by Tori Hudson, N.D.
When finally we understand premenstrual syndrome (PMS) we will have gone a long way toward understanding the interplay between the cultural, physiologic, and emotional factors that regularly affect women’s lives during the premenstrum. A huge piece of work will have been done toward improving women’s health.
Maintaining good health and attitude through all phases of the menstrual cycle is just not as simple as correcting female physiology gone awry but also involves on some level transforming our cultural image of women’s reproductive health, specifically menstruation, from negative (the “curse”) to positive. However idealistic this seems, what we are after is practical help for the woman who suffers premenstrually.
Eighty percent of women experience premenstrual emotional or physical changes, whereas only about 20-40 percent of these women have difficulties as a result. A much smaller number, about 2.5-5 percent, feel it has a significantly negative impact on their lives, to the point where work, relationships or home life are jeopardized.
There are about 150 symptoms that have been ascribed to PMS- most commonly feelings of anxiousness, irritability, and anger or moods vacillating unpredictably among the three. Physical changes include bloating, breast tenderness, food cravings, headache, and gastric upset. No particular assortment of symptoms is diagnostic; it is the regular recurrence of symptoms on a monthly basis, just before menses occurs, and that disappear with the onset of menses or within the first day or two of menses. Symptoms begin somewhere at or after midcycle ovulation and may last for just a couple of days or the full 2 weeks.
It is important to eliminate other possible sources of the symptoms that might indicate medical conditions a woman may suffer from even more dramatically in the premenstruum. Women who have asthma, migraines, epilepsy or herpes, for example, often note a cyclic worsening, a premenstrual magnification, if you will, but this is not considered to be PMS. Treatment for the underlying condition is more likely to be effective that is treatment aimed solely at PMS. Among women self-presenting to PMS clinics for medical care, fully 75 percent had another diagnosis that contributed significantly to their symptoms- major depressive or other mood disorders being most prominent. About 10 percent had early menopausal symptoms, 10 percent were affected by hormonal contraceptives, and about 5 percent each were found to have eating disorders or substance abuse issues predominating.
It is difficult to identify the cause in a condition that overlaps so broadly with normal physiology, affects so many, and has such a wide array of symptoms. Many theories have been explored and none found completely satisfying. Most likely this is because it is such a complex interaction of factors both physiologic and social. While absolute levels of estrogen and progesterone are no different in PMS sufferers, we know that in women in whom both hormones are pharmaceutically blocked, PMS diminishes by 75 percent. It is likely that ovarian hormones affect the neurotransmitter, neuroendocrine, and circadian systems that influence mood and behavior differently in each of us.
One of the theories about PMS is that it is influenced by serotonin levels. Anita Rapkin, M.D., studied serotonin levels in women with PMS and those without, and found that serotonin levels fell after ovulation in women with PMS. There is also evidence that estrogen levels affect the serotonin system.
Excessive and incorrect prostaglandin (PG) synthesis has been implicated in the cause of PMS, And a deficiency of prostaglandin E1(PgE1) at the central nervous system has been proposed to be involved in PMS. There are many nutrients important for the synthesis of PgE1. These include magnesium, linoleic acid, vitamin B6, zinc, vitamin C, and vitamin B3. This theory is carried through as a basis for some of the nutritional therapies in the treatment of PMS.
Another basic foundation for many alternative practitioners in treating PMS is the concept of the liver’s role in the detoxification process. If the liver function is compromised, then estrogen metabolism is inadequate, estrogens do not get conjugated, leading to excess estrogen levels and an estrogen-dominant state. A “sluggish liver” is then addressed with various dietary, nutrient, and herbal interventions. This is a theory with much speculation and little scientific support. One cannot argue, however, about the central role of the liver and its varied metabolic processes with subsequent influence on the biochemistry of hormone and enzymatic pathways. There may in fact be a role for liver function in PMS, but what that is remains unknown.
Numerous natural alternative therapies are appropriate for the treatment of PMS including lifestyle changes, vitamin and mineral supplementation, herbal medicines, and natural hormones. What follows is a brief review of some of the natural approaches to the management and treatment of PMS.
Women who have PMS typically have dietary habits that are worse than the standard American diet. In a nutritional analysis published in 1983, Guy Abraham, M.D., reported that PMS patients consumed 62 percent more refined carbohydrates than women who did not have PMS, 275 percent more refined sugar, 79 percent more dairy products, 78 percent more sodium, 53 percent less iron, 77 percent less manganese , and 52 percent less zinc.
I mentioned earlier that a deficiency of PgE1 may be a cause of PMS. The synthesis of PgE1 requires magnesium, linoleic acid, vitamin B6, zinc, vitamin C, and vitamin B3. Arachidonic acid is a precursor to PgE2, which has antagonistic effects with regard to PgE1. Vegetable oils are rich sources of linoleic acid and animal fats are the main dietary source of arachidonic acid. Patients with PMS would be wise to decrease their consumption of animal fats and increase their consumption of vegetable oils.
Many women with breast symptoms in the premenstrual phase benefit from avoiding caffeine. Even though scientific studies are controversial on this subject, the practical results speak for themselves. Dr. Virginia Ernster conducted the first randomized study of a moderate number of women, in which for four months 158 women eliminated caffeine (coffee, tea, cola, chocolate) from their diets as well as caffeinated medications. She found a significant reduction in clinically palpable breast findings in the abstaining group compared with the control group, although the absolute change in the breast lumps was quite minor and considered to be of little clinical significance. Several other studies have been done with mixed reports, three showing no association between methylxanthines and benign breast disease and two showing positive correlations.
General regular physical exercise has been the subject of several controlled trials. In all of these, the results show that women who exercise regularly have less intense or fewer PMS symptoms. Aerobic training appears more effective at reducing PMS symptoms than strength training. Frequency of exercise seems more effective than intensity; gradual increase in running distances correlate directly with greater reductions in symptoms; and regular exercisers show improvement in all PMS parameters, e.g., concentration, affect, pain, water retention, as well as hostility, fear, guilt, and sadness.
A multiple vitamin and mineral supplement may be helpful for women with PMS. A study was done in 1985 of a rather typical multiple. In a double-blind, placebo-controlled, crossover study, 16 of 23 subjects reported feeling better during the cycles in which they took the supplement, and 7 reported feeling better during the placebo cycles. When selecting a multiple vitamin and mineral supplement, I recommend one that has been formulated especially for women. These formulations take into account some of the special nutritional needs of women.
There have been over one dozen studies on vitamin B6 and PMS. Some of these have shown no effect, but most of the studies have shown that there was a substantial and broad effect on the whole range of PMS symptoms. An overview of these studies has been published in the British Journal of Obstetrics and Gynaecology. The studies have used anywhere from 50-500 mg per day. Vitamin B6 is thought to be unique in its ability to increase the synthesis of several neurotransmitters in the brain including serotonin and dopamine. Lower levels of serotonin and dopamine have been implicated in the etiology of PMS.
Essential Fatty Acids
The main strategy of supplementing with essential fatty acids is an attempt to raise the body’s own formation of PgE1. The most popular method of doing so has been to supplement with evening primrose oil (EPO) in order to supply increased levels of gamma linolenic acid. Several studies show positive results, but some of the studies did not include a placebo group, and other studies did not show a statistically significant difference between the treatment group and the placebo group. Four double-blind, crossover, controlled trials of EPO have demonstrated a significant effect over the placebo group. , , , One of these studies used 3 grams of EPO per day; the others used 4 grams per day. Other sources of oils that contain gamma linolenic acid and raise PgE1 levels include borage oil, black currant oil, and rapeseed oil.
Magnesium has shown some beneficial effect in the treatment of PMS. In menstrual distress questionnaire scores, relief of premenstrual mood fluctuations and depression during magnesium treatment has been significant. The mechanism of magnesium and its possible role in PMS are not well understood, but we do know that magnesium is involved in essential fatty acid metabolism and pyridoxine (vitamin B6) activity. Recommended doses are 300 mg, 1 to 3 times per day.
A very recent randomized, double-blind placebo-controlled, multicenter clinical trial was conducted to test the hypothesis that problems in calcium regulation may underlie some of the symptoms of PMS. Four hundred ninety-seven women were enrolled and given either 1,200 mg of calcium carbonate or placebo for three menstrual cycles. During the luteal phase of the treatment cycle, a significantly lower symptom complex score was observed in the calcium group for both the second and third months. By the third month, calcium effectively resulted in a 48 percent reduction in total symptom scores from baseline compared with a 30 percent reduction in the placebo group. All four symptom factors (i.e., negative mood affect, water retention, food cravings, and pain) were significantly reduced by the third treatment cycle.
Vitamin E is probably not a big play in PMS relief, although two studies have demonstrated a clinically significant effect in relieving pain and tenderness of the breast. , The studies have been done with varying dosages: 150, 300, or 600 IU daily.
Chaste Tree (Vitex agnus castus)
The single most important plant for the treatment of premensrual syndrome is chaste tree berry. The effect of chaste tree is on the hypothalamus-hypophysis axis. It increases secretion of luteinizing hormone and also has an effect which favors progesterone. Two surveys were done covering 1,542 women with PMS who had been treated with a German liquid extract of chaste tree for periods of up to 16 years. The average dose was 42 drops daily. Effectiveness as recorded by the patients’ doctors was either very good, goo, or satisfactory in 92 percent of the cases. Use 35 drops of liquid tincture daily or a standardized extract containing .75% acubin at 175 mg per day or .6% aucubin at 215 mg per day.
The newest study using chaste tree was a clinical trial of 170 women with PMS; this has been the most well designed trial yet studying the efficacy of chaste tree in women’s health. Women were assigned to take either a tablet containing an extract of chaste tree berry (20 mg) or a placebo tablet once daily for three months. Subjective reporting of irritability, mood changes, anger, headache, breast tenderness and bloating were recorded. At the end of the three months, women taking the chaste tree reported a 52% reduction in PMS symptoms versus 24% reduction for those in the placebo group. Women in the chaste tree group reported their significant reduction in all symptoms except for bloating before the menses.
Ginkgo (Ginkgo biloba)
A double-blind, placebo-controlled study was done in 1993 to determine the effectiveness of ginkgo extract on PMS symptoms. One hundred sixty-five women were studied and received either a ginkgo extract of 24 percent ginkgo flavonglycoside content at 80 mg twice daily or a placebo from day 16 of their cycle to day 5 of the next cycle. The ginkgo extract was effective against the congestive symptoms of PMS, particularly breast pain or tenderness.
Perhaps no other PMS therapy has been the target of so much controversy as natural progesterone. This has as much to do with the lack of agreement and scientific research to support a unified theory as to the cause of PMS as it has to do with the efficacy of natural progesterone itself. Dr. Raymond Green and Dr. Katharina Dalton advanced a theory in the 1950s that PMS was caused by unopposed estrogen during the luteal phase of the menstrual cycle. Dr. Dalton reports that she has used natural progesterone via injections (25-100 mg daily), vaginal and rectal suppositories (400-1,600 mg daily), and subcutaneous pellets (500-1,600 mg every 3-12 months) with results as good as complete relief of PMS symptoms in 83 percent of women. There have been several studies that demonstrate a lack of efficacy of rectal and vaginal suppositories in the treatment of PMS. Sampson and Freeman found these forms of progesterone to be no better than placebo. , Although the suppository method of delivering natural progesterone for PMS has not held up to scientific scrutiny, oral micronized natural progesterone has. A study by Dennerstein and colleagues in 1985 found an overall beneficial effect using 300 mg/day (100 mg a.m., 200 mg p.m.) for 10 days of each menstrual cycle starting 3 days after ovulation. After only one month of treatment, those receiving progesterone could be clearly distinguished from those receiving placebo in areas of stress, anxiety, and concentration. Most all other symptoms also continued to improve with each menstrual cycle.
Natural progesterone creams have not been subjected to scientific scrutiny although tens of thousands of women can attest to their benefit. In my practice, I largely use the transdermal creams that contain at least 400 mg of natural progesterone per ounce. Using Â¼ tsp per dose, that will deliver approximately 20 mg of USP natural progesterone, the same progesterone that is in oral micronized progesterone. I recommend applying Â¼ tsp twice daily starting at mid-cycle and stopping the day before the menses is due. For women whose significant symptoms begin at ovulation, I recommend Â¼ tsp per day from day 8 to day 14 and then Â¼ tsp twice daily until just before the menses begins, as described above. The best sites for rubbing in the cream include the palms, inner upper arms, chest, and inner thighs.
Historically, conventional mainstream medicine has not been able to offer women a known cause for PMS nor has it been able to offer a management approach short of pharmaceuticals with as many side effects as relief. Self-care with natural therapies has been the dominant method of how women manage PMS. Women have clearly taken this monthly familiar problem into their own hands and more often than not have determined what works for them. The astute and well educated practitioner can offer additional therapies and clinical insights to help the remaining women with severe symptoms who need more specific and effective dosing regimens of natural substances as well as a well thought out comprehensive approach. Treating PMS naturally serves as a touchstone for motivating women to make lifestyle changes that have a positive cascade effect on their general health.
- American College of Obstetrics and Gynecology (ACOG), Committee opinion. Int J Gyn and Obstet 1995;50:80.
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