Premenstrual Syndrome (PMS)
DISCLAIMER: All the following information is for educational purposes only. This article is not intended for medical or therapeutic advice, or directions of use for specific ailments.
Pathophysiology of Premenstrual Syndrome (PMS): Hormonal interplay and Herbal medicines
Overview of Hormonal Mechanisms & Interventions
Premenstrual syndrome (PMS) is often characterised by excess oestrogen in relation to low progesterone levels in the luteal phase of the menstrual cycle, usually due to an under functioning liver, constipation and/or high levels of stress (Gao, Gao, Sun, Cheng, An & Qiao, 2021). In other cases, symptoms may be in relation to an oestrogen deficit, blood sugar disruption and/or fluid accumulation & stagnation (Gao et al., 2021). Regardless, all are perpetuated by dysregulation of the hypothalamic-pituitary-adrenal/ovarian (HPA/O) axis due to cortisol’s inhibiting effect on progesterone and parasympathetic mechanisms (Gladstar, 2020).
Most cited phytochemical interventions geared towards hormonal modulation in PMS include:
· Chaste berry (Vitex agnus-castus) is well-known for its use in issues associated with the luteal phase (from ovulation to day 1 of menstruation) such as PMS, infertility & dysfunctional uterine bleeding (Rafieian-Kopaei & Movahedi, 2017). When taken at 120mg/d, chaste berry has shown to decrease follicle stimulating hormone (FSH) levels and increase luteinising hormone (LH), thereby decreasing oestrogen and increasing progesterone. Higher doses (~480mg/d) have shown to decrease prolactin levels thereby reversing LH suppression, encouraging full development of the corpus luteum and exhibiting dopaminergic qualities (Romm, 2018).
NOTE: The use of chaste berry is contraindicated in polycystic ovarian syndrome (PCOS) (Trickey, 2011).
· Peony (Paeonia lactiflora) is commonly used with other Chinese herbs (e.g., Angelica sinensis & Rehmannia glutinosa), primarily during the luteal phase, for depleted oestrogen levels (Trickey, 2011).
· Crampbark (Viburnum opulus) & California poppy (Eschscholtzia californica) for cramping and unrest (Romm, 2018).
· Bitter herbs to aid adequate liver function in relation to detoxification and hormonal metabolism (especially estradiol & estrone to estriol conversion), thereby decreasing incidence of constipation and facilitating excretion of oestrogenic metabolites, disallowing reabsorption and recirculation of oestrogens (Gladstar, 2020).
PMS-A (Anxiety)
Surges of oestrogen in the luteal phase (second half) of the menstrual cycle (where the GABA-inducing hormone, progesterone, should reign) are said to influence serotonergic pathways via decreasing the inhibition of noradrenaline, thereby resulting in perpetual sympathetic dominance, triggering fluctuations in mood and manifestations (including anxiety, tension, irritability, difficulty sleeping, aggression and fatigue) (Acikgoz, Dayi & Binbay, 2017; Romm, 2018).
| HERB | Mechanism/s of action (MOA) &/or Application | DUAL ACTIONS |
|---|---|---|
| Pasqueflower (Anemone pulsatilla) |
A specific remedy for ovarian pain, insomnia, nervousness, and a generally agitated emotional state with gloom and distress (Holmes, 2007). Pasqueflower also works well combined w/ Passiflora incarnata for tension headaches with nervousness caused by hypo-luteal PMS (Trickey, 2011). |
Antispasmodic, analgesic, mild sedative |
| e.g., California poppy (Eschscholzia californica), Lavender (Lavandula spp.), German chamomile (Matricaria recutita), Lemon balm (Melissa officinalis), Tulsi (Ocimum tenuiflorum), Skullcap (Scutellaria lateriflora), Valerian (Valeriana officinalis), Vervain (Verbena officinalis) |
Aromatic nervine herbal infusions are an effective and popular way to ingest herbs for alleviation of PMS (esp. with mood, sleep, and intestinal disturbances), combining adjuvant actions to cover a broad scope of mechanisms. Our main aim is to reduce reactivity to the stress response via downregulating sympathetic dominance. For best effect, consume 3–4 times daily in the 2 weeks leading up to period onset (Romm, 2018). |
Nervine (bitter, relaxing), carminative, GABAergic, anxiolytic, adaptogen |
| Ashwaghanda (Withania somnifera) | Via modulation of the HPA/O axis, alleviating consequences of prolonged stress, thus having downstream effects on catecholamines, thyroid hormones, neurotransmission, and relaxation of musculoskeletal tension (Romm, 2018). | HPO modulator, adaptogen, mild sedative, nervine tonic, anxiolytic |
PMS-C (Cravings)
Hormonal fluctuations, often resulting in energy depletion and blood sugar dysregulation, can result in cravings for sugar/carbohydrates due to progesterone’s blunting effect on insulin, a low protein diet and/or a personal/familial history of blood sugar disturbances (Trickey, 2011). Some symptoms of PMS-C include headaches, fatigue, dizziness, palpitations and an intense desire to consume chocolate!
| HERB | Mechanism/s of action (MOA) &/or Application | DUAL ACTIONS |
|---|---|---|
| Gymnema (Gymnema sylvestre) |
Via blocking sweet taste receptors throughout GIT when taken between meals and exerting a protective effect on the hepatobiliary system (Khan, Sarker, Ming et al., 2019). 1–2mL of liquid extract tds is suffice. |
Blood sugar regulator, antilipidemic, hepatoprotective |
| e.g., Gentian (Gentiana lutea), Common centaury (Erythraea centaurium), Dandelion (Taraxacum officinale) | Bitter herbs can assist to reduce sugar cravings through bile stimulation whilst regulating blood sugar fluctuations with cyclic or reactive hypoglycaemia (Romm, 2018). | Bitter tonic, choleretic, cholagogue |
| Diet & Lifestyle |
Protein (1g per kg of body weight daily): i) Eat regular meals with adequate protein (approx. every four hours) ii) Consume complex carbs (e.g., quinoa, rice) and healthy fats (e.g., olive, hemp, flax oils) for lasting satiety and stable energy iii) For cravings, carry a snack pack of nuts, seeds, dark chocolate (90%), or an apple with nut butter iv) Combine protein powders with magnesium-rich foods (Romm, 2018) Examples: eggs, fish, beans/legumes, fermented soy (tofu/tempeh), or whey/plant-based protein powders in smoothies with nutrient-dense additions (e.g., greens, broccoli-sprout powder, green banana, raw cacao) (Gladstar, 2020). |
PMS-D (Depression)
Premenstrual depression is characterised by cyclic fatigue, melancholy and introversion - often related to an excess of oestrogen and less often, low oestrogen levels. Like PMS-A, neurotransmitter production and release (e.g., serotonin, GABA, endorphins & melatonin) are disrupted by the changes with oestrogen thereby causing low mood and may exacerbate a pre-existing condition if there is an underlying depressive disorder (Trickey, 2011). Premenstrual dysphoric disorder (PMDD) is a more severe form of PMS-D affecting 3 – 8% of menstruating women (Gai et al., 2021). PMDD is diagnosed through a range of criteria listed in the Diagnostic and Statistical Manual of Mental Disorders V (DSM-5), where at least five of the listed symptoms are experienced (Gao et al., 2021).
| HERB | Mechanism/s of action (MOA) &/or Application | DUAL ACTIONS |
|---|---|---|
| Gingko (Ginkgo biloba) | Via alleviating congestive symptoms of PMS/PMS-D and downregulating stressors through its bioflavonoid content (Jang et al., 2014). | Antioxidant, decongestant |
| St John's wort (Hypericum perforatum) & Saffron (Crocus sativus) | Via influencing serotonergic pathways and modulating inflammation through suppression of proinflammatory cytokines and pro-oxidant free radicals contributing to physiological stress in PMS (Jang, Kim & Choi, 2014). | Thymoleptic, inflammatory modulator, antioxidant |
| Chaste berry (Vitex agnus-castus) | In combination with magnesium (200mg) and vitamin B6 for enhanced effects in supporting serotonin and neurotransmission (Rafieian-Kopaei & Movahedi, 2017). | SERM |
| * | See PMS-A herbs, many mechanisms and actions crossover here. |
PMS-H (Hyper-hydration)
Premenstrual water retention is linked to an elevation in prolactin and alteration of the aldosterone pathway influenced by high cortisol, high salt intake and/or medications like the oral contraceptive pill (OCP), antidepressants (e.g., SSRIs), antipsychotics and opiates (Trickey, 2011). Other potential exacerbators include hypothyroidism, alcohol, smoking, caffeine, under eating, excessive exercise and prolactinoma (Hashim, Obaideen, Jahrami et al., 2019; Nobles, Thomas, Valentine et al., 2016).
| HERB | Mechanism/s of action (MOA) &/or Application | DUAL ACTIONS |
|---|---|---|
| Evening Primrose (Oenothera biennis) | Evening primrose oil (EPO) contains omega-6-fatty acids incl. linoleic acid (60–80%) and γ-linoleic acid (8–14%). At a dose of 2–6g daily for 3–6 months, PMS symptoms (breast pain, swelling, irritability, IBS, acne) significantly reduce due to modulation of inflammatory prostaglandins (Mahboubi, 2019). Contraindicated with phenothiazine. | Inflammatory modulator, astringent, mild sedative |
| Poke root (Phytolacca decandra or P. americana) | Stimulates lymphatic drainage of excess fluids, particularly useful for breast tissue congestion, premenstrual breast pain, lumpiness, and ovarian neuralgia (Stansbury, 2018). | Lymphatic, inflammatory modulator |
| Parsley root (Petroselinum crispum) | Traditionally used as a diuretic for premenstrual fluid retention and as an emmenagogue in amenorrhea/dysmenorrhea related to hormonal depletion; coumarins offer hormonal-regulating and anti-inflammatory effects (Stansbury, 2018). | Diuretic, antioxidant, circ-enhancing, antispasmodic, emmenagogue |
| Dandelion (Taraxacum officinale) | Alleviates fluid retention and supports digestion by increasing secretions. For diuretic tea: combine 4–6 Tbsp herbs per quart water, bring to simmer, steep 20min. Drink 3–4 cups/day (Gladstar, 2020). | Diuretic, bitter tonic |
| Chaste berry (Vitex agnus-castus) | Reduces prolactin and increases progesterone (Trickey, 2011). Take dose each morning; if no relief within 3 days, discontinue. | Progestogenic |
Useful Diet & Lifestyle Advice
· Having an adequate intake of vitamin B3 and B6, magnesium, zinc, vitamin C, essential fatty acids (omega 3’s) (Trickey, 2011; Romm, 2018).
· Increasing cruciferous vegetable intake to support the liver for adequate oestrogen metabolism, soluble & insoluble fibre (e.g., flaxseed, chia seed and psyllium husk) to assist excretion & inhibit reuptake of oestrogens) and quality sources of proteins & complex carbohydrates (Gladstar, 2020).
· Exercise (30min daily) and limiting caffeine intake can reduce oestrogen and catecholamine levels, improved blood glucose and improved endorphin levels (Romm, 2018).
· Stress management techniques relevant to the individual client, in some cases psychotherapy & counselling may be useful (Romm, 2018).
· Reducing/eliminating tobacco use and high calorie/fat/sugar/salt consumption (Hashim et al., 2019).
· Avoiding exposure to xenoestrogens in plastics, pesticides and beauty products (e.g., parabens, phthalates, artificial fragrances and triclosan) (Romm, 2018).
Prognosis:
Hormonal readjustments can take time to notice a significant sustained change in premenstrual presentations, so patience and commitment are necessary for the client to maintain, sticking to their routine for at least 4 – 6 months (Gladstar, 2020).
References
Acikgoz, A., Dayi, A., & Binbay, T. (2017). Prevalence of premenstrual syndrome and its relationship to depressive symptoms in first-year university students. Saudi Medical Journal, 38(11), 1125–1131. https://doi.org/10.15537/smj.2017.11.20526
Gao, M., Gao, D., Sun, H., Cheng, X., An, L., & Qiao, M. (2021). Trends in Research Related to Premenstrual Syndrome and Premenstrual Dysphoric Disorder From 1945 to 2018: A Bibliometric Analysis. Frontiers in Public Health, 9(April), 1–14. https://doi.org/10.3389/fpubh.2021.596128
Gladstar, R. (2020). Herbal Healing for Women. Atria Paperback, New York: NY.
Hashim, M. S., Obaideen, A. A., Jahrami, H. A., Radwan, H., Hamad, H. J., Owais, A. A., Alardah, L. G., Qiblawi, S., Al-Yateem, N., & Faris, M. A.-I. E. (2019). Premenstrual Syndrome is Associated with Dietary and Lifestyle Behaviours among University Students: A Cross-Sectional Study from Sharjah, EAU. Nutrients, 11(8), 1–18. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28081191/%0Ahttp://www.ncbi.nlm.nih.gov/pubmed/31426498%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC6723319
Holmes, P. (2007). Energetics of Western Herbs vol. 2. Snow Lotus Press, Boulder: CO.
Jang, S. H., Kim, D. I., & Choi, M. S. (2014). Effects and treatment methods of acupuncture and herbal medicine for premenstrual syndrome/premenstrual dysphoric disorder: Systematic review. BMC Complementary and Alternative Medicine, 14. https://doi.org/10.1186/1472-6882-14-11
Khan, F., Sarker, M. M. R., Ming, L. C., Mohamed, I. N., Zhao, C., Sheikh, B. Y., Fei Tsong, H., & Rashid, M. A. (2019). Comprehensive review on phytochemicals, pharmacological and clinical potentials of gymnema sylvestre. Frontiers in Pharmacology, 10(OCT), 1–19. https://doi.org/10.3389/fphar.2019.01223
Mahboubi, M. (2019). Evening Primrose (Oenothera biennis) Oil in Management of Female Ailments. Journal of Menopausal Medicine, 25(2), 74. https://doi.org/10.6118/jmm.18190
Nobles, C. J., Thomas, J. J., Valentine, S. E., Gerber, M. W., Vaewsorn, B. A., & Marques, L. (2016). Association of premenstrual syndrome and premenstrual dysphoric disorder with Bulimia nervosa and binge-eating disorder in a nationally representative epidemiological sample. International Journal of Eating Disorders, 49(7): 641-650. doi:10.1002/eat.22539.
Rafieian-Kopaei, M., & Movahedi, M. (2017). Systemic Review of Premenstrual, Postmenstrual & Infertility Disorders of Vitex agnus-castus. Electronic Physician, 9(January), 3592–3597. doi: http://dx.doi.org/10.19082/3685
Room, A. (2018). Botanical Medicine for Women’s Health 2nd ed. Elsevier, St. Louis: MI.
Stansbury, J. (2018). Herbal Formularies for Health Professionals Vol. 3: Endocrinology. Chelsea Green Publishing, White River Junction: Vermont.
Trickey, R. (2011). Women, Hormones & the Menstrual Cycle. Melbourne Holistic Health Group, Melbourne: VIC.
