Premenstrual syndrome (PMS) is estimated to affect 3 out of every 4 women at some point in their lives. It has various signs and symptoms, including mood swings, breast tenderness, food cravings, fatigue, irritability, anxiety, and depression. An integrative approach to PMS usually involves a deeper dive into hormone levels, gut health, and detoxification ability, and then addressing the root cause with nutrition, lifestyle changes, and (if needed) personalized supplementation. Below is an excellent case study from Dr. Laura Decesaris, a Functional Medicine Practitioner.

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CC: Severe PMS Symptoms

Symptoms:

• Anxiety
• Irritability
• Bloating
• Acne
• Water Retention
• Pain and Cramping in the 7-10 days before the menstrual cycle. 
• Cycle ranges from 24-35 days and is somewhat unpredictable. 

Kate* was a 32-year-old female with a history of PMS-related symptoms that she had been experiencing fairly regularly for the last 3-4 years. She stopped using oral contraceptives four years ago after taking a combination pill for ten years to address acne and skin issues that started in high school.  

Kate had decided to stop taking oral contraceptives because she felt that they had contributed to weight gain and a loss of her sex drive, and she wanted her body to "recalibrate" before she decided to have kids.  

Since going off the pill, Kate had been dealing with frustrating symptoms such as an irregular cycle length and moderate-to-severe symptoms in the week or two leading up to the start of her period. These symptoms included acne, water retention and bloating, cramping and pain, anxiety, and mood swings/irritability.  

Kate's health history showed that, while Kate had a healthy, happy childhood without any significant health issues, she started to experience hormone-related symptoms shortly after hitting puberty at age 12. As a teen, Kate dealt with painful cystic acne (bad enough that she took Accutane for 18 months, which is when she initially went on oral contraceptives at age 17). She also experienced unwanted weight gain. Before going on oral contraceptives, her periods were so heavy that she fainted on a few occasions and had to start taking iron supplements per her pediatrician's advice. While starting the Accutane and oral contraceptive helped with the heavy flow and acne, she had "always carried extra weight." At the time of her initial intake, she admitted she had tried "every diet in the book" over the past five years to lose weight, with none providing long-lasting results or sustainability. 

Her recent bloodwork at the time showed elevated estradiol, C-reactive protein, sex-hormone-binding globulin (SHBG), as well as borderline high TSH, and low Free T3, serum progesterone, DHEA, ferritin, and vitamin D. Her primary doctor wanted her to go back on oral contraceptives to "help with her labs," but Kate wanted to try a more integrative approach before committing to birth control again.  

Additional History

Kate's diet consisted of a lot of carbohydrates and protein shakes. She avoided fat, mainly because "she was trying to lose weight," and admitted she didn't love vegetables that much. Her go-to meals were oatmeal for breakfasts, a protein shake or chicken and rice for lunch, a post-workout protein shake, and turkey burgers or pasta for dinner. She often had sugar cravings in the evenings and would keep sugar-free desserts like ice cream or sugar-free candy around after dinner. Kate's go-to workouts were boot camp classes at her gym or walking/running on the elliptical machine during her lunch break. She worked from home and had an elliptical machine in her basement, so it was convenient for her.

Kate also reported dealing with constipation "for years," averaging 2-3 bowel movements per week since she was in college. She often felt bloated after eating, especially at the end of the day. Nothing helped, even when she had tried to take laxatives or Miralax.

Kate was taking the following supplements at the time of her initial consultation:  

• Goli apple cider vinegar gummies
• Liquid collagen from Isagenix
• Nature Made iron gummies (18mg)

Initial Lab Work

Comprehensive Stool Test Results:

Pancreatic elastase: LOW

Bifidobacterium: LOW

Candida: 4+ HIGH

Meat Fibers, Vegetable Fibers: MODERATE

NutrEval (Genova Diagnostics) results:

Vitamin A: LOW

Plant-based Antioxidants: LOW

Vitamin C: LOW

Zinc: LOW

Lipid Peroxides: HIGH

Kate’s lab work points to a few core issues that are contributing to her PMS symptoms:

Hormone Imbalances:

• Kate has a history since her teenage years of hormone-related symptoms like acne and heavy periods/PMS prior to going on oral contraceptives for ten years. While she has been off of those medications for a few years, her hormones have not balanced out. A combination of elevated estradiol, low progesterone, low DHEA, and elevated SHBG are likely contributing to ongoing symptoms of PMS, such as water retention, bloating, acne, etc.  
• Additionally, her TSH is mildly elevated, and her free T3 is low, indicating she is also experiencing mild hypothyroidism. Hypothyroidism may be contributing to her inability to lose weight, and many symptoms of hypothyroidism - such as anxiety, water retention, and increased inflammation - are similar to those of PMS.

Digestive Health

• Kate’s comprehensive stool tests showed us several areas that needed support. She had low growth of beneficial bacteria such as Bifidobacterium, with high growth of Candida spp, a potentially pathogenic organism. She also had several markers indicating decreased digestive enzyme function and the presence of malabsorption. Without breaking down and absorbing her food, Kate is at risk of nutrient deficiencies, some of which we can see in her labs (low zinc, borderline low vitamin D, and low folate, to name a few).
• Dysbiosis and constipation can be linked to elevated estrogen levels as well.

Inflammation

• Kate’s Omega-3 index was relatively low, putting her in the high-risk category for inflammation in the body. Paired with an elevated CRP, it was clear that there was elevated inflammation at the time of her initial consult.

Nutrient Deficiencies

• Along with the results in her stool test of malabsorption, we saw in both her blood draw and nutreval that several nutrient deficiencies were going on (zinc, vitamin D, folate, vitamin A, and Vitamin C, to name a few), many of which are relevant to reducing inflammation and promoting healthy hormone function.

Functional Medicine Approach to PMS: Interventions

• We started Kate on an anti-inflammatory nutrition program to help support her body’s detox systems and focus more on nutrient-dense foods, including healthy fats, since she had been avoiding this macronutrient group. Healthy fats are essential for hormone production and fertility in women. 
• Kate started a diet lower in sugar and refined carbohydrates to help with her inflammation, focusing on quality protein, fats like avocado, olive oil, and coconut oil, and carbohydrates in the forms of fruits, green leafy vegetables, root vegetables, and some gluten-free whole grains. Each meal contained protein, healthy fat, and fiber, primarily in the form of vegetables, low-glycemic fruit, and sweet potatoes or another starch rather than white potatoes (due to her food sensitivity scores). We also added more pumpkin seeds and lean red meat at least once per week to help with her zinc levels.
• We added in a few other things to support her gut health, including a probiotic (Metagenics) and Enzymix-Pro digestive enzymes before meals and a targeted elimination diet with the removal of foods that came back in her food sensitivity panel.  
• Yeast-Cleanse by SolaRay to address the dysbiosis and high Candida spp levels.
• Vitamin D, 5000 IU per day.
• Antioxidant support, Organifi Red Juice, one scoop per day added to filtered water.
• Started omega-3 supplement, Metagenics SPM, 2000 mg per day
• Vitex (Chaste Tree), 225mg twice per day, to support healthy progesterone levels.
• Set up an endocrinologist referral for Kate due to her thyroid labs; her endocrinologist suggested low-dose NP thyroid (a glandular-based thyroid prescription) to help support her thyroid health while Kate was working on underlying imbalances we found in her labs.
• Increased water intake
• Dry brushing 2-3x week to help with lymphatic drainage and detox support.
• Daily walking/movement and adding in 2 days of strength training to her workouts, rather than only going to boot camp classes.

4 Month Follow Up

When we re-ran labs and intake at four months, we saw many things trending in the right direction. By this point, Kate had had two consecutive menstrual cycles of 29 days length, with minimal PMS-related symptoms, other than some mild anxiety and water retention the day before her period started. She had more energy and was “feeling back to herself.” Her endocrinologist was monitoring her medication dosage, which she felt good about.

We had supported Kate’s new nutrition approach with weekly check-ins with a nutritionist to help guide her and make recommendations to fit her lifestyle. She stuck to her plans and had done a great job of moderating her sugar intake and making healthy swaps most of the time to stick to her schedule without feeling overly restricted. After four months, Kate was finally having a bowel movement once per day, most of the time. She noticed her bloating disappeared quickly once she started digestive enzyme and probiotic support.  

At this point, we started working with her more intentionally on cycle syncing to help support her hormones. Kate decided to stick with her supplement routine since she felt so great and felt it was very manageable.

Summary

This case highlights how PMS can have a wide array of symptoms similar to other conditions, such as hypothyroidism and dysbiosis. Kate’s hormonal imbalances that had been present when she was younger before using oral contraceptives were still there when she went off of the medication. By approaching her PMS from a functional perspective that looked at her gut environment, hormones, inflammatory markers, and lifestyle, we were able to reduce her symptoms and get her back to feeling great again. At the time of her 6-month check-in, Kate still had regular 28-29 day cycles with minimal PMS-related symptoms, and she had lost 12 pounds from the time we started working together (without “dieting”).