By Stephen Holt, MD
Pre-menstrual syndrome (PMS) defies clear definition. In its classic form, it is a disorder of biorhythm that results in a series of unpleasant cyclical symptoms and signs, prior to menstruation. It is naïve to believe that PMS is a simple hormonal disorder requiring merely focused hormonal intervention. Complex socio-behavioral issues or adverse life events make PMS worse and PMS amplifies such events or exacerbates several diseases.
Among the most common symptoms of PMS are: emotional change, tiredness, irritability, anxiety, change of appetite, food craving and a litany of upsets in many body structures, resulting in: headaches, sinus problems, acne, joint pain and general clumsiness. PMS is often confused with many diseases or disorders and it can even masquerade as simple depression, chronic fibromyalgia, neurosis, organic disease of the female genital tract…to name a few misdiagnoses.
NATURAL MANAGEMENT STRATEGIES FOR PMS
Before any management strategies for PMS are proposed, an understanding of the causes of this clinical conundrum is advisable, but no simple or single cause of PMS can be defined. Suggested causes of PMS include: hormonal problems, water retention, body toxins, specific nutrient deficiencies, metabolic disturbances, imbalance of neurotransmitters in the central nervous system or, in isolated cases, frank neuroticism…and other matters.
The complex causes of PMS require multi-pronged interventions and the idea that there is a magic hormonal manipulation to treat PMS in a consistent manner is a “fairy tale”. Table 1 summarizes natural interventions that are linked to suggested causes of PMS.
SUGGESTED CAUSE COMMENT
Hormonal Problems Various studies have identified changes in hormone balance in women with PMS, but there are no consistent changes that permit a clear diagnosis. High levels of estrogen and low levels of progesterone have been associated with PMS. Failure of function of the corpus luteum which forms in the ovary after ovulation may be involved. Progesterone supplementation is a popular intervention and it may be effective in some women with PMS. A preferred approach, in my opinion, is the use of herbs, botanicals and nutrients that are adaptogenic or modulators of hormonal profiles. These natural substances can be used in synergistic formulations with good effects. The use of single supplements for PMS management are obsolete and the same may apply to disturbances around the menopause. Dietary supplement ingredients with the greatest evidence base for the management of menstrual disturbance include: black cohosh, soy and red clover isoflavones, L-theanine, evening primrose oil, dong quai, chasteberry, ginkgo biloba…and others with anecdotal benefit.
Water Retention Excessive salt and water retention is common in PMS, but it may be a result rather than a cause of PMS itself. Natural diuretics and herbal teas may be valuable (e.g. chamomile, dandelion root, green tea, etc.).
Body Toxins The concept of premenstrual intoxication was first reported 50 years ago, but scientific evidence that detoxification of the body with herbs or colon cleansing is universally effective has not been presented. Many women describe benefits of intermittent attempts to detoxify the body. One preferred route of detoxification is colon cleansing. Synergistic gentle colon cleansing formulae are most advisable with enhanced intake of fluids and dietary fiber.
Specific Nutrient Deficiencies Deficiency of vitamin B-complex has been linked to mood changes and depression in women with PMS or those taking progesterone hormone supplement. Excessive sugar intake and deficiency of omega-3 fatty acids have been variably implicated as a cause of PMS. For example, cramps may be caused by excess prostaglandin F2 alpha and alterations in prostaglandin production occurs with deficiencies or imbalances in the dietary intake of essential fatty acids. I recommend enteric coated fish oil capsules for all women with PMS, but I stress the advantages of delayed release, targeted delivery of fish oil in special gel capsules to improve absorption of the active omega 3 fatty acids EPA and DHA.
Hypoglycemia/Syndrome X Episodes of low blood sugar may occur in women with PMS and specific studies have shown that hypoglycemia may tend to occur more often in the premenstrual phase of the cycle. Alterations in the metabolism of glucose by the body due to insulin resistance and compensatory excess secretions of insulin are key factors in the metabolic Syndrome X, which is strongly associated with polycystic ovary syndrome (PCOS) and PMS. Lifestyle change and nutritional factors for Syndrome X are valuable.
Serotonin Balance Serotonin is an important factor in central nervous system and other body functions. Deficiencies in serotonin have been described in women with PMS. This has led to dietary recommendations to boost serotonin levels in the body and the use of supplements that are precursors of serotonin, such as 5-HTP. Serotonin levels in the brain are increased by some antidepressant drugs, e.g., Prozac.
Sleep Deprivation Restoration of the biorhythm of sleep is the most underestimated of all interventions in women with menstrual problems. Appropriate lifestyle changes and combination supplements can restore healthy sleep patterns. Without sleep PMS and menopause gallop in their progression.
Neuroticism PMS is real. While emotional disturbances are common in PMS, it is not acceptable to adopt the attitude that PMS is “all in a woman’s head.” Patients who visit physicians who have this opinion should vote with their feet.
Table 1. Potential causes of PMS with general comments about management options.
SYNDROME X AND PMS
The variable combination of hypertension, high blood cholesterol and an overweight status are fueled by insulin resistance. These problems form in the constellation of the metabolic Syndrome X. I emphasize that there is still widespread lack of knowledge about the importance of Syndrome X in women’s health, especially in relationship to menstrual function. The occurrence of cystic ovaries in young women has been quite clearly linked to Syndrome X. This condition is called polycystic ovary syndrome or Stein-Leventhal Syndrome. In popular medical literature, PCOS has been referred to as Syndrome X of the ovaries (or even Syndrome O). The typical female with PCOS is premenopausal, 18 to 28 years old, with variable degrees of obesity, excess body hair, irregular menstruation, period pains, acne and infertility. Lifestyle change and nutritional factors can be used to combat the Metabolic Syndrome X.
While topical progesterone cream has been proposed as a mainstay in the management of PMS, the application of this approach may require medical supervision and topical hormonal creams are not dietary supplements. Clearly, the general management approach to PMS involves its clear recognition together with good holistic management approaches, including but not limited to, psychosocial interventions, positive lifestyle changes and a first line approach with tailored nutritional medicine.