Your Guide to Relief from PMS

by Dr. Kyle Chavers, MD, IFMCP

Functional Medicine Treatments for PMS

Did you know that about 80% of women experience PMS and that in 20 to 40% of women, the symptoms are severe?

PMS, or premenstrual syndrome, is a hormonal disorder in which certain physical or psychological symptoms occur during the two weeks before your period up until the beginning or slightly after the beginning of the menstrual flow. So for some women, this is over half the month of sometimes debilitating symptoms that most commonly include mood swings, tender breasts, food cravings, fatigue, headaches, irritability and depression. And in addition to the symptoms most commonly associated with PMS, over 150 additional symptoms have been identified as part of this syndrome.

These include but are not limited to: bloating, weight gain, muscle aches, joint pain, sleep disturbances, low libido, constipation or diarrhea, anxiety, difficulty concentrating, withdrawal from family and friends, acne, dizziness, and even bleeding gums, vision changes and decreased hearing!

Many women experience some form of PMS from the time of their first period, but this is not always the case.

There are some factors that may bring about this condition later in life:

• Oral Contraceptives or “birth control pills”, due to the synthetic progestins (synthetic form of progesterone)
• Pregnancy, as your hormones may not always rebalance after delivery
• Miscarriage and abortion
• Tubal ligations—studies have shown after tubal ligation women have higher estrogen and lower progesterone during the second half of their cycle. This is abnormal and leads to the symptoms of PMS.
• Partial hysterectomy—when the uterus is removed, part of the blood supply to the ovaries is cut off, leading to hormonal dysfunction
• Age—as we get older and enter the peri-menopausal years, progesterone begins to decline leading to symptoms of PMS.
• But isn’t PMS just a normal part of life? NO! But what do we do about it? Conventionally, SSRIs are used to treat both the physical and psychological symptoms of PMS. This option should be considered only if the functional medicine therapies have failed or for the severe form of PMS known as PMDD, or premenstrual dysphoric disorder.

As with all other conditions managed from a functional medicine prospective, treating PMS takes into consideration lifestyle factors such as nutrition, exercise, and stress. It involves identifying nutritional and hormonal imbalances and correcting those with lifestyle changes when possible and using supplements and botanical treatments when necessary.

Functional Medicine Treatments for PMS

1. Dietary changes
   • Eliminate refined carbohydrates, refined sugars, and dairy. Sugar in particular decreases magnesium in the body. Magnesium is calming and lower levels are associated with anxiety, which is a common symptom of PMS. Sugar also causes a rapid increase in insulin, which leads to fluid retention, edema and breast engorgement. In addition, sugar may impair the metabolism of estrogen and high estrogen in some women is associated with PMS.
   • Increase protein intake.
   • Increase fiber intake, which will help the body properly metabolize or break down estrogen.
   • Eat regularly through the day, meals or snacks containing good fats (e.g. avocados, nuts, olive oil) and protein, to maintain an even blood sugar. Aim for 6 small meals a day.
   • Avoid caffeine and alcohol. In addition to the adrenal disrupting effects of these substances, they are also antagonists to B vitamins.
   • Avoid excess sodium consumption. Water retention and edema are often issues with PMS so try to incorporate natural diuretics such as strawberries and parsley, but avoid prescription diuretics, as these tend to age and dry out the skin.
   • Increase water intake to at least ½ ounce per pound of body weight per day (e.g. a 140 lb female would drink at least 70 ounces of water per day).
   • Consider eating an anti-inflammatory Mediterranean diet. An elevated CRP, which is a marker for inflammation, has been correlated with physical and psychological symptoms of PMS.
2. Supplementation
   • Calcium carbonate 600mg twice a day has been shown to reduce PMS by 50 percent.
   • Magnesium glycinate 400-600mg per day. This one is so important! Women with PMS in general tend to have lower levels of magnesium, in addition to eating more sugar due to cravings, which lowers the level even more. And many of the symptoms of magnesium deficiency are the same as PMS! Anxiety, Depression, Irritability, Headaches. Food sources of magnesium include pumpkin seeds, Brazil nuts, halibut, quinoa, spinach, almonds and quinoa.
   • Vitamin B6— this vital nutrient is required for Magnesium to get into the cells. It is a cofactor for more than 100 enzymatic reactions in the body, many of which are related to neurotransmitter function (think anxiety and depression). It also naturally increases progesterone. Studies show that the combo of magnesium and B6 improve PMS symptoms better than either nutrient by itself. Aim for 50 to 100 mg per day with no more than 200mg per day. Excess estrogen in the body, as seen in the perimenopausal period and in those taking birth control, depletes the body of B6. If you are on ANY type of estrogen replacement, you should consider taking a B-complex. In general, B6 may help with edema, bloating, headache, breast pain, depression, irritability, and possibly acne.
   • Vitamin A —This nutrient is a diuretic, an antioxidant and it combats stress and fatigue. Adequate amounts are often included in a good quality multivitamin. We recommend this one.
   • Vitamin E— In amounts found in your multivitamin, Vitamin E may improve anxiety, depression and sugar cravings.
   • L-Tryptophan— Studies have shown that in patients with PMS, this amino acidnimproves mood swings, insomnia, carb cravings, tension and irritability. We recommend 500-1000 mg daily taken on an empty stomach with carbs, starting on day 14 of your cycle until day 3 of your period. This must be used with caution in patients on an SSRI.
   • Calcium, vitamin D and manganese— This combo may improve mood and concentration.
   • Zinc is important for the synthesis and secretion of sex hormones, particularly progesterone, and has been found to be low in most patients with PMS. Remember that it is important to supplement copper if you are taking zinc long term. We recommend 1mg of copper for every 10-15mg of zinc.
   • Omega-3 Fatty Acids in doses up to 4 grams per day have been shown to be beneficial for depression and menstrual pain in patients with PMS.
   • Evening Primrose Oil 500-3,000mg/day may help with fluid retention
3. Exercise
   • Studies have shown that women who exercise do not have PMS as often as those who do not exercise. Exercise raises endorphin levels, improves glucose tolerance, decreases hormones that are associated with the sympathetic nervous system response (i.e. adrenaline), and helps normalize estrogen levels. All of these effects will improve the symptoms of PMS. Try to exercise at a moderate intensity for 30 minutes four times a week. For PMS, frequency is more important than intensity.
4. Botanical therapies
   • Black cohosh— This botanical acts as a relaxant and an anti-spasmodic. It has a serotonin and dopamine-like effect and may help to balance estrogen. These properties make it a good option for those with anxiety, depression and tension associated with PMS. We recommend 20-40mg of standardized extract twice a day. Side effects may include GI upset and headache and it must be used with caution if you have liver disease.
   • Chasteberry— This is our favorite botanical therapy for the symptoms of PMS. It raises levels of progesterone and helps it function more effectively. In addition, it acts as a diuretic and binds opiate receptors. In a German study, 57% of women taking Chasteberry reported improvement of symptoms with 33% having compete resolution. We recommend 20-40mg daily of the extract or 250-500mg daily of the dried fruit.
   • St. John’s Wort— 300-600 mg three times a day has been found to be helpful for anxiety, irritability, depression, nervous tension, moods swings, feeling out of control, and pain. You should not take St. John’s Wort if you are taking medications that increase photosensitivity, protease inhibitors, cyclosporine or certain other medications.
   • Ginko Biloba— 80 to 160 mg of standardized extract may improve symptoms associated with PMS. Avoid this one if you are taking blood thinners and look out for GI upset.
   • Saffron has a serotonin-like effect that has been shown to improve symptoms of PMS. We recommend 15 mg twice a day.
   • Lavender— Taking a capsule containing 80mg of lavender oil is very good for anxiety, irritability, insomnia and depression associated with PMS. Discontinue use after 6 to 10 weeks.
   • Motherwort may help with irritability, nervousness and dysmenorrhea and may decrease palpitations.
   • Dandelion is a potassium-sparing diuretic and may help with the fluid retention that occurs with PMS. It is also great for the liver! We recommend a 200mg capsule twice a day.
5. Hormone replacement
   • If your progesterone is low, we may recommend using bioidentical progesterone replacement, which is a natural diuretic. This is typically given on days 14-25 of the menstrual cycle and can be given orally or in a patch or cream. Testing before taking progesterone is important and we may check levels in the blood and/or the saliva, by collecting 11 samples throughout the 28 day menstrual cycle.
6. Mind-body therapies
   • Mind-body therapies have been shown to be helpful for PMS. These include cognitive-behavioral therapy, biofeedback, guided imagery, and stress reduction techniques such as mindful breathing.

When beginning your approach to managing PMS, always start with the lifestyle factors first. We cannot stress enough how important nutrition is when dealing with hormonal imbalance and exercise, sleep and stress management are just as important. These are interventions that are available to anyone, without a prescription, and they are going to have the biggest impact not only on PMS, but on your overall health. When implementing these lifestyle therapies, make sure you are getting adequate amounts of the nutrients noted above. Ideally, you will get as many of these as possible from your diet. This is often difficult to do, so beginning with a good multivitamin and one or two of the other targeted nutrients is a good place to start. After you have made these changes and gone through 2 or 3 menstrual cycles, if your symptoms are not considerably improved, we recommend trying the botanicals listed above. Thy them one at a time to see what effect they have on you. Chasteberry is a great place to start. If you are still not seeing significant improvement, you may need lab testing to determine hormone levels or to see if there is some other imbalance contributing to your problem. At that point, bioidentical hormone therapy may be necessary, especially if you are in the perimenopausal stage.