By Shirley Vanderbilt
Originally published in Massage & Bodywork magazine, October/November 2000.
Premenstrual syndrome (PMS) has evolved from being a taboo topic in our grandmother’s day to being a hot topic on the joke circuit today. But it’s no laughing matter for the estimated eight out of 10 women who suffer the emotional and physical symptoms of PMS at some point during their lifetime.1 Raging moods, cravings for chocolate and bloated stomachs are among common symptoms finding their way into greeting cards, e-mail jokes and comedic farces, while thousands of women miss work days, salvage remnants of disrupted relationships and wait for that day of the month when it will all turn around and they can feel “normal” again.
As a young woman in college during the 1960s, I remember a psychopathology professor explaining to the class that women who complained of premenstrual symptoms were actually neurotic, displaying characteristics Freud would have labeled as hysteria. Although PMS has been around since ancient times and the term was introduced into medical literature as early as 1931, physicians gave the symptoms scant attention until later in the century. According to Dr. Christine Northrup, in her book Women’s Bodies, Women’s Wisdom, an article on PMS in Family Circle magazine in the 1980s was a pivotal point for bringing PMS into the limelight: “The media picked up on this and within a few months, PMS became a nationally known problem and a household word.”2 Women began to demand treatment for their symptoms and their gynecologists were forced to pay attention.
Many approaches to treating symptoms of PMS have emerged over the past two decades — some tested in clinical studies, others carried on through the traditions of folk and native medicines. They have run the gamut, from nutrition and exercise to drugs and herbal remedies. Some medical treatments, such as drugs, hormones and surgery, carry risks of side effects and women have been increasingly turning to the field of alternative medicine for a safer solution to their problems.
One of the newest studies to come out of Touch Research Institute (TRI) in Miami has shown promising results in the use of massage to attenuate symptoms of anxiety, pain, water retention and depressed mood in women diagnosed with premenstrual dysphoric disorder (PDD), a more severe form of PMS. Researchers noted, “Based on these findings, massage therapy benefits would be expected to generalize to the milder PMS,” and would have no harmful side effects.3
Although women for the most part seem to be satisfied in casually using the term PMS to define an array of difficulties during “that time of the month,” medical professionals are obliged to fit the symptoms into a concise category in order to diagnose, treat and quantify the syndrome in scientific research. There are actually as many as 150 symptoms described in the literature as being connected to PMS, varying with each individual case.4 While some physical and emotional symptoms are more common than others, the specific symptoms identified are not necessarily critical to a diagnosis of PMS. “What is important is the cyclic fashion in which they occur,” said Northrup.5
In order to establish a medical diagnosis of PMS, symptoms are charted for three months to establish a continuing pattern of occurrence during the latter half of the menstrual cycle. Typically, symptoms disappear once menses begins, but in some cases they may continue through the first part of the menses, with only a few days of the month being experienced as normal. In addition to symptoms identified as PMS, pre-existing conditions such as arthritis, asthma and lupus may be exacerbated by these cyclical changes.6
A minority of women never experience PMS, but at the other end of the scale, as many as 40 percent have mild symptoms and up to 10 percent may be affected to the point of debilitation, being diagnosed with the severe form of PDD.7 It is this latter category of debilitation that TRI chose to focus on for the massage study. To meet criteria for PDD as laid out in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) the patient is required to have at least five recurring symptoms, of which four are affective (emotional), along with significant interference in social or occupational functions.8
Simple, Safe and Effective
Touch Research Institute at the University of Miami School of Medicine is well-known for successful clinical studies in the field of massage, tackling such conditions as fibromyalgia, depression, chronic fatigue syndrome and asthma. Through their program, researchers have been able to show the positive effects of massage on anxiety, stress, mood and pain in these and many other disorders. Based on these results,TRI established a study to measure the effects of massage therapy as compared to relaxation techniques for managing severe PMS. The study team postulated that the women receiving massage would “report lower anxiety, depression, pain and a reduction of PMS symptoms during the week prior to the onset of menstruation.”9 Relaxation in combination with diet, exercise and a behavioral treatment had been shown in a 1992 report by Pearlstein et al to attenuate PMS symptoms. Although the singular effects of relaxation could not be determined because of the combined treatment in this approach, it was expected that in the current TRI study relaxation would reduce symptoms of anxiety.10
The group of 24 women recruited for the study all met the diagnostic criteria of PDD. They ranged in age from 19 to 35 years, included an ethnic distribution of 38 percent Caucasian, 46 percent Hispanic, 8 percent African-American and 8 percent other, and were predominately middle class.11
In addition to the PDD classification, the subjects were required by TRI to meet 11 other criteria. Included were: dysfunction in work, school, or social and personal relationships; symptoms unrelated to psychological disorder; six-month history of PMS-related physical and emotional symptoms; not currently on birth control pills, hormones or psychotropic medication, or on any other medication during the study; menstrual cycle of 24 to 30 days and menstruation lasting no longer than seven days; PMS ending with the onset of menses; not lactating or pregnant six months prior; and a specified point difference in scoring on a menstrual distress questionnaire that was administered at two distinct phases of the cycle (medically termed follicular and luteal).12
Subjects were randomly assigned to a massage or relaxation group for the five-week study. The half-hour massage sessions, administered twice weekly, began on each woman’s first premenstrual week to establish a baseline and ended on the last day of her following premenstrual week. A specified massage protocol was adhered to and included work to the stomach area. In place of a control group, researchers used a progressive muscle relaxation treatment in the second group to control for placebo effect. Only the first and last sessions for this group were conducted at the institute, with the participants receiving written instructions for practicing the procedure at home on a twice-weekly, 30-minute schedule, the same as the massage group.13
While both groups exhibited a measured decrease in anxiety after the first session, only the massage group showed a decrease after the last session. The data also showed a marked improvement in mood for the massage group, although the benefits were not long-term. The study team suggested, “It is possible that one month of massage therapy is not sufficient to enhance the activity level or lead to long-term mood improvement for women with the more severe premenstrual dysphoric disorder.” In addition to the short-lived effects, researchers also reported long-term benefits in the massage group: decreased pain, as measured by two separate pain scales, and a reduction in water retention and overall menstrual distress.14 The report concluded that “massage therapy may be an effective adjunct therapy for treating severe premenstrual syndrome,”15 but that further research is needed “to determine whether continued massage sessions lead to continued improvement.”16
Improving the Status Quo
Perhaps it is because women have always accepted PMS as a natural part of their functioning that the medical profession has been slow to take an interest. As reported in a qualitative study from Finland, when the participants used the term PMS, “they are not saying that they have a medical condition. Rather, they say that they are aware of changes in various experiences during the premenstrual phase of some menstrual cycles.”17 Despite this general acceptance, research suggests we need to take a stronger stance in providing identification and treatment of this syndrome. In a 1999 survey of 1,045 women conducted in the United States, United Kingdom and France, it was found that approximately 80 percent reported symptoms, with more than 50 percent of working women reporting dysfunction on the job. However, almost 75 percent of the respondents had never sought treatment. The study team noted that those women with more severe symptoms were also less likely to believe that treatment was available.18
Now that the condition has gained acceptance by the medical profession, we have learned much about the interplay of PMS and our environment. Women have become aware of factors in their lifestyle, such as intake of caffeine, alcohol and sugars, that significantly affect the intensity of their symptoms. Exercise, stress reduction techniques and cognitive therapy have also emerged as important tools in providing an integrative approach to treatment. No single therapy or lifestyle change is known to diminish or cure the full spectrum of symptoms, but each has become a building block in the process of establishing protocols that will work. The TRI study on massage adds another potential piece to the construction.