Premenstrual Syndrome (PMS)

Published by NHC on January 5, 2021January 5, 2021

Premenstrual Syndrome (PMS)

Info
Description	A group of signs and symptoms experienced during the luteal phase of the menstrual cycle which are typically relieved within the first few days of menstruation. PMS symptoms subside by the end of the full flow of menses. PMDD (Premenstrual Disphoric Disorder) A more severe form of PMS PMS can be broken down into subtypes/categories: PMS-A (Anxiety) Anxiety, Insomnia, Irritability, Emotional changes, Palpitations, Stress induced sweating. PMS-C (Craving) Sugar cravings, Increased appetite, Headache, Hypoglycaemia, Palpitations, Increased sweating PMS-D (Depression) Depression, Despair, Crying, Fatigue, Insomnia, Low libido, Apathy PMS-H (Hyperhydration) Oedema of hands and feet, Weight gain, Bloating, Breast tenderness/swelling
Signs & Symptoms	Mood changes Irritability Anxiety Depression Loss of control Inability to cope Bloating Breast symptoms (pain/tenderness, swelling) Pain/cramping Fluid retention or weight changes Headaches or migraines Cravings or appetite changes Hot flushes Acne or skin changes Libido changes Worsening of current medical conditions: Epilepsy Migraine Asthma
Causes & Contributors	Hormonal imbalance Oestrogen excess Low progesterone during luteal phase Prostaglandin excess or deficiency Endogenous hormone allergy Hyperprolactinaemia Abnormal neurotransmitter response to ovarian signalling Disordered aldosterone function leading to sodium and water retention HPA dysfunction leading to altered adrenal hormone secretion Nutrient deficiency Magnesium Vitamin B6 Hypoglycaemia/Carbohydrate intolerance Environmental factors stress Family history Fluid and electrolyte balance High sodium to potassium ratio
Pathophysiology/Aetiology	PMS-A (Anxiety) Involves an excess of oestrogen and a deficiency of progesterone with a possible relation to poor clearance of oestrogens. Support oestrogen clearance and reduce cortisol secretion. PMS-C (Craving) Possibly enhanced insulin-binding effects Improve insulin sensitivity and regulate progesterone and dopamine PMS-D (Depression) Oestrogen leading to increased neurotransmitter degradation Support and regulate oestrogen and progesterone ratio PMS-H (Hyperhydration) Possible increased aldosterone in late luteal phase due to excess oestrogen. May be related to increased cortisol from poor HPA function. Support oestrogen clearance
Commonly Affected	Menstruating women 15-35 years
Complications	Progression to PMDD Further hormonal complications (eg. infertility)
Treatment
Best Therapeutic Treatment	Complete a menstrual diary for at least 2-3 cycles Give hand out Monthly Symptom Tracker, or Use App Hormonal Panel To find which hormones play a role Dietary Advice Follow an Anti-inflammatory Diet Additionally: Eat These: Low GI foods Vegetables (Try not to overcook. Steam or stir fry preferred) Fibre (helps bind to excess oestrogen) Brassica family (Try not to overcook. Steam or stir fry preferred) Broccoli, cabbage, cauliflower, brussel sprouts Helps eliminate excess oestrogens Organic meats Less oestrogens added to feed etc. Fish Omega 3 Eggs Avoid These: High GI foods Refined grains, sugar, cakes Spikes in insulin lower levels of SHBG which binds to excess oestrogen Caffeine Coffee, tea (black, green, oolong), chocolate Shown to worsen menstrual symptoms Exogenous oestrogens Dairy Soy Plastics (water bottles, food storage) Meat (particularly beef) Phthalates (synthetic scents, cling wrap) Nutritional B-complex if needed B6 (primarily) With magnesium and calcium would be beneficial Calcium D-glucarate Herbal Treatment Chaste tree 1:2 10ml St Johns Wort 1:2 20ml Schisandra 1:2 25ml Withania 1:1 25ml Skullcap 1:2 30ml 8ml in water twice a day. Every day of cycle OR Chaste tree 1:2 5-40ml a week (Only for two weeks prior to period) 10ml/week (1.5ml a day) 20ml total in 20ml bottle, will last 2 weeks and 1 menstrual cycle Take two weeks prior to period. Stop at start of period OR Chaste tree tablets 0.25-3g/day Lifestyle Exercise Improves metal health and mood Decreases fluid retention Reduce stress Stress exacerbates symptoms Meditation Yoga Walking Something to clear the mind (If stress is a contributor) Ensure good quality sleep Increase water intake
Herbal	Vitex agnus-castus Clinical evidence with great results over 3 cycles Increase progesterone Decrease prolactin Hypericum perforatum (St John’s Wort) Effective for depression Contraindicated in OCP Taraxacum officinale Diuretic for fluid retention Withania somnifera Improve stress response Paeonia lactiflora Anti-inflammatory, analgesic, antispasmodic Schisandra Phase 1 and 2 Liver detoxification for clearance of sex hormones Example Herbal formula: Chaste tree 1:2 10ml St Johns Wort 1:2 20ml Schisandra 1:2 25ml Withania 1:1 25ml Skullcap 1:2 30ml 8ml in water twice a day. Every day of cycle OR Chaste tree 1:2 5-40ml a week (Only for two weeks prior to period) 10ml/week (1.5ml a day) 20ml total in 20ml bottle, will last 2 weeks and 1 menstrual cycle Take two weeks prior to period. Stop at start of period OR Chaste tree tablets 0.25-3g/day If fluid retention is present, dandelion leaf 1:1 at 8ml, once a day can be added to the second half of the cycle
Nutritional	Vitamin B6 (50-100mg/day) B-vitamins For energy and stress support Decreased levels with OCP use Vitamin B1 Clinical evidence for PMS Vitamin B2 Required for B6 activation Neurotransmitter function Decreases with OCP use Vitamin B3 Hormone synthesis Neurotransmitter production Vitamin B5 Supports adrenal function and stress support Vitamin B6 Clinical evidence for PMS improvement Modulates GABA and Serotonin Magnesium transportation Especially good for high oestrogen/progesterone from OCP use Vitamins B9 & B12 Neurotransmitter formation Magnesium Assists in fluid retention Beneficial for anxiety Calcium Clinical evidence Omega 3 (1080mg/day EPA, 720mg/day DHA) Reduces pain and symptoms Evening Primrose Oil (GLA) Lacks evidence Suggested mechanism is that PMS patients are deficient in linoleic acid, which is needed for prostaglandin formation. Trytptophan or 5-HTP Serotonin precursor Some PMS patients have been found to be tryptophan deficient, leading to aggression and worsening of symptoms Calcium D-glucarate Indole-3-carbinol DIM (Diindolylmethane)
Dietary	Eat These: Low GI foods Spikes in insulin lower levels of SHBG which binds to excess oestrogen Vegetables (Try not to overcook. Steam or stir fry preferred) Fibre (helps bind to excess oestrogen) Brassica family (Try not to overcook. Steam or stir fry preferred) Broccoli, cabbage, cauliflower, brussel sprouts Helps eliminate excess oestrogens Organic meats Less oestrogens added to feed etc Avoid These: High GI foods Refined grains, sugar, cakes Spikes in insulin lower levels of SHBG which binds to excess oestrogen Caffeine Coffee, tea (black, green, oolong), chocolate Shown to worsen symptoms Exogenous oestrogens Dairy Soy Plastics (water bottles, food storage) Meat (particularly beef) Phthalates (synthetic scents, cling wrap) Increase water intake *Give food swap ideas if necessary
Lifestyle	Exercise Improves metal health and mood Decreases fluid retention Reduce stress Exacerbates symptoms Meditation Yoga Walking Something to clear the mind (If stress is a contributor) Ensure good quality sleep
Pharmaceutical	OCP Ethinyloestradiol + dropirenone NSAIDs SSRIs Fluoxetine Sertraline Highly effective in PMS Intermittent use (2 weeks prior to next period) Less adverse effects and more acceptable Not as effective as continual use Diuretics Spironolcatone Effective at relieving breast tenderness, bloating and oedema GnRH Agonists
Combination Products	B-complex P-Lift (metagenics) Vitex Withania Ginger Iodine Lutein (carotenoids) Selenium B6 Vitamin E Zinc
Other	Warm wheat bag, hot water bottle or bath
More
Differential Diagnosis	Dysmenorrhea Endometriosis Hypothyroidism OCP use Perimenopause Affective disorder Depression Anxiety Panic
Diagnostic Criteria	PMS Clinical presentation: (at least one of each) Affective symptoms: depression, anger, irritability, anxiety, confusion Somatic: breast tenderness, bloating, headache, swelling of extremities. Timing of symptoms (pre-menstruation) Symptoms relieved from days 4-13 of menstrual cycle PMDD (more sever form of PMS) DSM-IV diagnostic criteria
Testing/Examinations	Menstrual charting Monitoring symptoms with timing of menstrual cycle Use of App may be helpful Monthly Symptom Tracker Handout Hormone profile Serum or saliva LFT To assess any issues with detoxification pathways Functional Hepatic Detoxification Profile (FHDP) To assess if hormonal clearance is impaired Thyroid profile Rule out thyroid involvement
Additional Notes	There is a high response rate (up to 40%) for placebo in PMS that may continue for 3 months or more.
Images/Infographics

References

Bone, K. (2007). The Ultimate Herbal Compendium. Phytotherapy Press

Braun, L., & Cohen, M. (2015). Herbs and Natural Supplements, Volume 2. Elsevier Health Sciences.
Hechtman, L. (2018). Clinical Naturopathic Medicine. Elsevier Health Sciences.

Henshaw, C. (2007). PMS: Diagnosis, aetiology, assessment and management: Revisiting… Premenstrual syndrome. Advances in Psychiatric Treatment, 13(2), 139-146. doi:10.1192/apt.bp.106.003392

Kwan, I., & Onwude, J. L. (2015). Premenstrual syndrome. BMJ clinical evidence, 2015, 0806.

Noviyanti, N. I., Gusriani, Ruqaiyah, Mappaware, N. A., & Ahmad, M. (2021). The effect of estrogen hormone on premenstrual syndrome (PMS) occurrences in teenage girls at Pesantren Darul Arqam Makassar. Gaceta sanitaria, 35 Suppl 2, S571–S575. https://doi.org/10.1016/j.gaceta.2021.10.103