The menstrual experience is different for every woman, so the best advice is to expect the unexpected when it comes to your period. Over time, you will learn to know what is "normal" for you. But if you notice changes or symptoms of your period that seem abnormal to you or are uncomfortable, do not hesitate to consult your doctor for answers.

A. Premenstrual Syndrome (PMS)

In historical and modern times, many negative connotations regarding menstruation have existed, contributing to some women's unpleasant expectations of the premenstrual phase. However, Premenstrual Syndrome (PMS) was first noted as a true medical disorder by the American Gynecologist, Dr. T. Frank in 1931.

The medical community refers to PMS as a condition that is characterized by a constellation of physical and emotional symptoms that have a significant impact on a woman's day-to-day activities. This is in contrast to the common occurrence of premenstrual symptoms that many women, including you, may experience.

The criteria that physicians need to diagnose PMS are as follows: five (or more) of the following symptoms must occur during the premenstrual phase and be absent after menstruation. Also, at least one symptom must be from Group A.

• Depressed mood, feelings of hopelessness
• Anxiety, tension
• Sudden and dramatic mood swings
• Anger, irritability

• Decreased interest in usual activities
• Difficulty in concentrating
• Fatigue, lack of energy
• Change of appetite, overeating, food cravings
• Sleep disturbances
• Sense of being overwhelmed
• Physical symptoms such as breast tenderness or swelling, headaches, joint or muscle aches, bloating, weight gain

In addition, for a positive diagnosis of PMS, it is crucial that these disturbances interfere markedly with work, school, or personal relationships. The cyclic nature of these symptoms cannot be relied upon from memory. You must chart them on a daily basis for at least two to three months.

Finally, these symptoms cannot be a worsening of a psychiatric disorder such as Major Depression or Anxiety Disorder. Only 50 percent of women who visit their physicians believing that they have PMS actually meet the above criteria and have the diagnosis of PMS confirmed.

If you suspect you have PMS, it is imperative to relate the occurrence of the symptoms to the menstrual cycle. However, it is equally important for you to evaluate the stresses in your professional and personal life, since these may have a significant impact on how premenstrual symptoms are expressed.

Severe premenstrual symptoms

Some women experience very severe PMS. Symptoms of serious psychiatric problems, such as depression or panic attacks, are often most extreme during the premenstrual phase each month and studies have shown that women's suicide attempts, psychiatric hospital admissions, and violent criminal acts are most likely to occur in the premenstrual days. If you feel that you may hurt yourself or someone else, you should seek immediate medical attention. Fortunately, this is extremely rare.

There are no specific physical findings or laboratory tests that can diagnose PMS. There is also no symptom that is unique to PMS. The only way to determine whether or not you suffer from PMS is to record the timing and severity of your symptoms-both emotional and physical-throughout your menstrual cycle on a daily basis for two to three months.

In addition to the symptoms, monitoring basal body temperature (lowest body temperature during sleep) and vaginal secretion will contribute useful information to confirm when ovulation occurs. To accurately diagnose PMS, your physician will rely upon this charting. It is also useful to gauge your response to therapy.

When working with a doctor to confirm PMS, other disorders must be eliminated, since many symptoms of PMS resemble those of other underlying conditions. Your doctor may want to do a physical examination and a pelvic exam to rule out gynecologic problems.

In cases where fatigue is a major symptom, a blood test may be done to rule out anemia, hypothyroidism, and contributors to Chronic Fatigue Syndrome. It is also important to be aware that more serious psychiatric problems may have a cyclic pattern of worsening emotional symptoms in the premenstrual phase. For example, depression is very common in women and often worsens during premenstrual days.

PMS has been called everything from a hormonal dysfunction to a mental illness to the feminist issue of the 80s. Although it is known that PMS is associated with ovulation, the true cause remains unknown.

It is clear that two components are essential for PMS to occur. The first is the "trigger," which is clearly identified as ovulation and the resulting, reproductive hormonal changes. The second is the "vulnerability" to the "trigger" that produces the mood changes of PMS. What makes one women "vulnerable," and another not, is unknown.

This is the key to identifying the cause of PMS. Many factors have been suggested, but refuted, as contributors to the "vulnerability," such as a woman's social and economic status, number of children, diet, amount of exercise, stress level, personality, and characteristics of the menstrual cycle.

However, current data supports serotonin, a chemical in the brain, as having an important role in PMS. While no other cause has been nearly as conclusive as serotonin, other possible factors have been investigated and are interesting to consider.

Some theories that have been suggested include:

• Serotonin
• Cyclic fluctuations in reproductive hormones
• Abnormal thyroid function
• Endorphin deficiency
• Vitamins

Serotonin is a neurotransmitter. A neurotransmitter is a chemical that is involved in sending messages along nerves in the brain, spinal cord, and throughout the body. Serotonin affects mood. Impaired serotonin activity has been linked to symptoms of depression, anxiety, impulsivity, aggression, and increased appetite. Since depression is also a major symptom of PMS, scientists have questioned the role of serotonin in PMS. Abnormal serotonin levels and activities have been found in women suffering from PMS. Furthermore, drugs that enhance serotonin activity, called specific serotonin reuptake inhibitors (SSRI) (e.g., Prozac, Zoloft, Paxil), are effective in the treatment of PMS.

While it seemed logical to many that the reproductive hormones involved in the menstrual cycle were the cause of PMS, research has proven that there are no differences in estrogen, progesterone, FSH, LH, prolactin, and testosterone levels between women with and without PMS. This only confirms that ovulation acts as the "trigger" but is not in itself the cause.

In the past, progesterone supplementation was supported as a treatment for PMS, but has been proven to be ineffective. The only hormonal therapy that works is a regimen that prevents ovulation from occurring.

Thyroid disease is common in women. Symptoms of hypothyroidism, or low activity of the thyroid gland, can resemble symptoms of PMS. For this reason, it was thought that the thyroid gland played a role in the cause of PMS. If you suffer from PMS-like symptoms, you should get your thyroid checked.

However, it is clear that the majority of women with PMS have completely normal thyroid function. Thus, supplementation with thyroid hormone in the treatment of PMS is not helpful and may, in fact, be dangerous.

Endorphins are opium-like chemicals manufactured by the body. Opium-like chemicals, including endorphins, are involved in the sensation of euphoria and the perception of pain. Thus, some have proposed that PMS is a state of endorphin deficiency. Endorphin levels in the blood do fluctuate. However, these levels are not felt to reflect the activity of endorphins in the brain. Therefore, there is not enough evidence to support this theory.

Scientific research has not been able to confirm a difference in the levels of vitamins and minerals between those women with symptoms of PMS and those without. One particular vitamin that has received a great deal of attention is Vitamin B6. Vitamin B6 plays an important role in the synthesis of dopamine, a neurotransmitter that may also be involved in physical and emotional well-being. Thus, Vitamin B6 deficiency has been hypothesized as a cause of PMS.

Some researchers have shown improvements in PMS symptoms in women taking vitamin B6 daily, while others have not. However, it is important to limit the amount of vitamin B6 that you take, since nerve damage has been reported. Therefore, you should only take Vitamin B6 supplements with the supervision of a doctor.