PHILADELPHIA—”I have PMS.” Patients say it all the time. But just what does a patient mean when she asks you for help with her “premenstrual syndrome?”

Before reaching for your prescription pad to provide her with one of the growing number of pharmaceutical “answers” to PMS, it is important to clarify exactly what types of symptoms a woman is experiencing, and whether or not they are truly cyclic, said Wendy Warner, MD, at a conference on holistic primary care, sponsored by the American Board of Holistic Medicine, and the Philadelphia College of Osteopathic Medicine.

PMS has several characteristic patterns and each requires a somewhat different therapeutic approach, said Dr. Warner, an ob.gyn. in Langhorne, PA. The vast majority of patients will respond to relatively inexpensive non-prescription natural therapies. But you have to really know what you are treating.

The woman who becomes melancholy or depressed before her period is very different from the one who becomes agitated and anxious. The underlying hormonal and neurochemical changes are different in these cases, and they need to be treated differently. Dr. Warner believes there is validity to Abraham’s categorization of PMS into four subtypes: PMS-A (Anxiety), PMS-C (Carbohydrate cravings), PMS-D (Depression), and PMS-H (Hyperhydration).

Four PMS Subtypes

Women who have pre-period anxiety or agitation often have estrogen/progesterone imbalances. While the data are not strong enough to make a definitive causal link, there is a strong correlation. Those who experience melancholy and depression typically have low estrogen levels, as well as reduced serotonin and endorphin levels.

The hyperhydration or water-retention pattern reflects an underlying excess of aldosterone. The carbohydrate craving subtype, characterized by intense and relentless hunger for carbohydrates, is the least understood subtype. No one is really sure what drives these cravings, which can be very troublesome to weight-conscious patients.

Careful evaluation is essential for making useful therapeutic recommendations. “Elicit specific information about feelings, physical complaints and findings in regard to timing of menses. Are the symptoms she’s experiencing really cyclic? Or are they reflecting chronic underlying problems like depression?”

If the patient’s description is unclear or overly general, have her keep a daily diary for two or three cycles without any treatment whatsoever. “Patients don’t like you for this—they want relief—but sometimes it is really important,” said Dr. Warner. It is also helpful to gather information regarding her social support structure, perceived life stressors, and her overall outlook on life.

“You want to find out if her outlook varies with her cycle, and how her cycle impacts on her colleagues, family and loved ones.” It is good to know as much as possible about her diet, exercise patterns, and drug or supplement use.

Dietary Clues

A woman’s dietary habits often contain important clues and potential solutions for her PMS. “It is very common to find high intake of refined sugars, carbohydrates, dairy, and sodium, as well as low intake of manganese and iron in these patients.” A good first step in managing PMS is to work with the patient to normalize these levels.

Dr. Warner noted that many women with PMS, especially those who have the PMS-C pattern, “will go running for the sugar, which only exacerbates the symptoms in the long run. It gives you a few minutes of good feeling but worsens the overall process.”

Her general dietary recommendation for PMS patients is to increase fiber and reduce fat intake. This increases stool passage time, which in turn, reduces estrogen reabsorption. Women who do not consume much fiber tend to have slower stool passage times, which increases the chance of estrogen deconjugation and reabsorption in the bowel.

A wide variety of nutrients and botanicals can help women with PMS, depending on the symptoms they experience. Dr. Warner recommended the following:

• Calcium: While its mechanism is unclear, increased calcium intake does appear to improve PMS symptoms for many women. “Most women need it anyway, so there’s no real downside.” She advises 1,000 mg per day.
• Magnesium: Magnesium deficiency leads to fatigue, irritability, confusion, cramps and insomnia, all of which are common PMS complaints. Deficiency is very common, but easily rectified with 500 mg per day.
• Manganese: There are studies showing that this mineral can reduce mood swings associated with PMS. Though she doesn’t often use manganese supplements, Dr. Warner said it is worth considering for patients who have a lot of affective symptoms.
• Vitamin B6: Boosting the B6 level will increase synthesis of serotonin, dopamine, norepinephrine, histamine and taurine, all of which will improve the mood changes associated with PMS and increase a patient’s overall sense of well-being. Keep the dose within the range of 50–150 mg per day. At doses over 400 mg, some patients experience loss of sensation in their toes and fingers.
• Vitamin E: This antioxidant vitamin is particularly good for patients who experience a lot of breast pain and joint aches. A dose of 400 IU per day is usually effective.
• Tryptophan or 5-HTP: These serotonin precursors can be very valuable for patients who experience depression or sleep disorders prior to their periods. They should be taken at bedtime.
• Evening Primrose oil (Oenothera biennis): While published data are conflicting, Dr. Warner said her personal and professional experience weigh in favor of this botanical. It is particularly helpful for patients who have breast pain and emotional lability. The effective dose range is very broad, going from 500 mg to 3 g daily. “Start with a little, and if this is not enough, increase it gradually.”
• Chaste Tree Berry (Vitex agnus castus) and Black Cohosh (Cimicifuga racemosa): These herbs, commonly considered in the context of menopause, can also be helpful for PMS-related mood swings. Bear in mind, though, that they will not work if the patient is on oral contraceptives.
• Ginkgo biloba: Widely thought of for memory enhancement or prevention of dementia, Ginkgo is also helpful for pre-period “fuzzy thinking.”
• Bio-identical Progesterones: Consider natural progesterone for patients who have progesterone–estrogen imbalances, typically characterized by pre-period anxiety and agitation. Dr. Warner recommends against products derived from wild yam. “Humans cannot turn the wild yam compounds into progesterone, though many animals can.” But there are other forms of bioidentical progesterone, and transdermal creams are an excellent mode of delivery. “Make sure the patient knows to put the cream on areas with little subcutaneous fat. Put it on where it will be most absorbed.”

Exercise is also an important factor in attenuating PMS. “Regularity is more important than intensity,” said Dr. Warner. She tells her patients to do as much as feels comfortable. “Don’t kill yourself with intensity.” Yoga, Tai Chi, and various forms of meditation can also be helpful, as is acupuncture. Encourage patients to explore these options as they see fit.