Articles

Premenstrual Syndrome (PMS)

Introduction

Premenstrual syndrome (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 the etiology of PMS. Five to ten days prior to menses, plasma estrogens rise and progesterone levels decline. These changes are accompanied by an increase in follicle stimulating hormone (FSH) six to nine days prior to menstruation, and peak aldosterone levels two to eight days before menstruation. Prolactin levels are elevated in most PMS patients. Other biochemical pathways such as the insulin response, and uptake of vitamins and minerals are being studied as potential causative factors. One hypothesis suggests that PMS may be due to an aberration in blood viscosity and red blood cell hydration during the menstrual cycle. (1)

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 is a subjective experience, producing symptoms that are annoying but manageable. For some, PMS is a debilitating condition that renders them virtually paralyzed by their symptoms.

Moderate to severe PMS can be divided into four subtypes: (2)
  • PMS-A (Anxiety) is the most common type of PMS. Symptoms include anxiety, irritability, and nervous tension. Elevated serum estrogen and low progesterone are associated with this type.
  • PMS-C (Cravings) is characterized by an increase in appetite, craving for simple carbohydrates, and fluctuations in blood sugar. Indulgence in simple sugars results in fatigue, headaches, palpitations, dizziness, or fainting. This type of PMS is attributed to a deficiency in prostaglandin synthesis, excessive insulin response, and impaired glucose tolerance. Low cellular magnesium levels have been reported among this subgroup.
  • PMS-D (Depression) is the least common but most serious manifestation of PMS. Symptoms include depression, tearfulness, confusion, insomnia, and withdrawal. Low levels of estrogen, high progesterone, and elevated adrenal androgens are implicated in this subtype. Abnormal serotonergic responses have been found among women with PMS-D, suggesting a neurochemical etiology. (3) In 1994, the Diagnostic and Statistical Manual of Mental Disorders (4th Ed.) (DSM-IVR) included "premenstrual dysphoric disorder" among its catalog of disorders. (4)
  • PMS-H (Hyperhydration) is associated with symptoms of water retention, abdominal bloating, breast tenderness, and weight gain. Elevated serum aldosterone may be a causative factor, which is thought to increase in the presence of stress, excess estrogen, magnesium deficiency, and dopamine deficiency.

Treatment Options

Conventional

Conventional management of PMS symptoms includes hormonal contraceptives, diuretics, NSAIDs, and psychotropic agents.

    Oral contraceptives that suppress ovulation are widely used to treat severe PMS. Oral contraceptives work by stabilizing the hormones associated with PMS symptoms. Combined hormonal formulas and progestin-only types are both used successfully. Side effects of estrogen-containing contraceptives include nausea, breast tenderness, edema, hypertension, and cervical discharge. Progestin formulas are associated with hair loss, acne, weight gain, increased appetite, depression, hirsutism, and reduced menstrual flow. (5) Diuretics are generally prescribed only if dietary restrictions, such as reduction of salt and simple sugars, prove ineffective. Diuretics reduce edema by increasing the excretion of sodium ions by the kidneys. Since water follows sodium along an osmotic gradient, water is also eliminated in the urine. Abuse of diuretics can result in severe electrolyte imbalances and dehydration. Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit prostaglandin formation by interfering with the enzyme cyclooxygenase. They have demonstrated some benefit in symptomatic management of PMS and dysmenorrhea. (6) Naproxen administered to subjects in a double-blind, placebo-controlled trial demonstrated that the drug was effective for both premenstrual and menstrual pain. (7) Another study reported similar success with mefenamic acid. (8) Because the inhibition of prostaglandins is non-selective, beneficial prostaglandins are also inhibited. Therefore, it is recommended that NSAIDs be used only for short-term treatment of PMS symptoms. Antidepressants: The selective serotonin re-uptake inhibitors (SSRIs), including fluoxetine, paroxetine, sertraline, and clomipramine, have demonstrated effectiveness in relieving premenstrual dysphoria. SSRIs can be taken during the luteal phase of the menstrual cycle for relief of irritability, anger, sadness, cravings, and tension. (9) Intermittent administration of antidepressants appears to be more effective than continuous therapy, although the reasons for this are not completely understood. (10) Side effects of SSRIs may include insomnia, headache, nervousness, loss of appetite, and sexual dysfunction.

Nutritional Supplementation


Magnesium

Magnesium performs a number of critical functions in the body, including maintaining bone structure and regulating muscle contraction and nerve impulses. Sub-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 PMS Distress Questionnaire), specifically on questions related to mood. (11)

Estrogen is thought to enhance the uptake of magnesium into the bone and soft tissues, making premenopausal women particularly vulnerable to magnesium deficiencies. (12) A study at the SUNY Brooklyn Health Science Center reported that serum magnesium and calcium levels change significantly throughout the menstrual cycle. According to the study, serum magnesium increases in the early follicular stage, but decreases around ovulation and in the presence of progesterone. The study authors concluded that cyclic alterations in magnesium and calcium can produce premenstrual syndrome during the luteal phase in women who are deficient in magnesium. (13)


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 ameliorates PMS complaints.

Omega-3 fatty acid is a polyunsaturated fatty acid also known as alpha-linolenic acid (ALA). ALA is converted by the body to longer chain fatty acids such as eicosapentaenoic acid (EPA) and docosapenthaenoic acid (DHA). Omega-6 fatty acid is also known as linoleic acid, which the body converts into a longer chain fatty acid known as gamma-linolenic acid (GLA).


Soy Isoflavones

Soy isoflavones such as genistein and daidzein are rich in phytoestrogens, which have been reported to reduce PMS symptoms, support bone mineralization, and decrease the risk of some cancers. (14) , (15) Soy isoflavones may also improve HDL/LDL ratios. 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. (16)


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. A survey taken between 1976-83 consisted of 630 women suffering from premenstrual syndrome were administered daily doses of pyridoxine hydrochloride. The dosages varied from 40 to 100 mg in the beginning of the study to 120 to 200 mg later on. The results were a 65-68 per cent and a 70-88 per cent respectively in reduction of PMS symptoms. (17) Success is dependent on the body’s ability to convert vitamin B6 to its active metabolite, pyridoxal 5 phosphate (PLP). It can reportedly reduce menstrual complaints such as cramping, fibrocystic breasts, and excessive bleeding.


Vitamin E

In a randomized, double-blind study, doses of 400 IU daily have reportedly produced significant improvement in certain affective and physical symptoms in some women with PMS. (18)

Vitamin E includes eight compounds, which includes four tocopherols, alpha, beta, gamma, and delta. The natural form of vitamin E, d-alpha tocopherol has been reported to have greater bioavailability than synthetic iso-forms of the vitamin. (19)


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. Concluding, the authors stated that although large clinical trails are needed, a high intake of vitamin D and calcium may reduce the risk of PMS. (20)

Herbal Supplementation


Black Cohosh

Black cohosh rhizome has been reported to have phytoestrogenic properties. (21) The isoflavone formononetin has been reported to have estrogenic activity in laboratory rats. (22) 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. (23) , (24)

The triterpenoid 27-deoxyactein has also been reported to produce estrogen-like effects in humans. (25) In a controlled study, black cohosh tablets, standardized to 1mg of 27-deoxyactein, were given to 110 female patients in a university gynecological clinic. Patients received two tablets twice daily for two months. Half the patients took the black cohosh tablet, and half took a placebo. At the end of the required treatment period, both groups were tested for luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels, as increases in LH levels have been found in menopausal individuals complaining of hot flashes. There was no significant effect on the FSH serum concentration in either group. This study reported on the positive effects black cohosh has on LH suppression in postmenopausal women, with an estrogen-like manner. It should be noted, however, that naturally occurring estrogen in the body also affects the release of FSH through receptor binding; so even though black cohosh has estrogenic properties in the body, it does not have the exact pharmacology as naturally occurring estrogen.

Also, the constituent cimicifugoside is reported to affect the hypothalamus-pituitary system, producing a hormonal balancing effect in the female reproductive system. (26) 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 significant effect on the pituitary. (27) , (28) Studies point to a progesterone-like component and effect. (29) , (30) Studies report that vitex stimulates luteinizing hormone (LH) and inhibits follicle stimulating hormone (FSH). (31) , (32) Because of this activity, vitex has been recommended for a variety of female complaints, such as PMS, amenorrhea, menopausal symptoms, endometriosis, and hyperprolactinemia. (33) , (34) , (35) Several studies have reported beneficial effects of vitex on female-related disorders. (36) , (37) Several clinical studies have reported beneficial results using chasteberry in treating women with infertility associated with corpus luteum deficiency. (38)


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. (39) Dong quai is rich in phytoestrogens. (40) , (41) Phytoestrogens have a weaker effect on binding sites than do their drug counterparts. During PMS when estrogen levels are elevated, phytoestrogens bind to estrogen-binding sites, leaving the endogenous estrogen to be metabolized by the liver and thus reducing overall excess estrogenic effects. When estrogen levels are low, as in the case of menopause, phytoestrogens bind to estrogen-binding sites, activating the receptor site in a milder fashion than drug counterparts. There are a few conflicting reports about dong quai’s direct estrogenic effects. However, it is has been used for generations in females who report better results and fewer adverse effects than with prescription estrogen replacement products.


Dandelion Leaf

Dandelion leaf is reported to possess diuretic properties, and has potassium sparing qualities. (42) 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. In experiments on laboratory animals, a fluidextract (1:1w/v) of dandelion leaf (corresponding to 8 gm of dried leaf/kg body weight) was reported to possess diuretic activity comparable to that of furosemide (80mg/kg body weight). (43) A most promising point of this study was that the usual potassium loss seen with many conventional diuretics was not seen in dandelion’s use, due to the high potassium content in the leaves.


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. (44) , (45) 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. (46) , (47) Reports are conflicting as to whether kava’s anti-anxiety actions are GABA mediated. (48) , (49) Kavalactones appear to act on the limbic system, in particular the amygdala complex, the primitive part of the brain that is the center of the emotional being and basic survival functions. (50) It is thought that kava may promote relaxation, sleep, and rest by altering the way in which the limbic system modulates emotional processes. Tolerance does not seem to develop with kava use. (51) , (52)


St. John's Wort

St. John’s wort has several possible effects on body chemistry, including: the inhibition of cortisol secretion and the blocking of catabolic hormones, such as interleukin 6 (IL-6); (53) the inhibition of the breakdown of several central nervous system neurotransmitters, including serotonin. It may have mild MAO-inhibiting activity. This has not been clearly defined and cannot explain all the activity of St. John’s wort. Researchers do not consider this to be its major mechanism of action. (54) , (55) , (56) Amplification and improvement in the signal produced by serotonin once it binds to its receptor sites in the brain; (57) , (58) and contains the chemical melatonin (approximately 4.39mcg/gm), which may also contribute to the antidepressant effects of the plant. (59)

Although the constituent hypericin was originally thought to have the antidepressant effects seen when using St. John’s wort, recent research has reported that the constituents pseudo-hypericin and hyperforin may enhance serotonin, catecholamines, and glutamine levels in the brain. (60)

Recent literature has reported cytochrome P-450 enzyme-inducing activity of St. John’s wort in human studies. Interactions between St. John’s wort and anticoagulants, indinavir, cyclosporin, digoxin, ethinyl estradiol/desogestrel, and theophylline have occurred. (61) The mechanism of action was believed to be liver enzyme induction and subsequent alterations of drug levels by the herb. Also, several reports have suggested that concurrent use of St. John’s wort and SSRIs may result in "serotonin syndrome", including sweating, tremor, confusion, flushing, and agitation. (62) , (63) Use St. John’s wort with caution if individuals are on these medications.

Homeopathic

Apis mellifica

Typical Dosage: 6X or 6C, 30X or 30CRight-sided ovarian discomfort; Burning, stinging pains; Better from cold; Worse from heat

Lachesis mutus

Typical Dosage: 6CLeft-sided ovarian discomfort; Hot flashes; Nervousness and anxiety; Improvement when menstrual period starts

Lycopodium clavatum

Typical Dosage: 6X or 6C, 30X or 30CIrritability; Depression; Craves sweets; Right-sided ovarian pain

Nitricum acidum

Typical Dosage: 6X or 6C, 30X or 30CFluid retention; Swollen breasts; Sadness; Irritability

Pulsatilla

Typical Dosage: 6X or 6C, 30X or 30CPMS symptoms; Mood swings and crying; Painful breasts; Hot flashes; Irregular periods

Sepia

Typical Dosage: 6X or 6C, 30X or 30CProfuse menses; Melancholy; Weakness

Acupuncture & Acupressure

You treated 56 cases of PMS with acupuncture. Acupoints were selected for treatment as follows: 1) PMS due to liver-qi stagnation: all patients were treated at Taichong (Liv 3), Taixi (K 3), Qihai (Ren 6), Ganshu (B 18), Sanzhong (Ren 17), and Sanyinjiao (Sp 6); in addition, patients with fever were treated at Dazhui (D 14), Quchi (LI 11), patients with headache were treated at Taiyang (Extra 2), and Baihui (Du 20), patients suffering from severe insomnia were treated at Shenmen (H 7), Neiguan (P 6), and patients with breast tenderness were treated at Rugen (S18), and Qimen (Liv 14). 2) PMS due to spleen and kidney-yang deficiencies: all patients were treated at Zusanli (S 36), Pishu (B 20), Shenshu (B 23), Taixi (K 3), Sanyinjiao (Sp 6), and Guanyuan (Ren 4; moxibustion). In addition, patients suffering from diarrhea were treated at Zhongwan (Ren 12), and Tianshu (St 25); patients with edema were treated at Shuifen (Ren 9), and Qihai (Ren 6; moxibustion).

The gauge 28-30, 50-65 millimeter filiform needles were used, and the needles were retained for 30 minutes after insertion. The reducing method was used for patients of liver-qi stagnation, while the universal reinforcing-reducing method was used for patients of spleen and kidney-yang deficiencies. In addition to needling, the acupoints Guanyuan and Qihai were also moxibusted for five minutes. The treatment started 10 days before the menstrual cycle and ended when menstruation began. One unit of treatment lasted 10 days. The results: out of a total of 36 patients of liver-qi, 9 cases recovered, 22 improved, and 5 did not respond to the treatment, with a total effective rate of 86.1%; out of a total of 20 patients of spleen and kidney-yang deficiencies, 6 recovered, 10 improved, and 4 did not respond to the treatment, with a total effective rate of 80.0%. (64)

Xu treated 50 cases of PMS with acupuncture. All patients received treatment at the acupoint Zhongji (Ren 3). In addition, patients suffering from dizziness and insomnia were also treated at Taiyang (Extra 2), Baihui (Du 20), and Shenmen (H 7); patients who lacked appetite were also treated at Zhongwan (Ren 12)and Zusanli (St 36); and patients suffering from distention in the lower abdomen were also treated at Guanyuan (Ren 4). The universal reinforcing-reducing method was used, and the needles were retained for 30 minutes. The treatment began 3-5 days before the menstrual cycle, and was discontinued during menstruation. One unit of treatment consisted of six daily sessions. The results: after 1-3 units of treatment, 42 cases recovered (25 recovered after one unit of treatment, 11 recovered after two units of treatments, and 6 recovered after three units of treatment), 6 improved, and 2 did not respond to the treatment, with a total effective rate of 84%. (65)

Other Treatments
Ran treated 37 cases of PMS by pressing a single vaccaria seed against selected auricular acupoints. All patients received treatment at auricular acupoints related to the pituitary gland, endocrine, ovary, uterus, and liver. In addition, patients with liver-qi stagnation were treated at auricular acupoints related to the root of the acoustic labyrinth, sympathy, and liver-yang; patients with liver and kidney-yin deficiencies were treated at points related to the kidney; patients with spleen and kidney-yang deficiencies were treated at points related to the kidney, adrenal glands, and the root of the acoustic labyrinth; patients with accompanying headache were treated at relevant occipital, vertex, frontal, and temporal points; patients with accompanying dizziness were treated at brain stem and vertigo points; and patients with accompanying vomiting were treated at stomach and sympathy points.

The method: a single vaccaria seed was placed in the center of a small piece of adhesive cloth, and then the adhesive cloth with the vaccaria seed in place was applied to the above auricular points; the patients were instructed to press the treated points 5-10 times a day, 3 minutes each time. The bilateral points were alternated in receiving the treatment every three days, and the entire treatment lasted 3 menstrual cycles. The results: out of a total of 18 patients with liver-qi stagnation, 11 recovered, 4 significantly improved, 2 improved, and 1 did not respond to the treatment, with a total effective rate of 94.4%; out of a total of 11 patients with liver and kidney-yin deficiencies, 3 cases recovered, 3 significantly improved, 2 improved, and 3 did not respond to the treatment, with a total effective rate of 72.7%; out of a total of 8 patients with spleen and kidney-yang deficiencies, 3 cases recovered, 3 significantly improved, 2 improved, with a total effective rate of 100%. (66)

Aromatherapy

Aromatherapy for PMS

Symptoms of PMS may be relieved by using essential oil therapy in a bath or diffuser. If PMS is being aggravated by stress, oils used in stress therapy should also be used. However, if the symptoms are general PMS tension or excess water retention, the following oils may prove useful:

Premenstrual Tension
Use the following oils in a bath or in a diffuser as needs indicate:

    Clary Sage (Salvia sclerea) 5 drops Ylang Ylang (Cananga odorata) 4 drops Lavender (Lavendula augustifolia) 3 drops

Water Retention
Temporary relief from the symptoms associated with water retention may be experienced by using Juniper oil (Juniperus communis) in a hot bath and soaking for at least 20 minutes. No more that 8 to 10 drops should be necessary.

Caution: Essential oils should not be used during pregnancy or lactation unless under supervision of a trained aromatherapist or healthcare practitioner.

Traditional Chinese Medicine

Premenstrual Syndrome (PMS)

Extensive information regarding the treatment of this health condition using Traditional Chinese Medicine is available through the link above.

Clinical Lab Assessment

Some of the following laboratory testing can provide information necessary for diagnosis and treatment. In addition, the tests listed may also give insight to functional metabolism and functional nutrient status in the body.

Adrenal Function Profiles

Adrenal insufficiency can contribute to impaired resistance to infection. Stress activates the HPA axis and has impact on the immune system, particularly through the adrenal hormones. In assessing the HPA axis, adrenal functional abnormalities are relatively simple to identify and address (e.g., when compared to hypothalamic dysregulation or pituitary imbalance).

Mineral Analysis

It has been proposed that PMS is the result of mineral imbalances, most notably calcium deficiency. (67)

Fatty Acids

Dietary polyunsaturated fatty acids (PUFA) are primarily composed of omega-3 and omega-6 fatty acids. PUFA are vital in the production of eicosanoids – components involved in regulating inflammatory response, blood vessel leakage, lipid accumulation, and immune cell response. Disturbance of prostaglandin metabolism does appear to affect PMS; (68) however, studies are conflicting on the benefit of fatty acid supplementation for PMS symptoms. (69) , (70) , (71) The sequence of events leading to fatty acid elongation suggests that amino acid assay and organic acid assessment would likely be of more clinical significance in addressing the symptoms of PMS.

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