ESCAPING THE PMS MAZE
Geoffrey Redmond, MD

Quick Reference
Some important points about PMS
What is PMS?
Helping yourself get help
Help for PMS: The holistic approach
Lifestyle
Nutrition
Vitamins and Minerals
Herbs and supplements
Some other alternative approaches
Medications
Some final words of encouragement

This is a long article because I felt there is a lot that is important that needs to be said about PMS.

SOME IMPORTANT POINTS ABOUT PMS: 

PMS has many different patterns. It is very real and is not a joking matter.

Self-understanding is the first step: work out what your main symptoms are, when during your cycle they happen, what else sets them off.

Maintain your optimism; PMS nearly always gets better.

Anti-depressants have been heavily promoted for PMS. They are a good answer for some but for many women, simpler things work: herbs, supplements and lifestyle change.

All of these and more are discussed in the following article.

WHAT IS PMS?
All women know something about PMS (premenstrual syndrome) either from their own experience or from that of their friends. Although PMS has been questioned as a diagnosis, but it is all too real; millions of women suffer from it.  One reason PMS is confusing it that it is very variable. In truth, PMS is not one condition but many. It’s fair to say that there are as many varieties of PMS as there are women who have it. Women are reluctant to complain about PMS and studies suggest that most actually play down their symptoms when talking to doctors.

PMS includes both changes in body and changes in feelings. The official psychiatric diagnosis called PMDD (premenstrual dysphoric disorder) focuses on mood changes in the week before menstruation. My experience suggests that this is artificial because not just mood is involved and symptoms can occur at different times throughout the cycle – not just that one week before menstruation. Because it involves both body and mind, PMS needs to be understood holistically.

HELPING YOURSELF GET HELP
The first step in escaping the PMS maze is paying attention to how you feel.
Is the main problem mood swings or physical discomfort? Or do you have both? It is important to track when in relation to your cycle symptoms occur. Also notice if external events tend to trigger them. Are certain kinds of stress harder to take at particular times of your cycle? Do certain foods affect you differently at different times? Is your energy less?

 The following list may help you sort out the specifics of your PMS:

Feelings:
Anger
Irritability
Frustration
Dissatisfaction with self or others
Sadness
Crying for no reason
Fatigue
Sluggishness
Anxiety
Dizziness, lightheadedness
Insomnia
Decreased sexual desire (sometimes increased)
Food cravings

Physical symptoms
Weight gain
Bloating
Edema (fluid retention)
Breast discomfort
Cramps
Pelvic fullness or aching
Discomfort with intercourse
Worsening of hormonal skin problems
(oiliness, acne, unwanted hair, hair shedding)
Headache
Diarrhea and/or constipation

HELP FOR PMS: THE HOLISTIC APPROACH
PMS almost always gets better. But to be effective, treatment must take into account the many factors involved in each person because PMS is different for each woman who has it. The key to overcoming PMS is finding what your body needs.

The first step is a thorough medical evaluation which ideally includes a thorough discussion of your past health history, current lifestyle and nutrition as well as the specific symptoms you are having and what triggers them. Your life situation, stresses and relationships also should be taken into account. There are many effective treatments but none works for all women. A treatment which did not work by itself may help when it is combined with others.

A holistic plan should be made up from four components:

            Lifestyle

            Nutrition

            Herbs and supplements

            Medication (Sometimes)

  It usually takes at least two cycles to see if a treatment is helping.

LIFESTYLE
Self-awareness
Becoming more aware of how both internal and external factors affect your PMS helps you to adjust your lifestyle accordingly. A knowledgeable health care provider can often help you identify triggers.

Consistency in timing of cyclic biological functions such as sleep, waking, work, and relaxation helps even out mood and energy. This is not always easy with demands of career and family, but try at least to move toward order rather than disorder. As much as possible, important activities should be timed so that they will not occur during your difficult time. In most of human history it was accepted that life is to be lived in accord with natural rhythms: night, day, the seasons, the phases of the moon. Important tasks were undertaken only on favorable days.

Exercise is extremely effective in lifting mood. However, if you cannot exercise as well during the difficult times of your cycle remember that less is better than none. About 20 minutes 4 times a week is enough to help lift mood. More exercise than this may be good for you but probably will not have any greater effect on your mood.

Stress reduction techniques are extremely valuable – and not just for those with PMS. Practices many have found helpful include sitting meditation, yoga, tai chi and regular prayer. All involve a lowering of activity level which makes some anxious at first. Be patient; in our fast paced world these practices may seem to work slowly but they do work. You will get more from a spiritual practice which is harmonious with your own beliefs and values. A health care practitioner who is knowledgeable about these methods can be a great help in finding what will work for you.

Insight Sometimes the anger that comes out with PMS has a real basis. When you are calmer, consider if your annoyance has a justifiable cause and what might be done to improve the relationship. Or there may be an accumulation of frustrations, several of which need to be addressed. The problems may not be major but become overwhelming when you are also coping with hormone shifts.

NUTRITION
Frequent meals
For some women, skipping meals results in lowering of blood sugar which can release adrenalin into the bloodstream. Although this is harmless, it can feel like impending disaster and it may take your body an hour or more just to get back to baseline. Women with these hypoglycemia symptoms can be helped by a customized meal plan.

Vegetarian diets low in fat reduce premenstrual symptoms but not all can follow them. If you do want to go in this direction, a gradual, step-wise approach is usually more realistic than a sudden change which does not give your body time to adapt.

Soy Despite recent alarmist claims, soy is probably the healthiest food you can eat. It seems to have a soothing effect on hormones. Only real tofu or soy milk have all the healthy ingredients. Pills and capsules don’t do it. One ounce of tofu a day gives you adequate isoflavanoids.

Carbohydrate need not be avoided. It does have a soothing effect on mood and anxiety. The main guidelines are:

Meals should not be entirely carb.

Complex carbs and whole grains are best.

Minimize sweets and do not substitute sweets for real meals.

Avoid binging. If you are hungry and irritable, eat a modest amount then give it time to make you feel better.

Comfort foods Not all foods which make you feel good are unhealthy. Hot soup and fresh juices are good choices.

Water and salt Be sure to increase your water intake after ovulation (about 14 days after your period starts). Most women should limit salt but some slender women with low blood pressure lose salt before their periods rather than retaining it. If you feel dizzy or weak during the premenstrual week, you may need to increase salt.

VITAMINS AND MINERALS
Multiple vitamins
Take a standard women’s multiple vitamin with iron. Mainstream brands such as One A Day Within, Centrum, or the house brands of the major drugstore chains are as good as more expensive ones.

Certain vitamins and minerals have been said to help specifically with PMS when taken in higher doses. They do work for some women but not all. Since they are simple, safe and inexpensive, they are worth a try. The main ones are:

Vitamin B6 (Pyridoxine) but be careful, more than 100 mg/day can damage nerves.

Vitamin E  600-800 units per day. Here reading fine print is necessary. Vitamin E is alpha tocopherol but there are other tocopherols which may be beneficial so capsules containing “mixed tocopherols” are preferable. Also pick one which has “D”-alpha tocopherol rather than “D,L” – alpha tocopherol which is synthetic. Calcium (Ca) 1000 to 1500 mg per day has been reported to help. The citrate is probably best. Use one which includes Vitamin D (you need 600 to 800 units per day; multivitamin tablets contain only 400 units.) Ca does not always work for PMS but women should be taking it for their bones anyway.

Magnesium (Mg)has also been reported to help. Doses vary. Mg can cause diarrhea.

HERBS AND SUPPLEMENTS
A variety of botanical remedies have been reported to help with PMS. Picking the right dose and preparation is important. The biggest problem with herbs is that there are so many, and most of the information available is not reliable. The best source of advice is a trained medical professional with an interest in herbs. Self-described “herbalists” are often amateurs with incomplete knowledge.

I have listed some useful herbs and some which are popular but questionable. Names can be confusing; I have given the most commonly used ones.

Vitex (chaste tree or chaste berry). Best supported by research. It evens mood and can decrease breast pain. Evening primrose oil. Results of studies have been mixed. Black cohosh   Useful when PMS occurs around time of perimenopause.

Dong Quai  Used by hundreds of millions of Chinese women as a female tonic, usually as an ingredient in soup. Western studies have not shown clear benefit and safety is uncertain. L-phenylalanine This is converted in the brain to several important neurotransmitters. Not much published but experience suggests it can help. L-tryptophan has been reported to help but safety is problematic due to toxic contaminants in some preparations. The FDA withdrew it. Even if you find it, don’t  use it.

Eleutherococcus (Siberian ginseng) May be useful for improving energy.

American (Wisconsin) ginseng (Panax ginseng). This form is suitable for women. There are innumerable brands and not all are reliable. Some are adulterated with caffeine. Avoid the very expensive forms sold in Chinese stores unless you are a ginseng expert. Stick with an established brand with a good reputation. Traditionally Asian (as opposed to American) ginseng is considered too yang for women but it is hard to separate fact from folklore.

Hypericum  (St John’s Wort). This is widely used for mood problems. Onset is gradual and there are rumors of liver problems.

Choosing herbs and supplements. Different women vary in their response to these treatments so you should get advice from a knowledgeable practitioner and be willing to try other supplements if the first do not work. Be skeptical of sales pitches in health food stores which urge purchase of many different products.  In general, it is reasonable to use at most one or two herbs plus at most three vitamins and minerals. Not all are safe to combine with each other or with medications you may be taking. Also, when you feel better, you may not know which has helped. It’s best to develop a plan with a knowledgeable practitioner.

Safety of Supplements While most vitamins and herbs are safe, not all are. High doses may have different effects than normal ones. Some are nontoxic in themselves but contain dangerous contaminants. It is best to use only supplements for which adequate experience has been accumulated to give confidence in safety.

SOME OTHER ALTERNATIVE APPROACHES
 Acupuncture can be worth a try but it is time consuming and expensive. Be sure practitioner is reputable, licensed and uses disposable needles. Also, needles should not be inserted in chest wall.

Massage Works but effect wears off. Expensive if done regularly. Effect depends on ability and skill of therapist.

Fasting and detoxification These have been popular of late. Fasting is thousands of years old and is a major healing modality in Ayurveda (traditional Indian medicine). However, there may be adverse mood changes during fasting; if you want to try it, pick a time when you feel well and demands on you are low.  Follow common sense and avoid anything extreme. Slender women and those with hypoglycemia symptoms may not tolerate fasting well. It probably depends on individual metabolism but fasting advocates often do not allow for this. A physician who is aware of the effects of fasting can help you plan for a method that suits your individual metabolism.

MEDICATIONS
NSAIDs
such as Motrin and Advil (ibuprofen), Alleve (Naproxen) can help cramps and overall bodily discomfort. When these do not work, there are related prescription medications which last longer and are give more complete relief. Some of these can also make periods lighter.

Diuretics (“water pills”) These get rid of excess fluid but your body pays a price for this. By dehydrating you, diuretics set off a new cycle of fluid retention. Strong ones such as furosemide (Lasix) should be avoided. There are milder alternatives which can be considered for women who retain a lot of fluid.

Tranquilizers These can have a soothing effect but can be addicting so are not a good solution.

Antidepressants The newer antidepressants termed SSRIs (selective serotonin reuptake inhibitors) can make a major difference for some women with PMS. The term “antidepressant” is somewhat misleading because SSRIs can help symptoms of PMS such as low energy, irritability and difficulty concentrating. Many women with these symptoms feel better on SSRIs even though they were not unhappy.  They can be taken for some or all of each cycle.

The decision whether or not to use SSRIs or other prescription treatments is an important one. They are a good choice for some women but certainly are not necessary for all. Usually, herbs and supplements should be tried first but if PMS has reached a crisis point, SSRIs may offer the quickest relief. On the other hand, if you have a day or two of discomfort but are not slowed down by it, then supplements and other alternative approaches will probably be sufficient.

Trying an antidepressant does not commit you to a life on it. You can reassess once you are feeling yourself again.

Hormones Progesterone was once a common treatment for PMS but using it is complicated because of the need to time dosing with the menstrual cycle. But progesterone is worth a try if simpler measures do not work. It is best to have guidance from a physician experienced in adjusting progesterone to individual women’s cycles. Only a natural form should be used because some of the synthetics can make mood worse.

Some Final Words of Encouragement:
Don’t let the cultural negativity about PMS dishearten you. Though it may take time to find the right regimen, PMS almost always gets better. Most important, don’t stop too soon in your search for help. And be open to change; what used to work for you may need to be modified from time to time as you and your body change.

Finding a knowledgeable and sympathetic health care professional who takes PMS seriously is probably the most important step in escaping the PMS maze. You should not have to deal with it alone.

 

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