Premenstrual Syndrome, Part 2

As mentioned in part 1, 80% of women experience premenstrual emotional or physical changes, whereas only about 20% to 40% of these women have difficulties as a result. A much smaller number, about 2.5% to 5%,² feel it has a significantly negative impact on their lives, to the point where work, relationships, and home life are jeopardized. Nutrition, exercise, and nutritional supplementation are natural approaches in the management and treatment of premenstrual syndrome (PMS). What follows is a guide to the botanicals and natural hormones that have been investigated that also help symptoms of PMS.

BOTANICALS
Chaste Tree (Vitex agnus castus)
Chaste tree berry has been seen by many alternative practitioners as one of the most important herbs to treat PMS. The effect of chaste tree is on the hypothalamus-hypophysis axis. It increases secretion of luteinizing hormone and also has an effect that favors progesterone. Two surveys were done covering 1,542 women with PMS who had been treated with a German liquid extract of chaste tree for periods of up to 16 years.³ The average dose was 42 drops daily.

Effectiveness as recorded by the patients' doctors was either very good, good, or satisfactory in 92% of the cases. Comparable dosing in standardized capsules are one capsule at 175 mg if standardized to 0.75% agnuside, or one capsule at 215 mg if standardized to 0.6% aucubin. No certain comparable dose of straight chaste tree tincture is known, but most practitioners would use 1 to 2 teaspoons daily.

The newest study was a clinical trial on 170 women with PMS,⁴ the most well-designed trial yet studying the efficacy of chaste tree in women's health. Women were assigned to take either a tablet containing an extract of chaste tree berry (20 mg) or a placebo tablet once daily for 3 months. Subjective reporting of irritability, mood changes, anger, headache, breast tenderness, and bloating were recorded. At the end of the 3 months, women taking chaste tree reported a 52% reduction in PMS symptoms versus 24% reduction for those in the placebo group. Women in the chaste tree group reported their significant reduction in all symptoms except for bloating before the menses. This well designed clinical trial confirms the previous findings of the uncontrolled studies.

There have been less positive chaste tree and PMS studies. In one trial, dramatic improvements were seen during the first treatment cycle with chaste tree, and that improvement was maintained for the next two remaining cycles.⁵ However, this pattern also occurred in the placebo group. Twenty symptoms were assessed but only one improved significantly more than in the placebo group.

Ginkgo (Ginkgo biloba)
A double-blind, placebo-controlled study was done in 1993 to determine the effectiveness of ginkgo extract on PMS symptoms. One hundred sixty-five women were studied and received either a ginkgo extract of 24% ginkgo flavonglycoside content at 80 mg twice daily or a placebo from day 16 of their cycle to day 5 of the next cycle. The ginkgo extract was effective against the congestive symptoms of PMS, particularly breast pain or tenderness⁶ but not other PMS symptoms.

St. John's Wort
A prospective, open, uncontrolled, observational pilot study using St. John's wort standardized extract, 300 mg three times daily, was investigated to establish a hypothesis and to test methods for a future randomized controlled trial.⁷ Nineteen women with PMS underwent a preliminary screening interview and completed a daily symptom rating for one cycle. After taking the St. John's wort for two complete menstrual cycles, daily symptoms were rated using the Hospital Anxiety and Depression scale and a modified Social Adjustment Scale. The degree of improvement in overall PMS scores between baseline and the end of the trial was 51%, with more than two thirds of the sample demonstrating at least a 50% decrease in symptom severity. The mood subscale showed the most improvement (57%), and the symptoms with the greatest reductions in scores were crying (92%), depression (85%), confusion (75%), feeling out of control (72%), nervous tension (71%), anxiety (69%), and insomnia (69%).

Additional Herbs
Many other herbs that have not been subjected to scientific research for the treatment of PMS have also been used successfully by women and practitioners for decades. These include many species of wild yam, licorice root, dong quai, and black cohosh. Angelica or dong quai has been primarily regarded as a "female" remedy and used to treat menopausal symptoms, menstrual cramps, abnormal uterine bleeding, and premenstrual problems. No one knows exactly how dong quai works in addressing premenstrual symptoms although it is known to aid in uterine relaxation, as is needed with premenstrual uterine cramping. Licorice may be useful in treating PMS because of its ability to raise progesterone levels. Although abnormal hormone levels in women with PMS is not yet a proven finding, many women respond to either more progesterone or herbs that help the body to raise its own progesterone level. Black cohosh has been shown to reduce premenstrual depression, anxiety, tension, and mood swings in a study done back in the 1960s.⁸ Other plants are used because of their benefit with specific symptoms, and do have scientific efficacy and documentation; for example, kava extract is used for anxiety, St. John's wort for depression, dandelion leaf for water weight gain, valerian for sleep problems, and lemon balm for herpes eruptions. You will often find one or more of these herbs in a combination herbal and nutritional product that has been specifically formulated for PMS symptoms relief.

NATURAL HORMONES
Natural Progesterone
Perhaps no other PMS therapy has been the target of so much controversy as natural progesterone. This has as much to do with the lack of agreement and scientific research to support a unified theory as to the cause of PMS as it has to do with the efficacy of natural progesterone itself. Green and Dalton advanced a theory in the 1950s that PMS was caused by unopposed estrogen during the luteal phase of the menstrual cycle. Dalton reported in her book, the Premenstrual Syndrome and Progesterone Therapy⁹ that she has used natural progesterone via injections (25-100 mg daily), vaginal and rectal suppositories (400-1,600 mg daily), and subcutaneous pellets (500-1,600 mg every 3-12 months) with results as good as complete relief of PMS symptoms in 83% of women.¹⁰ There have been several studies that demonstrate a lack of efficacy of rectal and vaginal suppositories in the treatment of PMS. In 1979, Sampson conducted the first placebo-controlled, double-blind trial of rectal-vaginal progesterone. There was no significant difference between progesterone at either a 200 mg dose twice daily by suppository or pessary, rectally or vaginally, and placebo.¹¹ In 1983, Van der Meer et al published results of a randomized clinical trial of rectal progesterone. Twenty patients received 200 mg progesterone twice daily. Of the 13 who completed the trial, none showed a difference in psychologic or somatic symptoms.¹² In 1986, Maddocks et al restudied vaginal progesterone for PMS; 200 mg twice daily was delivered vaginally and compared with placebo in a double-blind trial.¹³ There were 48 women who entered the study and only 20 completed it. The somatic and affective symptoms were the same for both progesterone and placebo. In 1990, Freeman also found progesterone in vaginal and rectal suppositories to be ineffective.¹⁴ Although the suppository method of delivering natural progesterone for PMS has not held up to scientific scrutiny, oral micronized natural progesterone has. A controlled study by Dennerstein and colleagues in 1985 found an overall beneficial effect using 300 mg/day (100 mg in the morning; 200 mg in the evening) for 10 days of each menstrual cycle starting 3 days after ovulation.¹⁵ A statistically significant improvement was noted in anxiety, depression, distress, swelling, fluid retention, and hot flushes. No effect was seen in libido or restlessness. One subject experienced a severe premenstrual migraine as a side effect.

Natural progesterone creams have not been subjected to scientific scrutiny for PMS although tens of thousands of women can attest to their benefit. Progesterone cream is commonly used in over-the-counter products that contain up to as much as 400 mg of natural progesterone per ounce. Using 1/4 teaspoon per dose will deliver approximately 20 mg of United States Pharmacopeia natural progesterone, the same progesterone that is in oral micronized progesterone. Applying 1/4 to 1/2 teaspoon twice daily starting at midcycle and continuing for 12 days, stopping the day before the menses is a typical use. The best sites for rubbing in the cream include the palms, inner upper arms, chest, and inner thighs.

Prior to the use of selective serotonin reuptake inhibitors (SSRIs) for the treatment of PMS, conventional mainstream medicine has not been able to offer women a known cause for PMS nor has it been able to offer a management approach short of pharmaceuticals with often as many side effects as relief. Self-care with natural therapies has been the dominant method of how women manage PMS. Women have clearly taken this monthly familiar problem into their own hands and more often than not have determined what works for them. The astute and well educated practitioner can offer additional therapies and clinical insights to help most of the remaining women with more severe symptoms who need more specific and effective dosing regimens of natural substances as well as a well thought out comprehensive approach. Select individuals with clearly severe (especially mood and behavioral) symptoms can then be prescribed SSRIs. Treating PMS with a natural and holistic approach often serves as a touchstone for motivating women to make lifestyle changes that have a positive cascade effect on their general health.

Part 1, Exercise and Nutrition

References:

Tori Hudson, ND, is a professor, National College of Naturopathic Medicine, and director, A Woman's Time, PC, Portland, Ore.

REFERENCES

1. Hudson T. Premenstrual Syndrome. The Female Patient. 2002;27(5):47-49,59.

2. American College of Obstetrics and Gynecology (ACOG). Committee opinion. Int J Gynecol Obstet. 1995;50:80.

3. Dittmar F. Das pramenstruelle Spannungssyndrome. J Gynakol. 1989; 5(6):4-7.

4. Schellenberg R. Treatment for the premenstrual syndrome with agnus castus fruit extract: prospective, randomized, placebo controlled study. BMJ. 2001;20:134-137.

5. Turner S, Mills S. A double-blind clinical trial on a herbal remedy for premenstrual syndrome: a case study.Complement Ther Med. 1993;1:73-77.

6. Tamborini A, Taurelle R. "Value of standardized Ginkgo biloba extract in the management of congestive symptoms of premenstrual syndrome." Gynecol Obstet. 1993;88: 447-457.

7. Stevinson C, Ernst E. A pilot study of Hypericum perforatum for the treatment of premenstrual syndrome. Br J Obstet Gynaecol. 2000;107:870-876.

8. Schildge E. Essay on the treatment of premenstrual and menopausal mood swings and depressive states. Rigelh Biol Umsch. 1964;19(2):18-22

9. Dalton K. The Premenstrual Syndrome and Progesterone Therapy. 2nd ed. Chicago, Ill: Year Book Medical Publishers; 1976.

10. Keye W Jr. Medical treatment of premenstrual syndrome. Can J Psychiatry. 1985;30:483-487.

11. Sampson G. Premensrual syndrome: a double-blind controlled trial of progesterone and placebo. Br J Psychiatry. 1979;135:209.

12. Van Der Meer Y, Benedek-Jaszmann L, Van Loenen A. Effect of high-dose progesterone on the pre-menstrual syndrome; a double-blind cross-over trial. J Psychosomatic Obstet Gynaecol. 1983;2:220.

13. Maddocks S, Hahn P, Moller F, et al. A double-blind placebo-controlled trial of progesterone vaginal suppositories in the treatment of premenstrual syndrome. Am J Obstet Gynecol. 1986;154:573.

14. Freeman E, Rickels K, Sonheimer S, Polansky M. Ineffectiveness of progesterone suppository treatment for premenstrual syndrome. JAMA. 1990;264:349-353.

15. Dennerstein L, Spencer-Gardner C, Gotts, G et al. Progesterone and the premenstrual syndrome: a double blind crossover trial. Br Med J. 1985;290:1617-1621.