Definition. Premenstrual Syndrome (PMS) is a recurring condition consisting of one or more troublesome symptoms that occur 7 to 14 before the onset of menstruation. Typical symptoms of PMS would include any combination of the following:
- Nervousness, anxiety, irritability, mood swings, depression.
- Abdominal bloating, change in bowel function, cravings.
- Tender, swollen breasts, uterine cramping.
- Headache, backache, acne, swelling.
In order to be classified as PMS, the symptoms must begin 1 to 2 weeks prior to menstruation, and resolve at or shortly after the beginning of menstruation.
A variety of hormonal changes have been identified in patients with PMS, particularly an increase in the ratio of estrogen to progesterone. Abnormalities of thyroid function and in the production of prolactin, a milk producing hormone, have been identified. Many patients with PMS show a deficiency of Vitamin B6. But, a single, easily explained cause has yet to be found, making it difficult to arrive at a treatment suitable for most patients.
The diagnosis is made on the basis of a history, and it is made more reliable by keeping a symptom diary, noting the severity and timing of the symptoms in relation to a period. A PMS questionnaire exists to further aid in the diagnosis.
When the diagnosis is not certain, diagnostic studies can be done to assist in the diagnosis, or to rule out other conditions. These can be blood tests, typically done on the 21st day after a period, or they can be salivary tests, which are typically done on day 28. A full evaluation to work-up PMS would consist of:
- A complete blood count (CBC).
- Chemistry profile (electrolytes, liver function, kidney function, lipids).
- Thyroid evaluation.
- Serum prolactin, progesterone, and estrogen.
- Serum FSH and LH to evaluate pituitary and ovulatory function.
TREATMENT OF PMS
There is no single treatment for PMS that is effective for all patients. Due to the complex and varied array of symptoms found in different patients, treatment is individualized. As well, we believe that effective treatment should be comprehensive, holistic, and balanced, and should involve several different areas. General treatment recommendations can be given as follows:
“TRADITIONAL” MEDICAL TREATMENT:
A number of medical treatments are given for PMS. For patients with depression and anxiety as strong components of their PMS, anti-depressants such as Prozac and Zoloft are prescribed, and these have recently been approved by the FDA for use in treating PMS. Diuretics are prescribed for patients with significant fluid retention, bloating and edema. A number of hormonal therapies have been used for PMS, such as suppression of ovulation with oral contraceptives, as well as progesterone supplementation, but the research on the effectiveness of these treatments show mixed results.
It is our opinion that dietary changes are critical if improvement in symptoms is expected. These dietary changes also produce an added benefit by lowering the risk of breast cancer and heart disease. The dietary recommendations are summarized as follows:
- Follow a predominantly vegetarian diet.
- Reduce the intake of fat.
- Reduce or eliminate the intake of sugar.
- Increase the intake of soy.
- Eliminate the intake of caffeine.
- Reduce the intake of Sodium (salt).
- Avoid exposure to environmental estrogens.
This recommendation is based on the finding that patients who follow a near vegetarian diet, with increased amounts of fruits, vegetables, and legumes, and minimal ingestion of animal fat, have increased elimination of estrogen from the body, thereby reducing the estrogen/progesterone ratio. Studies have shown that when patients with PMS follow such a diet, an improvement in symptoms is seen.
Guidelines for such a diet would include limiting consumption of animal protein to 4 to 6 ounces per day, with most of that coming from fish, poultry, and lean meats. It is also advised to increase fiber intake to 40 grams per day, to help further the elimination of estrogen from the body.
The goals of this dietary advice can essentially be met by following the guidelines set forth by the USDA in their Food Pyramid.
REDUCED FAT INTAKE:
The best advice is to eliminate all intake of fat from animal sources. Short of that, fat intake should be limited, as above to 4 to 6 ounces a day of animal protein, and the calories from fat intake should account for no more than 25% of total calories. Saturated fat intake should be minimized in favor of polyunsaturated fat. Butter is to be discouraged in favor of Canola oil or olive oil. The advice on fat consumption also comes from the finding of greater elimination of estrogen from the body and an improved estrogen/progesterone ratio.
REDUCED SUGAR INTAKE:
The best advice is no consumption of refined sugars such as you would find in prepared sweets: candy, cookies, doughnuts, cakes etc., and which are also found in beverages and other prepared foods. Refined sugars will be listed on labels as: glucose, sucrose, maltose, lactose, fructose and corn syrup. Carbohydrates are allowed but should be complex rather than simple or refined.
The most symptom-producing food in PMS seems to be chocolate.
INCREASED CONSUMPTION OF SOY:
This recommendation comes from the known estrogenic action of the phytoestrogens contained in soy. These phytoestrogens bind to estrogen receptors in the body, and prevent natural estrogens from binding to these receptors. However, phytoestrogens produce only about two percent of the estrogenic effect of natural estrogens, thereby reducing the estrogen/progesterone ratio. Increasing the intake of soy can be difficult, but prepared soy products are commercially available, as are recipes and cooking tips on preparing meals with soy.
ELIMINATION OF CAFFEINE INTAKE:
This recommendation is easier to accomplish, by eliminating consumption of products containing caffeine, such as coffee, chocolate, colas, etc. Continued use of caffeine by patients with PMS has been linked to the severity of their psychological symptoms of anxiety, irritability, mood swings, and depression, as well as breast tenderness.
REDUCED SODIUM INTAKE: This is especially helpful for patients troubled with bloating, breast tenderness, and swelling. Sodium restriction involves more than not adding salt to your food. It requires attention to the sodium content of the food itself, and involves reading labels and limiting sodium intake to 1800 mg per day, which of necessity puts a limit on the use of most prepared and processed foods. At the same time, an increase is recommended in the intake of potassium containing foods, such as fresh fruits, vegetables, and whole grains.
AVOID EXPOSURE TO ENVIRONMENTAL ESTROGENS:
There are a number of chemicals used as pesticides and herbicides that mimic the effects of estrogen in the body, thereby increasing the estrogen to progesterone ratio. Patients with PMS may benefit by avoiding the ingestion of these chemicals. This is best accomplished by purchasing organically grown foods.
VITAMIN AND MINERAL SUPPLEMENTATION:
Supplementation with Vitamin B6 has been shown to be of benefit to most patients with PMS, especially those with psychological symptoms. The recommended dose for supplementation is 50-100 mg per day. Higher doses over long periods of time can produce neurological toxicity (resulting in tingling, numbness, loss of muscle coordination.)
Magnesium plays a crucial role in cellular metabolism, and deficiencies can produce a wide array of symptoms. Magnesium supplementation has been shown to be beneficial in patients with PMS. The recommended dose is 12 mg per kg of body wt (1 kg = 2.2lbs.), which would range from approximately 600-1000 mg per day, depending on weight.
Calcium supplementation has been found to improve the mood, behavior, concentration, and fluid retention in patients with PMS. The recommended dose is 1000 mg per day, which is the same amount advised to premenopausal women for osteoporosis prevention.
Women with PMS have been shown to have lower levels of zinc compared to controls. Supplementation is especially helpful for reducing breast tenderness and breast engorgement. The recommended dose is 15-20 mg per day.
Supplementation with Vitamin E, an anti-oxidant, has been shown improve the symptoms of breast tenderness, irritability, headache, fatigue, depression, and insomnia in patients with PMS. The recommended dose is 400 IU per day.
A practical way of providing the vitamins and minerals mentioned above would be:
- A Multi-Vitamin Supplement with minerals daily.
- A Calcium Supplement of 1000-1500 mg per day.
- Vitamin B6 as above, if troubled by symptoms of mood disturbance.
- Vitamin E supplementation as above as an anti-oxidant.