How many women with PMS does it take to change a light bulb?” The punch line to that old joke is, “That’s not funny.” And for 80 percent of all menstruating women—the number of women in the United States who experience premenstrual syndrome—it is no laughing matter. More than 150 symptoms have been attributed to PMS, and the symptoms are so common that there has even been a movement in the medical community to discard the term “PMS” and accept the symptoms as a normal part of the menstrual process. This attitude has trivialized the daily significance of PMS in the lives of women who suffer from it and has prevented many women from seeking and getting the help they need to more comfortably and productively experience their reproductive years—and for most women this is at least thirty years of their lives! For at least 5 percent of all menstruating women, the symptoms of PMS are so severe that they are incapacitated on a monthly basis.
PMS is the most common complaint of women of reproductive age, leading to the annual loss of millions of dollars due to work absenteeism and lost productivity as well as the disruption of individual lives due to difficulty in everything from parenting to maintaining healthy social relationships.
Do you have PMS?
The term “PMS” is loosely tossed around, sometimes being featured as a joke on a sitcom or as a way to dismiss someone’s behavior (“Oh, ignore her, she just has PMS.”). Because PMS is largely based on self-diagnosis, it is easy to determine whether you have it (see box, below). However, do not ignore the fact that there can be underlying disorders such as thyroid problems or serious hormonal problems that can cause PMS symptoms.
The following are among the most common symptoms that have been classified as part of premenstrual syndrome:
PMS is often categorized based on the symptoms, which can include difficulty concentrating and can range from mild to moderate to severe. There is PMS-A (anxiety), PMS-D (depression), PMS-C (carbohydrate cravings) and PMS-H (hyperhydration, or swelling). These categories can be particularly useful when any of the specific symptoms are extreme—however, most women experience a constellation of various symptoms. Premenstrual dysphoric disorder, or PMDD, is severe PMS, but the emotional symptoms are more serious; there is significant impairment in PMDD. The American Psychiatric Association describes PMDD as having at least five of the following symptoms: sadness, anxiety, mood swings, persistent irritability, withdrawal, difficulty concentrating, fatigue, marked changes in appetite and sleep patterns, a feeling of being overwhelmed, and physical symptoms such as weight gain/bloating, headache, and joint and muscle pain. Seek a full medical evaluation if your symptoms are severe or even mild and persistent to rule out more serious problems.
If you do not entirely meet the diagnostic criteria (for example, your symptoms begin seven to ten days prior to your period instead of the prescribed five days) but still experience what you think is PMS, do not write yourself off as not having it. Most women do not fit neatly into a box, and diagnostic criteria may not explain very mild, but nonetheless uncomfortable, PMS.
Premenstrual symptoms are nothing new. References to PMS date back to the writings of Hippocrates, where he mentions the symptoms of “headache” and a “sense of heaviness” in relationship to the menses. The menstrual cycle has long been a source of attention in medicine and religion. When menstruating women have “the curse,” they have long been considered “unclean” or to carry dangerous powers. Some cultures consider menstruating women to have strange and magical powers. For example, the Polynesian word “taboo,” which in English has come to mean something that is forbidden, actually means both “sacred” and “menstruating” in the Polynesian language. Among many Native American tribes, menstruating women were considered more powerful even than medicine men.
While there definitely are biological factors associated with PMS, there are also complex emotional, cultural and psychological factors that influence how women experience their bodies. It is thought that how women view their bodies and their menstrual cycles may, in part, influence how they experience menstruation. If a woman views menstruation negatively, with dread, or shamefully, all of which are deeply entrenched attitudes about menstruation, she may be more likely to experience menstrual difficulties than a woman who has a positive outlook on her body’s natural functions. Some interesting research has been conducted showing that animals who are more dominant and “in control” of their social environment have higher serotonin levels—and this can change positively or negatively as social status changes within the animal group. Decreased serotonin levels in humans are associated with increased depression. There is no end to how our experience of our lives affects our biology.
Many women today are embracing the menstrual cycle as a time of heightened emotional sensitivity, creativity, intuitiveness and personal power. The term “moon time” is sometimes used by women in place of the word “period” as a more poetic affirmation of this. Indeed, the words “menarche,” “menses,” and “menstruation” have their origin in the word “moon,” reflecting the cyclical nature of a woman’s body in harmony with the monthly cycles of the moon. While PMS is certainly not just “in your head,” positive reframing may be an important part of helping women to overcome menstrual difficulties.
What causes PMS?
In addition to complex social and emotional causes of PMS, numerous biological causes have been proposed (see “Examples of possible causes of PMS,” below). For most women, a combination of these causes is most likely, and they may be related to one another. For example, a woman may have nutritional deficiencies as well as hormonal imbalances that are at the root of her PMS symptoms. Sometimes improving one factor alone can improve symptoms, but most often a combination approach of improved diet, improved lifestyle habits (for example, adequate rest, increased exercise, and changed beliefs about menstruation), and herbal and nutritional supplements are needed. Again, persistent or worsening symptoms warrant a medical evaluation.
Examples of possible causes of PMS
Modified from An Integrative Approach to Premenstrual Syndrome (Integrative Medicine Education Associates, 2000) by T. Low Dog
Natural approaches to PMS
Herbal medicines have a great deal to offer women suffering from PMS. Modern research in endocrinology points out ways in which herbs and nutritional supplements can be used to reduce the symptoms and promote a healthier, more comfortable cycle. Most women with PMS symptoms prefer to self-treat over seeking medical care, making PMS an ideal condition for using natural approaches. Herbal medicines and nutritional supplements can not only help reduce the symptoms of PMS but they can alleviate some of the underlying causes.
In treating PMS, many herbalists recommend moving more toward a vegetarian-based diet that is rich in whole grains, legumes, and fresh vegetables and fruits, keeping dairy products to a minimum and including cold-water fish (such as salmon and tuna) a couple of times a week. The high fiber content of grains, fruits and vegetables can help the body to effectively eliminate excessive hormones from the intestine, particularly estrogen, while adequate intake of legumes can support the production of hormones when there is a deficiency. Dietary fats should come from good-quality olive oil, with small amounts of butter and high-quality vegetable oils.
It has been found that women with PMS consume significantly more sugar, dairy products, salt and refined carbohydrates than those who do not experience it. Caffeine intake has also been linked to premenstrual discomforts, especially breast tenderness. Cutting back on sugar, white-flour products and caffeinated items such as coffee, black tea, sodas and chocolate may be hard to do but can go a long way to relieve symptoms.
In addition to a healthy diet, several supplements may be beneficial in reducing PMS, particularly for improvement of mood, reduction of bloating, and reduction of breast tenderness. These include calcium (1,200 mg per day), magnesium (400 mg per day), vitamin B6 (50 mg per day as part of a B-complex supplement), and vitamin E (200 to 400 IU per day).
Evening primrose oil is commonly recommended by herbalists, in a dosage range of 1,500 to 3,000 mg daily, as part of a treatment protocol for PMS. Unfortunately, most clinical trials have failed to show consistent benefit. Nonetheless, increased fatty acid intake has been associated with improved mood when there is depression, and evening primrose is not harmful, making it a practical addition to a treatment plan until further research proves or disproves its benefits.
The importance of adequate rest and moderate exercise cannot be overstated for improving PMS symptoms. Fatigue from lack of regular sleep will exacerbate nearly all physical and emotional discomfort. Moderate exercise, even just walking or light cardiovascular exercise for as little as fifteen minutes three to four times per week can drastically improve mood and reduce fatigue. When women exercise, they are more likely to feel empowered in their lives and they are more likely to take care of themselves in ways that reduce PMS and improve overall quality of reproductive health.
In addition, honoring the premenstrual time as one of heightened awareness and emotions can help you to feel better. Ways to do this include journaling your PMS feelings; setting aside time during the week before your period to pamper yourself with a hot bath, a cup of herbal tea, and a good novel; splurging for a massage; taking a yoga or dance class; or having a night out with your girlfriends. If you have particularly dark thoughts and feelings during this time, record those in your journal. They may give you insight into some of your deeper feelings and point to things you might want to change in your life. Take the time to nurture yourself each month—eat better, rest more, move your body through exercise, and listen to your heart, mind, and spirit.
Herbs are powerful allies for women in many aspects of their reproductive cycles. PMS is no exception. Herbs can be used to improve mood, support hormonal regulation, and reduce many of the PMS symptoms.
Hormonal balancers. Herbalists almost always include herbs that help to regulate the hormones when treating PMS. Vitex (Vitex agnus-castus) is probably the most commonly used, purportedly helping to rectify ovarian dysfunction and corpus luteal insufficiency, which cause insufficient progesterone levels. Its prolactin-inhibiting effects may also, in part, explain its beneficial effects in treating PMS. Dosage is 2 to 5 ml of tincture one to two times daily, with one dose typically taken in the morning and the other midday. Black cohosh (Cimicifuga racemosa) and peony (Paeonia lactiflora) are also frequently used in formulas for PMS. Black cohosh has a long history of use by the Eclectic physicians for treating menstrual headaches, breast tenderness, anxiety and depression. Its effects may be due in part to its mild enhancement of serotonin reuptake. Peony has been shown to enhance ovarian function, improving levels of both estrogen and progesterone and reducing symptoms of PMS. A standard dose of black cohosh is one to two 40-mg capsules twice daily, or 2 to 4 ml of tincture one to three times daily. Peony is a popular herb in many Chinese gynecological formulas.
Nervines and sedatives. Supporting the nervous system by both tonifying and relaxing the nerves is an important herbal therapy for PMS, improving mood, reducing headache, stress, and anxiety, and promoting overall relaxation. Herbs such as passionflower (Passiflora incarnata), blue vervain (Verbena officinalis), St. John’s wort (Hypericum perforatum), skullcap (Scutellaria lateriflora), milky oats (Avena sativa), zizyphus (Zizyphus spinosa) and kava (Piper methysticum) are but a small sample of the amazing repertoire of herbs available in this category. These herbs may be used alone or in combination and with the exception of kava (which should be used for short durations only) they may be used throughout the month over an extended period of time, or just prior to and through the premenstrual time. The typical dose of most nervine herbs is 1 to 3 ml one to four times daily. Kava should be used with the supervision of a qualified herbalist or, if self-prescribing, no more than 3 ml twice daily for the week before the menses, and then discontinue.
Tonics. A number of herbs provide general support to the body, improving energy, sugar metabolism, mental functioning, mood, and general health. Among these are the adaptogenic herbs Asian ginseng (Panax ginseng) and American ginseng (Panax quinquefolius), eleuthero (Eleutherococcus senticosus), schisandra (Schisandra chinensis), and ashwaganda (Withania somnifera). These can be taken alone or in combination, and for best results should be taken for a minimum of two to three months before significant results are seen. Typical dosage ranges are 1 to 2 capsules twice daily or 2 to 4 ml of tincture twice daily.
Bitters. Bitter herbs have long been used to support and stimulate the function of the liver, an organ we now know to be intrinsically involved in hormone production, metabolism, and elimination. Herbalists often include bitter herbs such as blue vervain and dandelion root (Taraxacum officinale) in formulas for treating PMS. Other mild bitters include yellow dock (Rumex crispus) and burdock root (Arctium lappa). The four herbs are excellent for the treatment of premenstrual acne. They are typically included as about 10 to 25 percent of an herbal formula but can be taken alone before meals as a digestive aid. Take 20 to 30 drops of tincture in a small amount of warm water if using this way.
The bitter herb feverfew (Tanacetum parthenium) may be especially appropriate when a woman also experiences premenstrual headache, as it has been shown to reduce migraines. Feverfew can be taken preventively and for acute headaches. The preventive dose is
teaspoon of tincture twice daily. For acute conditions, take 1/2 teaspoon three to five times daily. Bitters also improve digestion and relieve mild constipation.
Chinese herbs. In Chinese medicine, it is believed that PMS is a result of one or more of several factors, most commonly “liver qi stagnation.” Liver qi stagnation is caused by long-term repressed emotions including anger and frustration, as well as imbalances in lifestyle, particularly a lack of adequate sleep and going to bed too late at night (after 11 p.m.). Excessive consumption of caffeine, alcohol, red meat, nuts, dairy products, and fried, fatty foods can cause or aggravate this condition. Creative activity can help to unblock stagnant liver qi. The premier herbal formula for regulating this problem is a bupleurum (Bupleurum chinense) and dong quai (Angelica sinensis) formula known as Rambling Powder (this formula is also used for building the blood). It is available through many herbalists, acupuncturists, and herbal medicine companies. The patent formula, which consists of tiny black pills, is taken in the dosage of 8 pills three times daily, until symptoms are relieved.
Building your own formula
Building a formula for yourself is not difficult using the basic information provided above about the individual herbs. You can substitute any of the herbs listed below for other herbs from the above categories. Learning more about each individual herb will provide you with a whole natural pharmacy to work with. Use this foundation formula as a springboard to your own creativity, or work with an herbalist or naturopath to create herbal formulas to meet your specific health needs.
Foundation formula for general PMS symptoms of tension and irritability:
A 4-ounce tincture bottle holds 120 ml. Using the volumes above to give you an idea of proportions, combine your tinctures, modifying the volumes to come up with the desired end volume. The standard dose is approximately 2 to 5 ml of tincture, one to three times daily, depending upon what herbs you have included. The tincture can be taken throughout the month, or just prior to the menses, again depending upon the purpose of the formula.
Aviva Romm is president of the American Herbalists Guild and a certified professional midwife. She’s the author of numerous books on herbal family health, including Naturally Healthy Babies and Children (Storey, 2000), The Natural Pregnancy Book (The Crossing, 1997), and Natural Health and Birth (Healing Arts, 2002).