on the type or number of symptoms experienced” [4].

However, without a list of the most common cyclical symptoms, or knowing how to differentiate between symptoms and ‘normal changes’, it’s possible for patients and clinicians to overlook the role that the menstrual cycle may play in their health…

So, here are some useful lists to help you and your doctor decide what’s going on [5]!


The most common PMS ‘symptoms’

(Cyclical changes that are so severe that they disrupt daily life and/ or require medical support-  affecting approx. 3-8% of the menstruating population only [4])

  1. Period pain
  2. Breast pain
  3. Muscle pain (lower back and thighs, in particular)
  4. Fatigue
  5. Diarrhoea
  6. Constipation
  7. Irritability
  8. Anxiety
  9. Low mood/ low self-esteem
  10. Bloating/ trapped gas
  11. Sleep disruption
  12. Headache
  13. Nausea/ vomiting 

Normal ‘menstrual changes’ 

(Cyclical changes that do not disrupt daily life or typically require medical support)

  1. Mild forms of any of the ‘PMS symptoms’ listed above
  2. Restlessness/ pins and needles (Note- this can also be a sign of anaemia)
  3. Mild acne
  4. Water retention
  5. Tearfulness – happy and sad
  6. Dizziness
  7. Libido changes – high and low
  8. Concentration level changes
  9. Mood changes – happy and sad
  10. Energy level changes – high and low
  11. Clumsiness – usually after poor sleep
  12. Body temperature changes

The most common menstrual cycle triggered/ worsened conditions

(Note: These are nearly all female-prevalent conditions)


References and notes:

[1] ‘Menstrual Changes’ were first described by the late, great Mary Brown Parlee (1943-2018) in 1973, as a means to differentiate the positive and non-medical changes associated with the menstrual cycle, in an effort to counter the prevailing (incorrect) assumption that the cycle was a form of illness in itself… Which can still happen all too easily! Parlee, M. B. (1973) ‘The Premenstrual Syndrome’ Psychology Bulletin 80(6) pp 454-465

[2] O’Brien, PMS. (2007) “Preface.” In The Premenstrual Syndromes: PMS and PMDD., edited by Patrick Michael Shaughan O’Brien, Andrea J Rapkin, and Peter J Schmidt, xi–xii. Boca Raton, FL, USA: CRC Press. http://docshare.tips/the-premenstrual-syndromes_58c49cb9b6d87f16458b5c3c.html  See page xi.

[3] Halbreich, Uriel. (2007) “The Diagnosis of PMS/PMDD- the Current Debate.” In The Premenstrual Syndromes: PMS and PMDD., edited by Patrick Michael Shaughan O’Brien, Andrea J Rapkin, and Peter J Schmidt, 9–19. Boca Raton, FL, USA: CRC Press. http://docshare.tips/the-premenstrual-syndromes_58c49cb9b6d87f16458b5c3c.html See page 17.

[4] RCOG. (2016) “Management of Premenstrual Syndrome: Green-Top Guideline No. 48.” BJOG: An International Journal of Obstetrics and Gynaecology 124 (3):73–105. https://doi.org/10.1111/1471-0528.14260 See page 80.

[5] These lists are all informed by data collected through the Menstrual Matters ‘Symptom checker’ application, together with previous research findings, and population studies (see below).

[6] IBS affects approx. 22.7% of UK females- Kennedy TM, Jones RH. Epidemiology of cholecystectomy and irritable bowel syndrome in a UK population Br J Surg. 2000 Dec;87(12):1658-63. Erratum in Br J Surg. 2001 Jul;88(7):1021 – and is well known to be affected by the menstrual cycle- e.g. Whitehead, W. E., Cheskin, L. J., Heller, B. R., Robinson, J. C., Crowell, M. D., Benjamin, C., & Schuster, M. M. (1990). Evidence for exacerbation of irritable bowel syndrome during menses. Gastroenterology98(6), 1485-1489.

[7] Migraine affects approx. 14.7% of UK adults- Stovner Lj, Hagen K, Jensen R, Katsarava Z, Lipton R, Scher A, Steiner T, Zwart JA. (2007) The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007 Mar;27(3):193-210. Menstrual migraine is a well known problem- e.g. MacGregor, E. A., & Hackshaw, A. (2004). Prevalence of migraine on each day of the natural menstrual cycle. Neurology63(2), 351-353.

[8] Insomnia affects approx. 10-30% of US adults- Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev. 2002 Apr;6(2):97-111. The menstrual cycle is known to be a factor in insomnia- e.g. Miller, E. H. (2004). Women and insomnia. Clinical cornerstone6(1), S6-S18.

[9] Hypersomnia affects approx. 5% of UK adults- Geddes, J., Gelder, M., Price, J., Mayou, R., McKnight, R. (2012) Psychiatry. 4th ed. Oxford University Press p365. The menstrual cycle is known to be a factor in hypersomnia- e.g. Billiard, M., Jaussent, I., Dauvilliers, Y., & Besset, A. (2011). Recurrent hypersomnia: a review of 339 cases. Sleep medicine reviews15(4), 247-257.

[10] Endometriosis affects approx. 7-10% of UK females- Sangi-Haghpeykar H, Poindexter AN. (1995) Epidemiology of endometriosis among parous women. Obstet Gynecol. Jun;85(6):983-92.

[11] Asthma affects approx. 9-11% of UK adults- Simpson, C. R., & Sheikh, A. (2010). Trends in the epidemiology of asthma in England: a national study of 333,294 patients. Journal of the Royal Society of Medicine103(3), 98–106. http://doi.org/10.1258/jrsm.2009.090348. Cyclical asthma is known but not well understood e.g. Sánchez-Ramos, J. L., Pereira-Vega, A. R., Alvarado-Gómez, F., Maldonado-Pérez, J. A., Svanes, C., & Gómez-Real, F. (2017). Risk factors for premenstrual asthma: a systematic review and meta-analysis. Expert review of respiratory medicine11(1), 57-72.

[12] Iron deficiency anaemia affects approx. 8% of UK females- Ruston D, Hoare J, Henderson L, et al. (2004) The National Diet and Nutrition Survey: adults aged 19-64 years. Volume 4: Nutritional status (anthropometry and blood analytes), blood pressure and physical activity. The Stationery Office. London. Menstruation is the leading cause of iron deficiency anaemia in young people e.g. Lainé, F., Angeli, A., Ropert, M., Jezequel, C., Bardou‐Jacquet, E., Deugnier, Y., … & Laviolle, B. (2016). Variations of hepcidin and iron‐status parameters during the menstrual cycle in healthy women. British journal of haematology175(5), 980-982.

[13] Acne affects approx. 85% of US 12-24 year olds and 8% of US adults aged 25 to 34 years-  Yentzer BA, Hick J, Reese EL, et al. Acne vulgaris in the United States: a descriptive epidemiology. Cutis. 2010 Aug;86(2):94-9. Menstrual acne is thought to be caused by a premenstrual reduction in pore size as a result of greater water retention in the skin e.g. Raghunath, R. S., Venables, Z. C., & Millington, G. W. M. (2015). The menstrual cycle and the skin. Clinical and experimental dermatology40(2), 111-115.

[14] Eczema affects approx. 1-3% of US adults- Leung D, Boguniewicz M, Howell MD, et al. New insights into atopic dermatitis. The J Clin Invest. 2004 Mar;113(5):651-7. Several skin conditions are worsened premenstrually e.g. psoriasis, atopic eczema and irritant dermatitis, and possibly also erythema multiforme, see; Raghunath, R. S., Venables, Z. C., & Millington, G. W. M. (2015). The menstrual cycle and the skin. Clinical and experimental dermatology40(2), 111-115.

[15] PMDD affects approx. 1-8% of UK females – population research is currently inadequate to be any more specific for PMDD- Dennerstein L, Lehert P, Heinemann K. Epidemiology of premenstrual symptoms and disorders. Menopause Int. 2012 Jun;18(2):48-51.

[16 & 17] Anxiety affects approx. 7% and depression affects approx. 4% of UK females- Stansfeld, S., Clark, C., Bebbington, P., King, M., Jenkins, R., & Hinchliffe, S. (2016). ‘Chapter 2: Common mental disorders’. In S. McManus, P. Bebbington, R. Jenkins, & T. Brugha (Eds.), Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey. Both conditions are known to worsen peri-menstrually e.g. Altemus, M., Sarvaiya, N., & Epperson, C. N. (2014). Sex differences in anxiety and depression clinical perspectives. Frontiers in neuroendocrinology, 35(3), 320-330.

[18] Diabetes Mellitis affects approx. 2-4% of UK adults- Wild S, Roglic G, Green A, et al. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004 May;27(5):1047-53. Glucose sensitivity is known to be affected by the menstrual cycle in Type 1 diabetes e.g. Herranz, L., Saez-de-Ibarra, L., Hillman, N., Gaspar, R., & Pallardo, L. F. (2016). Glycemic changes during menstrual cycles in women with type 1 diabetes. Medicina Clínica (English Edition)146(7), 287-291.

[19] ME/ CFS affects approx. 2-3% of English adults – Nacul LC, Lacerda EM, Pheby D, et al. Prevalence of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) in three regions of England: a repeated cross-sectional study in primary care. BMC Med. 2011;9:91. Anecdotal evidence suggests that some individuals notice a worsening of symptoms premenstrually.

[20] Epilepsy affects approx. 1% of UK adults- ONS (2002) Epilepsy Prescribing Patterns in England and Wales as cited here- http://researchbriefings.files.parliament.uk/documents/SN05691/SN05691.pdf Menstrual cycle-related epilepsy is known as ‘catmenial epilepsy’ e.g. Herzog, A. G. (2016). Current Concepts of Catamenial Epilepsy. Epilepsi: Journal of the Turkish Epilepsi Society22(3).

[21] MS affects approx. 0.125% of UK adults- Ford HL, Gerry E, Johnson M, et al. A prospective study of the incidence, prevalence and mortality of multiple sclerosis in Leeds. J Neurol. 2002 Mar;249(3):260-5. There is some evidence to suggest that MS symptoms can worsen during menstruation e.g. Mimosayyeb, O., Badihian, S., Manouchehri, N., & Shaygannejad, V. (2018). The interplay of multiple sclerosis and menstrual cycle: which one affects the other one? 

[22] Lupus affects approx. 0.028% of English adults- Johnson AE, Gordon C, Palmer RG, et al. The prevalence and incidence of systemic lupus erythematosus in Birmingham, England. Relationship to ethnicity and country of birth. Arthritis Rheum. 1995 Apr;38(4):551-8. Lupus is known to worsen premenstrually e.g. Boodhoo, K. D., Liu, S., & Zuo, X. (2016). Impact of sex disparities on the clinical manifestations in patients with systemic lupus erythematosus: a systematic review and meta-analysis. Medicine95(29).

[23] Rheumatoid arthritis affects approx. 1-2% of US adults- Alamanos Y, Voulgari PV, Drosos AA. (2006) Incidence and prevalence of rheumatoid arthritis, based on the 1987 American College of Rheumatology criteria: a systematic review. Semin Arthritis Rheum. 2006;36:182-188. There is anecdotal reporting of premenstrual worsening of arthritic pain e.g. Iacovides, S., Avidon, I., & Baker, F. C. (2015). Does pain vary across the menstrual cycle? A review. European Journal of Pain19(10), 1389-1405.

[24] Fibromyalgia affects approx. 0.5-5% of US adults- White KP, Harth M. (2001) Classification, epidemiology, and natural history of fibromyalgia. Curr Pain Headache Rep. 2001 Aug;5(4):320-9. Pain levels may fluctuate throughout the menstrual cycle e.g. Schertzinger, M., Wesson-Sides, K., Parkitny, L., & Younger, J. (2018). Daily Fluctuations of Progesterone and Testosterone Are Associated With Fibromyalgia Pain Severity. The Journal of Pain19(4), 410-417.


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