Premenstrual syndrome is one of the most common women's health concerns. Approximately 80% of people who menstruate will experience one premenstrual symptom monthly, and of those affected, nearly 30% report that these symptoms interfere with their lives every month. The good news is that women don't need to settle for a life dictated by premenstrual syndrome, and there is a path toward symptom resolution.
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What Is Premenstrual Syndrome (PMS)?
PMS refers to the group of cyclical symptoms that occur during the luteal phase of the menstrual cycle. The luteal phase is the second half of the menstrual cycle, beginning after ovulation and ending at the beginning of menstruation.
An estimated 75% of women experience some form of PMS. In some cases, symptoms may be so debilitating that they will be diagnosed as a more severe form of PMS called premenstrual dysphoria disorder (PMDD).
PMS Signs & Symptoms
There is a long list of symptoms associated with PMS, but most women only experience a few of them before menstruation. PMS symptoms vary in severity; the majority of women will experience mild-to-moderate symptoms, but up to 20% of women will experience severe symptoms that interfere with their daily activities.
Behavioral & Emotional Symptoms
- Depression
- Anxiety
- Irritability
- Anger
- Crying
- Confusion
- Difficulty concentrating
- Social withdrawal
- Insomnia
- Changes in libido
- Food cravings (7, 32)
Physical Symptoms
- Fatigue
- Acne
- Breast tenderness
- Headaches
- Fluid retention, swelling, and weight gain
- Aches and pains
- Bloating
- Abdominal pain
- Changes in bowel movements
- Changes in alcohol tolerance (7, 32)
Root Causes of PMS
The exact cause of PMS is still a bit of a mystery, but there are a few leading theories that explain why women may experience PMS:
Hormonal Imbalances
This is the most widely accepted theory. During the menstrual cycle, estrogen and progesterone levels rise and fall. Luteal phase hormonal imbalances, particularly excess estrogen in relation to progesterone, have been linked to the presence and increased severity of PMS symptoms.
Serotonin Deficiency
Because serotonin helps regulate mood, sleep, and appetite, low levels could contribute to PMS. According to some studies, normal drops in estrogen that occur before menstruation cause the hypothalamus to release norepinephrine, which triggers a decline in various neurotransmitter levels, including serotonin. Observational studies also show that women with PMS have significantly lower serotonin levels during the last ten days of their menstrual cycle.
Nutritional Deficiencies
Some studies suggest deficiencies in certain vitamins and minerals, like vitamin B6, calcium, and magnesium, might worsen PMS symptoms.
Dysbiosis
The connection between gut health and PMS is a growing area of research. Gut dysbiosis, an imbalance in the gut microbiome, may contribute to PMS by influencing hormonal and neurotransmitter imbalances.
The gut microbiome plays a role in metabolizing estrogen. When a specific subset of gut bacteria, called the estrobolome, is imbalanced, they may produce more enzymes that increase estrogen reabsorption (instead of elimination), contributing to estrogen dominance.
The gut microbiome also plays a role in producing neurotransmitters, such as serotonin and GABA. When dysbiosis is present, these neurotransmitters may be made in lower quantities, potentially worsening PMS symptoms like anxiety, depression, fatigue, and sleep disturbances.
How to Diagnose PMS
Using diagnostic criteria and various lab tests, healthcare providers can rule out conditions that mimic PMS, diagnose PMS, and understand the underlying factors responsible for causing these cyclical symptoms.
Step 1: Use the Diagnostic Criteria
The following criteria must be met to diagnose PMS:
- At least one symptom is present in the five days before menstruation
- The symptoms end within four days after a period starts
- Symptoms are present for at least three consecutive menstrual cycles
The Daily Record of Severity of Problems (DRSP) is a validated symptom-tracking tool that can help doctors diagnose PMS and PMDD.
Other conditions can present similarly to PMS or worsen during the luteal phase. These can often be distinguished from PMS because symptoms will persist throughout the entire menstrual cycle. The following labs, imaging, and screening questionnaires can be used to rule out alternative diagnoses:
- PHQ-9 to screen for depression
- GAD-7 to screen for anxiety
- Thyroid panel to screen for hypothyroidism
- Complete blood count (CBC) to screen for anemia
- Pelvic ultrasound to assess for endometriosis
Step 2: Order Labs to Evaluate the Root Causes of PMS
Blood tests may be an easy, cost-effective first-line screening for estrogen and progesterone imbalances. Given that estrogen and progesterone levels aren't constant throughout the menstrual cycle, it is generally accepted that estrogen (estradiol) should be measured on day 3 and progesterone between days 19 and 21 of the average 28-day menstrual cycle (19).
However, blood tests can easily miss hormonal fluctuations responsible for PMS symptoms that occur outside of the time of the blood draw. They also don't provide information on how the body metabolizes hormones, which is important because suboptimal hormone metabolism/elimination can contribute to estrogen dominance.
The following tests can be helpful in more comprehensively measuring hormone levels throughout an entire menstrual cycle, along with assessing how hormones are being metabolized and eliminated through the liver and bowels:
- DUTCH Cycle Mapping (Dried Urine) by Precision Analytical (DUTCH)
- DUTCH Complete by Precision Analytical (DUTCH)
- BiomeFx by Microbiome Labs
- Hepatic Function Panel by BostonHeart Diagnostics
Because micronutrient and neurotransmitter deficiencies have also been implicated in the pathogenesis of PMS, doctors may always want to assess these areas of health with one of the following panels:
- Micronutrient Test by SpectraCell Laboratories
- Neurotransmitters by ZRT Laboratory
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Treatment Plan for PMS
Once PMS has been officially diagnosed and lab results have revealed areas for improvement, a personalized treatment plan can be crafted to resolve PMS.
Step 1: Palliate Symptoms
Here's Why This Is Important:
While addressing the root causes of PMS through lifestyle changes and interventions is ideal, these approaches may take months to show significant improvement. For patients experiencing severe PMS symptoms that disrupt daily life, quicker symptomatic-based interventions may be necessary.
How Do You Do This?
Four classes of pharmaceutical medications are often prescribed for treating PMS symptoms:
- Antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs), are the first-line treatment for treating mood symptoms related to PMS.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) can be taken before or at the onset of a period to reduce pain and cramping.
- Diuretics can help eliminate excess fluid to ease symptoms related to water retention, such as weight gain, swelling, and bloating.
- Hormonal contraceptives stop ovulation and the natural cycling of hormones to reduce hormone-related PMS symptoms.
For those looking for a more natural approach, the following therapies have been shown to effectively reduce PMS symptoms:
- St. John's Wort 450 mg twice daily for natural antidepressant effects
- Evening Primrose Oil 250-500 mg daily to ease breast tenderness
- Ginger 500-2,000 mg daily for joint pain and menstrual cramping
- Abstaining from alcohol: alcohol intake is associated with moderately increased risk of PMS
Step 2: Correct Estrogen Dominance
Why Is This Important?
Because it appears that unopposed estrogen is the primary underlying mechanism of PMS, this is a major area of focus that needs to be addressed in most patients.
How Do You Do This?
The following dietary patterns can reduce inflammation, improve estrogen metabolism, and optimize the estrogen-to-progesterone ratio:
- People who adhere to a Mediterranean diet eating plan, which emphasizes the intake of fresh fruits, vegetables, herbs, spices, whole grains, and healthy fats, have the lowest occurrence of PMS. This diet encourages eating high-fiber foods and reduces the intake of refined carbohydrates and animal fats; these dietary habits are associated with reductions in circulating estrogen levels.
- Seed cycling can help create a healthy balance of estrogen and progesterone during the two phases of the menstrual cycle. To seed cycle, eat one tablespoon each of raw pumpkin and ground flax seeds during the follicular phase (days 1-14). During the luteal phase (days 15-28), eat one tablespoon each of raw sunflower and sesame seeds.
Regular exercise reduces physical and emotional PMS symptoms, including pain, fatigue, mood swings, and water retention. Exercise is also an excellent method for reducing stress, which can significantly contribute to female hormonal imbalances.
Slowed bowel function can exacerbate estrogen dominance by impairing the elimination of excess estrogen from the body. Patients should have at least one bowel movement daily. To support healthy bowel movements and prevent constipation, encourage patients to eat fiber-rich foods, drink plenty of water, and address underlying health conditions (e.g., hypothyroidism, intestinal methanogen overgrowth).
The liver's estrogen detoxification pathways require various nutrients for optimal functioning, which can be obtained by eating the following foods:
- Indole-3-Carbinol (I3C): cruciferous vegetables
- Sulforaphane: broccoli sprouts
- Resveratrol: red grapes, berries
- Vitamin B12: meat, seafood, dairy, eggs
- Folate: spinach, eggs, asparagus, cheese
- Riboflavin: eggs, meat, milk, cheese
- Vitamin B6: fish, bananas, grains, beans
- Choline: eggs, cauliflower, peanuts, flaxseeds
- Magnesium: green leafy vegetables, nuts, seeds
- Glutathione: asparagus, avocado, cucumbers
If needed, adding the following supplements has also been shown to improve hormonal ratios and PMS symptoms:
- Lactobacillus gasseri CP2305 probiotics
- Chasteberry extract 20 mg daily
- Vitamin B6 50-100 mg daily
- Calcium-D-Glucarate 1,500-3,000 mg daily
- Calcium Carbonate 500-1,200 mg daily
- Magnesium 200-500 mg daily
The Risks of Untreated PMS
PMS can result in a physical and emotional burden on women. Studies have shown women with PMS have a poor health-related quality of life; for women with PMDD, the symptoms can be as disabling as major depressive disorder. PMS can result in poor self-esteem, dissatisfaction, and inadequacy. It also can adversely affect interpersonal relationships. (48)
PMS also contributes to a significant economic burden. According to one study, women with PMS spend over $4,300 more on medical costs annually.
PMS Case Study
Read about a real PMS case here:
How One Patient Found Relief From Severe PMS Symptoms
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Key Takeaways:
- PMS is a common condition that affects most women at some point in their lives. Causing behavioral, emotional, and physical symptoms, PMS can negatively affect the quality of a woman's life.
- Treatment plans that address the underlying cause of PMS help women find freedom from these disabling cyclical symptoms.
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