Premenstrual Syndrome (PMS)

DESCRIPTION

Premenstrual syndrome (PMS) is a recurrent condition in menstruating women, characterized by a wide range of troublesome physical and emotional symptoms that arise during the week or two before menstruation, but usually cease when the menstrual flow begins. Common physical symptoms include tender, swollen breasts; headache; backache; abdominal bloating; fluid retention causing puffiness in ankles, fingers and face; decreased energy level; acne outbreaks; and higher incidence of minor infections such as colds. Common emotional symptoms include irritability, nervousness, depression, mood swings, and altered (decreased or increased) sex drive.

Between 30 and 40% of menstruating women are affected by PMS,  primarily during their 30s and 40s. Most experience only mild symptoms, but for about 10%, symptoms can be severe enough to affect work and social relationships.

All PMS symptoms stem from some abnormality in the complex hormonal changes that occur in a woman’s body during the menstrual cycle. Each month during a woman’s reproductive years, various hormones are secreted to ensure that only a single egg is released by the ovaries that month, and to prepare the endometrium (the lining of the uterus) for implantation of the fertilized egg. The hormonal secretions that occur to achieve these goals are controlled by complex interactions between the hypothalamus, pituitary, and ovaries. The hypothalamus, a region of the brain in the middle of the head just behind the eyes, controls the female hormonal system by releasing hormones – such as gonadotropin-releasing hormone (GnRH) and follicle-stimulating hormone-releasing hormone (FSH-RH) – which stimulate the release of pituitary hormones. In response to the hormones secreted by the hypothalamus, the pituitary gland then releases follicle-stimulating hormone (FSH) and luteinizing hormone (LH).

FSH, the hormone released by the pituitary during the first phase of the menstrual cycle, is primarily responsible for the maturation of an egg (ovum). Follicle-stimulating hormone is so named because each egg is housed inside an individual follicle within the ovary. As the follicle grows, estrogen levels increase, triggering the secretion of LH, the hormone responsible for initiating ovulation – the release of the fully developed egg. After ovulation, the now eggless follicle is transformed into the corpus luteum, which secretes progesterone and estrogen to help a fertilized egg become well established in the uterine lining. If fertilization does not occur, the corpus luteum recedes, hormone production decreases, and, approximately 2 weeks later, the lining is shed in the menstrual flow, and the entire process begins anew.

The normal menstrual cycle, which is completed in about 1 month, is divided into three phases, in order of occurrence: follicular, ovulatory, and luteal. The follicular phase lasts 10–14 days, the ovulatory phase when the egg is released lasts about 36 hours, and the luteal phase lasts for about 14 days.

Because of the complex interrelationships among the components of the endocrine system (a group of glands that secrete hormones, including the adrenals, thyroid, parathyroid and pancreas as well as the hypothalamus, pituitary, and ovaries), a disorder in any of these glands can affect hormone secretion and lead to menstrual abnormalities and/or PMS. For example, hypothyroidism (low thyroid function) and elevated cortisol (an adrenal hormone) are common in PMS. Elevated levels of prolactin (another hormone produced by the pituitary that regulates the development of the mammary gland and milk secretion during and after pregnancy) also play a role in PMS and infertility. In non-lactating women (women who are not producing milk), prolactin can inhibit maturation of the follicles in the ovaries and has been linked to PMS, menstrual abnormalities, absence of ovulation, ovarian cysts, and breast tenderness. Common hormonal patterns have been found in women with PMS that differ from those of women with no PMS symptoms.

The primary hormonal abnormality is that estrogen levels are elevated and plasma progesterone levels are reduced during the luteal phase of the menstrual cycle, 5–10 days before menses, or the ratio of estrogen to progesterone is increased.

Many researchers theorize that PMS reflects corpus luteum insufficiency. In addition to PMS, corpus luteum insufficiency has been linked to abnormal menstruation (excessive blood loss; absent, persistent, or more frequent menstruation), elevations in prolactin level, and low thyroid function. Corpus luteum insufficiency is usually diagnosed by measuring the level of progesterone in the blood 3 weeks after the onset of menstruation. If the level is below 10–12 ng/mg, corpus luteum insufficiency is a strong possibility.

Hypothyroidism and/or elevated prolactin levels are also common, FSH levels are typically elevated 6–9 days prior to the onset of menses, and aldosterone (a hormone produced by the adrenal glands that leads to sodium and water retention) levels are marginally elevated 2–8 days prior to the onset of menses.

In an attempt to bring some order to the clinical complexities of PMS, it has been classified into four distinct subgroups, each of which is linked to predominant symptoms, hormonal patterns, and metabolic abnormalities. However, women rarely fit into only one subgroup, and instead, usually experience symptoms related to two or more of the following subgroups:

PMS-A (A = anxiety): the most common symptom category, PMS-A is associated with excessive estrogen and deficient progesterone levels during the premenstrual phase. Common symptoms are anxiety, irritability, and emotional instability.

PMS-C (C = carbohydrate cravings): PMS-C is associated with increased appetite, craving for sweets, headache, fatigue, fainting spells, and heart palpitations. Glucose tolerance tests (GTT) performed during the 5–10 days before menses show a flattening of the early part of the curve (which usually implies excessive secretion of insulin in response to sugar consumption). This increased binding capacity for insulin appears to be hormonally regulated, but other factors including high salt intake, decreased levels of magnesium or hormone-like compounds called prostaglandins may also be involved.

PMS-D (D = depression): the least common type, PMS-D is associated with depression, occasional crying fits, forgetfulness, mild mental confusion, and episodes of insomnia. Depression, the key symptom, is usually associated with low levels of neurotransmitters in the central nervous system, which may, in turn, be due to increased neurotransmitter breakdown as a result of decreased output of estrogen by the ovaries (in contrast to PMS-A, which shows the opposite results). The decrease in ovarian estrogen output has been attributed to a stress-induced increase in adrenal androgen and/or progesterone secretion.

PMS-H (H = hyperhydration): PMS-H is characterized by weight gain (greater than 1.3 kg [3 lb]), abdominal bloating and discomfort, breast tenderness and congestion, and occasional swelling of the face, hands, and ankles. Symptoms are the result of an excess of the hormone aldosterone, which causes increased fluid retention. Aldosterone excess may be caused by stress, estrogen excess, magnesium deficiency, or excess salt intake.

FREQUENT SIGNS AND SYMPTOMS

  
By analyzing the symptoms and relating them to their probable subgroup(s) and cause(s) an effective treatment plan tailored to specific needs can be developed with physician guidance. Use the menstrual symptom questionnaire on the next page as a diary to help clarify the symptom pattern and document improvements.

 
CAUSES

Excess estrogen

One of the most common findings in women with PMS is an elevated estrogen-to-progesterone ratio, typically, mild estrogen excess combined with mild progesterone deficiency. This derangement contributes to PMS by leading to the following impairments:

• Impaired liver function: the liver is responsible for detoxifying estrogen and excreting it in the bile. When bile flow is diminished, a condition medically labelled cholestasis, estrogen detoxification and clearance are reduced. Since excess estrogen itself causes cholestasis, a vicious cycle is induced. In addition to estrogen excess, the following also cause cholestasis and can therefore promote estrogen excess:
• Alcohol
• Aanabolic steroids
• Endotoxins (internally produced toxic by-products of metabolism)
• Birth control pills
• Hereditary disorders, such as Gilbert’s syndrome (a thyroid disorder)
• Pregnancy
• Presence of gallstones
• Various chemicals or drugs.
• Reduced neurotransmitter synthesis: neurotransmitters are compounds that transmit nerve impulses.
• An increase in the estrogen-to-progesterone ratio results in the impairment of neurotransmitter manufacture, contributing to depression and insomnia:
• One group of neurotransmitters, the monoamines, includes serotonin, a lack of which negatively affectsmood, and melatonin, which is integral to sleep.
• The majority of the more than 12 million patients on Prozac (an antidepressant drug that increases serotonin levels in the brain, but has numerous, potentially dangerous side effects) are women between the ages of 25 and 50 – the same population that has a high frequency of PMS.
• In women with PMS, the use of natural therapies to normalize the estrogen-to-progesterone ratio (which, unlike Prozac, have only beneficial effects) may resolve the monoamine imbalances conventionally treated with antidepressant drugs.
• Reduced endorphin levels: endorphins are the body’s own mood-elevating and pain-relieving substances. When the estrogen-to-progesterone ratio increases, endorphin levels decline:
• Low endorphin levels during the luteal phase are common in women with PMS.
• Endorphin levels are lowered by stress and raised by exercise.

Decreased action of vitamin B6: the negative impact of estrogen excess on neurotransmitter and endorphin levels during the luteal phase may be secondary to estrogen’s impairment of vitamin B6 action:

• Estrogens negatively affect vitamin B6 function
• Vitamin B6 – which is involved in the formation of red blood cells, hormone-like compounds called prostaglandins, neurotransmitters and endorphins – is critical to maintaining hormonal balance
• Vitamin B6 levels are typically quite low in depressed patients, particularly women taking estrogens (birth control pills or Premarin).
  Supplementation with vitamin B6 has been shown to improve all PMS symptoms, especially depression, by reducing mid-luteal estrogen levels while increasing mid-luteal progesterone levels
• Hypothyroidism: another component of the interactive endocrine system, the thyroid gland secretes hormones that regulate metabolic rate. The hormone primarily secreted by the thyroid, T4, is inactive until it is converted, largely in the liver, to its active form, T3:
  Excess estrogens, both internally produced and ingested (as birth control pills, Premarin, hormone residues in meat and dairy products, or estrogenic pesticide residues in foods) can impair liver function, thus decreasing conversion of T4 to T3.
• Several studies have shown that a large percentage of women with PMS have low thyroid function, and many women with both PMS and confirmed hypothyroidism have experienced complete relief of symptoms when given thyroid hormone.
• Hypothyroidism, depression, and PMS are metabolically linked:
• A recent study indicates that both T3 and L-tryptophan (the dietary amino acid that the body uses to produce serotonin, a neurotransmitter that is important for feelings of wellbeing) are taken up by red blood cells using the same carrier.

Since vitamin B6 is needed for the formation of red blood cells, when B6 levels are low, neither T3 nor L-tryptophan will be adequately circulated.
Increased aldosterone secretion: estrogen excess increases secretion of aldosterone, a hormone produced by the adrenal glands that leads to retention of sodium and water:
In many cases of PMS, aldosterone levels are elevated 2–8 days prior to onset of menses.
Increased prolactin secretion: estrogens, both internally produced and ingested (as birth control pills or Premarin, hormone residues in meat and dairy products, or estrogenic pesticide residues in foods), increase prolactin secretion by the pituitary gland:
In women with breast pain or fibrocystic breast disease, elevated levels of prolactin are specifically implicated.
Prolactin levels also tend to be elevated in cases of low thyroid function.

Progesterone deficiency

Although the adrenal cortex makes some progesterone, it is mainly used as a precursor in the production of corticosteroid hormones (see Stress and adrenal dysfunction immediately below). The body’s supply of progesterone is primarily derived from the corpus luteum, which is produced after ovulation from the empty follicle. If ovulation does not occur, no corpus luteum will develop to secrete progesterone, thus leading to an imbalance in the estrogen-to-progesterone ratio.
Ovulation is triggered as a result of complex interactions between the hypothalamus, pituitary, and ovaries. Any disruption in this hormonal symphony from, for example, stress, illness, intense physical activity, emotional or psychological difficulties, can prevent ovulation.
Ovulation naturally begins to decline when a woman reaches her 30s, and by the mid-30s, anovulatory (without ovulation) cycles are common. Since no corpus luteum is formed, no progesterone is secreted, and estrogen, essentially unopposed, dominates the hormonal environment.
In addition to the corpus luteum, over 5000 plants have been identified as producing sterols with progestogenic effects, but when foods are processed or consumed days after being picked – as is typical of the food supply in the US – their sterol levels drop precipitously. The result is that our diets do not provide sufficient progestogenic substances to help offset the natural decline in progesterone that accompanies
aging.

 

Stress and adrenal dysfunction

Progesterone is a major precursor of corticosteroid hormones made by the adrenal glands. These hormones are responsible for mineral balance, sugar control, and our capacity to respond to all types of stressors including emotional stress, inflammation, and trauma. A lack of corticosteroids can lead to fatigue, immune dysfunction, hypoglycemia, allergies, and arthritis.

Constant stress increases the demand for corticosteroid production, exhausting the adrenal glands and using all the progesterone they produce to make corticosteroids.
Eventually, the overworked adrenal glands become so depleted they cannot even make enough progesterone to keep up with the demand for corticosteroids. Should ovulation occur, since the body places a higher premium on immediate survival needs than reproduction, much of the progesterone produced will be also shunted into corticosteroid production. The outcome is a hormonal imbalance in which lack of sufficient progesterone results in estrogen dominance.

Depression

Elevations in the level of the corticosteroid hormone cortisol are typical in depression and reflect a disturbance in the control mechanisms for adrenal function that reside in the hypothalamus and pituitary glands. As explained under Stress and adrenal dysfunction (immediately above), excessive cortisol production depletes progesterone, thus promoting estrogen dominance and PMS.

Macronutrient excesses and micronutrient deficiency

 Women who suffer from PMS typically have a low-fiber, high-fat, high-sugar diet that is even worse than the Standard American Diet (SAD).
Compared to symptom-free women, PMS patients consume: 62% more refined carbohydrates, 275% more refined sugar, 79% more dairy products, 78% more sodium, 53% less manganese, and 52% less zinc.
A low-fiber diet contributes to estrogen retention and recirculation:
Fiber promotes the excretion of estrogens both directly, by binding to estrogens prepared for excretion, and indirectly, because fiber is the preferred food of beneficial bacteria in the gut. These friendly bacteria produce only a tiny amount of the enzyme beta-glucuronidase that recycles estrogen, in contrast to unfriendly bacteria, which produce a lot of betaglucuronidase.
Beta-glucuronidase breaks the bond between estrogen and glucuronic acid – a carrier that is attached to estrogen in the liver to prepare it for excretion via the bile, which is then secreted into the small intestine.
When friendly bacteria, which depend on fiber as their food source, colonize the intestines, they supplant the unfriendly bacteria that produce betaglucuronidase. ¦ supplementation with friendly bacteria (see Nutritional supplements below) along with a highfiber diet can reduce beta-glucuronidase activity.
A diet high in fat, particularly saturated fat, and/or sugar has been shown to significantly increase levels of circulating estrogens:
Foods high in simple sugars not only impair estrogen metabolism, but also stress blood sugar control and, particularly when combined with caffeine, have a detrimental effect on mood in women with PMS.
In one study, when 17 women switched from the SAD diet (40% of calories as fat, 12 g of fiber q.d.) to a low-fat, high-fiber diet (25% of calories as fat, 40 g of fiber), their blood estrogen levels dropped 36% in 8–10 weeks.
Excessive salt consumption, especially when coupled with low intake of foods rich in potassium (fresh fruits and vegetables, whole grains, and beans), greatly stresses the kidneys’ ability to maintain proper fluid volume, resulting in fluid retention.
The micronutrients most important in PMS are discussed below under Nutritional supplements.

  
RISK INCREASES WITH

• Stress: increases cortisol production, further depleting progesterone.
• Lack of exercise: exercise decreases cortisol levels and increases endorphin levels.
• SAD (Standard American Diet): the SAD is high in refined carbohydrates, sugar, salt, fat, and caffeine – factors that impair estrogen metabolism, leading to an increase in circulating estrogen levels; have detrimental effects on mood; and promote water retention. In addition, the SAD is low in vegetables, fruits, whole grains, nuts and seeds, and legumes – the sources of the fiber, essential fatty acids, vitamins and minerals necessary for proper hormone metabolism.
• Depression: elevations in the stress-induced hormone cortisol are typical, and since progesterone is used to produce cortisol, an increase in cortisol production results in a decrease in progesterone.
• Perimenopause: during the years preceding menopause, anovulatory cycles increase and estrogen levels may fluctuate widely, further stressing a woman’s physical and emotional equilibrium.
•  Hypothyroidism: PMS and hypothyroidism can result from the same metabolic dysfunctions, e.g., cholestasis (impaired liver function) promotes estrogen retention and recirculation and lessens the conversion of T4 to T3, the active form of thyroid hormone.
• Gilbert’s syndrome: a type of hypothyroidism.
• Gallstones: indicate cholestasis.
• Alcohol consumption: alcohol dehydrates the body and leads to fluctuations in blood sugar levels that
  aggravate many premenstrual problems.
• Birth control pills: increase estrogen levels.
• Smoking: among its many harmful effects, cigarette smoke contains numerous toxic chemicals that place a significant burden on the liver.
• Caffeine: particularly in sensitive individuals, caffeine causes fluctuations in blood sugar levels, increasing adrenal stress and carbohydrate cravings.
• Frequent digestive disturbances: frequent bloating and/or gas suggests that unfriendly bacteria, which promote the reabsorption of estrogen from the intestines, are present in the digestive tract.
• Constipation: increases the time during which estrogen can be reabsorbed.

 
PREVENTIVE MEASURES

• Exercise regularly.
• Don’t smoke.
• Minimize consumption of caffeine: if anxiety or depression, or breast tenderness or fibrocystic breast disease are major symptoms, avoid all sources of caffeine, including coffee, tea, chocolate, and caffeinated sodas.
• Minimize consumption of alcohol: alcohol should be consumed no more than three times per week in the
  amount of no more than 350 ml (12 US fl oz) of beer, 140 ml (4–5 US fl oz) of wine, or 45 ml (1.5 US fl oz) of distilled spirits.
• Avoid salt.
• Consume a nutrient-dense fiber-rich diet based on whole, minimally processed, preferably organic foods, especially plant foods (fruits, vegetables, beans [particularly soybeans], seeds and nuts [particularly flaxseed and walnuts], and whole grains) and cold-water fish, and low in animal products and refined foods.
• Take a high-potency daily multiple vitamin and mineral supplement to ensure basic micronutrient needs
  are met. This should include 400 ?g of folic acid, 400 ?g of vitamin B12, and 50–100 mg of vitamin B6. Folic acid supplementation should always be accompanied by vitamin B12 supplementation to prevent folic acid from masking a vitamin B12 deficiency.
• If using birth control pills, discuss alternative methods of contraception with a health care provider.

Expected outcomes

Significant improvement should be noted within two to three menstrual cycles. The first month may be devoted to clarifying which PMS subset(s) match the characteristics of the symptoms while following the general recommendations outlined in Preventive Measures.

During the second month, an individualized program targeted at the underlying causes should result in a
lessening of symptoms.

By the third menstrual cycle, the hormonal and nutritional imbalances identified as contributing to the PMS symptoms should resolve.

 
TREATMENT

• Evaluate PMS symptoms by completing the symptom diary above.
• Rule out hypothyroidism: determine basal body temperature (discussed in the chapter on Hypothyroidism). If this is below 36.56?C (97.8?F), or if suffering from other symptoms associated with PMS, consult with a physician for complete thyroid function testing.
• Rule out depression: review the symptoms discussed in the web article on Affective disorders: depression. If four or more of the eight symptoms listed have been present for a month or more, follow the recommendations given in that article.
• Follow the dietary recommendations given below.
• Select the appropriate herbal support.
• Get regular exercise.
• Avoid excessive stress as much as possible by avoiding excessive work hours, poor nutrition, and inadequate rest.

Diet

• Follow a vegetarian or predominantly vegetarian diet: vegetarian women have been shown to excrete two to three times more estrogen in their feces and have 50% lower levels of estrogen in their blood than omnivorous women:
• These differences are thought to result from the lower fat and higher fiber intake of a vegetarian diet and may also explain the lower incidence of breast cancer, heart disease and menopausal symptoms in vegetarian women.
• Increase consumption of soy foods: soy foods contain phytoestrogens (plant estrogens) whose estrogenic effect is only 2% as strong as that of human estrogens. When these phytoestrogens bind to estrogen receptors, they prevent human estrogens from doing so, thus decreasing overall estrogenic effects.
• Eat less saturated fat and cholesterol by reducing or eliminating meat and dairy products. Avoid the hydrogenated or trans fats in margarine and many processed foods:
• Diet low in fat, especially saturated fat, has been shown to dramatically reduce circulating estrogen levels – changing from a diet composed of 40% of calories as fat and only 12 g of fiber to a diet consisting of 25% of calories as fat and 40 g of fiber daily resulted in a 36% reduction in blood estrogen levels in 8–10 weeks.
• A low-fat diet has also been shown to relieve PMS symptoms.
• Saturated and trans fats are used to produce the types of prostaglandins that promote inflammation and pain.
• Limit consumption of animal protein sources to 110–175 g (4–6 oz) q.d.
• Eliminate red meat, which promotes the absorption of estrogen from the intestines.
• Choose wild-caught cold-water fish, such as salmon, several times a week. In addition to protein, cold-water fish contain anti-inflammatory omega-3 fats. Wild-caught is preferred over farm-raised since wild fish contain higher amounts of omega-3 fats.
• If eating chicken, remove the skin, preferably before cooking.
• Increase consumption of fiber-rich plant foods (fruits, vegetables, grains, legumes): a higher intake of dietary fiber promotes the excretion of estrogens both directly and indirectly by nourishing the friendly intestinal bacteria that produce lower levels of betaglucuronidase (the enzyme that frees estrogen bound for excretion and sends it back into circulation).
• Eliminate high-sugar foods:
• When high-sugar foods are eaten alone, blood sugar levels rise quickly, producing a strain on blood sugar control.
• Sugar, especially when combined with caffeine, has a detrimental effect on PMS and mood. The most significant symptom-producing food in PMS appears to be chocolate, which contains sugar, saturated fat and caffeine.
• A high intake of sugar impairs estrogen metabolism and is associated with higher estrogen levels and higher frequency of PMS.
• Read food labels carefully. Sugar can appear as sucrose, glucose, maltose, lactose, fructose, corn syrup, or white grape juice concentrate.
• Eliminate caffeine: especially if anxiety or depression, or breast tenderness and fibrocystic breast disease are major symptoms. Considerable evidence shows that caffeine consumption is strongly related to the presence and severity of PMS (caffeine is found in sodas, chocolate, and tea, as well as coffee).
• Monitor salt and potassium consumption: keep salt intake below 1,800 mg and increase intake of foods high in potassium. Excessive salt consumption, especially when coupled with diminished dietary potassium, stresses the kidneys’ ability to maintain proper fluid volume, leading to fluid retention and, in sensitive individuals, high blood pressure:
• If water retention is a problem, consuming potassium-rich foods can have a beneficial diuretic effect.
• Potassium is found in fresh fruits, vegetables (especially green leafy vegetables), whole grains, and beans.
• Salt (as sodium) is found in most processed foods.
• Reduce exposure to environmental estrogens in food: a variety of toxic pesticides including DDT, DDE, PCB, PCP, dieldrin, and chlordane are known to mimic estrogen in the body and are thought to be a major factor in the growing epidemics of estrogen-related health problems including PMS, breast cancer and low sperm counts:
• These chemicals are hard to break down and are stored in fat cells – another reason to avoid meat, cheese, whole milk, and eggs.
• Whenever possible, choose organically grown foods. Even in conventionally grown produce, however, the presence of pesticides in fruits and vegetables is much lower than levels found in animal products, plus the various antioxidant compounds of fruits and vegetables help the body deal with the pesticides.
• Eat small meals at regular intervals throughout the day to keep blood sugar on an even keel.

Nutritional supplements

• A high-potency multiple vitamin and mineral supplement: this should include 400 ?g of folic acid, 400 ?g of vitamin B12, and 50–100 mg of vitamin B6. (folic acid supplementation should always be  accompanied by vitamin B12 supplementation to prevent folic acid from masking a vitamin B12 deficiency):
• Many PMS symptoms are caused by deficiencies of the nutrients needed for normal hormonal regulation
• A daily multiple providing all of the known vitamins and minerals provides a foundation upon which to build an individualized PMS treatment program.
• Vitamin B6: in the early 1970s, vitamin B6 was successfully used to treat depression caused by birth control pills, and since then, the effectiveness of vitamin B6 in relieving PMS has been studied in at least a dozen double-blind clinical trials:
• Although vitamin B6 supplementation alone was found to benefit most PMS patients, some did not improve. These negative results may result from the inability of some women to convert B6 to its active form (pyridoxal-5-phosphate) because of a deficiency in another nutrient needed for the conversion (e.g., riboflavin or magnesium) that was not supplemented.
• To overcome this potential conversion problem, supplementation with a multiple vitamin and mineral as described above is recommended. In addition, vitamin B6 can be supplemented in its active form (pyridoxal-5-phosphate).
• Caution: one-time doses of greater than 2,000mg q.d. can produce symptoms of nerve toxicity in some individuals:
• Chronic intake of more than 500 mg of B6 q.d. can be toxic over many months or years.
• Although quite rare, toxicity has been reported at chronic long-term dosages as low as 150mg q.d.
• Toxicity is thought to result from supplemental pyridoxine overwhelming the liver’s ability to add a phosphate group to produce the active form of vitamin B6 (pyridoxal-5-phosphate).
• Magnesium: magnesium plays such an integral part in normal cellular function that magnesium deficiency alone can account for many of the symptoms attributed to PMS, and red blood cell magnesium levels have been shown to be significantly lower in PMS patients than normal subjects:
• Estrogen increases the uptake of magnesium in bone and soft tissues (which helps to explain why estrogen protects young women against osteoporosis and heart disease, as well as women’s increased risk of these diseases during and after menopause when estrogen levels drop). However, when estrogen levels are too high, as they frequently are in PMS, too much magnesium is transferred into bone and soft tissue, leaving too little available for many types of cells to function normally.
• Magnesium stabilizes cellular membranes, activates more than 300 cellular enzymes, and is involved in the production of ATP, the energy currency of the body.
• Magnesium interacts extensively with vitamin B6 in many enzyme systems and is also dependent upon B6 to gain entry into cells. One of the primary ways in which vitamin B6 relieves symptoms of PMS is by increasing levels of magnesium within cells.
• A low magnesium state triggers cells to release stress hormones and other substances that promote inflammation and pain, and can impair circulation.
• Four independent studies have now confirmed that intracellular magnesium is chronically depleted in women with PMS and that it is a major predisposing factor to luteal-phase emotional instability, excessive nervous sensitivity, generalized aches and pains, and a lower premenstrual pain threshold.
• Supplementation with magnesium alone has been shown to dramatically reduce PMS-related mood changes, nervousness, breast tenderness and weight gain.
• In several studies, when PMS patients were given a multivitamin and mineral containing high doses of both magnesium and vitamin B6, they experienced a tremendous reduction in PMS symptoms.
• Magnesium bound to aspartate or one of the Krebs cycle intermediates (malate, succinate, fumarate, or citrate) is preferred since these forms are better absorbed and have fewer laxative side effects.
• For best results, magnesium should be taken with vitamin B6
• Calcium: women with PMS frequently have reduced bone mineral density, and studies have shown improvements in mood, concentration, and lowered water retention with supplementation of calcium and manganese (1,336 mg and 5.6mg, respectively):
• Animal research suggests that calcium improves altered hormonal patterns, neurotransmitter levels, and smooth muscle responsiveness in PMS.
• Caution: high calcium intake due to high milk consumption is a possible causative factor of PMS via the amalgamation of calcium with vitamin D and phosphorous in milk since this combination reduces the absorption of magnesium.
• Avoid calcium derived from oyster shells, dolomite or bone meal; studies have indicated that these calcium supplements may contain substantial amounts of lead, a toxic metal that primarily affects the brain, kidney and manufacture of red blood cells.
• Calcium hydroxyapatite, which is basically a purified bone meal, should also be avoided. Not only is it derived from bone meal (a high lead source of calcium), but comparison studies have also shown that it is not as well absorbed (only 20% absorption) as either calcium carbonate or calcium citrate (both of which have a 30% absorption rate).
• Zinc: in women with PMS, zinc levels have been shown to be low:
• Zinc is involved in the control of hormone secretion and is required for the proper action of many hormones, including sex hormones:
• Specifically, zinc is one of the control factors for prolactin secretion – low zinc levels promote prolactin release; high zinc levels inhibit prolactin release.
• High prolactin levels have been correlated with PMS symptoms.
• Zinc is particularly helpful in lessening premenstrual acne
• Take zinc with food to prevent stomach upset.
• If taking more than 30 mg q.d. for more than 1 month, also take 1–2 mg of copper q.d. to maintain proper mineral balance. (This amount of copper should be present in the daily multiple.)
• Vitamin E: double-blind studies have demonstrated significant reductions in breast tenderness, weight gain, anxiety, headaches, cravings for sweets, depression, insomnia, and fatigue with vitamin E supplementation. Higher energy levels have also been noted:
• Caution: avoid D-alpha-tocopherol, which is synthetic vitamin E.
• Flaxseed oil: women with PMS frequently exhibit essential fatty acid and prostaglandin abnormalities
• The abnormality most often reported is a decrease in gamma-linolenic acid (GLA):
• GLA is derived from linoleic acid in a conversion that requires adequate vitamin B6, magnesium, and zinc levels, as these nutrients are all necessary components of delta-6-desaturase, the key enzyme responsible for the conversion.
• Studies using GLA supplements in the forms of evening primrose oil, blackcurrant, and borage oil have, however, failed to show benefits. A better approach is to provide the nutrients necessary for proper essential fatty acid metabolism along with an excellent source of essential fatty acids, such as flaxseed oil.

Botanical medicines

• Angelica sinensis (dong quai): angelica, a uterine tonic with beneficial phytoestrogenic effects, is particularly helpful in, in addition to PMS, women who experience painful menstruation (dysmenorrhea). The pre-eminent female remedy in Asia, Angelica is used to treat menopausal symptoms (especially hot flashes); painful, abnormal or lack of menstruation; and to assure a healthy pregnancy and delivery:
• To treat PMS, begin taking Angelica on day 14 and continue until menstruation begins.
• If dysmenorrhea is experienced, continue taking Angelica until the menstrual flow has stopped.
• Glycyrrhiza glabra (licorice root): particularly useful in treating water retention associated with PMS, licorice blocks the effects of aldosterone, the adrenal hormone that reduces sodium excretion, thus causing water retention (edema). In addition, licorice lowers estrogen levels, while raising progesterone levels by inhibiting the enzyme responsible for breaking down progesterone:
• Licorice lessens the effects of aldosterone in much the same way that it impacts estrogen, via its chief component, glycyrrhetinic acid, which binds to aldosterone receptors, but its activity is only about one-fourth as strong as aldosterone. The result in cases of high aldosterone (as often occur in PMS) is a lessening of aldosterone’s effect.
• Caution: if aldosterone levels are normal, chronic ingestion of licorice in large doses can result in symptoms of aldosterone excess – high blood pressure due to sodium and water retention. Prevention of this potential side effect may be possible by following a high-potassium, low-sodium diet (the diet recommended above for PMS). Patients who normally consume high-potassium foods and restrict sodium intake, even those who have high blood pressure and angina, have been reported to be free of the aldosterone-like side effects of glycyrrhizin:
• To err on the side of safety, licorice should probably not be used by patients with a history of hypertension, renal failure, or who are currently using digitalis preparations.
• Cimicifuga racemosa (black cohosh): a special extract of Cimicifuga standardized to contain 1 mg of
  triterpenes calculated as 27-deoxyactein per tablet (trade name: Remifemin) has been used in Germany for over 40 years and has been found to be a safe and effective natural alternative to HRT, as well as offering
  benefits in PMS:
• In one study of 135 women, Remifemin “performed very well” in reducing feelings of depression, anxiety, tension, and mood swings.
• Black cohosh is also recommended for patients with uterine fibroids.
• Vitex agnus-castus (chasteberry): the most popular herbal used in treating PMS in Germany, chasteberry has been evaluated in studies involving more than 1,500 women. One-third of the women experienced complete resolution of their symptoms; another 57% reported significant improvement; 90% reported symptom improvement or resolution:
• Chasteberry, which affects the function of the hypothalamus and pituitary, is able to normalize the secretion of hormones; for example, it reduces the secretion of prolactin and lowers the estrogen-toprogesterone ratio, making it especially useful in cases of prolactin excess or corpus luteum insufficiency.
• Chasteberry is particularly recommended if there is PMS-associated breast pain, infrequent periods, or a history of ovarian cysts.
• Chasteberry may resolve amenorrhea (lack of menstruation) resulting from prolactin excess, but it takes about 3 months for chasteberry to lower prolactin levels.

Drug–herb interaction cautions

• Glycyrrhiza glabra (licorice):
• Plus digoxin, digitalis: due to a reduction of potassium in the blood, licorice enhances the toxicity of cardiac glycosides. Interaction with these cardiac glycoside drugs could lead to arrhythmias and cardiac arrest.
• Plus stimulant laxatives or diuretics (thiazides, spironolactone or amiloride): licorice should not be used with these drugs because of the additive increase of potassium loss to potentially dangerous levels.
• Vitex agnus-castus (chasteberry):
• Plus birth control pills: might interfere with efficacy of birth control pills because of its hormoneregulative actions.

ICIM Medics Approach

If you feel that this article relates to you then please make an appointment for your Female Hormone Assessment : http://icimmedics.com/medical-assessments/female-hormone-assessment/

The results from the assessment can then be used by one of our Natural Medical Practitioners who will help you with your individualised treatment plan. This may include dietary, nutritional and/or botanical advice.

Should other underlying issues be suspected such as digestive related problems, liver or gall bladder imbalances or thyroid related problems, other assessments can be structured for the patient such as :
http://icimmedics.com/medical-assessments/digestive-assessment/ , http://icimmedics.com/medical-assessments/thyroid-function-assessment/ 
 
This article is not meant to be used for treatment but for information purposes only. If you feel that this approach is appropriate for you please contact ICIM Medics on 045 844 819 or www.icim.ie e-mail : info@icim.ie  The necessary appointments can be arranged for you.

Tags: Menstural Cycle, PMS, Premenstrual Syndrome