Definition
Premenstrual Syndrome (PMS) is a recurring condition consisting of one or more troublesome symptoms that occur 7 to 14 before the onset of menstruation. Typical symptoms of PMS would include any combination of the following:
Nervousness, anxiety, irritability, mood swings, depression.
Fatigue.
Abdominal bloating, change in bowel function, cravings.
Tender, swollen breasts, uterine cramping.
Headache, backache, acne, swelling.
In order to be classified as PMS, the symptoms must begin 1 to 2 weeks prior to menstruation, and resolve at or shortly after the beginning of menstruation.
ETIOLOGY:
A variety of hormonal changes have been identified in patients with PMS, particularly an increase in the ratio of estrogen to progesterone. Abnormalities of thyroid function and in the production of prolactin, a milk producing hormone, have been identified. Many patients with PMS show a deficiency of Vitamin B6. But, a single, easily explained cause has yet to be found, making it difficult to arrive at a treatment suitable for most patients.
Diagnosis
The diagnosis is made on the basis of a history, and it is made more reliable by keeping a symptom diary, noting the severity and timing of the symptoms in relation to a period. A PMS questionnaire exists to further aid in the diagnosis.
DIAGNOSTIC STUDIES:
When the diagnosis is not certain, diagnostic studies can be done to assist in the diagnosis, or to rule out other conditions. These can be blood tests, typically done on the 21st day after a period, or they can be salivary tests, which are typically done on day 28. A full evaluation to work-up PMS would consist of:
A complete blood count (CBC).
Chemistry profile (electrolytes, liver function, kidney function, lipids).
Thyroid evaluation.
Serum prolactin, progesterone, and estrogen.
Serum FSH and LH to evaluate pituitary and ovulatory function.
TREATMENT OF PMS
There is no single treatment for PMS that is effective for all patients. Due to the complex and varied array of symptoms found in different patients, treatment is individualized. As well, we believe that effective treatment should be comprehensive, holistic, and balanced, and should involve several different areas. General treatment recommendations can be given as follows:
"TRADITIONAL" MEDICAL TREATMENT:
A number of medical treatments are given for PMS. For patients with depression and anxiety as strong components of their PMS, anti-depressants such as Prozac and Zoloft are prescribed, and these have recently been approved by the FDA for use in treating PMS. Diuretics are prescribed for patients with significant fluid retention, bloating and edema. A number of hormonal therapies have been used for PMS, such as suppression of ovulation with oral contraceptives, as well as progesterone supplementation, but the research on the effectiveness of these treatments show mixed results.
DIETARY RECOMMENDATIONS:
It is our opinion that dietary changes are critical if improvement in symptoms is expected. These dietary changes also produce an added benefit by lowering the risk of breast cancer and heart disease. The dietary recommendations are summarized as follows:
Follow a predominantly vegetarian diet.
Reduce the intake of fat.
Reduce or eliminate the intake of sugar.
Increase the intake of soy.
Eliminate the intake of caffeine.
Reduce the intake of Sodium (salt).
Avoid exposure to environmental estrogens.
VEGETARIAN DIET:
This recommendation is based on the finding that patients who follow a near vegetarian diet, with increased amounts of fruits, vegetables, and legumes, and minimal ingestion of animal fat, have increased elimination of estrogen from the body, thereby reducing the estrogen/progesterone ratio. Studies have shown that when patients with PMS follow such a diet, an improvement in symptoms is seen.
Guidelines for such a diet would include limiting consumption of animal protein to 4 to 6 ounces per day, with most of that coming from fish, poultry, and lean meats. It is also advised to increase fiber intake to 40 grams per day, to help further the elimination of estrogen from the body.
The goals of this dietary advice can essentially be met by following the guidelines set forth by the USDA in their Food Pyramid.
REDUCED FAT INTAKE:
The best advice is to eliminate all intake of fat from animal sources. Short of that, fat intake should be limited, as above to 4 to 6 ounces a day of animal protein, and the calories from fat intake should account for no more than 25% of total calories. Saturated fat intake should be minimized in favor of polyunsaturated fat. Butter is to be discouraged in favor of Canola oil or olive oil. The advice on fat consumption also comes from the finding of greater elimination of estrogen from the body and an improved estrogen/progesterone ratio.
REDUCED SUGAR INTAKE:
The best advice is no consumption of refined sugars such as you would find in prepared sweets: candy, cookies, doughnuts, cakes etc., and which are also found in beverages and other prepared foods. Refined sugars will be listed on labels as: glucose, sucrose, maltose, lactose, fructose and corn syrup. Carbohydrates are allowed but should be complex rather than simple or refined.
The most symptom-producing food in PMS seems to be chocolate.
INCREASED CONSUMPTION OF SOY:
This recommendation comes from the known estrogenic action of the phytoestrogens contained in soy. These phytoestrogens bind to estrogen receptors in the body, and prevent natural estrogens from binding to these receptors. However, phytoestrogens produce only about two percent of the estrogenic effect of natural estrogens, thereby reducing the estrogen/progesterone ratio. Increasing the intake of soy can be difficult, but prepared soy products are commercially available, as are recipes and cooking tips on preparing meals with soy.
ELIMINATION OF CAFFEINE INTAKE:
This recommendation is easier to accomplish, by eliminating consumption of products containing caffeine, such as coffee, chocolate, colas, etc. Continued use of caffeine by patients with PMS has been linked to the severity of their psychological symptoms of anxiety, irritability, mood swings, and depression, as well as breast tenderness.
REDUCED SODIUM INTAKE:
This is especially helpful for patients troubled with bloating, breast tenderness, and swelling. Sodium restriction involves more than not adding salt to your food. It requires attention to the sodium content of the food itself, and involves reading labels and limiting sodium intake to 1800 mg per day, which of necessity puts a limit on the use of most prepared and processed foods. At the same time, an increase is recommended in the intake of potassium containing foods, such as fresh fruits, vegetables, and whole grains.
AVOID EXPOSURE TO ENVIRONMENTAL ESTROGENS:
There are a number of chemicals used as pesticides and herbicides that mimic the effects of estrogen in the body, thereby increasing the estrogen to progesterone ratio. Patients with PMS may benefit by avoiding the ingestion of these chemicals. This is best accomplished by purchasing organically grown foods.
VITAMIN AND MINERAL SUPPLEMENTATION:
VITAMIN B6:
Supplementation with Vitamin B6 has been shown to be of benefit to most patients with PMS, especially those with psychological symptoms. The recommended dose for supplementation is 50-100 mg per day. Higher doses over long periods of time can produce neurological toxicity (resulting in tingling, numbness, loss of muscle coordination.)
MAGNESIUM:
Magnesium plays a crucial role in cellular metabolism, and deficiencies can produce a wide array of symptoms. Magnesium supplementation has been shown to be beneficial in patients with PMS. The recommended dose is 12 mg per kg of body wt (1 kg = 2.2lbs.), which would range from approximately 600-1000 mg per day, depending on weight.
CALCIUM:
Calcium supplementation has been found to improve the mood, behavior, concentration, and fluid retention in patients with PMS. The recommended dose is 1000 mg per day, which is the same amount advised to premenopausal women for osteoporosis prevention.
ZINC:
Women with PMS have been shown to have lower levels of zinc compared to controls. Supplementation is especially helpful for reducing breast tenderness and breast engorgement. The recommended dose is 15-20 mg per day.
VITAMIN E:
Supplementation with Vitamin E, an anti-oxidant, has been shown improve the symptoms of breast tenderness, irritability, headache, fatigue, depression, and insomnia in patients with PMS. The recommended dose is 400 IU per day.
A practical way of providing the vitamins and minerals mentioned above would be:
A Multi-Vitamin Supplement with minerals daily.
A Calcium Supplement of 1000-1500 mg per day.
Vitamin B6 as above, if troubled by symptoms of mood disturbance.
Vitamin E supplementation as above as an anti-oxidant.
ESSENTIAL FATTY ACID SUPPLEMENTATION:
These compounds are referred to as essential because they are required for the production of prostaglandins, which are involved in the regulation of many many processes and bodily functions. They are also involved as precursors in the production of a number of hormones, and they serve as building blocks in the production of cell walls. A deficiency of essential fatty acids can produce a myriad of symptoms such as those in PMS. There are several sources of essential fatty acids available as supplements, to include borrage oil, flaxseed oil, evening primrose oil, and fish oil. We believe the best supplement for essential fatty acids in treating the symptoms of PMS is fish oil. Clinical trials involving evening primrose oil for the treatment of PMS show it t o be no more effective than placebo. Dietary sources of EFA's, cold water fish, should also be addressed.
PROPER GASTROINTESTINAL FLORA:
The bacteria in our intestines are involved in the process whereby a variety of substances including estrogen are either eliminated from or recycled back into our bodies. If the intestinal flora is not balanced, an excess of estrogen can occur, worsening the symptoms of PMS. Proper intestinal flora can be encouraged by supplementation with Lactobacillus Acidophilus daily. Dosages are given on the label of the Lactobacillus supplement.
DETOXIFICATION:
Before estrogen is excreted into the intestinal tract, it must first be metabolized by the liver. As such, proper liver function is requires for the elimination of estrogen from the body. A detoxification program should be considered in patients with PMS especially those who have not responded to other methods. Please see our handout on detoxification for guidance.
There are available nutritional supplements and botanical preparations that can support the liver in its role of detoxification and elimination of estrogen. An adequate supply of anti-oxidants is essential for this function. As well, a variety of what are known as "lipotropic agents" are also involved in this process. These are substances such as methionine, betaine, and choline, and are available individually or combined into a liver support/dteox formula. Milk thistle is an herbal remedy which, likewise, supports liver function and the detoxification process. Milk thistle is the flavonoid extract from plant Ssylibum marianum. The daily dose of milk thistle is 70 mg three times a day.
HERBAL THERAPY:
The scientific evidence supporting the use of herbal therapy for PMS is less strong than for the dietary or supplementation advice. However, the herbal therapies used carry with them the support of thousands of years of successful use in Traditional Chinese Medicine. As well, there is an understanding of their mechanisms of action, which would lend theoretical support for their use. The mechanisms of action are believed to be from phytoestrogens contained in the herbs, acting in a way similar to those in soy. The herbs currently used for the treatment of PMS are as follows:
ANGELICA, OR DONG QUAI:
The mechanism of action of Dong Quai is felt to be through its phytoestrogenic activity. In addition to PMS, Dong Quai has also been successfully used to treat dysmenorrhea (painful menstrual cramps). Treatment is started on the 14th day after the onset of menstruation, and can be taken as follows:
Powdered root or as tea- 1-2 gm per day.
Tincture- (1:5)-1 tsp. per day, or as a fluid extract, 1/4th tsp. per day.
LICORICE ROOT:
The mechanism of action of licorice root is by inhibiting an enzyme involved in the metabolism of progesterone, thereby increasing the estrogen/progesterone ratio. It also blocks the binding of the hormone aldosterone, which regulates sodium excretion and fluid balance and retention. As such, licorice root is especially helpful in patients with significant fluid retention and edema. Treatment is started on the 14th day following menstruation, and can be given as follows.
Powdered root or tea-1-2 gm per day.
Fluid extract- (1:1)- 1 tsp. per day.
Solid extract- (4:1)- 250-500 mg per day.
Because of the effect on sodium metabolism, licorice root is not to be used by patients with hypertension, renal failure, or who are taking digitalis preparations.
BLACK COHOSH:
Black Cohosh has been studied in Europe and found to be effective in treating the PMS symptoms of depression, anxiety, and mood swings. The active ingredient is 27-deoxyacteine, available commercially as "Remifemin." The dosage is in the form of an extract containing 4 mg of 27-deoxyacteine twice a day.
CHASTEBERRY:
This is the most popular herbal approach to treating PMS, with improvement in symptoms noted in several European studies. The mechanism of action is felt to be through regulation of pituitary function that controls ovulation and, therefore, estrogen and progesterone. The pituitary also regulates production of prolactin, a milk-producing hormone, and this herb is especially helpful in treating breast tenderness. The dosage is as follows:
GINKGO BILOBA:
Ginkgo has been shown to be helpful for patients experiencing breast tenderness and fluid retention. Treatment is started the 15th or 16th day after the onset of a period and continued until the 5th day of the next. The dose is 80 mg twice a day.
LIFESTYLE CHANGES AND SELF-HELP:
EXERCISE:
The benefits of exercise in improving the symptoms of PMS are without question, most notably in improving mood swings, irritability, and depression. Exercise increases the brains' production of endorphins, our "natural opiate." Likewise, research has shown that women who exercise regularly do not have symptoms of PMS as often as do sedentary women.
REST AND RELAXATION:
Getting the right amount of sleep is important, as it is during sleep that our brains' neurotransmitters undergo changes that restore or maintain the balance responsible for normal mood, behavior, and coping with stress. Likewise, relaxation assists in achieving a balanced lifestyle, with time away from work and/or family for enjoyable activities, self-fulfillment, and personal growth.
STRESS MANAGEMENT:
The ability to handle stress is an important aspect of dealing with the symptoms of PMS. It has been shown that patients with PMS, as a group, show a higher degree of negative coping skills. The following characteristics are considered indicative of negative coping skills, considered negative as they do not support good health:
Overeating.
Too much TV.
Emotional outbursts.
Overspending.
Behaviors to excess, including work.
The reliance on chemicals: drugs, alcohol, and smoking.
Learning positive coping skills is an essential part of handling stress. A variety of paths can be taken to develop positive coping skills, including self-help literature, individual and group therapy, the development of a more balanced life-style, and the strengthening of a spiritual connection. A type of therapy known as cognitive-behavioral therapy is especially useful in this process.
The physicians and staff of Nature's Healthcare welcome the opportunity to become partners in your care, and to assist you in achieving your goal of improved health and wellness.
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