What is PMS?
PMS stands for pre-menstrual syndrome and involves symptoms that occur prior to menstruation, (your period)! More specifically, PMS occurs in the 'luteal phase' of the menstrual cycle, which the second half of the cycle that occurs following ovulation (see diagram below).
PMS can present with psychological symptoms including:
- Depressed moods
PMS can also present with physical and behavioural symptoms including:
- Low energy
- Sleep disturbances
- Food cravings
- Changes in appetite
- Abdominal pain
- Breast tenderness
- Water retention
Is it common?
PMS is extremely common with up to 90% of menstruating women experiencing at least one pre-menstrual symptom each month. Despite this, experiencing debilitating symptoms for a week or so out of every month should not be considered normal.
With research continually expanding in the area of women's health, there is so much that can be done to assist women suffering with PMS. With a little education around what's actually driving these symptoms, we can dive into the evidence based strategies to help improve symptoms of PMS.
What are the causes?
The research isn't 100% clear on the exact cause of PMS, but we do know it involves various hormones and neurotransmitters. This sections gets a little in depth with the imbalances we see in PMS, so if you're just here for my recommended treatment options, skip down to the 'naturopathic approach to managing PMS' section.
There are several different types of PMS but typically women experience a combination of these types. As we'll discuss, PMS may be driven by an imbalances in the sex hormones and their effect on specific neurotransmitters such as serotonin, dopamine and GABA. It's traditionally thought that women with PMS have an imbalance between the sex hormones oestrogen and progesterone, with a relative deficiency of progesterone in comparison to a relative oestrogen excess.
Further research suggests that fluctuating oestrogen levels, specifically the large drop during the luteal phase of the cycle, triggers a drop in dopamine and serotonin which contributes to low moods, poor sleep, fatigue and various other PMS symptoms. Additionally, a rapid drop in progesterone 3 days prior to menstruation was noted in women that experienced PMS, as opposed to those who had more stable progesterone levels based on a salivary progesterone test.
The important note to remember here is that although hormones naturally rise and fall throughout the menstrual cycle, we want progesterone and oestrogen so be at a very specific balance with each other at different stages of the menstrual cycle. So whilst a big drop in oestrogen may trigger some PMS symptoms, healthy progesterone levels may help mitigate this. It should also be noted that women with Premenstrual Dysphoric Disorder (PMDD), a much more severe form of PMS, appear to have an increased sensitivity to progesterone and it's effect on neurotransmitters in the brain.
*Diagram from 'Clue Period & Cycle Tracker' app
What about stress?
Prolonged periods of stress can also contribute to both PMS and PMDD symptoms. High stress hormones impact progesterone production and also alter the hypothalamic-pituitary-adrenal axis (HPA) which controls our stress response. The HPA axis is complex, but describes the communication between the brain and adrenal glands that helps us deal with stressors. Dysregulation of this HPA axis is a risk factor for PMS.
Aside from the hormonal alterations in PMS, research shows that diet, exercise, sleep, blood glucose levels, nutritional deficiencies, inflammation and genetic factors may also play a role in the development of PMS. Therefore, when treating PMS and PMDD, it's important to consider all of these different areas.
Types of PMS:
PMS-A (Anxiety): women who experience PMS-A experience heightened anxiety and mood changes throughout the luteal phase, more commonly towards the end. It's understood that a lack of progesterone in comparison to estrogen contributes to the altered state due to the hormones effect on neurotransmitters such as GABA (our calming brain chemical/neurotransmitter).
PMS-D (Depression): with PMS-D, low moods and depression in the luteal phase are the predominant symptoms. Moods may stabilise again following menstruation. The drop in estrogen towards the end of the luteal phase is thought to contribute to low moods due to the impact of estrogen on serotonin in the brain.
In women with PMDD, a more severe form of PMS which commonly results in depressive symptoms, it's believed allopregnanolone, a hormones produced from progesterone, plays a major role. Allopregnanolone binds to specific GABA receptors in the brain, remember that GABA typically has a calming action. At the end of the menstrual cycle when progesterone drops, so does the action of allopregnanolone. Some women are more sensitive to this rapid change, contributing to PMDD.
PMS-C (Cravings): those with PMS-C have elevated food cravings, generally for carbohydrate rich foods. Other symptoms include headaches, fatigue and heart palpitations. Blood sugar and neurotransmitter imbalances most likely play a role in this type of PMS.
PMS-H (Hyper-Hydration): in those with PMS-H excess fluid retention can cause symptoms of swelling in the hands and feet, bloating, breast tenderness and weight fluctuations (although typically water weight). This is beacuase hormones like oestrogen and progesterone influence electrolyte balance and hydration. A magnesium deficiency may also contribute to PMS-H.
PMS-P (Pain): those with PMS pain commonly experience pelvic pain and cramping in the lead up to menstruation. The pain is associated with an increase in inflammatory prostaglandins which cause pelvic muscles to contract.
Naturopathic approach to managing PMS:
I'll start by saying this discussion should not replace advice from own your health practitioner. It's certainly not specific, individualised advice and does not take into account your specific needs or health history. Please use this information for the purpose of education, so from here you can go to your health practitioner armed with information that may assist you in getting the right treatment. So with that little disclaimer out of the way, let's discuss!
Magnesium: studies have shown that even 200mg of magnesium for x2 months reduces symptoms of PMS-H. I generally recommend 300mg (300mg is a therapeutic dose) of a high quality form of magnesium in the form of a bisglycinate or citrate so these results are impressive with a lower dose. I also find magnesium helps with other PMS symptoms including anxiety and pain. Of course we also want to ensure adequate intake of magnesium rich foods, which include pumpkin seeds, dark leafy green vegetables, avocado, dark chocolate (at least 70% cacao) or cacao powder, tuna, lima beans, almonds and natural yoghurt to name a few.
B vitamins: vitamin B6, or pyridoxine, is another great option for those with PMS. However we do have to be careful with the dose and form of B6 we use so again, chat to a professional. B6 is thought to improve PMS, in particular the mood related symptoms, due to it’s role in progesterone production, neurotransmitter function and oestrogen metabolism. In addition to B6, other B vitamins are also important for energy production, carbohydrate metabolism and stress support, so utilising a B complex formula over just straight B6 may be a safer and more suitable option for many women. A lot of the time you can find great formulas that combine both magnesium and B vitamins to reduce how many supplements you're taking.
Essential fatty acids: essential fatty acids, in particular the omega 3 essential fatty acids (EPA and DHA) have an anti-inflammatory effect which is useful for reducing menstrual pain. A few studies have confirmed this showing that fish oil supplementation (containing both EPA and DHA) significantly reduces pain and menstrual related symptoms in women. We also know that omega 3s are really important for brain health and mood, so there may be additional benefits for women suffering with anxiety and low mood premenstrually. If supplementing, the qaulity of your fish oil supplement is very important so please don't go grabbing just anything off the pharmacy/supermarket shelf. You need to make sure the product has gone through the appropriate testing to ensure quality. Fish is generally the richest source of omega 3s, however there are some fantastic algal products around now if you're vegan. Seeds including chia, hemp and flaxseeds also contain some omega 3s if you're wanting some additional food sources.
Chaste tree: chaste tree or Vitex agnus castus has some really promising research around it for the use of PMS and PMDD. Whilst there are certainly some instances I wouldn't recommend it due to interactions with some medications, I've seen some impressive improvements in women using this herb for PMS and PMDD. In particular, Chaste Tree seems to work really well for the mood related symptoms of PMS. It's believed to work by supporting ovulation and healthy progesterone levels, whilst also acting on dopamine receptors in the brain.
Saffron: you're probably familiar with saffron as a culinary herb, but it's also a beautiful herbal medicine with some evidence for treating PMS. Also called Crocus sativus, it's commonly used for mood symptoms in PMS as it's believed to have an effect on serotonin. Also having anti-inflammatory and antispasmodic actions, it may also be helpful for tension and abdominal cramping.
Withania: also called Ashwaghanda, Withania somnifera is a beautiful choice when stress and axniety is involved in PMS. Withania has been shown to regulate stress hormones such as cortisol and help the body adapt to stressful situations. In naturopathy we refer to this action as 'adaptogenic'.
As we discussed earlier, excessive activation of the HPA axis, or more simply put our 'stress response', has been shown to contribute to both PMS and PMDD.
Something I've noticed recently is that many of us don't feel inherently stressed or anxious, but still present with symptoms of high stress hormones such as muscle tension, jaw clenching and afternoon energy crashes. It may be that we're so used to being busy, on the go and overwhelmed we are a little out of touch with our own nervous system response, or maybe it just presents so differently for every individual.
Regardless, calming this stress response is essential, but looks different for everyone. Gentle exercise, meditation, yoga, breathing practices, hobbies, creativity, time spend it nature, time spent with pets and loved ones, adequate and routine sleep, magnesium baths (honestly even just regular plain baths), reduced stimulants (including caffeine), adequate time off to rest and recover, eating regular balanced meals and limiting screens are just a few ways we can support our nervous system.
I've found that creating better routines and habits on a daily basis has helped me to actually bring a few of these approaches into my every day life. I absolutely love the book 'Atomic Habits' if you're someone who struggles with creating change and better habits.
Sugar: there is evidence to suggest that high intake of sugar is associated with PMS. Studies show that excessive intake of sugar and refined carbs is much higher in women with PMS. We do need to consider here that PMS also increases sugar cravings, so it's a bit of a vicious cycle either way. This being said, we know excess sugar can cause havoc on our hormonal balance.
Other: other dietary factors associated with PMS include excessive coffee consumption and junk food intake. Mineral intake, including magnesium as discussed above, is also so improtant when it comes to PMS and overall hormonal balance. Consuming adequate amounts of seafood, red meat, poultry, tofu, seaweeds, seeds, nuts, eggs and leafy greens is a good place to start.
If you're still a little confused or not sure where to start, PMS is something I absolutely love treating. Please reach out if you need a little more support and guidance.