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Premenstrual Syndrome (PMS): Natural Treatment Options
Most women of reproductive age have experienced either physical or emotional symptoms of varying severity leading up to their period. Men across the globe are familiar with 'that time of the month' and how it can change their partner. Some women describe it as a 'flipping of a switch' by a certain day in their cycle. You see the comedies on tv portraying women binge eating and having mood swings - but is this normal? Do you have to put up with it?
What’s Normal:
A few, mild symptoms 1-2 days before a cycle. They shouldn’t cause distress or any impairment in daily functioning. They’re basically subtle signs to let you know that a period is coming. This is not considered PMS. It’s estimated that 75% of reproductive-aged women experience this.
PMS
To meet the clinical criteria for PMS outlined by the College of Obstetricians and Gynecologists, one must experience at least one symptom from each category below for 5 days prior to start of menstruation and is present for at least 3 months in a row. The symptom(s) have an impact on social interactions, and school or work performance.
Image: American Family Physician: 'Premenstrual Syndrome and Premenstrual Dysphoric Disorder'
Premenstrual Dysphoric Disorder (PMDD)
Consider this as PMS's evil older sister. To meet criteria for PMDD, one must experience at least 5 symptoms for 7 days leading up to period. It occurs in the majority of menstrual cycles. The symptoms are more ‘marked’ or intense. See chart below.
Image: American Family Physician: 'Premenstrual Syndrome and Premenstrual Dysphoric Disorder'
For both PMS and PMDD, symptoms must disappear after onset of menstruation. Typically, this happens within a few days after start of period.
How common is PMS?
There is quite the range of estimates in the literature. Anywhere from 12-40% of reproductive-aged women experience PMS, whereas PMDD is less common – affecting 1-5%.
What Causes PMS?
It’s multifactorial. There is no single underlying cause, but generally a combination of the following:
1. Hormonal Factors – Estrogen:progesterone ratios and sensitivity of hormone receptors to falling (or rising) levels of hormones at specific times in the cycle.
2. Neurotransmitter Factors – Relative levels of serotonin, dopamine, and GABA.
3. Body Weight – Likely linked to resulting inflammation affecting hormone signalling and higher levels of aromatase enzyme, which increase estrogen levels. Aromatase is found in fat cells.
4. Acute or Chronic Stress – Cortisol impact on sex hormones. Essentially, lowers progesterone - our calming, mellow hormone that can offset the effects of estrogen.
5. Nutrient Deficiencies – Vitamin D, magnesium, calcium, zinc, omega 3 fatty acids– all cofactors for hormonal production and metabolism.
6. Genetic Predisposition – Tends to relate to genes (enzymes) and their ability to effectively clear estrogen from the body or genes involved with oxidative stress.
7. Overall Systemic Inflammation – Interferes with hormone signalling.
8. Environmental – Pollution, endocrine disrupting chemicals, pesticides, etc. via their direct disruption on hormones, but also via generation of inflammation disrupting signalling.
Naturopathic Treatment
Here are a few effective strategies for addressing PMS. It’s a good starting point for PMDD, but more intensive treatment may be required. Never underestimate the power of lifestyle and dietary changes!
1. Reduce exposure to endocrine disrupting chemicals (EDCs)
Essentially, this refers to low-dose chemical ingredients found in our environment and personal products that negatively impact our endocrine function. They interfere with hormone production, binding, and signalling.
2. Dietary Changes
This affects hormonal health indirectly via various mechanisms:
a.) Microbiome Influence
The food we eat should support the health of our ‘good’ gut bacteria. However, these guys don’t do so well on convenient, processed, nutrient-devoid food (the standard American diet.) Our gut bacteria help eliminate hormone metabolites, notably estrogen, so it doesn’t re-enter circulation and continue to exert an effect on receptors.
b.) Fiber Content
Fiber makes our gut bacteria happy to support their function, but fiber also helps with stool bulking and elimination to rid body of hormone metabolites. This prevents the estrogen enterohepatic recirculation of metabolites discussed above.
c.) Vitamin, Mineral, and Micronutrient Content
These act as cofactors and are required for proper hormone production and elimination. Each time we eat, it’s an opportunity to consume all the basic nutritional building blocks our body needs to function. Unfortunately, with our busy/stressful modern lifestyle, wholesome meals sometimes take a hit.
3. Weight Loss
Higher body mass index is associated with higher risk of PMS.
4. Stress Reduction
Cortisol affects sex hormones. This is true for acute, short-term high stress as well as chronic daily stress
Cortisol can interfere with progesterone,
5. Nutritional Supplementation
Magnesium, Calcium, Vitamin D, Omega 3, Zinc, Vitamin B6, etc. etc. I won’t go into all of these, but here are some recent studies:
a.) Vitamin D & Calcium- A recent systematic review found that low levels of calcium and vitamin D in the blood during the luteal phase was associated with worsening symptoms of PMS.
b.) Vitamin B6 - Thought to influence synthesis of neurotransmitters related to PMS (serotonin and dopamine.) This specific B Vitamin has been very well studied and although some studies show mixed results, it tends to have a significant improvement on emotional symptoms of PMS, specifically, depression.
6. Chastetree/Vitex
In 10 randomized placebo controlled trials, 9 of them found that Vitex was superior to placebo in relieving PMS symptoms. Vitex was found to be comparable to oral contraceptive pills but with fewer side effects.
I like using a high potency tincture in practice or a standardized extract made by a reputable brand, like Mediherb.
Vitex is NOT a good idea if you have PCOS as it could worsen symptoms by influencing LH.
7. Exercise
Studies show that women who exercise regularly have fewer symptoms or less intense symptoms. Aerobic exercise tends to have a greater impact compared to strength training.
8. Progesterone
This isn't my initial go-to for PMS, but 20mg of transdermal (topical application) can be prescribed for stubborn symptoms for last 14 days of the menstrual cycle.
9. Acupuncture
There are some studies that assess efficacy of acupuncture for addressing PMS, however the study quality is usually deemed 'poor.' Acupuncture doesn't fit into RCT model too well - it's hard to have a control group who are blinded - they have a pretty good idea if they're getting treatment or not.
Regardless, acupuncture is routinely performed in the Eastern part of the world for regulating endocrine function and improving symptoms of PMS. I find it to be a valuable adjunctive when paired with several of the treatment options listed above.
Uncertain if you meet the criteria for PMS or PMDD? Start tracking! Apps like Flo or Clue can provide valuable insight into your menstrual cycle and can make it easier on your healthcare provider too who will be assessing your cycle stats to gain insight into hormonal health ;)
Time Frame
Since the life cycle of an ovarian follicle (that produces estrogen) is 90 days, you generally have to wait about 3 months after initiating supplementation/dietary changes etc. for full benefit. Although for some, it’s possible to notice sooner. Remember, ovarian production of hormones is one piece of the complex, hormonal puzzle.
References:
Tovey, A. & Cannell, JJ. Does vitamin D help treat PMS symptoms? The Vitamin D Council Blog & Newsletter, January, 2016.
Bertone-Johnson ER, Hankinson SE, Willett WC, Johnson SR, Manson JE. Adiposity and the development of premenstrual syndrome. Journal of women's health. 2010 Nov 1;19(11):1955-62.
Flores R, Shi J, Fuhrman B, Xu X, Veenstra TD, Gail MH, Gajer P, Ravel J, Goedert JJ. Fecal microbial determinants of fecal and systemic estrogens and estrogen metabolites: a cross-sectional study. Journal of translational medicine. 2012 Dec;10(1):253.
Doll HE, Brown SU, Thurston AM, Vessey MA. Pyridoxine (vitamin B6) and the premenstrual syndrome: a randomized crossover trial. JR Coll Gen Pract. 1989 Sep 1;39(326):364-8.
Hudson T. Premenstrual Syndrome; A Natural Approach.