PMT

One in five women suffers from pain, irritability, tiredness, lack of concentration, aggression, weight gain, anxiety, paranoia, hunger, shaking, sensitivity. But, asks Jane Feinmann, can anything be done to alleviate it?

Teresa Hall has two young daughters and a successful career in publishing. She has a happy marriage and a loving relationship with her children, and is good at her job and satisfied with her life. At least she is most of the time. For up to two weeks before her period, Hall often feels that she carries the woes of the world upon her shoulders. She is snappy with her children, aggressive with her husband and her confidence in her professional abilities dissolves, leaving her indecisive, paranoid and unable to concentrate. Problems magnify in her mind out of all proportion. "I can feel grief-stricken over things that happened ages ago," she says, "paranoid about what my friends or colleagues think of me, or heart-broken over some way in which I feel I've let my children down." Each month her period brings blessed relief. "For the fortnight after that, I am happy, energised, confident and pleasant to be with," she says.

Teresa Hall has two young daughters and a successful career in publishing. She has a happy marriage and a loving relationship with her children, and is good at her job and satisfied with her life. At least she is most of the time. For up to two weeks before her period, Hall often feels that she carries the woes of the world upon her shoulders. She is snappy with her children, aggressive with her husband and her confidence in her professional abilities dissolves, leaving her indecisive, paranoid and unable to concentrate. Problems magnify in her mind out of all proportion. "I can feel grief-stricken over things that happened ages ago," she says, "paranoid about what my friends or colleagues think of me, or heart-broken over some way in which I feel I've let my children down." Each month her period brings blessed relief. "For the fortnight after that, I am happy, energised, confident and pleasant to be with," she says.

Though she's aware of the cyclical nature of her behaviour, Teresa often feels ashamed of herself. And, beyond taking the evening primrose oil capsules recommended by her GP, she has no idea how to make her life better.

It's more than 50 years since Katharina Dalton, the gynaecologist who died last month, first described the hormone-related illness, premenstrual syndrome (PMS). Dalton was co-author of the first paper on PMS, published in 1952. She also founded the world's first PMS clinic, at University College Hospital in London. She ran the clinic, unpaid, for 40 years and published many books and papers on PMS and postnatal illness. She was an expert witness in the successful defence of Anna Reynolds, who killed her mother while suffering from postnatal illness, and Nicola Owen, an arsonist whose crimes were shown to follow her menstrual cycle. Not all medical opinion agreed with her methods of treatment, but, without doubt, Dalton helped to put PMS on the map.

Yet today's PMS experts, at a conference on women's menstrual health on Friday - organised by the National Association of Premenstrual Syndrome (Naps), which Dalton set up in 1983 - had to acknowledge that the serious nature of the illness and the size of the problem is still not widely understood.

For a start, PMS is far more widespread than previously believed, according to a new study of 960 women, aged between 20 and 35, that was presented at the conference. One-in-five women suffer significant symptoms of PMS, including irritability, anger, panic attacks, drinking too much and binge eating, along with feelings of worthlessness, anxiety and depression, together with a loss of efficiency and concentration - with migraine and breast tenderness being the most common physical symptoms.

And while PMS became part of the language in Dalton's lifetime, it remains poorly managed, with a recent study showing that 75 per cent of women with severe PMS don't seek medical treatment. "Bearing in mind that 45 per cent of the workforce is female, it's very worrying that there is not proper recognition that a substantial proportion are burdened by premenstrual symptoms," says lead researcher and Southampton GP Carrie Sadler. "These are very disabling symptoms, especially for working women with young children whose lives are already over-stretched. Yet there is still a wide perception that PMS is an excuse for women who can't cope."

So, how should a woman like Teresa go about intelligently managing her PMS symptoms? The first step is to complete a menstrual chart (available free from Naps website) over three months to identify cyclical symptoms. Women with PMS have no more hormonal changes than women who don't suffer - but "PMS sufferers appear to be particularly sensitive to these changes, probably because they have unusually low levels of certain brain chemicals, including serotonin", explains Nick Panay, a gynaecologist at Queen Charlotte's and Chelsea Hospital.

Dietary changes are next on the agenda. According to Naps, most women can control PMS symptoms by eating little and often in the premenstrual period - a PMS management method originally pioneered by Dalton. That means avoiding gaps of more than three hours without food and consuming regular portions of slow-release carbohydrates that help the brain to make serotonin.

"The idea is to establish an eating pattern of six small meals a day with each meal based on a starchy food that is preferably high in fibre," explains Naps nutritional expert Gaynor Bussell. "Eating starchy food should help reduce mood swings and sugar cravings. Keeping meals low in fat and sugar means you shouldn't gain weight."

But this beneficial eating pattern can be difficult to maintain, especially for women with young children - a group with particularly high levels of PMS - "probably because it's more difficult to control your diet and take regular exercise when you've got a family to look after," says St George's Hospital gynaecologist Claudine Domoney.

She recommends agnus castus, a herbal remedy that was one of Hippocrates' favourite herbs and widely used in Europe, particularly Germany, as a first-line treatment for PMS. Other over-the-counter remedies include evening primrose oil to treat breast tenderness (though a larger bra can often be as effective), as well as vitamin B6, magnesium and St John's Wort for emotional problems, including anxiety and depression.

Red clover is a promising remedy, with a trial of its efficacy under way. Natural progesterone, though still widely promoted, is considered by experts to be, at best, only marginally useful.

Weight gain is a further important issue. Sadler's research has shown, for the first time, that there is a significant association between being overweight and PMS - with the frequency of significant premenstrual symptoms increasing with body mass index. "By losing weight, you not only reduce risk of heart disease and diabetes but you also reduce the intensity of PMS symptoms," says Sadler.

For women who need further help, Domoney normally suggests the Pill - which balances hormone levels and boosts levels of serotonin. "The Pill helps many women, though the synthetic progestogen can sometimes make symptoms worse," she says. A new combined Pill, Yasmin, which contains a diuretic, appears to be helpful for women with PMS.

Antidepressants are a significant option, with a major review of 15 randomised, placebo-controlled trials, published in the Lancet in 2000, showing that SSRIs (selective serotonin re-uptake inhibitors) are effective in treating physical and behavioural PMS symptoms. Leading researcher Professor Shaughn O'Brien of Keele University recommended the therapy as "an effective first-line treatment for PMS".

Interestingly, antidepressants are effective when taken only during the second half of the menstrual cycle. "We don't quite understand why antidepressants work in this way," says Domoney. "When SSRIs are taken for depression, there's a time lag of around two weeks before they start working. This doesn't happen with PMS."

Further promising work in genetic research should soon enable early identification of those predisposed to PMS, "which will mean that mothers can be counselled about their daughters, to look for help sooner rather than later", says Panay. But while these therapies offer effective management of PMS, women like Teresa will only truly be helped to manage their lives when society as a whole, including employers, doctors and partners, accept it for the genuine illness it is, says Naps - and that is rather more problematic.

"Katharina Dalton was quite clear that women had to face up to their hormones by getting adequate treatment but also, if necessary, by avoiding stressful events at the wrong time of the month," says Chris Ryan, the chief executive ofNaps. "Unfortunately, there's been a lot of worry about acknowledging that PMS is a major issue, for women fear that it will feed into chauvinistic views of women as the weaker sex because they are slaves to their hormones. Yet by not acknowledging their problem and demanding the support they need, women are allowing a situation where the problem is not being taken seriously by society."

The association is committed to confronting these issues and campaigning for a coherent strategy on PMS at work, supported by trade unions, as well as the Government. Naps websiteoffers significant personalised support for sufferers - exactly what Dalton herself realised women needed.

Premenstrual syndrome... something to ease the pain

Evening primrose oil

The oil from the small, yellow wildflower, the evening primrose, is rich in linoleic acid, an essential fatty acid with anti-inflammatory properties.

Does it work? Some early trials of this oil suggested a beneficial effect for PMS, particularly mastalgia (breast pain and tenderness). But more rigorous trials suggested it has little effect on PMS.

Regular carbohydrates

For some women, PMS is caused by their blood-sugar falling rapidly before a period, giving rise to shaking, tiredness, hunger, lack of concentration and anxiety. To avoid this, cut down on sugary foods, and have a regular and frequent supply of carbohydrates, with six small meals a day based around the starchy foods that provide glucose, the body's main fuel. Foods that are also high in fibre, such as wholemeal bread, are the best option.

Does it work? Yes, studies have shown that dietary change helps most women with PMS.

Cut down on alcohol, caffeine and saturated fat

They all interfere with the body's production of a hormone-like compound called prostaglandin E1, which is thought to be one reason why PMS sufferers are extra sensitive to changes in hormone levels, particularly causing breast tenderness.

Does it work? Worth trying.

More/regular exercise

Twenty to 30 minutes, three to four times a week, raises the heart rate above 120 beats per minutes - appearing to bring a variety of benefits. These include a reduction in abdominal bloating, as well as weight loss, which may help reduce the frequency of PMS symptoms.

Does it work? Exercise makes you feel good and is worth the effort.

Agnus castus

This herbal remedy has been shown to lead to greater production of progesterone - which helps to reduce premenstrual symptoms - and inhibits the hormone prolactin.

Does it work? A large, randomised placebo-controlled trial has shown it is effective in treating physical and emotional PMS problems.

SSRIs

These successful anti-depressants work by boosting levels of serotonin and are frequently taken by PMS sufferers only during the premenstrual period.

Does it work? A large, randomised placebo-controlled trial has shown they are very effective in treating PMS health problems.

Natural progesterone

This hugely popular remedy is widely believed to counter-act oestrogen dominance.

Does it work? There is no evidence to demonstrate benefit.

Oral contraceptive

By suppressing the menstrual cycle, the Pill should help to reduce PMS symptoms.

Does it work? Studies show that the Pill is effective in treating PMS, but there is evidence of women who have never had the symptoms of PMS who start to suffer once they start taking oral contraceptives.

Calcium supplement

This cheap and cheerful mineral helps muscles relax.

Does it work? Two studies have shown that taking 1,200 to1,600mg daily helps physical symptoms.

Vitamin B6

A controversial remedy due to concerns about side effects from high doses (100mg a day).

Does it work? Most trials have been of poor quality, but a recent review of the evidence suggests it isworthwhile and is safe, as it only needs to be taken for a short period of time.

Contact Naps on 0870 777 2178 or www.pms.org.uk. If you wish to take part in research studies and are able to travel to London regularly, call 020-8383 4172