What causes pre-menstrual tension

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Premenstrual Syndrome (PMS) is not a single pattern of symptoms.

The common underlying link is disruption to emotional and physical wellbeing that occurs during the luteal phase of the menstrual cycle. However the actual realisation of symptoms is highly variable and individual, and can include anxiety, depression, fatigue, cravings, water retention, headaches, and muscle cramps. This complexity has led to the development of subcategories of PMS such as PMS-C (where a predominant symptom may be increased cravings). In fact the reality is likely to be even more complex than that. 

As with many conditions, the cause of PMS is multifactorial. There appears to be a genetic predisposition for at least some people. As you'd expect, fluctuations in oestradiol, progesterone and prolactin are also implicated. Some aspects of PMS symptomatology relate to high oestrogen (increased irritability) in comparison to relatively lower progesterone, and some to low oestrogen (depression), and in fact studies of hormone levels show mixed results. Given the differences in symptom patterns, this is unsurprising. 

Often psychological symptoms occur as a result of hormonal changes affecting neurotransmitter function or as a side effect of other metabolic changes such as insulin resistance, low cortisol, reduced opioid peptides, dysfunction in circadian pattern of melatonin, disruption in prostaglandin synthesis, and intracellular alteration to electrolytes. 

Perhaps the heterogeneous nature of PMS is a result of the underlying metabolic imbalances in a given individual, imbalances that are amplified by the potent hormonal fluctuations of the luteal phase? Certainly our therapies need to be highly adapted to the individual to work effectively.