Premenstrual Syndrome, typically referred to as PMS, is a condition that affects three in every four women at some point in their lives. PMS can result in a physical and emotional burden on women and an economic burden; one study showed women with PMS spent over $4,300 more annually on medical costs than those who do not have PMS. This article will discuss PMS and its associated causes, functional medicine labs to help assess the root causes and integrative treatments to resolve PMS.

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What is Premenstrual Syndrome (PMS)?

PMS is a group of behavioral and physical symptoms that can occur before a woman's menstrual period. Diagnostic criteria for PMS include having symptoms that occur five days before menstruation and end within four days after for three consecutive months. Additionally, symptoms must affect normal activities.

PMS Symptoms

PMS symptoms can vary between women; some women may only have physical symptoms, some may only have behavioral symptoms, and some can have a mix of both. The severity of symptoms can vary from mild to severe.

Behavioral Symptoms:

• Mood swings
• Depressed mood
• Anxiety
• Social withdrawal
• Difficulty concentrating
• Insomnia
• Increased appetite
• Food cravings
• Libido changes

Physical Symptoms:

• Fatigue
• Acne
• Breast tenderness
• Headache/migraine
• Fluid retention causing weight gain
• Aches and pains
• Constipation or diarrhea
• Abdominal bloating
• Alcohol tolerance changes

What Causes PMS?

There is no specific cause for PMS. Rather, we know there are contributing factors, including hormonal changes, environmental exposures, vitamin and mineral deficiencies, gut health, and changes in the level of the neurotransmitter serotonin.

Hormonal Changes

A woman's primary hormones, estrogen and progesterone, will fluctuate during a monthly menstrual cycle. During the first half of the cycle, known as the follicular phase, estrogen should be dominant. Ovulation occurs about halfway through the cycle for most women and is categorized as an increase and then a sudden drop in estrogen which is also when the egg is released from the ovary. The release of the egg leads to the luteal phase, where the production of progesterone, the other main female hormone, occurs. If the egg does not implant, both progesterone and estrogen levels will begin to decline until the levels become low enough that menstruation is triggered. Some research suggests that it's higher levels of estrogen that trigger PMS symptoms, while others show the culprit to be lower levels of progesterone.

Environmental Exposures

Many chemicals used in everyday household products and personal care products can interfere with proper hormone production. These chemicals are known as endocrine disruptors because they affect our endocrine (hormonal) system. In a study assessing PMS and environmental exposures, women who avoided these exposures experienced fewer PMS symptoms.

Vitamin and Mineral Deficiencies

Levels of individual vitamins and minerals may affect the occurrence of PMS. In higher levels, calcium, vitamin D, thiamine (B1), and riboflavin (B2) have been linked to lower occurrences of PMS.

Unbalance Gut Microbiome

The microbiome is a collective group of organisms that reside in the large intestine. The microbiome influences many body processes, including digestion and absorption, immune function, and more. A dysbiosis, or imbalance, in the organisms of the microbiome may play a role in PMS. One study showed that supplementation of a specific bacterial strain (Lactobacillus gasseri CP2305) lessened PMS symptoms. Additionally, the third step of estrogen metabolism occurs in the gut by a specific group of bacteria known as the estrobolome. A dysbiosis in these bacteria can lead to estrogen recycling rather than expulsion, thus contributing to a hormonal imbalance.

Low Serotonin

Serotonin is a neurotransmitter that impacts our mood. According to an observational study, women who have PMS have a drop in serotonin levels around the same time. Specific behavioral and physical symptoms seem to be attributed to low serotonin levels, such as depression, anxiety, fatigue, insomnia, and food cravings.

Functional Medicine Labs to Test for Root Cause of PMS

Evaluating the root causes of PMS can be accomplished through various functional labs such as the labs listed below:

Hormone Panel

A hormone panel, such as the DUTCH Complete test by Precision Analytical, will assess levels of hormones, including estradiol, estrone, progesterone, and testosterone. These hormone levels can help assess if a hormonal imbalance is at the root of PMS. This test will also show a metabolite of serotonin, giving insight into this neurotransmitter level that may also be causing PMS.

Environmental Testing

Testing environmental toxins, such as the LRA Environmental Chemicals Block 61 test by ELISA / ACT Biotechnologies, can help to assess exposures to toxins, many of which are endocrine disruptors that may be playing a role in PMS.

Comprehensive Stool Test

A comprehensive stool analysis such as Doctor's Data GI360 will give an overview of the composition of the microbiome. Additionally, this test shows levels of beta-glucuronidase, an enzyme produced by the bacteria in the estrobolome that helps absorb estrogen. When high, it can cause estrogen to be recycled in the body.

Micronutrient Panel

A micronutrient test, such as the Spectracell Laboratories Micronutrient Test, will give numerous vitamin and mineral levels in one test. As mentioned above, certain vitamins and minerals have been linked to PMS symptoms, and other vitamins and minerals have been linked to hormonal fluctuations, which, in turn, can also cause PMS.

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Functional Medicine Treatment Protocol for PMS

A functional medicine treatment approach to PMS considers the root causes. Nutrition, supplementation, and complementary and integrative therapies are all useful for the treatment of PMS.

Therapeutic Diet and Nutrition Considerations for PMS

Diet can play a role in the progression of PMS. A study was done assessing the Mediterranean Diet and PMS. Of the 262 women that participated, those who adhered to the Mediterranean Diet the best had the lowest occurrence of PMS. The Mediterranean Diet consists of fresh fruits, vegetables, herbs, and spices, minimally processed whole grains, healthy fats such as nuts, seeds, fatty fish, and olive oil. The diet also emphasizes eating locally and seasonally.

Seed Cycling for PMS

Seed Cycling is a method used to help balance two phases of your menstrual cycle, the follicular and the luteal phases, by influencing the key hormones involved.

The concept behind seed cycling is that specific seeds can benefit your follicular phase while other seeds support the luteal phase. Rotating these seeds throughout the menstrual cycle can help regulate dysfunction, resulting in more balanced hormones and fewer hormone-related symptoms associated with PMS.  

Supplements Protocol for PMS

In addition to an anti-inflammatory diet, such as the Mediterranean Diet, certain supplements can be helpful for PMS.

Evening Primrose Oil

Oenothera biennis, known as evening primrose, is a botanical grown worldwide. Evening primrose oil, the medicinal part of the plant, is extracted from the seeds and has high amounts of fatty acids. Numerous placebo-controlled studies have shown that evening primrose oil supplementation can reduce the severity and occurrence of PMS. It is recommended to use evening primrose oil for four to six months before expecting to see results.

Dose: 1.5-6.0 grams

Duration: Until Symptoms Subside or Retesting Confirms Labs are Stabilizing

Chaste Tree Berry

Chaste tree berry (chasteberry) is a botanical that has been used for medicinal purposes for 2,500 years. It is a common gynecological agent in Germany, where gynecologists and family physicians often prescribe it. Chaste tree berry affects the hormones progesterone and prolactin, increasing progesterone levels and both increasing and decreasing prolactin levels, depending on the dose. In a randomized, placebo-control trial of 170 women, women who took chaste tree berry for three consecutive months reported a 50% or greater reduction in PMS symptoms as opposed to the placebo group. Another randomized placebo control trial focusing on the PMS symptom of breast tenderness showed that symptoms were reduced after three consecutive months of chaste tree berry supplementation.

Dose: 4mg per day (standardized extract of 6% of the agnuside constituent)

Additional dose recommendations: 20-40 mg per day of standard fruit extract; 35-45 drops of tincture three times per day; 40 drops per day of fluid extract

Duration: Until Symptoms Subside or Retesting Confirms Labs are Stabilizing

Pyridoxine, B6

Pyridoxine, commonly known as vitamin B6, is a cofactor for over 100 enzymatic reactions in the body. Pertinent for the metabolism of carbohydrates, fats, and proteins, B6 also plays a role in neurotransmitter synthesis, blood sugar regulation, immune and inflammatory functions, and oxygen circulation. Pyridoxine has also been researched for PMS. A systematic review of 10 studies showed that overall, B6 effectively reduced PMS symptoms. Another study on 94 women showed that B6 reduced behavioral symptoms of PMS but not physical symptoms.

Dose: 50-600 mg per day

Duration: Until Retesting Confirms Labs are Stabilizing

Calcium

Calcium is the most abundant mineral inside the human body. Calcium is used for bone and tooth enamel formation, muscle and nerve conduction, and blood clotting. Calcium may also be helpful for PMS. A double-blind clinical control trial gave women a calcium carbonate supplement with a dosage of 500 mg three times per day for three months. Fatigue, appetite changes, and depressive symptoms were improved in the group given the calcium supplement as compared to the controls.

Dose: 500mg three times per day

Duration: Until Retesting Confirms Labs are Stabilizing

Calcium-D-Glucarate

Calcium-d-glucarate can lower beta-glucuronidase, an enzyme released by the estrobolome in the microbiome. As discussed above, the estrobolome's job is to package estrogen up to be put into the stool. When dysbiosis is present, instead of packaging the estrogen into the stool, these bacteria release the enzyme beta-glucuronidase in high amounts, which will lead to estrogen being put back into the bloodstream. This, in turn, can lead to higher estrogen levels and, thus, a hormonal imbalance that has the potential to cause PMS.

Dose: 1,500-3,000 mg per day

Duration: Until Symptoms Subside or Retesting Confirms Labs are Stabilizing

When to Retest Labs

Most functional medicine labs should be retested within 3-6 months. However, retesting labs will vary depending on the previous results and treatment plan. Your functional medicine provider will help individualize a plan for you that includes when to retest your specific labs.

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Summary

PMS is a common condition that affects most women at some point in their lives. Causing behavior and physical symptoms, PMS can affect the quality of a woman's life. Functional medicine testing can help women discover the root cause of PMS, and functional medicine treatments can be utilized to help resolve the underlying cause.