PMS 101 - Know Thyself
Imagine a disease as old as humanity ... acutely distressing to both body and mind ... afflicting half the population at least a dozen times per year ... its very existence reputed until recently - yet even today nobody understands exactly how it works!
What is PMS (PMDD)?
Physical Symptoms of PMS
Mental Symptoms of PMS
What Causes PMS
Defining characteristics of PMS
Diagnosing PMS: How Do You Feel?
Treating PMS - Chart Up!
Multi-faceted Treatment Plan
PMS Treatment - Lifestyle
PMS Treatment - Exercise & Fitness
PMS Treatment - Nutrition
Vitamins, Minerals, and Supplements
PMS Treatment - Herbs & Supplements
A word about herbs and supplements
PMS Treatment: Hormone Therapy
Bio-Identical Hormone Therapy
PMS Treatment - Alternative Medicine
PMS Treatment: Anti-Depressants
PMS Treatment: Other Medications
The Last Word: Hope
PMS (Pre Menstrual Syndrome): The physical and psychological symptoms that occur in the week before a woman’s menstrual period. (health.webmd.aol.com)
Well, that’s a start, but we still haven’t answered the question: what is it? Ahem ... ah ... well, actually we don’t quite have 100% agreement on that point… While some folks think it’s hormonal, others say it’s nutritional. Some people believe it’s genetic, and still others are convinced that it’s all in your head! Most physicians generally agree that PMS can be defined as a set of conditions, cyclical in nature, producing both physical and mental symptoms, linked to the hormonal changes of the female reproductive cycle. That’s better; but I should add that there are approximately as many variations on PMS as there are women reporting them. Psychiatrists, naturally, felt compelled to devise the (more “psychiatric” sounding?) name “PMDD” (Premenstrual Dysphoric Disorder), however most physicians agree the two definitions refer to the same set of conditions.
Over 150 symptoms have now been associated with the disorder. However, to minimize confusion, we shall list only the most commonly reported.
Weight gain
Bloating, fullness
Edema (water retention)
oliguria (reduced urination)
Sensitive, painful breast
Joint and muscle pain
Cramps, diarrhea, constipation
Pelvic discomfort
Vaginal dryness, discomfort
Heart palpitations
Sweating
Skin problems (acne, oily skin)
Unwanted Hair (or) Hair loss
Greasy or dry hair
Headache
Anger, Irritability
Anxiety
Frustration
Sadness, Impulsive Crying
Mood swings (severe or frequent)
Insomnia (or) hypersomnia
Sluggishness, fatigue
Dizziness, light-headed, vertigo
Paresthesia (tingling sensations)
Decreased sexual desire
Decreased concentration, indecision
Food (and other) cravings
After a great deal of study (and millions of patients) PMS’s defining characteristics and patterns are well known. While disagreement exists regarding the best way to treat PMS, agreement is fairly universal that the group of conditions results from hormonal changes (i.e. declines) just prior to menstruation. However, the exact mechanism of this action - and why so many symptoms result - remains a mystery!
Defining characteristics of PMS TOP
Cyclic Pattern: The most obvious characteristic of PMS. Symptoms are usually most severe a few days after ovulation - and there should be a symptom free time period 1 week after menstruation ends. If symptoms occur during this time, other conditions should be considered.
Broad Spectrum of Effect: Why do PMS symptoms affect some patients profoundly and not others? At one end of this spectrum some women may reach the point of dysfunction - while others notice only mild discomfort.
Genetic Component: If a patient’s mother or sister has PMS symptoms, then her chances of having them are much greater.
Mind and Body: PMS affects both the body and mind, giving rise to a holistic treatment philosophy.
Neurotransmitters: Some physicians have linked PMS to reduced levels of gaba and Serotonin resulting in depression - which can be treated by supplements.
Turbulence: PMS often increases at times of hormonal turbulence, for example, puberty, childbirth, after miscarriage or pregnancy termination or changes in contraception.
Child birth: Women who experience postnatal illness are more prone to PMS.
Gradual worsening: Women aged 30-45 years often experience most severe PMS.
Pre-existing: PMS often makes pre-existing conditions worse.
Diagnosing PMS: How Do You Feel? TOP
Few conditions frustrate mainstream physicians more than PMS. It has no clear cause, a multitude of diverse symptoms all found in other disorders, no simple test, no drug or surgical cure ... and finally, it eventually cures itself! (after menopause) Even today some physicians actually doubt its existence. (Undoubtedly they are male physicians!)
PMS symptoms mimic other conditions, (PCOS, Perimenopause, pcd, etc.) and these need to be ruled out. Additionally, your history and physical information should rule out autoimmune disease, vascular disease, seizures, endometriosis and other problems. In addition checking your thyroid (tsh), blood work for diabetes and anemia may be required. In some cases a psychometric written test can be useful to determine whether depression, anxiety or panic disorder are creating or exacerbating your symptoms.
The key to the PMS diagnosis is the cyclical nature of the disorder. If we cannot identify a symptom-free period at some time during the patient’s cycle - usually about 1 week after menstruation ends - we must consider other problems. (Symptoms during pregnancy or after menopause also indicate other problems)
Since there is no “PMS Test” certain diagnosis is greatly aided by the patient’s ability to “listen” to her body and communicate her impressions and feelings to her physician.
Since there is no “PMS pill”, successful treatment will again require diligent patient self-examination and good communications between doctor and patient.
There are many treatments and strategies for treating PMS as a whole, and for zeroing-in on specific symptoms. The starting point for PMS treatment is determining what your body needs, and what it responds to best.
Chart Your Symptoms: the first step is to chart your symptoms throughout your entire cycle, noting the type, duration, intensity, and possible trigger of each symptom. This chart will become a powerful reference in your treatment plan for both you and your physician.
- Copy the list of symptoms (above) down the left margin of a sheet (leaving room for several columns to the right).
- Check or underline each of the symptoms you experience. (Add any not listed to the bottom)
- Next to each symptom, first, rank the severity: mild, moderate, or severe.
- Next note the time of occurrence relative to your cycle.
- Next to that, note any events that seemed to trigger that symptom. Do certain stresses have more impact? Do certain foods impact you differently at these times?
- Leave empty space at the end of each line, or underneath. (will be used to note treatment and result).
Multi-faceted Treatment Plan TOP
A Multifaceted or “holistic” approach is generally the best for dealing with the multiple and overlapping symptoms of PMS. Using your Symptom Chart, you can first identify the most severe symptoms, then select treatments from the options listed below that make sense for you. Be sure to try options from all the major categories, because some categories of treatment are more effective for certain symptom groups.
Its OK - in fact quite necessary - to experiment with the various options, being sure to fastidiously note the results in your next chart. In other words, you will create a new Symptom chart for each cycle going forward, noting the treatments used and resulting changes to the symptom(s).
Activity and Stress: When are you taking on your biggest stresses? Since you have “better” times and “worse” times throughout the day, try and adjust your schedule to take the pressures off during the times you are least able to cope. (i.e. when your symptoms are peaking) The object of time/stress management isn’t always easy given the demands of work and family, but you can probably make a few positive adjustments.
Stress Reduction: helpful practices range from prayer and meditation to simple breathing exercises and other relaxation techniques, to tai chi and yoga. The benefits of these techniques may not seem apparent at first - in fact, the perceived drop in energy makes some people feel anxious. This sensation passes however, and you will learn to use the relaxed moments to refresh and reinvigorate yourself. Imagine awakening from a good night’s sleep twice each day ... that’s the purpose of these “waking naps.”
PMS Treatment - Exercise and Fitness TOP
Studies show that women who exercise regularly tend to have milder PMS symptoms. Not surprising, since exercise is a proven mood elevator, besides being vital for long-term and overall health. We suggest you get started with a low impact aerobic exercise program, at least 3 30-minute sessions per week. If your PMS symptoms make the exercises unappealing or downright painful, try a lighter version, such as dancercise, or for that matter, swimming or a room full of treadmill machines.
The choice is your’s. The benefits are real - but you will have to work for them. (Remember: better late than never and a little is infinitely more than nothing.) Finally, you don’t have to do it all at one sitting. Consider dividing your workout into 2 or 3 10-minute periods throughout the day.
Reflection: Through the lens of PMS, many women say they gain a deeper understand of themselves, and their relationships with others. They can use the period of heightened sensitivities to put their feelings and responses in perspective. (Silver linings have turned up in stranger places!)
Sleep: get as much as possible.
Smaller, Frequent Meals: Smaller, more frequent meals are recommended particularly as you near menopause. Consider 6 small meals per day. Research indicates that rapid changes in blood sugar wreaks more PMS havoc than a more constant level. Skipping a meal can result in a blood sugar drop which releases adrenaline into the bloodstream, likely to send moods off the map. Overeating or binging on sweets and carbs will bounce the blood sugar, inviting bloating fatigue and irritability which PMS will probably magnify.
Carbohydrates and Serotonin: According to MIT researcher judith wurtman, during PMS the brain becomes deficient in the mood controlling neurotransmitter Serotonin. As any women who has experienced PMS knows, intense food cravings often result. Dr. Wurtman’s work contributed to the development of antidepressant drugs specifically designed for PMS (PMDD) patients, (discussed below). “Dr. judy” also suggests you can give your brain a boost by laying off proteins and fat. Her formula for brainy bliss is five parts carbohydrate for one part protein. (our protein suggestion: turkey or tuna) High in complex carbohydrates, this snack should do an good job stimulating the brain’s production of PMS-relieving serotonin!
Craving and Comfort: If your brain is screaming “chocolate chip cookies” what it really means is “serotonin, please!” You can grant that wish just as thoroughly by eating a complex carb, (e.g. a lovely bean-curd and tofu on rye crisp) and avoid the blood sugar havoc created by a sugar/fat delight. However, a small “comfort foods” treat on occasion isn’t out of the question. (After all, the object is to feel better!) Enjoy a hot cup of soup, fruit, or a sugar-free sherbert! (Well, maybe one medium choc-chip - but just one!)
Vegetarian diet: Minimizing fat in your diet should ease PMS symptoms, but if you decided to go “vegan”, make the change gradual or the plan could backfire. Your body needs time to adjust to the new menu.
Caffeine, alcohol: Substantially reduce or eliminate these to reduce bloating, fatigue, tension and depression.
Water: Since water retention is a problem with PMS, many patients avoid drinking it. The opposite is true. Drinking more water will flush the body and prevent retention.
Salt: Reducing salt the week before your period helps reduce bloating and fluid retention - however if you are thin and have low blood pressure, use caution. If you feel weak or dizzy the week prior to menses, take salt normally.
PMS Treatment - Vitamins, Minerals, and Supplements TOP
Start with an adult multi-vitamin that includes iron, then the following are optional.
Vitamin B-6: (Pyridoxine) no more than 100 mg per day - The most powerful of the B-vitamins for reducing PMS symptoms. B6 plays a vital role in the body’s utilization of carbohydrates, fats, and proteins and is also important to the proper function of the nervous system; has beneficial effect on brain chemistry; Reduces water retention
Vitamin B-complex: is also used in some PMS formulations, in combination with B-6.
Vitamin E: 600-800 units per day - Good for sore breasts. Improves oxygen utilization and limits free radical damage. Note: check the label - “mixed tocopherols” are preferable to “alpha tocopherol,” which is preferable to “D,L-” which is synthetic.
Calcium: 1000-1500mg/day - May be abnormally low during the luteal phase of the menstrual cycle in patients with PMS - can relieve cramping, backache, and nervousness. Suggest using one with Vitamin-D included, (600-800IU) calcium doesn’t work for everyone, but it’s good for your bones.
Magnesium: (Mg) 500-1000mg/day - Supports the action of both calcium and B-6. Also helps to normalize the metabolism of sugar and stabilize moods. (dose conservatively, has been known to cause diarrhea)
PMS Treatment - Herbs & Supplements TOP
Botanical remedies have been reported helpful for many symptoms of PMS. The trick is finding what works for your PMS, then fine tune the dose and master the preparation. A few problems with herbs and botanicals:
- Information can be sketchy and incomplete.
- Quality can be poor or inconsistent
- Low availability of quality research on most products
- Much usage information is exaggerated or inaccurate.
- Since they are not regulated, Caveat Emptor applies.
- The ideal source would be a degreed medical professional. Others ("herbalists") may be useful, however check credentials and reputation.
American (Wisconsin) ginseng (Panax ginseng). This form is suitable for women. There are innumerable brands and not all are reliable. Some are adulterated with caffeine. Avoid the very expensive forms sold in Chinese stores unless you are a ginseng expert. Stick with an established brand with a good reputation.
Agnus castus: A very powerful hormone regulating herb, and hence it should be used with care. Those using oral contraceptive or HRT should ideally seek medical advice before use. Not recommended for persons with history of hormonal imbalance. If you suffer from pain around the time of ovulation or you have a family history of ovarian cysts - do not take this herb unless under the guidance of a medical herbalist or trained physician. Regular use is not suitable for women under 20 years of age. If you feel safe to take this herb it can be a fantastic remedy for the classic symptoms of PMS.
Black cohosh: Useful when PMS occurs around time of perimenopause. A Herb tonic to enhance any reduction in nervous tension and anxiety. Do not use if allergic to aspirin.
DLPA: As directed - Lifts depression, associated with PMS
Dong Quai: Used by millions of Chinese women as a tonic, said to relieve PMS symptoms including pain, bloating, vaginal dryness, and depression. Often taken in soups. Western studies have not proven benefit. Long term safety is unknown.
Siberian ginseng: (Eleutherococcus) May be useful for improving energy.
Evening primrose oil. Said to help reduce breast tenderness, requires 3 months to work, Omega 3 EFAs should be included in diet and meat consumption reduced. .
St John’s Wort: (Hypericum) This is widely used for mood problems. Onset is gradual and there are rumors of liver problems.
Liquorice tea: Taken in the second half of the cycle liquorice is said to reduce estrogen and increase progesterone levels. It also nourishes the adrenal glands. Do not take liquorice if you have high blood pressure or suffer from severe water retention. In mild cases of water retention it may be beneficial if taken in moderate amounts.
L-phenylalanine: This is converted in the brain to several important neurotransmitters. Not much published but experience suggests it can help.
L-tryptophan: has good reports, however safety is currently a concern due to contaminated shipments. The FDA has withdrawn - do not risk using until these problems are resolved.
Vitex: (chaste tree or chaste berry). Best supported by research. Test subjects reported help with breast tenderness, edema, inner tension, headache, constipation, and depression.
A word about herbs and supplements. TOP
Not all vitamins, minerals and herbs are absolutely safe. At high doses, some vitamins have produced unforseen and damaging effects. In an unregulated industry contamination can be a problem.
We recommend a conservative approach. Although some health food stores urge the purchase of many different products, we recommend limiting your use to one or two herbs plus two-three vitamins and/or minerals concurrently. Check with your doctor about potential conflicts with any prescription medications you may be taking. Give new products time to prove themselves.
PMS Treatment: Hormone Therapy TOP
Over the counter “natural hormone creams:” While these may provide minor, temporary relief from a few symptoms; they are not effective hormone therapy. The reason: they are not true bio-identical hormones. They can be called “natural” because they are derived from organic plants (e.g. yam and soy) however their hormone-like natural ingredients are not nearly as effective as the true bioidentical hormones available only by prescription. Their minimal, unpredictable effects tend to fade quickly resulting in escalating cost with diminishing returns - unregulated quality, and dosing difficult to control and maintain.
PMS Treatment: Bio-Identical Hormone Therapy TOP
Available only via prescription, FDA approved bio-identical Hormones consist of estradiol, micronized progesterone and micronized testosterone. The active hormones are extracted from soy and yam oils via purifying and concentrating pharmaceutical processes, graded and distributed in crystaline powder form to compounding pharmacies.
In our experience bio-identical hormones can be the most powerful PMS treatment, because the address the basis of the problem: shifting/declining hormones. The key to success, as always, is dosing. It is therefore imperative that you work with a physician or practitioner experienced in using bio-identical hormone therapy with a compounding pharmacist. Your physician should evaluate your history and physical, including a special blood workup on your reproductive and other hormones, and use the findings to determine the correct dosing protocol. You will begin a schedule of supplements taken at times during your cycle to compensate severe hormonal shifts. Some adjustment may be necessary before the ideal individualized protocol is reached. However, when that happens, you should be very pleased with the result.
Note: Bio-identical hormones are not, and should not be confused with synthetic hormones such as Premarin or Prempro, which are extremely powerful, not bio-identical, (they are made from conjugated horse urine and other chemicals) and should never be used to treat PMS.
PMS Treatment - Alternative Medicine TOP
Acupuncture: may be worth a try, however it is time consuming and expensive. Be sure your practitioner is reputable, licensed and uses disposable needles. Also, needles should not be inserted in chest wall.
Acupressure massage: another ancient Oriental healing method, applies finger pressure to specific points on the skin surface to help prevent and treat illness. Acupressure has been used to help relieve the cramps, bloating, fluid retention, weight gain, and low back pain relating to their menstrual cycle.
Massage: Massage has proven therapeutic benefit, but treatments must be repeated, adding to the expense. Shop around, bearing in mind the efficacy of treatment will depend entirely on the skill of your therapist.
Fasting and detoxification: Fasting an ancient healing practice from India and other eastern countries. However, fasting has risks including negative mood changes and a weakening of the bodies defenses over time. If you decide to try this, please proceed with common sense and caution. Slender women and those with hypoglycemic tendencies may not tolerate it well. We suggest working with an experienced, licensed practitioner who can (an integrative physician) help you design a safe fast that is well suited to your metabolism.
PMS Treatment: Anti-Depressants TOP
By “antidepressant” we actually refer to a class of drug called SSRIs (selective serotonin reuptake inhibitors), developed by MIT researchers about 25 years ago. Prosaic is probably the most recognizable name in this category - and is classified as an antidepressant. However SSRIs are also being used to treat PMS symptoms in women who are not otherwise clinically depressed - with good results. Drugs such as Sarafem (licensed in 2000) were designed specifically for treating severe PMDD (PMS), and can provide significant reduction in symptoms such as low energy, mood-swings, irritability, and concentration problems.
The decision to sue SSRIs is a serious one that we don’t believe necessary for everyone - especially as a first step in PMS treatment. We would suggest trying other methods first, while reserving the use of drugs like Serafem as a last resort. However, if you have been struggling with PMS for some time, and feel you are losing ground, then an SSRI may offer the relief you need.
On the other hand, if your PMS symptoms are mild enough to usually “take in stride” then supplements and other treatments will probably suffice. Antidepressants are not addictive. You can try them, and stop at will without experiencing “withdrawal symptoms” or other ill effects.
Note: do not take Sarafem if you’re currently taking another type of antidepressant called a “MAO inhibitor.” Examples include Isocarboxazid, Phenelzine, and Tranylcypromine.
PMS Treatment: Other Medications TOP
NSAIDs: including Advil (ibuprofen), Alleve (Naproxen), and Motrin can reduce cramps and other discomforts. Be sure to take these with food, and if you have pre-existing gastric or liver problems, consult your physician first. Alternatively, there are more powerful prescription versions of these available as well. Prescription pain-killers can also provide powerful relief, however due to their habit-forming nature, many physicians are reluctant to use these when many alternatives exist.
Diuretics: (aka “water pills") rid your body of excess fluid by dehydrating you - which also stresses your body, then triggers another cycle of fluid retention. If fluid retention is a big problem, you might consider a mild diuretic. However we suggest avoiding powerful ones such as Lasix (furosemide) which may “put you through the wringer”.
Tranquilizers: (Benzodiazepines) trade names include Valium, Xanax, Serax, Ativan, Klonopin, Librium and Tranxene - these may alleviate depressive and anxiety symptoms in some patients. We do not recommend their use however, because they are addicting, and can produce severe withdrawal symptoms - in extreme cases: death.
GnRH agonist: shown to benefit a broad range of symptoms in most patients. However it increases the risk for osteoporosis and should used only for a short time. Hormonal add-back therapy can also be administered in a low dose to reduce this issue.
Spironalactone: A steroid with diuretic and antiandrogen properties, has been used for quite some time - however results have been mixed.
PMS can be a confusing, frustrating, sometimes disheartening condition ... but whatever you do - don’t give up. PMS almost always gets better when patients and physicians persist. Follow the instructions outlined above with a positive, creative attitude; keeping open to change and new ideas.
Don’t go it alone: Find help. Trained health care professionals who care about PMS are out there, and waiting to help you. This is one of the most important, positive steps you can take. Try to remember: you are not alone and help is available.