PREMENSTRUAL SYNDROME
Definition
A recurrent clinical condition in women characterized by somatic or psychogenic symptoms which occur sometime
during the two weeks prior to menstruation and stop at the onset of menses or within 24-48 hours.
Symptoms
PMS encompasses a wide variety of symptoms and a spectrum of severity ranging from mild to severe. Reported
manifestations include the following (Lichtman and Papera, Gynecology: Well-Woman Care, 1990):
SOMATIC: headache/migraine, breast swelling/tenderness, abdominal bloating, nausea, edema of extremities,
joint pain, backache, pelvic/low abdominal pain, increased thirst or appetite, allergic rhinitis/asthma, cravings for
sweet or salty foods, cold sweats, palpitations, ulcerative stomatitis, herpes, dermatosis/acneiform eruptions,
hives, conjunctivitis/sties, glaucoma, increase in refractive errors in vision, hot flashes, epileptiform seizures, spot
bruising, constipation, lack of coordination
PSYCHOGENIC: fatigue, depression, irritability and tension, lack of concentration/distractibility, insomnia,
aggressiveness, moodiness/mood swings, indecision, inefficiency, psychotic episodes, forgetfulness, crying easily,
confusion, loneliness
Abraham model of PMA
PMS-A: anxiety, irritability, nervous tension (sufferers may report increased consumption of dairy products and
refined sugar)
PMS-C: increased appetite, craving for sweets; increased intake of refined sugar followed by palpitations, fatigue,
fainting spells, headache, tremors
PMS-D: depression, withdrawal, insomnia, forgetfulness, confusion
PMS-H: edema, abdominal bloating, mastalgia, weight gain
DDx
Systemic infx
Endometriosis
Anemia
Hypothyroidism
Etiology/Epidemiology
PMS-A: B vitamin deficiency, low intracellular magnesium
PMS-C: hypotheses: (1) increased cellular capacity to bind insulin, (2) PGE1 deficiency in pancreas/CNS (inhibits
glucose induced insulin secretion in humans)
PMS-D: low B vitamins, low magnesium, possibly increased heavy metal levels
PMS-H: stress, low B vitamins, magnesium, hi refined sugar intake
Jane Guilitan:
Theoretical causes:
1)evolutionary adaptation: via mood will reject male when infertile
2)neuroendocrine: high estrogen: progesterone ratio
3)MAD theory: monoamine oxidase->breaks down NE->mood disturbances (rational behind antidepressants rx)
4)prolactin levels elevated->PMS (Sage, B-6 are prolactin inhibitors)j
5)pyroxidine (B6 is a cofactor in dopamineand tryptophan metabolism)
Psychodynamics theories
1)increased family tension
2)fear or negative attitude to menarche and menses
3)poor self experience with menses
4)poor performance of feminine pyschosocial role
5)poor acceptance of feminine psychosocial role
-amazingly above two are in current textbooks, JG mentioned but does not agree
6) feeling of being unable to cope with day to day life
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PREMENSTRUAL SYNDROME
Etiology/Epidiemology (cont)
Affects 40-90 % of menstruating females and 5-10 % are severely affected (DB)
Most common in the 30-40 year age range (DB)
Abraham found the following characteristic of the diet of PMS patients: (DB)
62% higher in refined CHO
275% higher in refined sugar
79% higher in dairy products
78% higher in sodium
53% lower in iron
77% lower in magnesium
52% lower in zinc
Pathophysiology
PMS-A: high serum estrogen (decreased hepatic clearance), low serum progesterone
PMS-C: increased carbohydrate tolerance, low red cell magnesium
PMS-D: low serum estrogen, high progesterone, elevated adrenal androgens
PMS-H: high sodium and water retention, high serum aldosterone, decreased dopamine at renal level
Key PE
Weight
Blood pressure
Heart and lung assessment
Breast and pelvic exam
Key Lab
Pap smear w/ maturation index (from upper lateral 1/3 vagina)
-could measure estrogen levels just b/f her period; estrogen levels should be low; positive test if estrogen high
(JG)
CBC: to r/o systemic infx and anemia
Thyroid studies
W/U, Strategy
1. Evaluate liver and bowel function.
2. Diet diary.
3. PE to r/o other disease.
4. Key labs + maturation index if needed.
5. Determine level of impairment, assess risk of suicide/homicide.
6. Once sx resolved, maintain with multiple and good diet (JG)
7. It takes a couple cycles to notice improvement; some take up to 6-8 months; 1 month for every year you had the
condition (JG)
8. if alcohol increases symptoms: think B6 def. and malnutrition (JG)
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PREMENSTRUAL SYNDROME
TX PROTOCOLS
Nutrient Considerations
1. Lipotropic factors (normalize estrogen metabolism)
2. Folate
3. Vit B6:
-200 mg qd days 1-14; 400 mg qd days 15-menses (decreases edema, works w/ Mg)
-100-200 mg QID (DB)
-using pyridoxine with magnesium and/or in the context of a multiple vitamin-mineral supplement is far more
successful (DB)
4. Magnesium:
- 500 mg qd days 1-14; 1000 mg qd days 15-menses (divided doses; watch laxative effect)
-400 to 600 mg/day (DB)
-Check Mg deficiency (AJCN 34:2364 6 1981 Nov)
5. B complex (estrogen breakdown, proper liver function)
6. Vit C
7. Vit E:
-400-1200 IU (decreases breast tenderness/congestion) (JG)
-keep on dose until sx gone or down to a minimal level (JG)
8. Zinc, Calcium
9. PABA
10. Choline 1 gram
11. Inositol 500 mg
12. Dessicated liver
13. Cu, Se, Cr, Fe
14. Tyrosine 500 mg bid-qid (type D)
15. Lugol's Solution weekly (Bruce Dickson)
16. Vitamin A
- 100,000 - 300,000 I.U./day for second half of cycle (DB)
Dietary Considerations
1.Anti-Estrogenic diet
2. Phytoestrogens ---> dietary (e.g. soy) (DB)
3. Avoid raw goitrogens
4. Avoid oranges (increases 5-beta reductase) (BM)
5. Diet: 70% CHO, 15% protein, 15% fat
6. EFAs: Flax oil, EPO, Sunflower, or cod liver oil: 3 T/day
-delta-6-desaturase activity is impaired in pts with PMS (DB)
7. Small frequent meals
8. Decrease sugar (depletes B vitamins & magnesium)
9. Brewer's yeast 1-2 T qd
10. Kelp (iodine for thyroid fxn)
11. Bran
12. Decrease refined/processed food, EtOH
13. Eliminate methylxanthines (coffee, tea, cola, chocolate)
14. Decrease or eliminate red meat/dairy (contain hormones, pro-inflammatory)
15. Decrease salt (assoc w/ increased magnesium excretion)
- to at least 3 grams/day three days before menses (DB)
16. Reduce dairy products
- dairy products impair the absorption of magnesium(Ca:Mg ratio higher in PMS-A pts) (DB)
Botanicals
1. Phytoestrogens: Angelica, Medicago, Leonurus, Glycyrrhiza, Soy, Cimicifuga (JG)
2. Hypericum (type D)- avoid tyramine containing foods (JG)
3. Progesterone cream (JG)
4. Smilax, Dioscorea, Hydrastis, Collinsonia, Equisetum
5. Vitex agnus-castus, Angelica sinensis (DB)
6. phytoprogesterones ¿ (JG)
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PREMENSTRUAL SYNDROME
Homeopathy
Bovista, Borax
Physical Medicine
Exercise - 20-30 min. 3-4 times weekly has been shown to increase progesterone (DB)
Oriental Medicine
Psychology
1. Stress Reduction (DB)
2. reframing; discussing positive effects it can offer (JG)
Other
1. Increase exercise, decrease body fat (adipose stores estrogen) (JG)
2. Sunlight 1 hour/day
3. Menstrual chart
4. Allopathic: BCP(inhibits ovulation so the rhythms of the estrogen do not happen), lithium, bromacryptin(lowers
prolactin levels), B6, tranquilizers, diuretics, antidepressants (JG)
5. Reflexology - ear, hand, foot (DB)
6. Melatonin hypothesis (DB)
7. PMS-D (JG)
-tyrosine(500mg 2-4 x day); precursor to serotonin; use B6(200-400 mg) which is a cofactor
-hypericum as mood enhancer; JG uses standard extract
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