Premenstrual Syndrome

Premenstrual syndrome (PMS) refers to the different kinds of symptoms experienced by some women during the luteal and menstrual phase of the estrus cycle. It affects upwards of 75% of all women of menstruating age in varying degrees. The most common physical symptoms of PMS are abdominal distension, breast swelling and tenderness, headaches, changes in appetite, food cravings, fatigue, dizziness, weight gain, fluid retention, joint pain, pelvic congestion, poor immunity, constipation or diarrhea, herpes outbreak, and acne. Psychological symptoms might include insomnia, poor memory, grief, irritability, anger, anxiety, poor concentration, and confusion. Such symptoms, when recognized by the physicians of the middle ages, gave rise to all kinds of interesting ideas, such as the concept of a “wondering womb” that searched the body looking for a baby, and in its journey caused the myriad symptoms that we now define as PMS. The modern medical approach to this condition is little better however, and the prevailing notion is that PMS is nothing but a kind of female nervous tension best treated by sedation. (Trickey 1998 35-37; Berkow 1992, 1791)

Although the causes of PMS are varied, in her book Women, Hormones and the Menstrual Cycle, author Ruth Trickey illustrates some common themes, all of which are related to neuroendocrine control:

  • Estrogen- Elevated levels of estrogen relative to progesterone 5 – 10 days prior menses is thought to cause feelings of irritability and aggression by elevating norepinepherine in the brain.
  • Progesterone– A relative deficiency of progesterone 5 – 10 days prior menstruation allows for the elevation of aldosterone, enhancing sodium retention and the resulting edema. The progesterogenic effects of the luteal phase are also inhibited by elevated norepinepherine from emotional stress and elevated estrogen.
  • Aldosterone- Aldosterone is a cause of premenstrual fluid retention, and is enhanced with stress, low progesterone, high estrogen, and a deficiency of magnesium.
  • Prolactin– Women with PMS are thought to have an excessive sensitivity to, or mildly elevated levels of, prolactin. Prolactin is normally secreted in high levels during lactation, and prolactin is implicated in the increased breast sensitivity and swelling of some forms of PMS.
  • Endorphins- Endorphins are natural opiates that elevate mood, and when decreased, can give rise to symptoms of depression. Additionally, endorphins appear to regulate the secretion of the gonadotropins.
  • Dopamine- Dopamine in a prolactin antagonist, and is decreased under the influence of estrogen and a deficiency of magnesium and vitamin B6. Dopamine also appears to regulate mood, and a deficiency is implicated in anxiety, irritability, and emotional lability.
  • Eicosanoids– Eicosanoids are locally acting hormones cleaved from the fatty acids that make up the cell membrane. Eicosanoids are of many different types, including prostaglandins, thromboxanes, and leukotrienes. Depending on the fatty acid and the activity of biosynthetic pathways, eicosanoids can have a wide range of activity, and can exert significant effects uponthe menstrual cycle. (Trickey 1998, 109-118)

A deficiency of vitamin B6 is often implicated in PMS, and treatment with this nutrient may provide relief from depression and anxiety, although because high doses are neurotoxic supplement with no more than 200-300 mg daily, with a vitamin Bc complex. The breast swelling and tenderness associated with elevated prolactin levels may be relieved by supplementation of vitamin B6 through the enhanced synthesis of dopamine. Vitamin B6 is also a cofactor in the production of the series 1 prostaglandins (a type of eicosanoid) and can normalize cellular magnesium levels. Magnesium too is a factor in dopamine synthesis, and a deficiency can lead to depression, anxiety, and cyclic breast pain. Other factors in PMS include the overgrowth of Candida albicans or other fungal pathogens that lead to problems such as vaginitis, linked to a relative estrogen excess.(Trickey 1998, 109-118)

There are five different subcategories of PMS, first devised by G.E. Abraham, and each of these subtypes have a unique set of symptoms and metabolic abnormalities associated with them. The following chart describes these subtypes and the mechanisms that could cause them. It is important to note that a woman with PMS may experience more than one subtype.

PMS Subgroup Symptoms Mechanisms
  • anxiety
  • nervousness
  • mood swings
  • nervous tension
  • estrogen excess
  • progesterone deficiency
  • liver congestion
  • craving for sweets
  • increased appetite
  • palpitations
  • fatigue
  • dizziness
  • headaches
  • hypoglycemia
  • Mg deficiency
  • eicosanoid imbalance
  • often occurs in association with PMC A
  • breast tenderness
  • bloating
  • weight gain
  • edema
  • elevated aldosterone
  • estrogen excess
  • progesterone deficiency
  • elevated prolactin
  • depression
  • poor memory
  • grief
  • confusion
  • insomnia
  • estrogen deficiency
  • lower back pain
  • abdominal pain
  • joint pain
  • headaches
  • estrogen excess
  • eicosanoid imbalance

(Trickey 1998, 118-121)

Treatment of PMS A

The primary treatment of PMS A is to enhance progesterone levels, and the most frequent recommendations typically include Chasteberry (Vitex agnus castus), 40 gtt. of a 1:3 extract taken every morning for at least 6 months. It is important to note, however, that Vitex is traditionally considered to be a drying herb, traditionally used to inhibit sexuality (hence it’s name “chaste” berry). Thus while Vitex may have a specific effect to boost LH secretion, it should be combined with “yin-restorative” herbs such as Peony (Paeonia lactiflora) to support the uterus and its secretory functions. In traditional Chinese medicine, such herbs are often used to prepare a medicinal soup to support fertility, including Peony, as well as other yin/blood-restorative botanicals including Shu Di Huang (Rehmannia glutinosa), Xi Yang Shen (Panax quinquefolium), Tien Men Dong (Asparagus cochinchinensis), and Dang gui (Angelica sinensis). In addition to supporting hormone production, botanicals that reduce anxiety and pain, as well as promote a feeling of well-being are an important aspect of treatment, and include relaxing nervines such as Valerian (Valeriana officinalis), Skullcap (Scutellaria lateriflora), Passionflower (Passiflora incarnata), Vervain (Verbena officinalis), and anodynes such as Kava (Piper methysticum) and Pasqueflower (Anenome occidentalis). Adaptogens are particularly indicated in anxiety with exhaustion, including Ashvagandha (Withania somnifera) and Siberian Ginseng (Eleuthrococcus senticosus). Hepatics can be useful to enhance the excretion of conjugated estrogens, and include Buplerum (Buplerum chinensis), Barberry (Berberis vulgaris), and Dandelion root (Taraxacum officinalis). Phytoestrogenic herbs that compete with estrogen-binding are useful, such as Red Clover (Trifolium pratense), as well as phytoestrogen-containing foods such as fermented and sprouted legumes. Fiber intake should be enhanced, and greasy fatty foods and refined carbohydrate intake should be curtailed. In particularly recalcitrant cases, natural progesterone creams can be used to enhance serum progesterone levels, 1/4 tsp (equal to 20 mg natural progesterone) applied over the extremities once daily before bedtime. Vitamin B6, at a dose between 100-600 mg daily, taken with 50-100 mg of a full spectrum B-complex, is best used 10-14 days prior menses. Magnesium is an important supplement as well, taken at a dosage between 200-800 mg throughout the cycle can be helpful.

Treatment of PMS C

The primary treatment of PMC C is to regulate blood sugar levels, best accomplished by enhancing protein and fat intake, especially in the morning, and decreasing refined carbohydrate intake throughout the day. Although, smaller, more frequent meals are typically recommended, ensuring the patient eats a proper breakfast, and avoids eating carbohydrate rich foods through the day will dramatically improve symptoms. In addition, the elimination of methylxanthine-containing beverages such as coffee and tea can help reduce anxiety, as they tend to promote labile blood sugar levels. Supplementation with magnesium is useful (800-1000 mg daily), as is chromium (250 mcg thrice daily with meals). To correct the eicosanoid imbalance that can accompany this condition, supplementing with cold water fish oil may be indicated, 1-2 grams EPA/DHA daily taken mid cycle until menstruation, or throughout the cycle on a daily basis. As much of the fish oil on the market is re-esterified, which is a concentrated, unnatural form of the oil, choose a triglyceride oil, purchase it in small amounts, and use it up quickly as these oils become rancid very quickly. As a result, a better recommendation is to avoid all sources of seed oils and feed lot meat in the diet, and emphasize foods naturally rich in n3 fatty acids including pasture-fed meat, wild fish, sea vegetables, and leafy greens. Additionally, vitamin B6 (100 mg daily, taken with a B-complex), vitamin E (200-600 IU daily), and zinc citrate (50 mg daily) can facilitate the production of PGE1, the eicosanoid responsible for inhibiting inflammation.

Treatment of PMS H

The treatment of PMS H is essentially the same as it is for PMS A, with the addition of treatments to correct aldosterone levels and the sodium-potassium balance. To this end botanicals that are rich in potassium such as Dandelion leaf (Taraxacum officinalis), Catnip (Nepeta cataria), and Skullcap (Scutellaria lateriflora) are helpful when taken as an infusion, as are potassium-rich foods such as kelp, raisins, avocados, apricots, potato skins, cantaloupe, and broccoli. Although the treatment for PMS-H is similar to that of PMS A, the use of Licorice root (Glycyrrhiza glabra) is contraindicated because of its aldosterone-like activity, which may promote water retention.

Treatment of PMS D

As PMS D relates to a relative estrogen deficiency, therapies that enhance estrogen production or facilitate the cellular activities of estrogen are all helpful. From a herbalists perspective this includes botanicals such as Tien Men Dong (Asparagus cochinchinensis) and Dang gui (Angelica sinensis), as well as phytoestrogenic herbs such as Red Clover (Trifolium pratense), Wild Yam (Dioscorea villosa), False Unicorn root (Chamaelirium luteum), and True Unicorn root (Aletris farinosa).  It appears that lead, found in some fuels, paints, and other household products can accumulate in the body and interfere with the activity of estrogen receptors, and thus agents that decrease lead absorption and retention such as magnesium, iron, copper, and zinc may be indicated, as well as herbs to support liver function such as Dandelion root (Taraxacum officinalis) and Chai Hu root (Bupleurum chinense). A diet high in fibre can promote the excessive excretion of estrogen, and thus fibre intake should be monitored. And, just as for PMS A, botanicals that reduce anxiety and pain, as well as promote a feeling of well-being are an important aspect of treatment. For severe pain, follow the recommendations under PMS P. Serotinergic foods such as those high in tryptophan (e.g. turkey and hard cheeses) can also be taken to mildly boost serotonin levels, or with severe depression, the biological precursor to serotonin, 5-HTP (100-300 mg daily).

Treatment of PMS P

PMS P relates to an increased sensitivity to pain, perceived to be an imbalance of the proinflammatory and pain-promoting eicosanoids, facilitated by elevated estrogen and poor estrogen clearance. Supplements that help reduce pain and pain sensitivity include magnesium, vitamin B6, zinc and omega 3 fats rich in EPA/DHA are all here, following the dosage ranges described under PMS C. The additional usage of herbs that have a phytoestrogenic property are helpful, as is increasing dietary fiber. Herbs that inhibit the inflammatory cascade include hepatics such as Feverfew (Tanacetum parthenium), Turmeric (Curcuma longa), Devil’s Claw (Harpagophytum procumbens), and Baical Skullcap (Scutellaria baicalensis). Astringent botanicals help to tone the uterus and promote regular contractions, including Red Raspberry (Rubus idaues), Lady’s Mantle (Alchemilla) and Bethroot (Trillium erectum). Botanicals that have potent analgesic and anodyne properties used for pain and cramping include re Crampbark (Viburnum opulus), Black Haw (Viburnum prunifolium), Kava (Piper methysticum), Wild Lettuce root (Lactuca virosa), Jamaican Dogwood (Piscidia erythrina), White Willow bark (Salix alba), California Poppy (Eschscholzia californica), and Pasqueflower (Anenome occidentalis).