• Recurrent signs and symptoms that develop during the 7 to 14 days prior to menstruation
• Typical symptoms include decreased energy level, tension, irritability, depression, headache, altered sex drive, breast pain, backache, abdominal bloating, and swelling of the fingers and ankles
Premenstrual syndrome (PMS) is estimated to affect between 30 and 40% of menstruating women, with peak occurrences among women in their 30s and 40s. In most cases, symptoms are relatively mild. However, in about 10% of all women, symptoms can be quite severe. Severe PMS, with depression, irritability, and extreme mood swings, is referred to as premenstrual dysphoric disorder (PMDD).
Signs and Symptoms of Premenstrual Syndrome
• Nervousness, anxiety, and irritability
• Mood swings and mild to severe personality change
• Fatigue, lethargy, and depression
• Abdominal bloating
• Diarrhea and/or constipation
• Change in appetite (usually cravings for sugar)
Breasts and reproductive system
• Tender and enlarged breasts
• Uterine cramping
• Altered libido
• Swelling of fingers and ankles
The Normal Menstrual Cycle
In order to appreciate the hormonal abnormalities that have been found in some women with PMS, it is important to briefly review the normal menstrual cycle. The menstrual cycle reflects the monthly rhythmic changes in the secretion rates of the female hormones and corresponding changes in the lining of the uterus and other female organs.
The menstrual cycle is controlled by the complex interactions of the hypothalamus, pituitary, and ovaries. Each month during the reproductive years, the secretion of various hormones is designed to accomplish two primary goals: (1) ensure that only a single egg is released by the ovaries each month, and (2) prepare the lining of the uterus (the endometrium) for implantation of the fertilized egg. To accomplish these goals, the concentrations of the primary female sexual hormones, estrogen and progesterone, fluctuate during the menstrual cycle.
The control center for the female hormonal system is the hypothalamus, a region of the brain roughly the size of a cherry, situated above the pituitary gland and below another area of the brain called the thalamus. The hypothalamus and pituitary gland are housed in the middle of the head just behind the eyes. The hypothalamus 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 hypothalamus, the pituitary gland releases follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSH is the hormone primarily responsible for the maturation of the egg during the first phase of the menstrual cycle. It is called follicle-stimulating hormone because each egg within the ovary is housed inside an individual follicle. LH is responsible for initiating ovulation, the release of the fully developed egg.
The release of LH is triggered by increasing estrogen levels as a result of the growing follicle. After ovulation, the eggless follicle is transformed into the corpus luteum, which functions primarily to secrete 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, menstruation occurs approximately two weeks later, and the entire menstrual cycle begins anew.
The usual menstrual cycle is completed in about a month. It is divided into three phases, in order of occurrence: follicular, ovulatory, and luteal. The follicular phase lasts for 10 to 14 days, the ovulatory phase lasts for about 36 hours and involves the release of the egg, and the luteal phase lasts for 14 days.
Because of the complex interrelationships among the components of the endocrine system, disorder of any of the individual parts of the system (pituitary, ovaries, adrenals, thyroid, parathyroids, and pancreas) can lead to menstrual abnormalities and/or PMS. For example, low thyroid function (hypothyroidism) and elevated levels of cortisol (an adrenal hormone) are common in women with PMS.
Prolactin, another hormone produced by the pituitary, also plays an important role in PMS and female infertility. Prolactin’s chief function is to promote the development of the mammary glands and milk secretion during pregnancy and nursing. Increased production of prolactin in lactating women can inhibit the maturation of the follicles in the ovaries, thus delaying the return of fertility after childbirth. In nonlactating women, elevated levels of prolactin are often linked to cases of PMS, menstrual abnormalities, ovarian cysts, breast tenderness, and absence of ovulation.
Hormonal Patterns in Women with PMS
There is no consistent alteration in hormonal patterns among PMS patients compared with women who have no symptoms of PMS. For many years it was commonly believed that women with PMS experienced elevated estrogen levels and reduced progesterone levels 5 to 10 days before the menses, increasing the ratio of estrogen to progesterone. While this association is no longer accepted in the medical literature as a causative factor in most cases of PMS, it may be a factor for some women. Other factors in some cases of PMS may include hypothyroidism, elevated prolactin levels, elevated FSH levels six to nine days prior to the onset of menses, and excessive amounts of aldosterone (a hormone produced by the adrenal glands that leads to sodium and water retention).
The dominant belief now is that PMS is the result of alterations in brain chemistry that affects the brain’s sensitivity to hormones. Lower levels of the neurotransmitter serotonin are most often suggested as the underlying issue in PMS. The influence of serotonin on mood and behavior is fully discussed in the chapter “Depression.” It is thus not surprising that recent research and therapy have focused on the use of antidepressant drugs for PMS, particularly the selective serotonin reuptake inhibitor drugs such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil). Interestingly, many of the natural antidepressant agents also show benefits in PMS.
Even though it is now understood that there is no significant disturbance in serum estrogen or progesterone levels in most cases of PMS, it is possible that a relative excess or insufficiency of either hormone may have an effect on the central nervous system. Owing to the lack of scientific understanding in this area and to clinical experience with improving estrogen metabolism in women with PMS, it is still something to be considered. The bottom line is that there is no single cause of PMS; rather, each woman needs to understand her unique imbalances, which then need to be addressed.
In the early 1940s, Morton Biskind, M.D., observed an apparent relationship between B vitamin deficiency and PMS.1,2 He postulated that PMS, as well as fibrocystic breast disease, was due to an elevation in estrogen levels caused by decreased detoxification and elimination of estrogen in the liver as a result of B vitamin deficiency.
There appears to be support for Biskind’s theory. Estrogen excess is known to produce cholestasis (diminished bile flow or “sluggish liver”). Cholestasis reflects minimal impairment of liver function because normal indicators of liver status (such as concentrations of the liver enzymes in the blood) are not elevated. These enzyme measurements, the conventional means of assessing liver status, are not very useful, however, as they serve only to indicate liver damage, being elevated only when the liver cells are leaking enzymes. Because of the liver’s important role in numerous metabolic processes, even a minor impairment of liver function can have profound effects.
Cholestasis can be caused by a large number of factors besides excess estrogen, chief among them being obesity and/or insulin resistance (see the chapter “Non-Alcoholic Fatty Liver Disease (NAFLD)/Non-Alcoholic Steatohepatitis (NASH)”). The presence of cholestasis may be a predisposing factor in PMS, because with cholestasis there is reduced estrogen detoxification and clearance, producing a positive feedback cycle. The high incidence of gallstones and non-alcoholic fatty liver disease is a clear indication that many American women suffer from cholestasis.
One study found a direct correlation between the estrogen/progesterone ratio and endorphin activity in the brain.3 In essence, when the estrogen/progesterone ratio increased, there was a decline in endorphin levels. This reduction is significant considering the known ability of endorphins to normalize or improve mood. Other studies have shown that low endorphin levels during the luteal phase are common in women with PMS.4 Endorphins are lowered by stress and raised by exercise. The role of endorphins is discussed further later.
The way in which estrogen levels during the luteal phase negatively affect neurotransmitter and endorphin levels may be connected to the way in which estrogen impairs the action of vitamin B6. Vitamin B6levels are typically quite low in depressed patients, especially women taking estrogens (birth control pills or conjugated estrogens such as Premarin).5,6 Vitamin B6 supplementation has been shown to have positive effects on all PMS symptoms, particularly depression, in many women (discussed in greater detail later). Historically, this improvement was thought to be the result of a combination of a reduction in estrogen levels and an increase in progesterone levels in the mid-luteal phase. Now, however, the possible explanation centers on the influence of B6 on brain chemistry. Vitamin B6 has the ability to increase the synthesis of several neurotransmitters in the brain, including serotonin, dopamine, norepinephrine, epinephrine, taurine, and histamine.
Women suffering from PMS typically eat a diet that is even worse than the standard American diet. Compared with the diets of symptom-free women, the diets of PMS patients are more likely to feature the following:7
• 62% more refined carbohydrates
• 275% more refined sugar
• 79% more dairy products
• 78% more sodium
• 53% less iron
• 77% less manganese
• 52% less zinc
A diet that is high in dairy products may also contribute to some PMS symptoms. A survey of 39 women with PMS and 14 women without reported that the women with PMS consumed five times more dairy products and three time more refined sugar than the women without PMS.8 Another study observed that women with PMS tend to have an increased intake of dietary fat, carbohydrates, and simple sugars and a decreased protein intake.9
Food cravings are also more often present in women with PMS; this may in part be due to a decrease in serotonin during the luteal phase in PMS sufferers. Serotonin-enhancing treatments (e.g., 5-HTP) may be helpful in controlling such food cravings.10
Another nutritional factor in PMS is the effect of refined sugars. These produce a rapid increase in insulin, which then causes the retention of sodium and subsequent water retention, resulting in swelling in the hands and feet, abdominal bloating, and breast engorgement. Sugar, especially combined with caffeine, has a detrimental effect on mood (discussed later).11 A high intake of sugar also impairs estrogen metabolism. The evidence is based on the higher frequency of PMS symptoms in women consuming a high-sugar diet and the fact that a high sugar intake is also associated with higher estrogen levels.12 One study found that a low-fat, high-complex-carbohydrate diet alleviated premenstrual breast tenderness.13 Of course, eating sugar and other refined carbohydrates results in increased cravings for more when blood sugar levels drop, creating a vicious circle. (See the chapter “Hypoglycemia” for a more complete discussion.)
C-reactive protein, a marker of inflammation, has been correlated with the severity of both physical and psychological symptoms of PMS.14 A diet that includes large amounts of sugar, poultry, eggs, cheese, milk, white flour, white rice, and partially hydrogenated oils stimulates inflammatory pathways. Foods that can reduce inflammation include fresh fruits (especially berries), green leafy vegetables, fish, nuts, seeds, turmeric, garlic, and onions.
Vegetarian women have been shown to excrete two to three times more estrogen in their feces and to have 50% lower levels of free estrogen in their blood than omnivores.15,16 These differences are thought to be due to vegetarians’ lower fat consumption and higher fiber intake. These dietary differences may also explain the lower incidence of breast cancer, endometriosis, and uterine cancer in vegetarian women, and perhaps play a role in PMS.
At the very least, women suffering from PMS should lower saturated fat and cholesterol intake by reducing consumption of animal foods and increasing consumption of fiber-rich plant foods (fruits, vegetables, whole grains, and legumes).
Decreasing the percentage of calories as fat, in particular saturated fat, has dramatic effects on the reduction of circulating estrogen.17,18 In one study, when 17 women switched from the standard American diet (40% of calories from fat and only 12 g fiber per day) to a low-fat, high-fiber diet (25% of calories from fat and 40 g fiber per day), there was a 36% reduction in blood estrogen levels, with 16 out of the 17 women demonstrating significant reductions in only 8 to 10 weeks.19
It should be noted that not all nutrition research shows a clear-cut association with PMS. In the Study of Women’s Health Across the Nation, a cross-sectional analysis was conducted of PMS symptoms in a multiethnic sample of 3,302 midlife women.20 The researchers sought to determine if the frequency of physical or emotional premenstrual symptoms was associated with dietary intake of phytoestrogens, fiber, fat, or calcium; consumption of alcohol or caffeine; exposure to cigarette smoke; lack of physical exercise; and race/ethnicity or socioeconomic status. In this study, most dietary factors did not appear to be related to PMS. A lower fat intake was associated with food cravings and bloating. A higher fiber intake was associated with a reduction in breast pain. Alcohol intake was negatively associated with anxiety, mood changes, and headaches. Exposure to cigarette smoke, whether passive or active, was associated with cramps and back pain. Ethnic differences in the reporting of symptoms and in associations with other medical conditions were observed as well.
Low thyroid function (hypothyroidism) has been shown to affect a large proportion of women with PMS.21,22 For example, in one study, 51 of 54 subjects with PMS demonstrated low thyroid status compared with 0 of 12 in the control group.23 In another study, 7 of 10 subjects in the PMS group had low thyroid status compared with 0 of 9 in the control group.22 Other studies have shown hypothyroidism to be only slightly more common in women with PMS than in controls.23,24 Many women with PMS and confirmed hypothyroidism who are given thyroid hormone experience complete relief of symptoms.21 For more information, see the chapter “Hypothyroidism.”
Study of the interaction of stress/serotonin and PMS has shown that serotonin levels in women with PMS fall after ovulation. Those without PMS had much higher levels of serotonin during the last half of the menstrual cycle.25 A key factor may be how women with PMS handle stress, as many women with PMS tend to employ negative coping styles, including:26
• Watching too much television
• Emotional outbursts
• Excessive behavior
• Dependence on chemicals
Drugs, legal or illicit
There are also some important relationships between PMS and depression. Depression is a common feature in many cases of PMS, and PMS symptoms are typically more severe in depressed women. The reason appears to be a decrease in the brain level of various neurotransmitters, with serotonin and GABA being the most significant.27,28 The standard medical approach to both PMS and depression involves antidepressant drugs. However, various psychotherapy methods have been equally if not more successful in improving the psychological aspects of PMS. In particular, biofeedback and short-term individual counseling (especially cognitive therapy) have documented clinical efficacy.29,30 One of the advantages of these therapies over antidepressant drug therapy in the treatment of PMS is that learning better coping skills can produce excellent results that are maintained over time.
Several studies have shown that women who engage in regular exercise do not suffer from PMS nearly as often as sedentary women.31–33 In one of the more thorough studies, mood and physical symptoms at various points during the menstrual cycle were assessed in 97 women who exercised regularly and in a second group of 159 women who did not exercise.31 Mood scores and physical symptoms showed that exercise significantly decreased negative mood states and physical symptoms. The regular exercisers had significantly lower scores for impaired concentration, negative mood, unwanted behavior changes, and pain.
In another study, 143 women were monitored for 5 days in each of the three phases of their cycles.32 The group included 35 competitive athletes, two groups of exercisers (33 high-frequency exercisers and 36 low-frequency exercisers), and 39 sedentary women. The high-frequency exercisers experienced the greatest positive mood scores and sedentary women the least. The high-frequency exercisers also reported the least depression and anxiety. The differences were most apparent during the premenstrual and menstrual phases. These results are consistent with the belief that women who exercise frequently (but not competitive athletes) are protected from PMS symptoms. In particular, regular exercise protects against the deterioration of mood before and during menstruation.
These studies provide convincing evidence that women with PMS should engage in regular exercise. Exercise may reduce PMS symptoms by a number of different mechanisms, including elevating endorphin levels.34
The first use of vitamin B6 in the management of cyclic conditions in women was in the successful treatment of depression caused by birth control pills, as noted in several studies in the early 1970s. These results led researchers to try to determine the effectiveness of vitamin B6 in relieving PMS symptoms. Since 1975 at least a dozen double-blind clinical trials have been performed. Some of these studies have shown no effect, but most of the studies have demonstrated a significant effect on the whole range of PMS symptoms at dosage ranges from 50 to 500 mg per day.35 For example, in one double-blind crossover trial, 84% of the subjects had a lower symptom score during the B6treatment period.36 In another double-blind crossover trial, 50 mg per day of B6 was effective in decreasing premenstrual depression, fatigue, and irritability.37
Although B6 supplementation alone appears to benefit most patients, not all double-blind studies of vitamin B6 have shown a positive effect.35,38 Additional support may be required. For example, the negative results in some trials may have been caused by the inability of some women to convert B6 to its active form, pyridoxal-5-phosphate (P5P), owing to a deficiency in another nutrient (e.g., vitamin B2 or magnesium) that was not supplemented.
We do not feel that high dosages of B6 are necessary or a good idea. For most indications, the therapeutic dosage of vitamin B6 is 50 to 100 mg per day. A single dose of 100 mg pyridoxine did not lead to significantly higher pyridoxal-5-phosphate levels in the blood than a 50-mg dose, possibly indicating that a 50-mg oral dose of pyridoxine is about all the liver can handle at once.39 We recommend a dosage of 25 to 50 mg twice per day. This dosage level is well below any reported toxicity. If you do not see enough improvement, then try 15 mg per day of the more expensive P5P.
Another mechanism by which vitamin B6 may improve the symptoms of PMS is by increasing the accumulation of magnesium within body cells.40 Without vitamin B6, magnesium does not get inside the cell. Magnesium deficiency has been implicated as a causative factor in PMS.41 Red blood cell (RBC) magnesium levels have been shown to be significantly lower in patients with PMS than in normal subjects.42Because magnesium plays such an integral part in normal cell function, magnesium deficiency may account for the wide range of symptoms attributed to PMS. Furthermore, magnesium deficiency and PMS have many common features, and magnesium supplementation has been shown to be an effective treatment for PMS. In one study involving 32 women with PMS, 360 mg magnesium three times per day was given from midcycle to the onset of menstrual flow.43 Relief of premenstrual mood fluctuations and depression during magnesium treatment was significant.
The most recent study designed to improve understanding of the association between magnesium and the menstrual cycle measured plasma, RBC, and mononuclear blood cell (MBC) magnesium concentrations in 26 women with confirmed PMS and in a control group of 19 women during the follicular, ovulatory, early luteal, and late luteal phases of the menstrual cycle.44 Although there were no significant differences in plasma magnesium levels between PMS patients and control subjects and there was no menstrual cycle effect on plasma magnesium, women with PMS had significantly lower RBC magnesium concentrations than those in the control group, and this finding was consistent throughout the menstrual cycle.
The observation of low RBC magnesium concentrations in patients with PMS has now been confirmed by four independent studies. In general, it is thought that women with PMS have a “vulnerability to luteal phase mood state destabilization”44 and that chronic intracellular magnesium depletion serves as a major predisposing factor.
In addition to emotional instability, magnesium deficiency in PMS is characterized by excessive nervous sensitivity, with generalized aches and pains and a lower premenstrual pain threshold. One clinical trial of magnesium in PMS showed a remarkable reduction of nervousness in 89% of subjects, of breast tenderness in 96%, and of weight gain in 95%.7 In another double-blind study, high-dose magnesium supplementation (360 mg three times per day) was shown to dramatically relieve PMS-related mood changes.43
Although magnesium has been shown to be effective on its own, even better results may be achieved by combining it with vitamin B6 and other nutrients. Several studies have shown that when PMS patients are given a multivitamin/multimineral supplement containing high doses of magnesium and pyridoxine, they experience a substantial reduction in PMS symptoms.45,46
The optimal intake of magnesium should be based on body weight, 6 mg/kg. For a 110-lb woman, the recommendation would be 300 mg; for a 200-lb. woman, 540 mg. Because these dosages are difficult to achieve by diet alone, supplementation is recommended. In the treatment of PMS, a dosage of twice this amount, 12 mg/kg, may be needed.
Magnesium bound to aspartate, citrate, fumarate, malate, glycinate, or succinate is preferred to magnesium oxide, gluconate, sulfate, or chloride because of better absorption and less chance of a laxative effect.47,48
Calcium has emerged as a common nutrient to supplement for PMS. Because calcium deficiency can actually mimic some PMS symptoms, supplemental calcium has been tested as a treatment. An important multicenter clinical trial was conducted with 479 women who were given either 1,200 mg calcium carbonate or a placebo for three menstrual cycles.49 A significantly lower symptom score was observed in the calcium group during the luteal phase of the cycle for both the second and the third cycles. By the end of the third cycle, calcium resulted in a 48% reduction in total symptom scores from baseline compared with a 30% reduction in the placebo group. Other studies also show improvements in PMS symptoms with calcium supplementation (1,000 to 1,336 mg).50,51 In one of the later studies, calcium and manganese supplementation (1,336 and 5.6 mg, respectively) improved mood, concentration, and behavior. In another study, 1,000 mg per day improved mood and water retention.50
Zinc levels have been shown to be low in women with PMS.52 Zinc is required for proper action of many body hormones, including the sex hormones, as well as in the control of the synthesis and secretion of hormones. In particular, zinc serves as one of the control factors for prolactin secretion.53 When zinc levels are low, prolactin release increases; high zinc levels inhibit this release. Hence in high-prolactin states, zinc supplementation is very useful. An effective dosage range for zinc supplementation for elevated prolactin levels in women is 30 to 45 mg in the picolinate form.
Although vitamin E research concerning PMS has focused primarily on breast tenderness, significant reduction of other PMS symptoms has also been demonstrated in double-blind studies.7,54 Nervous tension, headache, fatigue, depression, and insomnia were all significantly reduced. In one double-blind study, patients receiving vitamin E (400 IU per day) demonstrated a 33% reduction in physical symptoms (such as weight gain and breast tenderness), a 38% reduction in anxiety, and a 27% reduction in depression after three months of use.54 In contrast, the placebo group reported only a 14% reduction in physical symptoms. The group taking vitamin E also noted higher energy levels, fewer headaches, and fewer cravings for sweets.
Essential Fatty Acids
Women with PMS have been shown to exhibit essential fatty acid and prostaglandin abnormalities, the chief abnormality being a decrease in gamma-linolenic acid (GLA).55 Evening primrose, blackcurrant, and borage oils contain GLA, typical levels being 9%, 12%, and 22%, respectively. Although these essential fatty acid sources are quite popular, the research on GLA supplements in the treatment of PMS shows no benefit over placebos. In the four double-blind, controlled crossover trials of evening primrose oil, this issue may be complicated by a very high response in the placebo group.56,57 One of these studies used 3 g per day and the others used 4 g per day. A meta-analysis of the clinical trials of evening primrose oil concluded that it is of little value in the management of PMS.56
A better recommendation for PMS will probably turn out to be fish oils, given the benefits of the long-chain omega-3 fatty acids EPA and DHA in depression (see the chapter “Depression”). As of this writing, there are no clinical studies of fish oil supplementation for PMS despite considerable evidence of possible benefits.
Multivitamin and Multimineral Supplements
Given the numerous nutrients demonstrating benefit in PMS, it is clear that a high-quality multivitamin/multimineral supplement providing all of the known vitamins and minerals can serve as a foundation on which to build. Women with PMS have two very sound reasons for taking a high-potency multiple vitamin: nutritional deficiency is relatively common among women with PMS, and high-potency multivitamin/multimineral formulations have been shown to have significant benefits in PMS.
The frequency of nutritional supplementation and the calculated intake of selected nutrients have been shown to be much lower in patients with PMS than in normal women.16 Several double-blind studies have shown that patients with PMS who were given a multivitamin/multimineral supplement containing high doses of magnesium and pyridoxine experienced reductions (typically of at least 70%) in symptoms.45,46
As discussed earlier in this chapter, decreases in serotonin may be the cause of PMS or at least may exacerbate PMS. Tryptophan is a precursor to serotonin. Studies using tryptophan in doses of 6 g per day for 17 days from ovulation to day three of menses demonstrated significant reductions in mood swings, insomnia, carbohydrate cravings, tension, irritability, and dysphoria.58,59 However, we feel that a stronger recommendation is the use of 5-HTP—the intermediate compound between tryptophan and serotonin—which can be used at much lower dosages and with greater efficacy. The benefits of 5-HTP in low-serotonin conditions is detailed in the chapter “Depression.”
Chasteberry (Vitex agnus-castus) is native to the Mediterranean and has long been used for women’s health. Chasteberry extract is probably the single most important herb in the treatment of PMS, not only because of its long tradition of use but also as a result of modern scientific research. In two surveys of gynecological practices in Germany, physicians graded chasteberry extract as good or very good in the treatment of PMS. More than 1,500 women participated in the studies.60,61 One-third of the women experienced complete resolution of their symptoms, and another 57% reported significant improvement.
The beneficial effects of chasteberry in PMS and certain other conditions appear to be related to profound effects on the hypothalamus and pituitary function. As a result, it is able to normalize the secretion of various hormones—for instance, reducing the secretion of prolactin and reducing the estrogen-to-progesterone ratio.
In one of the more recent studies, a double-blind trial compared 20 mg of chasteberry extract standardized for casticin with a placebo in 170 women with PMS over three consecutive menstrual cycles.62Women were asked to rate changes in PMS symptoms, such as irritability, mood changes, anger, headache, breast tenderness, and bloating. At the end of the trial, women taking the chasteberry reported a 52% overall reduction in PMS symptoms, compared with only 24% for those taking the placebo. Women taking the chasteberry extract reported significantly greater reductions in irritability, mood changes, anger, headache, and breast tenderness than the women taking the placebo; bloating was the only symptom that did not change significantly. Another study has looked at the effectiveness of chasteberry extract vs. fluoxetine (Prozac) in decreasing PMS symptoms and found the two treatments to have comparable results, with the main difference being that fluoxetine was more effective in treating psychological symptoms and chasteberry was more effective with physical symptoms.63 Additional well-designed studies show a significant advantage of chasteberry extract in moderate to severe PMS.64
A combination of Saint-John’s-wort extract and chasteberry extract was studied in the treatment of PMS-like symptoms in women approaching menopause.65 This clinical trial was conducted over 16 weeks, and information rating PMS scores in perimenopausal women who were experiencing irregular menses was collected at 4-week intervals. Results for the active treatment group were statistically superior to those for the placebo group for total PMS symptoms as well as subgroups of PMS-related depression and food cravings.
In the first randomized placebo-controlled clinical trial evaluating ginkgo biloba extract in PMS, 165 women of reproductive age who had fluid retention, breast tenderness, and vascular congestion were assigned to receive either ginkgo biloba at 80 mg twice per day or a placebo from day 16 of one cycle to day 5 of the next. Symptom diaries kept by patients and physician evaluation of symptoms demonstrated that ginkgo biloba extract was effective against the congestive symptoms of PMS, particularly breast pain and breast tenderness.66
In a subsequent study, 85 women were given ginkgo biloba extract (40 mg three times per day) or a placebo from day 16 of one cycle to day 5 of the next. Overall severity of symptoms in the ginkgo group was 34.80 before the treatment and fell to 11.11 after the treatment (comparable rates in the placebo group were 34.38 and 25.64).67
Saint-John’s-wort (Hypericum perforatum) is frequently used for depression because of its influence on raising serotonin, so it should not be surprising that this herb would be an important botanical in the treatment of PMS. In a double-blind trial of 36 women with regular menstrual cycles and mild PMS the women were randomly assigned to receive Saint-John’s-wort extract (900 mg per day and standardized to 0.18% hypericin and 3.38% hyperforin) or a placebo for two menstrual cycles.68 After a one-month washout period, the women were crossed over to the opposite group for two additional cycles. Saint-John’s-wort was statistically more beneficial than the placebo in relieving food cravings, swelling, poor coordination, insomnia, confusion, headaches, crying, and fatigue. Saint-John’s-wort was not statistically more beneficial for anxiety, irritability, depression, nervous tension, mood swing, feeling out of control, or pain-related symptoms during two cycles of treatment. However, these pain-related symptoms appeared to improve more than with the placebo toward the end of each treatment period.
In an observational study, 19 women who were diagnosed with PMS completed a daily symptom rating questionnaire for one menstrual cycle and underwent a screening interview with physicians. The participants then took Saint-John’s-wort extract daily for two complete menstrual cycles.69 The degree of improvement in overall PMS scores between the beginning of the study and the end was 51%, with more than two-thirds of the women having at least a 50% decrease in the severity of symptoms. The mood subscale showed the most improvement (57%); the specific symptoms with the greatest reductions in scores were crying (92%), depression (85%), confusion (75%), feeling out of control (72%), nervous tension (71%), anxiety (69%), and insomnia (69%).
Saffron (Crocus sativus L.) has been shown to have an antidepressant effect in women with mild to moderate depression, so again it is not surprising that it would be beneficial in PMS. A double-blind placebo-controlled trial was done to study whether saffron could be used to relieve PMS symptoms. Fifty women of reproductive age with regular menstrual cycles and PMS symptoms for at least the last six months were randomly assigned to receive 15 mg saffron twice per day or a placebo twice per day for four full menstrual cycles.70 According to daily symptom reports, 19 of the 25 women in the saffron group responded with at least a 50% reduction in severity of symptoms vs. only 2 of 25 in the placebo group. A significant difference between the saffron and the placebo groups occurred between the third and fourth cycles and was statistically significant by the end of the study. Based on a depression rating scale, 15 of 25 women in the saffron group responded to treatment vs. only 1 of 25 in the placebo group.
Saffron, which is the dried stigmas of the flowers, can be very expensive, so we recommend using extracts prepared from the petals of the saffron crocus. Please see the discussion on saffron in the chapter “Depression” for more information.
• Premenstrual syndrome (PMS) is estimated to affect between 30 and 40% of menstruating women.
• There is no consistent alteration in hormonal patterns among PMS patients compared with women who have no symptoms of PMS.
• The dominant thought now is that PMS is the result of alterations in brain chemistry that influence many factors, including the sensitivity of the brain to hormones.
• Impaired liver function could lead to reduced levels of serotonin in the brain, lower endorphin levels, impaired vitamin B6 activity, and alterations in other hormone levels.
• The primary nutritional recommendations for PMS are to increase consumption of plant foods (vegetables, fruits, legumes, whole grains, nuts, and seeds), consume small to moderate quantities of meat and dairy products, reduce fat and sugar intake, eliminate caffeine intake, and keep salt intake low.
• Low thyroid function (hypothyroidism) has been shown to affect a large percentage of women who have PMS.
• Most women who have PMS tend to employ negative coping styles to deal with stress.
• Vitamin B6 and magnesium are the two most important nutritional supplements for treating PMS.
• Exercise is extremely helpful in eliminating PMS.
• Chasteberry extract is probably the single most important herb in the treatment of PMS.
• Ginkgo biloba extract is well known for its effects in improving blood flow to the brain, and it has also been shown to be of great benefit in PMS in several clinical trials.
• Saint-John’s-wort extract and saffron have also shown benefits in relieving PMS symptoms.
Dealing with PMS usually requires a comprehensive plan involving many general health-improving strategies. Diet, lifestyle, attitude, and proper nutritional supplementation are all very important in reducing symptoms. PMS has many diverse causes and treatments, so each woman needs to learn which therapies work best for her unique needs.
The dietary recommendations in the chapter “A Health-Promoting Diet” are important in PMS. It is very important to avoid salt, eat a low-glycemic Mediterranean-style diet, increase consumption of fiber-rich plant foods (fruits, vegetables, grains, legumes, nuts, and seeds), and avoid caffeine and alcohol.
Lifestyle and Attitude
• Exercise at least 30 minutes at least three times a week.
• Spend 10 to 15 minutes per day on relaxation or stress reduction techniques.
• Follow the recommendations in the chapter “A Positive Mental Attitude.”
• A high-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”
• Key individual nutrients:
Vitamin B6: 100 mg per day
Magnesium (aspartate, citrate, malate, succinate, or glycinate: 250 mg two times per day
Zinc: 15 to 20 mg per day
Vitamin E (mixed tocopherols): 400 IU per day
Vitamin C: 500 to 1,000 mg per day
Vitamin D3: 2,000 to 4,000 IU per day
• Fish oils: 1,000 mg EPA + DHA per day
• One of the following:
Grape seed extract (>95% procyanidolic oligomers): 100 to 300 mg per day
Pine bark extract (>95% procyanidolic oligomers): 100 to 300 mg per day
Some other flavonoid-rich extract with a similar flavonoid content, super greens formula, or another plant-based antioxidant that can provide an oxygen radical absorption capacity (ORAC) of 3,000 to 6,000 units or more per day
• 5-HTP: 50 to 100 mg three times per day
• One or more of the following:
Chasteberry: tablets or capsules standardized for 0.5% agnuside, 175 to 225 mg per day; liquid extract, 2 to 4 ml (1/2 to 1 tsp) per day
Saint-John’s-wort extract (0.3% hypericin content): 600 to 1,800 mg per day, or from day 17 of one menstrual cycle through day 3 of the next
Ginkgo biloba extract (24% ginkgo flavonglycosides): 240 to 320 mg per day
Saffron petal extract: 15 mg twice per day