Premenstrual Syndrome (PMS)

PREMENSTRUAL SYNDROME (PMS)

Synopsis:
Background
Causes & Risk Factors
Nutrients for PMS
Suggested Supplementation
References

 

Millions of women, at some point in their lives, experience troublesome physical, emotional, and cognitive symptoms during the two weeks leading up to menstruation (Bhatia 2002; MGH 2013). When these symptoms interfere with day-to-day life, this is called premenstrual syndrome or PMS (Marjoribanks 2013; O'Brien 2011; Rapkin 2012; Alvero 2014). It is estimated that 8–20% of reproductive-aged women experience moderate-to-severe PMS (Rapkin 2009).

Premenstrual dysphoric disorder or PMDD is a premenstrual condition closely related to PMS that affects an estimated 3–8% of women (Rees 2014; Marjoribanks 2013; Steiner 2006). PMDD is usually characterized by severe psychological symptoms such as depression, anxiety, or persistent anger. PMDD is much more severe than PMS and can impact a woman’s life as much as major depressive disorder (Pearlstein 2008; Rapkin 2009; Epperson 2012).

The specific PMS or PMDD symptoms each woman experiences may differ. However, a woman will typically experience the same symptoms from one cycle to the next. Symptoms occur during the luteal phase of the menstrual cycle, usually peak approximately two days before menstruation, and are typically relieved by the start of menstruation or a few days thereafter. In some women, symptoms linger into the next cycle, but there must be a symptom-free period of time before the next ovulatory phase in order for the condition to qualify as PMS. PMS, by definition, cannot occur after menopause. Nevertheless, symptoms similar to those caused by PMS can occur during perimenopause or after the reproductive years

Common Signs and Symptoms of PMS

Physical:

• Bloating, weight gain
• Acne
• Breast tenderness
• Constipation or diarrhoea
• Joint/muscle pain

Psychological:

• Irritability
• Mood swings
• Fatigue
• Sleep disturbance
• Reduced concentration

Behavioural:

• Food cravings
• Angry outbursts
• Decreased motivation

 

Dietary and lifestyle changes may be sufficient to resolve symptoms in mild cases of PMS. These include:

• Exercising regularly
• Eating a healthy diet rich in vegetables, whole grains, and fruits
• Avoiding excess salt, sugar, alcohol, and caffeine
• Getting adequate sleep
• Managing stress
• Not smoking.

Over-the-counter pain relievers can help address physical symptoms such as cramps, pain, and headaches, but are not without side effects, especially if used long-term (OWH 2012; Alvero 2014).

 

Possible Causes of PMS:

• Estrogen and progesterone are high when PMS occurs
• Deregulation of the hypothalamic-pituitary-adrenal axis
• Altered serotonin levels

Risk Factors for PMS:

• Smoking and alcohol consumption
• Obesity
• High-fat, high-sugar diet
• Traumatic stress

 

 

Chasteberry (Vitex agnus-castus)

Chasteberry (Vitex agnus-castus) is a shrub found on riverbanks and shores of the Mediterranean region, Southern Europe, and Central Asia (Rani 2013). A rigorous review of published clinical trials found that seven out of eight trials deemed chasteberry superior to placebo for PMS treatment (van Die 2013). Results from a randomized, controlled trial showed that 91 women who took 20 mg chasteberry extract daily had more improvements in psychological and physical PMS symptoms than 87 women who took placebo. Symptoms of irritability, mood, anger, headaches, and breast fullness were reduced (Schellenberg 2001). A follow-up study found that women who took 20 mg chasteberry had greater improvements in symptoms than women who took 8 mg chasteberry extract. However, symptom improvement peaked at 20 mg, and no additional benefit was observed by increasing the dose to 30 mg (Schellenberg 2012).

Three randomized studies comparing chasteberry extract to placebo, and two open-label trials have shown similar benefits with 20–40 mg chasteberry extract or 40 drops of crude chasteberry extract. Marked improvement in aches and pains, anger and short temper, anxiety and nervousness, appetite and food cravings, backache, bloating, breast swelling or pain, crying spells, depression, extremity swelling, fatigue, irritability, lower abdominal cramping, mood, and restlessness were observed (Momoeda 2014; Zamani 2012; Ambrosini 2013; Ma, Lin, Chen, Wang 2010; Ma, Lin, Chen, Zhang 2010).

A trial of chasteberry extract for PMS in nursing students found a significant benefit, with nearly 70% of participants reporting complete resolution of their PMS symptoms by the end of the trial. The authors called chasteberry extract “one of the most effective therapeutic options for PMS” (Ibrahim 2012). A comparison of chasteberry extract with the SSRI fluoxetine in PMDD found that a similar percentage of participants responded to each, with chasteberry more effective for physical symptoms and fluoxetine more effective for psychological symptoms (Atmaca 2003).

Calcium and Vitamin D

Levels of calcium and vitamin D fluctuate throughout the menstrual cycle in all women, most likely because calcium and vitamin D metabolism are influenced by ovarian sex hormones (Thys-Jacobs 2000). However, one study found that compared with women who do not have PMDD, women with PMDD had lower ionized calcium levels during menstruation, lower urinary excretion of calcium during the late follicular phase and early luteal phase, and lower vitamin D levels during the luteal phase (Thys-Jacobs 2007).

A large, multi-center trial compared treatment with 1200 mg calcium carbonate daily to placebo for moderate-to-severe PMS. The women in this study took calcium or placebo for three menstrual cycles. The women who took calcium had significantly lower average PMS symptom scores in the second and third months of treatment. They also had an overall 48% reduction in total symptom score by the third cycle. Negative mood, bloating, food cravings, and pain were all significantly reduced by the third menstrual cycle in the calcium group (Thys-Jacobs 1998). A more recent double-blind trial of 1000 mg calcium carbonate daily for three months found that calcium treatment effectively relieved PMS-related fatigue, appetite changes, and depression (Ghanbari 2009). A literature review of pharmaceutical and integrative treatments for PMS recommended calcium supplementation as first-line treatment for mild-to-moderate PMS symptoms (Douglas 2002).

Women with lower dietary intake and blood levels of vitamin D may have an increased risk of PMS. An analysis was performed in 401 women who were free of PMS at baseline but later developed PMS. It was found that among those whose vitamin D levels were measured before they were diagnosed with PMS, lower vitamin D levels were related to a significantly higher risk of developing premenstrual breast tenderness, fatigue, depression, and constipation or diarrhea (Bertone-Johnson 2014). A case-control study compared 1057 women who developed PMS with 1968 controls; researchers found that women in the highest 20% total vitamin D intake group had a 41% lower risk of PMS compared to women in the lowest 20% total vitamin D intake group. In this study, those who consumed the most calcium had a 30% reduced risk of developing PMS (Bertone-Johnson 2005).

B Vitamins

Two separate analyses, including data from 9 and 13 randomized controlled trials, found that 100 mg vitamin B6 may be more effective than placebo for the treatment of PMS symptoms. One of these reviews found that, among 541 women from four of the studies, those taking vitamin B6 had 2.3 times greater likelihood of an improvement in their overall PMS symptoms compared to those taking placebo, and 1.7 times greater likelihood of an improvement in depressive symptoms (Nevatte 2013; Whelan 2009; Wyatt 1999). Vitamin B6 has been shown to improve symptoms of bloating, headache, breast pain, depression, and irritability (Gaby 2011).  

A large 10-year study found that women with the highest dietary intake of vitamins B1 (thiamin) and B2 (riboflavin) had a lower incidence of PMS. Women whose dietary intake of riboflavin was in the highest one-fifth of the distribution had a 35% lower risk of developing PMS compared to those in the lowest one-fifth (Chocano-Bedoya 2011).

Magnesium

Magnesium may play an important role in the treatment of PMS (Higdon 2013; UMMC 2013a). Some studies have found that women with PMS have lower blood levels of magnesium than women without PMS (Posaci 1994; Rosenstein 1994). Several successful trials have used magnesium to treat symptoms of PMS. A randomized, placebo-controlled trial found that supplementation with 200 mg of magnesium daily significantly reduced weight gain, bloating, and breast tenderness in women with PMS (Walker 1998). Results from two additional randomized, placebo-controlled trials demonstrated that supplementation with 360 mg magnesium daily significantly improved symptoms related to mood, and the incidence of migraines (Facchinetti, Borella 1991; Facchinetti, Sances 1991). Women may also benefit from the combination of magnesium and vitamin B6. Two randomized controlled trials showed that magnesium (200–250 mg) combined with vitamin B6 (40–50 mg) reduced general symptoms of PMS and anxiety more than either supplement alone or placebo (Fathizadeh 2010; De Souza 2000).

Saffron

Saffron, derived from the plant Crocus sativus, has historically been a part of traditional Persian medicine. Saffron has been shown to modulate serotonin neurotransmitter signaling, and has been investigated for treatment of depression and PMDD (Agha-Hosseini 2008). In fact, several clinical trials have found that saffron effectively relieves depression, with efficacy comparable to that of some antidepressant medications (Noorbala 2005; Akhondzadeh 2004; Akhondzadeh 2005).

A randomized, controlled trial enrolled 50 women between the ages of 20 and 45 who had been experiencing PMS symptoms for six months or more. For two menstrual cycles, 25 of the women received 30 mg of saffron extract daily and 25 received placebo. In the saffron group, 76% of women experienced a 50% or greater reduction in overall premenstrual symptom severity, while in the placebo group only 8% of the women did. In the saffron group, 60% of women experienced a 50% or greater reduction in depression symptoms, while in the placebo group only 4% did. In the saffron extract group, there was a significant improvement from the first to the second month in depression score and overall premenstrual symptom scores. Women in the saffron group had significantly greater reductions in depression and overall premenstrual symptom scores compared with those who received a placebo (Agha-Hosseini 2008).

Omega-3 Fatty Acids  

Omega-3 fatty acids are found in fish and some plant foods such as flaxseeds and walnuts. Omega-3 fatty acids include eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and alpha-linolenic acid (ALA) (UMMC 2013b; Huang 2010). Within the body, omega-3 fatty acids help suppress inflammation and are important structural components of cells (Calder 2015).

A randomized, controlled trial assessed the ability of omega-3 fatty acids to decrease symptoms of PMS. Compared with placebo, 90 days of treatment with 2 g omega-3 fatty acids daily led to significant reductions in depression, anxiety, lack of concentration, bloating, nervousness, headaches, and breast tenderness (Sohrabi 2013). A controlled trial found that krill oil or fish oil were both effective for the treatment of PMS, but krill oil was more effective than fish oil (Sampalis 2003).

Gamma-Linolenic Acid

Gamma-linolenic acid (GLA) is a fatty acid derived from seeds of plants such as evening primrose, borage, and black currant (EBSCO 2014). One of these, evening primrose oil, has been used to treat symptoms of PMS, but studies have been inconclusive (UMMC 2013c). However, one randomized controlled trial in 120 women with PMS or PMDD compared a GLA-containing formula with placebo. Subjects received one or two capsules per day containing 210 mg each of GLA along with other fatty acids, or placebo. This trial followed these women over six months, evaluating the results at three and six months. Both dosages significantly reduced PMS symptoms, with the two capsule dosage resulting in greater improvement than one capsule (Rocha Filho 2011).

Tryptophan

Tryptophan is an amino acid that can be metabolized into serotonin, and altered serotonin activity is thought to contribute to premenstrual symptoms (Higdon 2014; Rapkin 2012). In a randomized controlled trial, women with PMDD who received 2 g of L-tryptophan three times daily reported 34.5% reductions in mood, tension, and irritability symptoms, compared with 10.4% reductions in women who took placebo (Steinberg 1999).

Ginger

Ginger, which contains anti-inflammatory compounds, has been used for a variety of ailments, including menstrual pain and cramping (Shimoda 2010). A randomized, placebo-controlled trial of ginger in 66 women used 250 mg ginger tablets twice daily, beginning seven days before menstrual bleeding started and continuing until three days after the onset of bleeding. The ginger treatment produced significant improvements in mood, physical, and behavioral symptoms of PMS, and in overall PMS symptom scores. This symptom reduction was significantly greater after one, two, and three months in the ginger group, compared with placebo (Khayat 2014).

Chamomile Extract

A randomized trial in 90 women with PMS compared 100 mg of chamomile extract three times daily to 250 mg of the NSAID mefenamic acid three times daily. Women who received chamomile extract had greater improvement in emotional symptoms than women who took mefenamic acid, and mefenamic acid was not significantly superior to chamomile extract in providing relief from physical symptoms (Sharifi 2014).

 

    Calcium: 700 – 1200 mg daily

    Vitamin D: 5000 – 8000 IU daily; depending upon blood levels of 25-OH-vitamin D

    Vitex: standardized extract: 20 mg daily

    Magnesium: 500 – 1500 mg daily

    Vitamin B6 (as pyridoxal 5’-phosphate): 100 mg daily

    Vitamin B1 (thiamin): 100 mg daily

    Vitamin B2 (riboflavin): 50 – 100 mg daily

    Saffron; standardized extract: 176 mg daily

    Fish oil (with olive polyphenols and sesame lignans): 1400 mg EPA and 1000 mg DHA daily

    Gamma-linolenic acid (GLA): 299 – 1495 mg daily

    L-tryptophan: 500 – 1500 mg daily

    Ginkgo biloba: 120 mg daily

    Chamomile extract: 75 mg daily

    Ginger extract: 150 - 450 mg daily

 

 

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