The etiology of PMS and the factors that place a woman at risk for developing PMS remain uncertain. Etiologic hypotheses that have been proposed include abnormalities in hormonal secretory patterns (ovarian steroids, melatonin, androgens, prolactin, mineralo-corticoids, thyroxin, insulin), neurotransmitter levels (biogenic amines such as epinephrine and norepineph-rine, endogenous opioids), circadian rhythms (temperature, sleep), prostaglandins, vitamin B6 levels, nutrition, allergic reactions, stress, and other psychological factors. Although investigators may advocate vehemently for one or more of these possibilities, no single, fully explanatory mechanism has been isolated as yet. Furthermore, there are physiological and behavioral correlates of menstrual cycle rhythms such as increases in appetite premenstrually and abdominal discomfort during menstruation that are present in women without PMS. These findings have led to the belief that the etiology of PMS resides in the interaction of many different factors that culminate in symptom expression.
Although not demonstrated conclusively, research suggests that genetic factors may place a woman at a relatively greater risk for the development of PMS or for greater severity of PMS symptoms. In one small study conducted by Dalton and colleagues, the pattern of identical twins both having PMS was found to be significantly higher (93%) than in nonidentical twins (44%) and in nontwin control women (31%). A questionnaire survey of 462 female volunteer twin pairs published by Van den Akker and colleagues fur
Pre-Menstrual Syndrome Treatment Interventions ther supports the possibility that a genetic predisposition for PMS exists. Similarly, evidence from developmental studies suggests a familial pattern as well. For instance, in a study of 5000 adolescent Finnish girls and their mothers, daughters of mothers with premenstrual ''tension'' were more likely to complain of PMS than were daughters of mothers who were symptom-free. In addition, 70% of daughters whose mothers had nervous symptoms in this study also had symptoms themselves, whereas only 37% of daughters of unaffected mothers experienced symptoms. These studies represent a crucial step toward clarifying the contributions of nature and nurture to the expression of PMS.
As with all medical illnesses, a number of psychological factors may contribute to PMS symptomatology in women. A young woman's symptoms and signs around menstruation may be interpreted as pathological or as normal according to her internalized sense of sexual health drawn from early family experiences, societal views of gender, and other influences. The ability to cope effectively with severe PMS symptoms may be hampered by the extraordinary stresses (e.g., balancing family and work responsibilities, single-parenting, dealing with financial pressures, or surviving the loss of a spouse) that have become commonplace in women's lives. Sadness and anxiety, vulnerability, and helplessness can become linked to a woman's experience of her menstrual cycle and may be attributed to PMS. Moreover, if a woman has disowned or devalued parts of herself, if she has endured interpersonal violence or other trauma, her suffering may be expressed symbolically through PMS symptoms. In summary, it is likely that the etiology of PMS resides in the interaction of multiple influences from a woman's biology, developmental events, and contemporary life circumstances which find expression in a unique cultural context.
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