Women who had the highest intake of thiamine were 25% less likely to develop PMS than those with the lowest intake. Women with the highest intake of riboflavin were 35% less likely to develop PMS. The intake of all B vitamins together in a B-complex supplement did not appear to lower the risk for PMS.

Comments: Vitamin B6 (pyridoxine) has shown benefits in treating PMS in most, but not all studies, and has shown a substantial and broad effect on the whole range of PMS symptoms in the positive studies. Doses have ranged from 50 gm to 500 mg per day. Given this body of research and information spanning since 1973, I’m not sure what compelled the investigators in this current study to track vitamins B1 and B2, rather than vitamin B6.

Reference: Chocano-Bedoya P, et al. Dietary B vitamin intake and incident premenstrual syndrome. Am J Clin Nutr 2011 May; 93:1080

Symptoms were rated using the Daily Symptom Report, The State Anxiety Inventory, the Beck Depression Inventory and the Aggression Questionnaire and Barratt Impulsiveness Scale. Numerous hormones and physiological markers were also measured in the follicular and luteal phases: follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, progesterone, prolactin, testosterone, cytokine interleukins= IL-1B, IL-6, IL-8, interferon and tumor necrosis factor alpha.

St. John’s wort was statistically more beneficial than placebo in food cravings, swelling, poor coordination, insomnia, confusion, headaches, crying and fatigue. There were no significant effects of St. John’s wort compared with placebo in any of the biochemical blood measurements. St. John’s wort was not statistically more beneficial in anxiety, irritability, depression, nervous tension, mood swings, feeling out of control and pain-related symptoms during two cycles of treatment. However, these pain-related symptoms appeared to improve more than placebo towards the end of each treatment period

Commentary: The results of this PMS study demonstrate once again, the benefit of St. John’s Wort for the treatment of PMS. In this study, it was determined their PMS was mild. The benefit received by women taking St. John’s Wort was achieved during the first menstrual cycle in which it was taken. While St. John’s Wort did not prove to be statistically better than placebo for mood and pain-related PMS symptoms, the pain symptoms did appear to improve more than placebo towards the end of each treatment period, implying that there may be more pain benefits with St. John’s wort after a longer duration of treatment. Several other studies have shown benefit with St. John’s wort.

Reference: Canning S, Waterman M, Orsi N, et al. The efficacy of Hypericum perforatum (ST John’s Wort) for the treatment of premenstrual syndrome. CNS Drugs 2010; 24(3):207-225.

This study was a double blind clinical trial in 150 women in Iran. Two groups of 75 women each were evaluated for severity and duration of breast pain which was measured according to a breast pain chart and something called a Visual Analog Scale.

Chewable tablets of either vitamin E 200 mg tablets or a placebo were given twice a day for 4 months, and again, the severity and duration of breast pain was evaluated at the end of the second and fourth month. The results at two months for vitamin E were dramatically better than placebo in severity and duration, and appear to be achievable in about 70% of the women. The improvement was seen as soon as two months, and no continued improvement after 4 months.

Commentary: Other studies have been conducted in vitamin E and breast pain. In 1997, Khanna et al compared vitamin E with a drug called Danazol. Vitamin E reduced pain in 41% of the women in the studies and Danazol had similar pain reduction in 72% of the women. Clearly the drug helped more women, but the side effects of that drug are significant and one third of the women developed other side effects. Meyer et al did a study in 1990 but did not show any benefit from Vitamin E. Ernester in 1985 studied 201 women with mastalgia as it relates to fibrocystic breast disease. He concluded that vitamin E was not effective, but he was not evaluating breast pain as a distinct issue. In 2004, Bespalov et al studied 66 women with a combination of beta-carotene, vitamin E, vitamin C and garlic powder. There was a reduction in the severity of mastalgia, premenstrual syndrome, infrequent menses and menstrual cramping as well as a reduction in symptoms of fibromatosis in 75% of the women compared with 45% of women on placebo.

If vitamin E alone is not sufficiently helpful in reducing mastalgia, evening primrose or borage oil should be considered, as well as carotenoids, iodine, eliminating caffeine, lowering saturated fats in the diet and increasing fiber.

References

Parsay S, Olfati F, Nahidi S. Therapeutic effects of vitamin E on cyclic mastalgia. The Breast Journal 2009;15(5):510-514.

The daily dose of herbal products given were 3 tablets containing 5400 mg of St. John’s wort standardized to contain 990 mcg hypericin, 9 mg hyperforin and 18 mg flavonoid glycosides. The daily dose of chaste tree berry was one tablet of an extract equivalent to 1000 mg of dry fruit. This was not a standardized extract. There was a matching placebo group. Participants recorded the severity of their PMS symptoms using the Abraham’s Menstrual Symptom Questionnaire.

The active treatment group was statistically superior to placebo for total PMS-like symptoms as well as subgroups of PMS depression and PMS food cravings.

Commentary: Based on previous research in PMS and chaste tree berry and PMS and St. John’s wort, as well as my clinical experience, it is not surprising that a combination of the two plants would be effective. PMS symptoms are common in regularly menstruating women, and it is also a common phenomenon in peri-menopausal women whose cycle and hormonal regularity is beginning to change. While this study evaluated a small group of women, it does address a significant population of women— those who are peri-menopausal and newly or still, experiencing PMS symptoms.

Reference:

Van Die M, Bone K, Burger H, et al. Effects of a combination of Hypericum perforatum and Vitex agnus-castus on PMS-like symptoms in late-perimenopausal women: Findings from a subpopulation analysis. J Alternative and Complementary Medicine 2009;15(9):1045-1048.

Peer-reviewed research studies were located in various data-bases searching for studies investigating vitamin D and depression, seasonal affective disorder, PMS, postpartum depression, perinatal depression, depressive disorder or mood disorder in women. Eleven studies were initially identified, but five were eliminated because they did not meet the inclusion criteria. Of these six studies, four reported significant results showing an association between low serum 25 (OH) D levels and symptoms of a mood disorder, SAD, major depressive disorder, or PMS. One study of major depression and one on SAD did not report an association. Only one of the four positive studies was a randomized controlled trial.

Vitamin D receptors are involved in the regulation of glucocorticoid signaling and dysfunctional glucocorticoid signaling and increased glucocorticoids have been implicated in major depressive disorder. Other biochemical mechanisms may also exist, associating vitamin D with mood disorders.

I look forward to more research on specific mood disorders in women and vitamin D levels.

References:

Murphy P, Wagner C. Vitamin D and mood disorders among women: an integrative review. J Midwifery Women’s Health 2008;53:440-446.

After the treatment period, there was a significant decrease in the overall severity of symptoms and physical and psychological symptoms in both the Ginkgo group (23.68%) and the placebo group (8.74%). The average decrease in the severity of symptoms was significantly more in the Ginkgo group compared to the placebo group.

Comments: The results of this study demonstrated that ginkgo was more effective than placebo in reducing the severity of symptoms and the severity of physical and psychological symptoms in young women in Iran, with PMS. A previous study also found benefits with ginkgo and PMS, especially with breast tenderness and fluid retention. They also saw significant improvements in irritability and aggression, compared with placebo. The current study confirms the benefits of a standardized extract of ginkgo for the treatment of PMS. Based on the published -research to date, standardized extracts of – Vitex agnus castus (chaste tree berry), Hypericum perforatum (St. Johns wort) and Ginkgo biloba (ginkgo), appear to be the most effective botanical treatments for PMS. I would encourage women and their practitioners to seek PMS formulas that have at minimum, these three botanicals in the formulation.

References

Ozgoli G, Selselei E, Mojab F, Majd H. A randomized, placebo-controlled trial of ginkgo biloba in the treatment of premenstrual syndrome.

The mean total Premenstrual Syndrome Diary (PMSD) score decreased from 29.23 at baseline to 6.41 at the end of the third cycle for the Vitex group and from 28.14 at baseline to 12.64 at the end of the third cycle for the placebo group. The difference in the PMSD score from baseline to the third cycle was significantly lower in the treatment group than in the placebo group. The Premenstrual Tension Syndrome Self-Rating Scale (PMTS) decreased from 26.17 at baseline to 9.92 for the treatment group and from 27.10 to 14.59 for the placebo group; similar positive results to the PMSD scores.

Comments: I’ve long used Vitex for the treatment of PMS and in my opinion, it is the single most important plant for the treatment of PMS. The effect of Vitex is on the hypothalamus-hypophysis axis and results in an increased secretion of luteinizing hormone which then favors a progesterone effect. Several other placebo controlled studies have found that Vitex reduced a variety of PMS symptoms. The current study adds to the clinical relevance of this plant in the treatment of moderate to severe symptoms of PMS.

References

He Z, Chen R, Zhou Y, et al. Treatment for premenstrual syndrome with Vitex agnus castus: A prospective, randomized, multi-center placebo controlled study in China. Maturitas 2009; 63:99-103

At the end of treatment, the severity of dysmenorrhea decreased in all groups and no differences were found between the groups in pain severity, pain relief or satisfaction. More women in the ginger group became completely pain free, vs. the mefenamic acid and ibuprofen groups. The rate of satisfaction from the treatments was 20/50 women in the mefenamic acid group, 22/50 women in the ibuprofen group and 21/50 women in the ginger group.

The cause of menstrual cramps is thought to be due to an increased production of prostaglandins in the endometrium (lining of the uterus). Menstrual blood of women with primary dysmenorrhea has greater amounts of the prospasmodic and proinflammatory prostaglandins, PGE2 and PGF2 alpha. Both mefenamic acid and ibuprofen act as inhibitors of the synthesis of these prostaglandins. It is thought that the anti-inflammatory properties of ginger are due to the gingerols, also leading to and prostaglandin reduction as well as some inflammatory substances. Consider using ginger root either alone, or in combination with other important natural ingredients in the relief of menstrual cramps such as cramp bark, niacin, vitamin B6, valerian, wild yam and more.

References

Ozgoli G, Goli M, Moattar F.  Comparison of effects of ginger, mefenamic acid, and ibuprofen on pain in women with primary dysmenorrhea.  J Alternative and Complementary Med 2009; 15(2):129-132.

According the Hamilton Depression Rating Scale, 15 of 25 women in the saffron group responded to treatment vs only 1 of 25 in the placebo group. (P< 0.0001). Again, a significant difference was seen between cycles 3 and 4 with a statistically significant difference by the study end (P< 0.0001).

Crocus sativus L. (saffron) in the treatment of premenstrual syndrome: a double-blind, randomised and placebo-controlled trial. Agha-Hosseini M, Kashani L, Aleyaseen A, et al. BJOG 2008;115:515-519.

Commentary: Improvements in the Total Premenstrual Daily Symptoms and the Hamilton Depression Rating Scale with saffron should give us definite motivation to try this simple treatment. Saffron has been previously shown to have an antidepressant effect in women with mild to moderate depression, through a serotonergic mechanism, so it’s not surprising that it would work in PMS. Research on PMS in the last several years has pointed strongly to the etiology being the dysregulation of the serotonergic system. This is why we have seen conventional medical practitioners focus on the use of SSRIs in treatment.

This is the first clinical trial I’ve seen in the use of saffron for the treatment of PMS. While only a small study and short follow-up, the positive results warrant further study, and in the meantime, accumulating some clinical experience.

Pregnancy is demanding in it’s own unique way: hormonal changes, increased nutritional demands, changes in sleep and eating patterns. Regular exercise, good healthy eating habits, a prenatal supplement, regular sleep, and moderating one’s work load, are usually enough to maintain energy throughout the pregnancy. Some women may become anemic during pregnancy and simple tests can detect this followed by simple nutrients as supplementation. At times, other health problems emerge during the pregnancy that can cause fatigue such as hypothyroid and diabetes. With good prenatal care, these can be detected and treated appropriately.

The cycles or phases of hormonal change such as the monthly premenstrual time, and the perimenopause transition can challenge what is called our stress adaptation mechanisms. There are three phases to this stress response which are regulated in large part, by our adrenal glands. The initial phase is the alarm reaction, or fight-or-flight response. This is triggered by reactions in the brain that cause the pituitary gland to produce a hormone, which causes the adrenals to secrete adrenaline as well as other stress related hormones. The alarm phase is usually very short lived. The next phase is the resistance reaction, which allows us to continue to deal with stress, after the fight-or-flight response has worn off. Hormones such as cortisol and other corticosteroids secreted by the adrenal cortex are in motion here and responsible for the resistance reaction. These hormones stimulate the conversion of protein to energy so that we have adequate fuel, after our glucose reservoirs have been used. The resistance reaction provides the energy and stabilizes our circulation under times of stress, as well as enabling us to deal with the emotional aspects of stress, fight infections and continue to perform our tasks. If the stress insult is prolonged and the resistance reaction is extended beyond our body’s capabilities to maintain balance, we become at risk for significant health care problems and end up in the final stage of general adaptation syndrome— exhaustion. In the exhaustion phase, our adrenal glands
have become depleted of hormones called glucocorticoids, and our body has a loss of potassium. In this phase, the body’s cells and tissues do not receive enough glucose or other nutrients to function properly.

As the exhaustion phase continues, our cells and organs in general feel the tremendous demand, and our metabolism is extremely challenged. Now we enter what we might call cellular fatigue and literally, our cells don’t get enough fuel to drive their function. This stress to our system takes a toll and nutritional status declines and disease status increases.

Premenstrual syndrome and perimenopause are their own kind of stress on the system. During these times, many women find their threshold of tolerating stress decreases. The complicated interaction of our hormones and our brain chemistry challenges our stress adaptation mechanisms, and fatigue can result. These fluctuating levels, both decreases and increases, in hormones such as estrogen, progesterone, cortisol and thyroid, interact with brain neurotransmitters such as serotonin, dopamine, GABA, and others, that affect our emotional and physical responses to life, to stressors in our environment, to insults, and even to infections.

Different circumstances call for different approaches, and if persistent fatigue is something that plagues you, it is important to consult with a licensed health care practitioner to determine the cause. A good medical history, physical exam, and selected laboratory tests can determine if the cause is low thyroid, anemia, an infectious agent, low or high blood sugar, or a serious illness. Licensed alternative practitioners will also have tools and perspectives to consider food sensitivities, toxicities, neurotransmitter imbalances, hormonal status and something we call adrenal fatigue syndrome.

A condition alternative medicine often calls “adrenal fatigue”, is a unique contribution to understanding a sometimes elusive problem such as fatigue.

Adrenal gland function and its production of hormones are vital performance tasks in our response to stress and our larger responses in our general adaptation syndrome. Nutritional and herbal support for a person who displays symptoms of intense or prolonged stress, and/or a fatiguing of the ability to adapt to the stress, can play a critical role in supporting our adrenal glands to adapt. An abnormal adrenal response, whether it is deficient or excessive hormone release, can be in large part addressed with key nutrients such as pantothene, B6, zinc, magnesium and vitamin C. These nutrients play a critical role in the optimal function of the adrenal glad and in the manufacture of adrenal hormones. Levels of these nutrients can be diminished during times of stress. Urinary excretion of vitamin C is increased during stress. Pantothene is also important during times of high stress or in individuals with adrenal fatigue. A deficiency of pantothenic acid results in fatigue, headaches, insomnia and more. Notable botanicals can also support adrenal function and enhance resistance to stress such as Siberian and Panax ginseng. These ginsengs are referred to as general tonics or adaptogens. Both Chinese and Siberian ginseng can be used to restore vitality in individuals who are chronically fatigued or who have decreased mental and physical performance and/or stamina. These ginseng species have been shown to act as tonics and anti-stress agents, enhancing the ability to cope with both physical and emotional stressors., , Individuals who take ginseng often report an increase in vitality, well being, increased mood, competence at work, mental and physical performance and reduced feelings of stress and anxiety. Rhodiola is well known amongst the Eastern Europeans for its ability to enhance energy, stamina and endurance. rhodiola appears to increase the chemicals that provide energy to the muscle of the heart and to prevent the depletion of adrenal hormones induced by acute stress.

Ashwagandha is also a significant adaptogen providing adrenal and immune support, , for increasing resistance to environmental stressors and as a general tonic. Ashwagandha contains several important active constituents including withanolides. Its mechanisms of action include pain relief, antioxidant effects, reducing inflammation, stimulating thyroid function, as well as respiratory and immune function. Some researchers have claimed that ashwagandha as an antistressor effect. It appears that it may suppress stress induced increases in dopamine receptors in the brain.

Astragalus has been used historically for strengthening and regulating the immune system, as a tonic, antioxidant, anti-inflammatory, antibacterial antiviral and to protect the liver. A lengthy list for sure. Although there is insufficient evidence to support the effectiveness of all of these uses, there is preliminary research that it is positive in some areas. Astragalus extracts seem to be able to restore or improve immune function in immune deficient cases. It may be able to restore suppressed T-cell function in cancer patients.7 Abnormal liver enzyme tests have improved in people chronic hepatitis when taking Astragalus. Astragalus is also thought to increase cardiac output and may be beneficial in individuals with congestive heart failure and compromised blood flow to the heart muscle. 8

We’re all familiar with our favorite spaghetti sauce that contains basil, but we may not know that this same plant, also known as Holy basil is a rich source of vitamin C, calcium, magnesium, potassium and iron. Holy basil has been gaining some attention due to experimental studies in humans on blood glucose. Elevated glucose levels were lowered by 21 mg/dl and lowering glucose after a meal, was also a positive effect of the basil. Many individuals with adrenal dysfunction, have increased glucose levels due to the increased cortisol as a result of stress.

Shisandra is plant most familiar to those who use Chinese herbs. In traditional Chinese medicine, schisandra is used for many common problems, including physical fatigue. Schisandra is used for improving immune function, recovery after surgery, increasing physical performance and endurance, and for increasing resistance to disease and stress. Schisandra is also possibly effective for improving concentration. It is thought that the variety of lignans found in the fruit, are the active constituents in schisandra.

Maca, or Peruvian Ginseng, may be one of the most important plants having a diverse effect on the female reproductive system. Traditionally, it has been used for chronic fatigue syndrome, enhancing energy, stamina and overall energy. In the female reproductive system, its use for enhancing fertility, regulating the menstrual cycle, treating common menopause symptoms and to increase libido has been familiar to the traditional peoples of Peru and elsewhere, for many a generation. Studies soon to be published, will be able to document some of its specific effects for menopausal women.

This type of herbal/nutritional support is especially helpful for those who have been determined to have adrenal fatigue. Symptoms such as fatigue, low vitality, low libido, depression, anxiety, poor memory, low stamina, and difficulty handling the premenstrual phase and the perimenopausal transition are key indications of adrenal fatigue.

Some women who have premenstrual fatigue or perimenopausal fatigue, may need additional hormonal support as well. This may include actually using hormones as medicines, but also may involve improving the metabolisim of our hormones. These considerations can best be addressed utilizing a comprehensive approach with a licensed naturopathic physician who has both the alternative medicine perspective, as well as the ability to prescribe various hormones such as progesterone, estrogen, testosterone, cortisol and thyroid.

The best approach to fatigue is to find out the cause. Don’t just ignore your fatigue and “gut it out” and don’t make assumptions about the cause of your fatigue. With good health care team approach utilizing your insights, your reading and natural foods store resources, a naturopathic physician, and possibly medical doctor or other allied practitioners, you can be more assured of understanding the cause and therefore the best solutions.

ReferencesÂ

• Farnsworth N, et al. Siberian Ginseng: Current status as an adaptogen. Economic Medicinal Plant Research 1985;1: 156-215.
• Hikino H. Traditional remedies and modern assessment: The ase of Ginseng. In R.O.B. Wijeskera, ed. The Medicinal Plant Industry (Boca Raton, FL: CRC Press, 1991), 149-166.
• Shibata S, et al. Chemistry and Pharmacology of Panax. Econ Med Plant Research 1985;1:217-284.
• Hallstrom C, Fulder S, Carruthers. Effect of Ginseng on the performance of nurses on night duty. Comp Med East and West 1982;6:277-282.
• Maslova L, Kondrat’ev B, Maslov L, Lishmanov I. The cardioprotective and antiadrenergic activity of an extract of Rhodiola rosea in stress. Eksp Klin Farmakol 1994;57:61-63. (Article in Russian).
• Upton R, ed. Ashwagandha root (Withania somnifera): Analytical, quality control, and therapeutic monograph. American Herbal Pharmacopoeia 2000;April: 1-25.
• Sun Y, Hersh E, Talpaz M, et al. Immune restoration and/or augmentation of local graft versus host reaction by traditional Chinese medicinal herbs. Cancer 1983;52(1): 70-3.
• Upton R, Ed. Astragalus Root: analytical, quality control, and therapeutic monograph. Santa Cruz, CA: Am Herbal pharmacopoeia; 1999; 1-25.
• Agrawal P, Rai V, Singh R. Randomized placebo-controlled, single blind trial of holy basil leaves in patients with noninsulin-dependent diabetes mellitus. Int J Clin Pharmacol Ther. 1996;34(9): 406-409.
• Upton R, ed. Schisandra Berry: Analytical, Quality and Control, and Therapeutic Monograph. Santa Cruz, CA: American Herbal Pharmacopoeia 1999; 1-25.