Premenstrual Syndrome (PMS) is characterized by various emotional and physical symptoms that occur in the days leading up to the menstrual period. About 75% of women of reproductive age are affected by PMS, making this one of the most common reproductive conditions women experience.

Those suffering from PMS find it occurs in a predictable pattern each month. While there is a long list of possible symptoms, most women find that they have only a few. The severity of these symptoms can range from mild to debilitating. Regardless of severity, PMS symptoms can disrupt everyday life each month.

A functional medicine approach to treating PMS involves looking into the possible root causes and creating a holistic treatment plan that can help ease symptoms and prevent the continuation of these symptoms each month.

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PMS Signs & Symptoms

There is a long list of potential signs and symptoms of PMS, including emotional and behavioral type symptoms and physical symptoms. However, most women tend to only have a few symptoms from either or both categories, meaning that PMS can look quite different from individual to individual. The severity of each symptom can also vary widely.

Examples of Emotional and Behavioral Symptoms

• Depressed mood and/or anxiety
• Crying easily and seemingly out of nowhere
• Mood swings, including irritability or anger
• Appetite changes
• Food cravings
• Sleep difficulties (insomnia)
• Social withdrawal
• Difficulty concentrating/brain fog
• Changes in libido

Examples of Physical Symptoms

• Breast tenderness
• Headache/Migraine
• Acne
• Fatigue
• Achiness or pain in joints or muscles
• Weight gain from fluid retention
• Abdominal bloating
• Constipation or diarrhea
• Change in alcohol tolerance

Typically, regardless of which are present or their severity, these signs and symptoms resolve within four days of the onset of the menstrual period.

Diagnosing PMS

There are no objective measures such as lab work or imaging available for diagnosing PMS. Instead, the only way to get an official diagnosis is by having a pattern of symptoms confirmed by an ob-gyn. According to the American College of Obstetricians and Gynecologists, a PMS symptom must be present the five days before a period, be present for at least three consecutive menstrual cycles, end within four days of the onset of the menstrual period, and interfere with some normal activities.

The best way to help your ob-gyn evaluate your symptoms and receive an accurate diagnosis is to keep a journal each month to note and rate any symptoms you feel during the premenstrual time.

PMS Possible Causes

The exact cause(s) of PMS is not currently known. However, a few factors are likely contributing to this syndrome.

Hormone Imbalances

Hormonal fluctuations throughout the menstrual cycle are likely contributing to PMS symptoms. This is confirmed by the fact that PMS symptoms discontinue during pregnancy and after menopause when hormones stop fluctuating. However, it is still unclear why certain women are more sensitive to these fluctuations than others. Research confirms that higher estrogen contributes to the severity of PMS, while other studies show that lower progesterone can also affect severity.

Estrogen & Progesterone Optimal Range

Low Serotonin

Chemical changes in the brain may also be contributing to PMS. Serotonin is a neurotransmitter that plays a vital role in our mood. Observational research shows that women with PMS have significantly lower serotonin levels during the last ten days of the menstrual cycle (which is the exact time PMS symptoms show up). Low serotonin levels could account for various PMS symptoms such as depression, fatigue, sleep issues, and food cravings.

• ‍Serotonin Optimal Range: 79 – 235 μg/g

Vitamin & Mineral Deficiencies

Certain vitamin and mineral deficiencies may also play a role in PMS. Calcium and Vitamin D levels have been shown to have an inverse relationship to PMS severity. Women with high intakes of Thiamine and Riboflavin (B Vitamins) through their diet have been shown to have less PMS as well.

• ‍Calcium Optimal Range: 9.2-10 mg/dL
• Vitamin D Optimal Range: 35-50 ng/mL
• Thiamine Optimal Range: 66.5 - 200 nmol/L
• Riboflavin Optimal Range Ages 19-50 for females 1.1 mg for females

Gut Health

Dysbiosis, which is the imbalance of microorganisms in the gut, is another theory for a contributing factor to the symptoms of PMS. A study found that by daily supplementation of Lactobacillus gasseri CP2305, a beneficial bacteria, women increased the diversity of their gut microbiome and then experienced fewer PMS symptoms. This suggests that the lack of diversity in the gut may be contributing to PMS symptoms.

Endocrine Disruptors

Endocrine disruptors are chemicals found in the environment that can interfere with and alter our endocrine system (our hormones). A study looked at endocrine disruptors and PMS and found a correlation that women who took action to reduce endocrine disruptors in their environment experienced less PMS than those who did not reduce their exposures.

Functional Medicine Labs for PMS

Since there is no known cause for PMS, conventional medicine currently has no lab or imaging tests to help diagnose. However, because functional medicine focuses on the root cause(s), there are several that may help identify some functional issues that may be present.

Hormone Test

Hormones are typically tested through serum (blood) or sometimes through saliva. However, The DUTCH Cycle Mapping Test is a dried urine test and is an excellent option for hormones because it collects samples throughout the menstrual cycle. This allows for a thorough evaluation of the total cycle rather than merely a snapshot of where the hormones are at the time of the blood draw.

Since PMS is associated with the fluctuations of hormones in the menstrual cycle, it is a great start to see where the hormone levels are during the premenstrual part of the cycle and surrounding days.

Neurotransmitter Test

Since research has associated low serotonin levels with PMS, it may be helpful to analyze the neurotransmitters to understand better the body’s ability to secrete and metabolize the neurotransmitters. Doctor’s Data Comprehensive Neurotransmitter Profile is a urine test that can provide important information about the neurotransmitter levels in the body.

Micronutrients Test

SpectraCell's Micronutrient Test is a valuable test for determining possible deficiencies in various vitamin and mineral levels. Understanding these levels is vital to creating an individualized treatment plan.

Gut Health Test

PMS is associated with an imbalance of and lack of diversity in the gut microbiome (the beneficial bacteria in our gut). Therefore, it is helpful to look at the microbiome via the stool to assess microbial imbalances.

GI-MAP by Diagnostic Solutions is a comprehensive stool test that can help discover a gut imbalance and tell us which microbes are present in general and which microbes may present a problem to address in a treatment plan.

Endocrine Disruptors

The Total Mycotoxin Panel by RealTime Laboratories, the Environmental Pollutants Profile (EPP) by US BioTek, and the Heavy Metals, 21 Toxic, Urine (24-hour) by Access Medical Laboratories test for total environmental toxins, mycotoxins, and heavy metals.

Another valuable test would be to measure overall liver function to ensure that whatever is coming into the body can be adequately detoxified by the liver. Access Med Labs offers a Hepatic Function Panel to assess general liver function.

Conventional Treatment for PMS

There are four classes of pharmaceuticals that are typically prescribed for the treatment of PMS: Antidepressants, Nonsteroidal anti-inflammatory drugs (NSAIDs), Diuretics, and Hormonal Contraceptives.

• Antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs), are prescribed to reduce the mood symptoms associated with PMS.
• NSAIDs are commonly recommended for pain reduction, specifically cramping and breast discomfort.
• Diuretics are recommended if weight gain, swelling, and bloating are symptoms the PMS sufferer may be facing.
• Hormonal contraceptives are commonly prescribed to reduce PMS symptoms because they stop ovulation and therefore stop the fluctuation of hormones, which relieves the hormonal-related symptoms.

The above conventional approaches come with a host of side effects, so they should be used with caution.

Functional Medicine Treatment for PMS

PMS is complex and consists of many potential combinations of symptoms, making treatment options challenging to pinpoint. However, if we look closely at the root causes of what is likely going on, we can devise a holistic plan to reduce problematic symptoms and hopefully prevent these symptoms from arising each month in the first place.

Balancing Hormones

Hormonal imbalances are likely a significant root cause of PMS, and the best way to approach a hormone imbalance holistically is to treat the gut. Treating the gi tract should improve the microbiome balance and indirectly treat the hormone balance issues affecting PMS.

Ensuring a healthy gut is also essential for balancing the neurotransmitters such as serotonin through the gut-brain-microbiome-axis.

Nutrition

The Mediterranean Diet is commonly prescribed and very beneficial for the gut microbiome. Daily intake of certain probiotics can also help to rebalance the gut microbiome.

Herbs

• ‍Vitex agnus castus, also known as Chasteberry, is a safe and effective herbal treatment to reduce PMS hormonal symptoms.
• ‍Evening Primrose Oil is also considered safe and effective for reducing symptoms. However, studies show that dosing for at least 4-6 months may be necessary to gain the full effect.
• ‍Jia Wei Xiao Yao San, a Traditional Chinese Herbal formula, is commonly used to help relieve cramps, irregular menstrual cycles, infrequent periods, and premenstrual syndrome (PMS).

Toxins Reduction

Endocrine disruptors are also likely involved in PMS. While there is no direct treatment for ridding these from the body, the best action to take is to reduce exposure to these in the first place.

The Environmental Working Group is an excellent resource for learning how to reduce these exposures in daily life.

Gently supporting the liver is also vital for mitigating the effects of endocrine disruptors since the liver is responsible for detoxifying the body of these products. Metabolic Detoxes and some herbs like Milk thistle are highly studied for supporting the liver.

Furthermore, addressing possible nutrient deficiencies is essential in the treatment of PMS. Specific deficiencies such as Vitamin D, Calcium, and Magnesium have been shown in those with PMS, and supplementation may be advised to correct those deficiencies.

*Note that you should never take supplements without guidance from a healthcare professional. You should work with an integrative healthcare provider to set up the best plan for your root cause.

Summary

Premenstrual Syndrome (PMS) is a common and debilitating condition affecting millions of women each month before the onset of their menstrual period. It can consist of various symptoms, including emotional/behavioral signs and physical symptoms.

Functional lab tests can be beneficial in looking further into those possible root causes so that we can start to put the pieces together and understand what mechanisms are at play when it comes to these various symptoms. Functional medicine helps us look deeper to formulate holistic treatment plans and achieve better outcomes.

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