- Premenstrual Syndrome
Medical Herbalism 12(1):1,3-6
Pre-menstrual syndrome (PMS) is a condition affecting, to some degree at least, up to 75% of all women at some time in their menstruating years. It usually occurs from 2 - 14 days prior to menstruation, and is thought to be primarily a problem of inappropriate hormone secretion or inappropriate bodily response to hormones (receptor site defects or enzyme defects at cell surfaces). Symptoms are many and varied, often inconsistent from month to month and affected by many different factors. They include tension and irritability, headaches, decreased or increased energy, insomnia, fatigue, breast swelling and pain, bloating, bowel disturbance, acne, sweet or salt cravings and depression. There is a wide spectrum of symptoms in PMS but some common underlying hormonal states include:
Unusually high estrogen and low progesterone levels 5-10 days before menses (common)
Low estrogen and high progesterone levels 5 - 10 days before menses (less common)
Elevated Prolactin levels.
Elevated FSH levels 6 - 9 days before the period.
Elevated Aldosterone levels 2 - 8 days before the period.
imbalance of estrogen and progesterone may be
due to a disruption of
normal feedback systems that control the
or to a dysfunction of any one of these glands
(most commonly the
This is commonly considered to indicate a
deficiency or failure of the
corpus luteum and points to the use of ovarian
tonic herbs (Anemone
pulsatilla, Chamaelirium luteum) for
treatment. It may also be
the ovaries are functioning fine, but hepatic
metabolism and excretion
of estrogens is impaired. Dr Morton Biskind in
the 1940s showed that B
vitamin deficiencies caused liver impairment and
that contribute to PMS, fibro-cystic breast
disease and menorrhagia. B
vitamins, in particular B6, are required for the
hepatic metabolism of
estrogens prior to excretion and it is
reasonable to extrapolate that B
vitamin deficiency contributes to estrogen
loading and PMS in a
way. Estrogen therapy and the birth control pill
are known to
to cholestasis (the so-called sluggish liver)
and so there may be a
cycle where B vitamin deficiency causes
diminished estrogen clearance
impairs liver function.
Bitter hepatic stimulants and cholagogues are
called for here (Taraxacum
off., Berberis vulgaris, Fumaria off., Arctium
lappa, Curcuma longa),
along with nutritional co-factors such as B
choline, inositol, N-acetyl-cysteine and
Estrogens are conjugated in the liver for excretion via bile. An enzyme called beta-glucuronidase from intestinal bacteria can convert conjugated excreted estrogen back into an active form that can be reabsorbed. A diet high in fiber provides a substrate for optimal bacterial growth with reduced levels of beta-glucuronidase, and encourages a rapid transit time and enhanced elimination of excretory substances. Women with higher amounts of dietary fiber more estrogen in their feces and lower plasma levels of unconjugated estrogens.
Elevated prolactin levels imply a degree of pituitary imbalance or dysfunction, especially a lack of sensitivity to the usual inhibitory messages. Prolactin is produced by the anterior pituitary in response to estrogen and is responsible for milk production and glandular activity in the breast. It is normally inhibited by dopamine, which itself is inhibited by high circulating estrogen. Elevated FSH levels may be due to pituitary dysfunction. Elevated aldosterone, like FSH, implies a degree of pituitary dysfunction and lack of sensitivity to a rising water content of the body.
Low thyroid function affects a large percentage of women with PMS. Hypothyroidism may manifest as reduced pituitary stimulation, impaired thyroid hormone formation or impaired cellular conversion of T4 to T3. Careful testing of these parameters can reveal the origin of the problem. Low thyroid hormone and elevated TSH indicates primary hypothyroidism or glandular dysfunction and consequent reduced hormone manufacture. Low TSH and low thyroid levels indicate secondary hypothyroidism or pituitary deficiency. Normal thyroid levels and normal TSH levels combined with low basal metabolic rate and symptoms of slow metabolism indicate cellular defects in T4 - T3 conversion. Hypothyroidism is also associated with depression, which can contribute to PMS symptomatology.
PMS is classified into 4 sub groups, each with specific symptoms, hormonal pictures and metabolic abnormalities .
In this type of PMS there is an excess of estrogen relative to progesterone. Estrogen stimulates the brain by altering the ratio and levels of certain neurotransmitters. Specifically, estrogen raises levels of adrenalin, noradrenaline and serotonin and decreases levels of dopamine and phenylethylamine . This brain stimulation brings about the symptoms of anxiety, nervous tension and mood swings. Estrogen also affects mood by blocking the action of vitamin B6 and decreasing the bodyís ability to maintain normal blood sugar levels. There is also a possibility that high estrogen and low progesterone may impair the functioning of the endorphins which promote mental relaxation.
symptoms of this type of PMS are similar to
those of hypoglycemia, and
following general guidelines to control
hypoglycemia will be
Glucose Tolerance tests performed on PMS C
sufferers in the 10 days
the period indicate an excessive secretion of
insulin in response to
sugar levels, the insulin: blood sugar ratio
being normal at other
of the month. The exact mechanism by which this
comes about is not
understood but a deficiency of PGE1 is known to
insulin production and thus may be operative in
PMS C. Sodium chloride
enhances insulin response to sugar ingestion and
levels leads to increased insulin production.
Thus when treating this
of PMS it is advisable to avoid table salt and
supplement with 300 -
mg. of magnesium daily.
This type of PMS appears to be due to an excess of progesterone relative to estrogen, the progesterone acting on the brain as a depressant. It may also be aggravated by the low levels of estrogen which promote breakdown of mood-enhancing neurotransmitters. PMS D is aggravated by deficiencies of B6 and magnesium, and by stressing some cases of PMS-D there is an excess of lead in the plasma as measured by hair analysis. This is thought to be due to the relative deficiency of magnesium which thus favors the uptake of lead. This is significant because lead blocks the binding of estrogen to receptor sites yet has no effect on progesterone binding
The symptoms of PMS H are essentially those of water retention, brought about by stress, low magnesium and high estrogen, which disrupt the normal ACTH/Aldosterone axis. A vicious circle can occur in which the high aldosterone level increases the renal output of magnesium, which further raises the aldosterone level. Because pyridoxine requires magnesium for conversion into itís active form, a deficiency of vitamin B6 is commonly associated with PMS H.
PMS Case Study
was 40 years old when she first consulted with
me in the summer of
just finished graduate school and anxious to get
pregnant before it was
too late. She and her husband had been trying to
conceive for over a
and were fearing infertility. Until the age of
35 she had virtually no
gynecological disturbance except for mild PMS.
Her symptoms included
for chocolate, salt, carbohydrates and coffee.
She also complained of
fibrocystic breast tissue with a pre-menstrual
flare, irritability and
depression (PMS types C, D, H). In 1995 she
began to experience severe
dysmenorrhoea and worsening PMS. Six months
later she was leading a
class one day when she experienced an acute
abdominal pain that was
lived and self limiting, but severe. The
following day she had an
temperature and grumbling right abdominal pain.
An ultrasound revealed
a large chocolate cyst on the right ovary,
and two 2 - 3" intra-muscular fibroids. She took
(formulas not available) and found some relief
from the worst of her
After three months she had surgery to remove the
cyst but has not had
on the fibroid. When she consulted with me she
had been unable to
the Chinese herbs for several months. She was
experiencing worsening of
the PMS symptoms and menstrual pain. She was
aware of acute pain
every other month on the right side and she
charted regular ovulation
menses with a specially calibrated thermometer
for basal body
Her OBGYN was urging her to have surgery again
to remove more small
on both ovaries and to undergo a fallopian tube
patency test. She was
to have more surgery seeing that it hadnít
solved anything the first
She had undergone no hormone testing nor had her
husband had any sperm
tests done. She was a professional yoga teacher
and also swam several
a week. Her diet was fairly restricted. She
noticed a sensitivity to
and dairy products and generally avoided them.
She had been vegan for
years and became anaemic and B12 deficient which
had been adequately
After the surgery she had re-introduced some
fish, turkey, chicken and
eggs, all free-range and organic. She prepared
most foods at home,
grains, tofu, fruit and vegetables. She drank
water, green tea and ice
tea, and had recently broken a long standing
coffee habit. Her dietary
supplements were vitamin C 2 - 3 grams daily,
acidophilus and Fergon
I suggested a hormone screen using saliva samples. Eleven samples were sent over a one month period. While waiting for these results and before commencing with the herbs, I prescribed the following herbs and supplements:
Green Goddess Tea
A proprietary blend that tonifies and strengthens all the female organs and aids in regulating the cycle.
Red raspberry (Rubus ideaus), Nettle (Urtica dioica), Chamomile (Chamomilla recutita), Lemon balm (Melissa off.), Black haw (Viburnum prunifolium), Chaste berry (Vitex agnus-castus), Motherwort (Leonurus cardica), False unicorn (Chamaelirium luteum), Ginger (Zingiber off.) and Yarrow (Achillea millefolium). 1 heaping teaspoon per cup of hot water three times daily.
Womenís Balancing Essential Oil Blend
A synergistic blend of essential oils in a base of pure grapeseed oil. Lavender, Melissa, Clary sage, Fennel and Verbena. To be applied over the lower abdomen and lower back daily.
For use during menstrual cramping.
Jamaican dogwood (Piscidia erythrina) 1:3 25 ml analgesic, sedative, relaxing
Black haw (Viburnum prunifolium) 1:3 25 ml anti-spasmodic, anti-inflammatory
Valerian (Valeriana off.) 1:3 25 ml analgesic, sedative, anxiolytic
Chamomile (Chamomilla recutita) 1:3 15 ml analgesic, sedative
1:4 10 ml warming, pelvic decongestant
Dosage: 1 tsp in hot water, sipped as needed.
Calcium citrate, magnesium citrate and vitamin B6 each in daily doses of 300 mg from day 1 until 7 days after ovulation and in daily doses of 500 mg from 7 days after ovulation until the menses.
Vitamin C to bowel tolerance
B complex to 100 mg
Floradix liquid iron supplement 2 tbsp daily till hemoglobin level is at 10 and 1 tbsp thereafter. Taken with vitamin C for maximum absorption and increased dose after heavy menses.
Digestive enzymes (broad spectrum) after each meal Acidophilus
Castor oil packs over the lower abdomen several times a week. Can be combined with aromatherapy if desired (Clary sage, Rose, Jasmin, Vetivert, Patchouli, Sandalwood, Benzoin)
The hormone tests revealed a delayed follicular phase (18 - 20 days) meaning late ovulation, reduced pre-ovulatory estrogen surge, low estrogen overall, low progesterone in the follicular phase, low end of normal range progesterone in the luteal (glandular) phase of the cycle and a low-normal level of DHEA. Overall, these results indicated reduced ovarian function, probably due to a peri-menopausal state super-imposed on fibroids and endometriosis. In response to these findings I prescribed a bi-phasic formula that allows for natural alterations in hormone levels throughout the month. This concept was pioneered by Silena Heron ND and has shown to very useful in clinical practice. To support DHEA, adrenal tonics and adaptogens were used. To support the ovaries, phytoestrogens and ovarian tonics were used. Bitters promote optimal liver function, and nervines provide a soothing and relaxing effect.
Moon Phase 1
A specific synergistic combination of herbs designed to support, strengthen and tonify the hormonal systems of the first phase of the menstrual cycle (the follicular or proliferative phase).
Alfalfa (Medicago sativa) 1:3 20 ml estrogenic, nutritive, tonic
Black cohosh (Cimicifuga racemosa) 1:3 15 ml estrogenic, nervine
Dandelion root (Taraxacum off.) 1:3 15 ml bitter hepatic stimulant
Chaste berry (Vitex agnus-castus) 1:3 10 ml pituitary normalizer, LH promoter
Motherwort (Leonurus cardiaca) 1:3 10 ml bitter, tonic nervine
luteum) 1:3 10 ml
ovarian normalizer, pro-estrogenic
Licorice (Glycyrrhiza glabra) 1:4 10 ml estrogenic, adrenal tonic
Arbor vitae (Thuja occidentalis) 1:4 10 ml anti-mitotic, pelvic decongestant
1 tsp. morning and night from day one of the cycle (first day of menstrual bleeding) until ovulation.
Additionally 40 drops of Dong quai (Angelica sinensis) tincture 1:3, to be taken twice as a day from day 1 to ovulation.
Moon Phase 2
A specific synergistic combination of herbs designed to support, strengthen and tonify the hormonal systems of the second phase of the menstrual cycle (the luteal or secretory phase).
Wild yam (Dioscorea villosa) 1:3 10 ml progesterone balancing, promotes DHEA
Chaste berry (Vitex agnus-castus) 1:3 10 ml pituitary normalizer, promotes LH
Black haw (Viburnum prunifolium 1:4 10 ml anti-spasmodic, anti-inflammatory
Blue vervain (Verbena off.) 1:3 10 ml endocrine normalizer, bitter, nervine
Dandelion root (Taraxacum off.) 1:3 10 ml bitter hepatic stimulant
Ladies Mantle (Alchemilla vulgaris) 1:3 10 ml astringent uterine tonic
Partidge berry (Mitchella repens) 1:3 10 ml uterine tonic and female balancer
Sarsaparilla (Smilax app) 1:4 10 ml adrenal stimulant and alterative
Arbor vitae (Thuja occidentalis) 1:4 10 ml anti-mitotic, pelvic decongestant
Siberian ginseng (Eleutherococcus sen) 1:3 10 ml adrenal tonic, adaptogen
Dosage: 1 tsp. morning and night from ovulation until the beginning of the next menstrual period. Repeated use over several months of this bi-phasic formula may be required to obtain lasting change.
I have treated Ms. C for just over 4 months and she has noticed a marked decline in the PMS symptoms. The pain formula has been very helpful and she thinks the dysmenorrhoea is lessening overall. I have advised her to repeat the hormone pael after 6 months on the herbal formula to assess if the fundamental imbalance has been rectified. As long as she has this low endogenous estrogen level then she may be ovulating, as evidenced by the basal temperature changes, but unable to hold an implantation due to inadequate thickening of the endometrium in the luteal phase. Additionally the presence of cystic material around the ovary may impair ovum release into the fallopian tube, the patency of the fallopian tubes is unclear and the fibroid may also inhibit implantation. Overall I advised her that conception and pregnancy were unlikely though not impossible, but that management of symptoms was reasonable to expect. Due to the low levels of estrogen it appears that she is in peri-menopause and the fibroid and endometriosis symptoms can be expected to abate as the menses ceases.Copyright 2001 Paul Bergner