Premenstrual Syndrome (PMS)

Introduction

What should I know about PMS?

Are we all getting a little tired of the PMS jokes and all the horror stories associated with Premenstrual syndrome (PMS)? It is always good to keep a sense of humor about life, but it is also good to be knowledgeable and aware of things that affect so many women as does this syndrome. So, ignoring all of the usual adjectives associated with this condition, just exactly what is PMS?

In 1994, the Diagnostic and Statistical Manual of Mental Disorders (4th Ed.) (DSM-IVR) included "premenstrual dysphoric disorder" among its catalog of disorders. (1) PMS is a cluster of physical and emotional symptoms associated with the menstrual cycle. Most women experience some degree of PMS at some point in their menstrual history, although symptoms vary significantly from woman to woman. Reproductive hormones and neurotransmitters are thought to play a central role in PMS. Five to ten days prior to menses, estrogen levels rise and progesterone levels decline. These changes are accompanied by an increase in something known as follicle stimulating hormone (FSH) six to nine days prior to menstruation. Then, around two to eight days before menstruation aldosterone levels peak. Prolactin levels are elevated in most PMS patients. So you can see that a lot of changes are occurring in a short period of time.

There are many theories around what causes these major changes to occur and why they are more dramatic in some women and less dramatic in others. One theory is that the way that the body uses vitamins and minerals may be a factor. Another hypothesis is that there is some deviation in the viscosity or thickness of the blood along with a change in the amount of water within the red blood cells during the menstrual cycle. (2)

Statistic

Women's Health in the Department of Health and Human Services, 1999.

    Nearly 2 out of 5 women ages 14 to 50 experience some symptoms of premenstrual syndrome(PMS). 10 percent of women have symptoms severe enough to disrupt their usual activities.

Signs and Symptoms

[span class=alert]The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.[/span]

For most women, PMS produces symptoms that are annoying but manageable. For some, PMS is debilitating, leaving the woman unable to carryout daily activities. (3)

PMS can be divided into four subtypes:

    PMS-A (Anxiety)

    This is the most common type of PMS. Symptoms include anxiety, irritability, and nervous tension. Elevated estrogen and low progesterone levels are associated with this type.

    PMS-C (Cravings)

    These symtoms are characterized by an increase in appetite, craving for simple carbohydrates (breads, sugars, grains, snack foods), and fluctuations in blood sugar. Giving in to this craving results in fatigue, headaches, racing heart beats, dizziness, or fainting.

    PMS-D (Depression)

    This symptom is the least common but most serious type of PMS. Symptoms include depression, tearfulness, confusion, insomnia, and withdrawal from daily and social activities. Low levels of estrogen, high progesterone, and elevated adrenal androgens are all found in this subtype. In 1994, the Diagnostic and Statistical Manual of Mental Disorders (4th Ed.) (DSM-IVR) included "premenstrual dysphoric disorder" among its catalog of disorders.

    PMS-H (Hyperhydration)

    Hyperhydration is associated with symptoms of water retention, abdominal bloating, breast tenderness, and weight gain. High levels of aldosterone may be a factor, which is thought to increase in the presence of stress, high levels of estrogen, and low levels of magnesium and dopamine.

    Treatment Options

    Conventional

    Conventional management of PMS symptoms includes drugs which work with either the hormones, water retention, pain, or mood. In some instances a combination of therapies is recommended. These therapies might include oral contraceptives, diuretics, NSAID’s, and anti-depressants.

    Nutritional Suplementation


    Magnesium

    Magnesium performs a number of critical functions in the body, including maintaining bone structure and regulating muscle contraction and nerve impulses. Less than optimal levels of magnesium have been noted in women suffering from PMS. In one double blind, randomized study, women deficient in magnesium and suffering from PMS were given 360mg of magnesium three times a day or a placebo for the last half of their menstrual cycle. After the second month, the treatment group reported a significant improvement (using The Menstrual Distress Questionnaire), specifically on questions related to mood. (4) Premenopausal women may be prone to magnesium deficiency because it is believed that estrogen may enhance the uptake of magnesium into the bones and softer tissues.


    Omega-3, Omega-6

    Essential fatty acids like borage oil, evening primrose oil, and flax oil help reduce inflammatory prostaglandins and increase prostaglandins that relieve menstrual cramping, breast pain, water gain, and increased clotting. They can also help stimulate small amounts of estrogen, which lessens menopausal complaints.


    Soy Isoflavones

    Soy isoflavones such as genistein and daidzein are rich in phytoestrogens, which have been reported to reduce menopausal symptoms, support bone mineralization, and decrease the risk of some cancers. (5) , (6) In cultures where soy products (bean curd, tofu, tempeh) and other sources of phytoestrogens (legumes) are consumed in abundance, women’s health problems, certain cancers, and cardiovascular disease are less prevalent. (7)


    Lactobacillus, Bifidobacteria

    Acidophilus cultures that are dairy-free and certified live can promote healthy flora in the bowel. Healthy bacterial flora in the GI tract influences the metabolism of phytoestrogens in the body. Many women with chronic yeast infections, a history of antibiotic use, a high intake of refined foods, high stress, chronic corticosteroid use, or birth control pill use may have a bowel flora imbalance (dysbiosis). A program to enhance bowel flora can be of benefit in these conditions. Lactobacillus acidophilus and Bifidobacterium bifidus metabolize phytoestrogens into isoflavones, making acidophilus supplementation a valuable component to a woman’s wellness/prevention program.


    Vitamin B6

    Vitamin B6, also known as pyridoxine, has reported benefits for reducing PMS symptoms. (8) It can reportedly reduce menstrual complaints such as cramping, fibrocystic breasts, and excessive bleeding.


    Vitamin E

    Combating the adverse effects of saturated and trans fats, vitamin E can reduce nervous tension, headaches, fatigue, depression, and PMS-related insomnia. Doses of 400 IU daily have reportedly produced significant improvement in certain affective and physical symptoms in some women with PMS. (9)


    Calcium, Vitamin D

    One study involved 1057 women free from PMS at baseline who then developed symptoms and 1968 women who were symptoms free. Using food frequency questionnaires, intake of vitamin D and calcium were measured in 1991, 1995, and 1999. After adjustment for age, smoking habits and other risk factors, the results showed that those with the highest intake of vitamin D had the lowest risk of PMS. The same was shown for dietary intake of calcium. Skim or low-fat milk was also associated with a lower risk of PMS. (10)

    Herbal Suplementation


    Black Cohosh

    Black cohosh rhizome has been reported to have phytoestrogenic properties. (11) The isoflavone formononetin has been reported to have estrogenic activity in laboratory rats. (12) Formononetin was reported to act as a competitor with estrogen in binding to uterine cells ex vivo. Clinical studies have reported positive effects on menopausal and postmenopausal complaints when using standardized extracts of black cohosh. (13) , (14)

    One of the chemicals in black cohosh has been reported to produce estrogen-like effects in humans. (15)

    Another chemical has been reported to affect the hypothalamus-pituitary system, producing a hormonal balancing effect in the female reproductive system. (16) The hypothalamus and pituitary glands control many aspects of human biochemistry, including hormonal release and regulation.


    Chasteberry

    The chasteberry tree has a long folk history of use in women’s health. Chasteberry has been recommended for use in mild to moderate complaints, especially in endometriosis, menopause, and PMS symptoms. The actual activity of the constituents of chasteberry is not fully established at this time. Studies have reported it to have a significant effect on the pituitary. (17) , (18) Studies point to a progesterone-like component and effect. (19) , (20) Studies report that vitex stimulates luteinizing hormone (LH) and inhibits follicle stimulating hormone (FSH). (21) , (22) Because of this activity, vitex has been recommended for a variety of female complaints, such as PMS, amenorrhea, menopausal symptoms, endometriosis, and hyperprolactinemia. (23) , (24) , (25)


    Dong Quai

    Dong quai is considered one of the most important remedies in Chinese medicine. It has been used for centuries for a variety of female complaints and is considered a tonic for women who are tired, recovering from illness, or have low vitality. (26) Dong quai is rich in phytoestrogens. (27) , (28) During PMS when estrogen levels are elevated, phytoestrogens bind to estrogen-binding sites, leaving the estrogen that is produced by the body to be metabolized by the liver and thus reducing some of the excess estrogenic effects.


    Dandelion Leaf

    Dandelion leaf is reported to possess diuretic properties, and has potassium sparing qualities. (29) There have not been human clinical studies to support these uses, but many years of positive use by physicians around the world warrant further research.


    Kava

    In European phytomedicine, kava has long been used as a safe, effective treatment for mild anxiety states, nervous tension, muscular tension, and mild insomnia. (30) , (31) Studies have reported that kava preparations compare favorably to benzodiazepines in controlling symptoms of anxiety and minor depression, while increasing vigilance, sociability, memory, and reaction time. (32) , (33)


    St. John's Wort

    St. John’s wort may be useful in treating depression and mood. However, using it in combination with other drugs or with dietary supplements should be monitored by a healthcare professional due to potential interactions.

    References

    1. The American Psychological Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychological Association; 1994.
    2. View Abstract: Simpson LO. The etiopathologies of premenstrual syndrome as a consequence of altered blood rheology: A new hypothesis. Med Hypothesis. 1988;25(4).
    3. View Abstract: Abraham GE. Nutritional factors in the etiology of the premenstrual tension syndromes. J Reprod Med. 1983;28(7):446-64.
    4. View Abstract: Facchinetti F, et al. Oral magnesium successfully relieves premenstrual mood changes. Obstet Gynecol. 1991;78(2):177-81.
    5. Steinberg PN. Isoflavones and the New Concentrated Soy Supplements. New York: Healing Wisdom Publications; 1996:4-7.
    6. View Abstract: Aldercreutz H. Phytoestrogens: Epidemiology and a possible role in cancer protection. Environ Health Perspect. 1995;103S(7):103-12.
    7. View Abstract: Barnes S. Evolution of the health benefits of soy isoflavones. Proc Soc Exp Biol Med. 1998;217(3):386-98.
    8. View Abstract: Brush MG, et al. Pyridoxine in the treatment of premenstrual syndrome: a retrospective survey in 630 patients. Br J Clin Pract. 1988;42(11):448-52.
    9. View Abstract: London RS, et al. Efficacy of alpha-tocopherol in the treatment of the premenstrual syndrome. J Reprod Med. 1987;32(6):400-4.
    10. View Abstract: Bertone-Johnson ER, et al. Calcium and Vitamin D Intake and Risk of Incident Premenstrual Syndrome. Arch Inter Med. Jun 2005;165(11):1246-52.
    11. Jarry H, et al. The Endocrine Effects of Constituents of Cimicifuga racemosa. 2. In Vitro Binding of Constituents to Estrogen Receptors. Planta Med. Aug1985;4:316-19.
    12. Jarry H, et al. Endocrine Effects of Constituents of Cimicifuga racemosa. 1. The Effect on Serum Levels of Pituitary Hormones in Ovariectomized Rats. Planta Med. Feb1985;1:46-49.
    13. View Abstract: Lieberman S. A Review of the Effectiveness of Cimicifuga racemosa (black cohosh) for the Symptoms of Menopause. J Womens Health. Jun1998;7(5):525-29.
    14. Jarry H, et al. The Endocrine Effects of Constituents of Cimicifuga racemosa. 2. In Vitro Binding of Constituents to Estrogen Receptors. Planta Med. Aug1985;4:316-19.
    15. View Abstract: Duker EM, et al. Effects of Extracts from Cimicifuga racemosa on Gonadotropin Release in Menopausal Women and Ovariectomized Rats. Planta Med. Oct1991;57(5):420-24.
    16. View Abstract: Koeda M, et al. Studies on the Chinese Crude Drug "Shoma." IX. Three Novel Cyclolanostanol Xylosides, Cimicifugosides H-1, H-2 and H-5, from Cimicifuga Rhizome. Chem Pharm Bull (Tokyo). May1995;43(5):771-76.
    17. Amann W. Amenorrhea. Favorable Effect of Agnus castus (Agnolyt) on Amenorrhea. ZFA. Stuttgart. 1982;58(4):228-31.
    18. View Abstract: Sliutz G, et al. Agnus castus Extracts Inhibit Prolactin Secretion of Rat Pituitary Cells. Hormone and Metabolic Research. 1993;25:253-55.
    19. View Abstract: Liu J, Burdette JE, Xu H, et al. Evaluation of estrogenic activity of plant extracts for the potential treatment of menopausal symptoms. J Agric Food Chem. May2001;49(5):2472-9.
    20. View Abstract: Makwana HG, et al. General Pharmacology of Vitex leucoxylon Linn Leaves. Indian J Physiol Pharmacol. 1994;38(2):95-100.
    21. View Abstract: Milewicz A, et al. Vitex Agnus castus Extract in the Treatment of Luteal Phase Defects Due to Latent Hyperprolactinemia. Results of a Randomized Placebo-controlled Double-blind Study. Arzneim Forsch/Drug Res. 1993;43(7):752-56.
    22. View Abstract: Bhargava SK. Antiandrogenic Effects of a Flavonoid-rich Fraction of Vitex Negundo Seeds: A Histological and Biochemical Study in Dogs. J Ethnopharmacol. 1989;27(3):327-39.
    23. Hillebrand H. The Treatment of Premenstrual Aphthous Ulcerative Stomatitis with Agnolyt. Z Allgemeinmed. 1964;40(36):1577.
    24. McGibbon D. Premenstrual Syndrome. CMAJ. 1989;141(11):1124-25.
    25. View Abstract: Jarry H, et al. In Vitro Prolactin But Not LH and FSH Release Is Inhibited by Compounds in Extracts of Agnus castus: Direct Evidence for a Dopaminergic Principle by the Dopamine Receptor Assay. Exp Clin Endocrinol. 1994;102(6):448-54.
    26. View Abstract: Zhu DPQ. Dong Quai. Am J Chin Med. 1987;15(3-4):117-25.
    27. View Abstract: Hirata JD, et al. Does Dong quai Have Estrogenic Effects in Postmenopausal Women? A Double-blind, Placebo-controlled Trial. Fertil Steril. 1997;68(6):981-86.
    28. Xu LN, et al. The Effect of Dang-gui (Angelica sinensis) and Its Constituent Ferulic Acid on Phagocytosis in Mice. Yao Hsueh Hsueh Pao. 1981;16(6):411-14.
    29. Newall CA, et al. Herbal Medicines: A Guide for Health Care Professionals. London: The Pharmaceutical Press; 1996:96-97.
    30. View Abstract: Volz HP, et al. Kava-kava Extract WS 1490 Versus Placebo in Anxiety Disorders--A Randomized Placebo-controlled 25-week Outpatient Trial. Pharmacopsychiatry. Jan1997;30(1):1-5.
    31. View Abstract: Singh YN. Kava: An Overview. J Ethnopharmacol. Aug1992;37(1):13-45.
    32. View Abstract: Munte TF, et al. Effects of Oxazepam and an Extract of Kava Roots (Piper methysticum) on Event-related Potentials in a Word Recognition Task. Neuropsychobiology. 1993;27(1):46-53.
    33. Drug Therapy of Panic Disorders. Kava-specific Extract WS 1490 Compared to Benzodiazepines. Nervenarzt. Jan1994;65(1Supp):1-4.