Premenstrual Syndrome

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)

The imbalance of estrogen and progesterone may be due to a disruption of the normal feedback systems that control the hypothalamus-pituitary-ovary axis or to a dysfunction of any one of these glands (most commonly the ovaries). 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 that 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 accumulation of estrogens 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 significant way. Estrogen therapy and the birth control pill are known to contribute to cholestasis (the so-called sluggish liver) and so there may be a vicious cycle where B vitamin deficiency causes diminished estrogen clearance and elevated estrogen 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 vitamins, methionine, phosphatidyl choline, inositol, N-acetyl-cysteine and glutathione.

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 body’s 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.

The symptoms of this type of PMS are similar to those of hypoglycemia, and following general guidelines to control hypoglycemia will be beneficial. Glucose Tolerance tests performed on PMS C sufferers in the 10 days preceding the period indicate an excessive secretion of insulin in response to blood sugar levels, the insulin: blood sugar ratio being normal at other times of the month. The exact mechanism by which this comes about is not clearly understood but a deficiency of PGE1 is known to inhibit glucose-induced insulin production and thus may be operative in PMS C. Sodium chloride enhances insulin response to sugar ingestion and low pancreatic magnesium levels leads to increased insulin production. Thus when treating this form of PMS it is advisable to avoid table salt and supplement with 300 - 600 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 it’s active form, a deficiency of vitamin B6 is commonly associated with PMS H.

Ms. C. was 40 years old when she first consulted with me in the summer of 2000, 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 year and were fearing infertility. Until the age of 35 she had virtually no gynecological disturbance except for mild PMS. Her symptoms included cravings for chocolate, salt, carbohydrates and coffee. She also complained of some 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 yoga class one day when she experienced an acute abdominal pain that was short lived and self limiting, but severe. The following day she had an elevated temperature and grumbling right abdominal pain. An ultrasound revealed a large chocolate cyst on the right ovary, indicating progressed endometriosis, and two 2 - 3" intra-muscular fibroids. She took Traditional Chinese Medicine (formulas not available) and found some relief from the worst of her symptoms. After three months she had surgery to remove the cyst but has not had surgery on the fibroid. When she consulted with me she had been unable to obtain the Chinese herbs for several months. She was experiencing worsening of the PMS symptoms and menstrual pain. She was aware of acute pain (mittelschmerz) every other month on the right side and she charted regular ovulation and menses with a specially calibrated thermometer for basal body temperature. Her OBGYN was urging her to have surgery again to remove more small cysts on both ovaries and to undergo a fallopian tube patency test. She was reluctant to have more surgery seeing that it hadn’t solved anything the first time. 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 times a week. Her diet was fairly restricted. She noticed a sensitivity to wheat and dairy products and generally avoided them. She had been vegan for some years and became anaemic and B12 deficient which had been adequately treated. After the surgery she had re-introduced some fish, turkey, chicken and eggs, all free-range and organic. She prepared most foods at home, whole 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 (Iron).

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:

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.

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.

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.

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.

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.

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).

False unicorn (Chamaelirium luteum) 1:3 10 ml ovarian normalizer, pro-estrogenic

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.

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).

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.