Posted on Nov 18, 2020, 5 p.m.
Premenstrual syndrome (PMS) is a monthly condition that afflicts many women ranging from young girls (sometimes even before menses) to women approaching menopause. Symptoms related to PMS typically occur after ovulation, during the luteal phase of the menstrual cycle (beginning approximately 14 days before menstruation), and cease at menstruation or shortly thereafter. The type and intensity of symptoms vary dramatically from woman to woman, with over 150 identified.
Dr. Katharina Dalton defined PMS as “the recurrence of symptoms before menstruation with complete absence of symptoms after menstruation.” She claimed that the most important criteria for an accurate diagnosis are the cyclical nature and timing of symptoms, relative to menstruation, rather than which specific symptoms occur. Therefore, if symptoms are not restricted to the luteal phase, they may indicate another condition.
Healthcare practitioners will often try to rule out other conditions such as:
- Thyroid imbalance
- Yeast infection
- Chronic fatigue syndrome (CFS)
One or more of these conditions are often present in women suffering from PMS symptoms. In PMS: Solving the Puzzle, author Linaya Hahn reports that early research indicated that one in six women with PMS symptoms also had a thyroid imbalance.
Hormonal Influences on Premenstrual Syndrome
Because it occurs only in women who are still menstruating, most researchers agree hormone imbalances may contribute significantly to the occurrence or severity of PMS symptoms. The levels of the hormones associated with menstruation fluctuate widely during a woman’s cycle. In Once a Month: Understanding and Treating PMS, Dr. Dalton notes that estrogen hormone levels vary throughout the cycle, and that blood levels of progesterone are much smaller during the first half of the cycle and then suddenly rise at ovulation to levels that are far greater.
The Role of Progesterone
Previously, many researchers and practitioners believed that it was the amount of progesterone in the bloodstream that affected PMS symptoms. With more advanced analysis tools, researchers discovered that PMS sufferers do not necessarily have low progesterone levels. Molecular biology advances have allowed researchers to explore how progesterone is absorbed into the nucleus of cells, leading to a greater understanding of progesterone receptors.
Dr. Dalton relates how Bruce Nock, et al. “showed that progesterone receptors do not transport progesterone molecules into the nucleus of cells if adrenaline is present,” such as during times of stress or drops in blood sugar levels—times during which PMS symptoms are also exacerbated. Additionally, progesterone receptors do not transport artificial progestogens (also called progestins) to the cell nucleus, which may help explain why they have not been effective in treating PMS-related symptoms.
According to Dr. Dalton, the locations of progesterone receptors are also the primary locations of the most common PMS symptoms. She thinks this is no coincidence, and that the cause of PMS may be linked to progesterone receptors. For example, the largest concentration of progesterone receptors in women is in the limbic area of the brain, the area that controls emotions and has been identified as the center of rage and violence.
Other parts of the body have concentrations of progesterone receptors, including:
- The cells lining the brain, which are involved in headaches, a very common PMS symptom
- The breasts, which may explain why breast tenderness is also a common PMS symptom
- The womb, ovaries, and fallopian tubes, which go through significant premenstrual changes
- The optic pathway, which may account for changes in ocular pressure during menstruation
- The nose, nasal passages, and lungs, which may explain a tendency for premenstrual asthma, rhinitis, sinusitis, or laryngitis
Dr. Dalton states that “the widespread distribution of progesterone receptors in different target cells explains the numerous different symptoms of PMS.”
Neurotransmitters and Serotonin
Dr. Thomas Shiovitz and senior research scientist Edyta Frackiewicz, PharmD found that women with PMS tend to have abnormal neurotransmitter function during the luteal phase of their menstrual cycle, particularly concerning serotonin. Serotonin is a vital neurotransmitter that decreases at ovulation, and has been linked with:
- Poor impulse control
- Increased carbohydrate cravings
Serotonin reuptake inhibitors (SSRIs) such as Prozac have shown some effectiveness in reducing the symptoms of severe PMS-related mood disorders and PMDD. Hahn notes that our bodies produce serotonin from tryptophan, an essential amino acid.
During menstruation, when serotonin levels are low, the body may trigger an insulin surge to get tryptophan to the brain. This may be indicated by craving sweets (including foods such as pasta, bread, or alcohol) which are quickly converted to blood sugar. Tryptophan generally increases serotonin levels, but there are many factors related to the efficiency of that conversion:
- While many women crave sweets, snacks with aspartame (an artificial sweetener) contain phenylalanine that competes with the tryptophan.
- Vitamin B6 is necessary for converting tryptophan to serotonin, and which may explain why B6 helps suppress some women’s PMS symptoms.
- Sodium is necessary to keep serotonin active, which may be why salt cravings are also common during PMS.
- Light, a switch that triggers the conversion of melatonin to serotonin, may also be linked to PMS. Hahn sees a connection with Seasonal Affective Disorder (SAD, especially among women with primarily mood-related PMS symptoms.
Hormone Therapies for Treating PMS Symptoms
Dr. Dalton notes that severe PMS sufferers tend to have high levels of estrogen hormones and may benefit from bioidentical progesterone therapy. (Women with high estrogen levels tend to have fewer symptoms as they approach menopause, while other women typically need estrogen therapy for menopausal symptom relief.) Bioidentical progesterone is fairly inexpensive, has few (if any) side-effects, and has been effective in reducing or relieving many PMS symptoms.
Typical progesterone therapy requires adjusting dosages throughout the cycle. However, Dr. Dalton emphasizes that clinicians must also take into account the behavior of progesterone receptors when determining the appropriate dosages. After the first dose, subsequent doses must be much higher to achieve the same reaction in the progesterone receptor cells.
Primary goals in treating PMS are to reduce or eliminate symptoms, restore daily function, and optimize overall health. Many women struggle for years with changing symptoms as their reproductive systems evolve through life stages. However, understanding and taking measures to treat the underlying causes of PMS provide options to help minimize its debilitating symptoms.
This article was written by the staff at Women’s International Pharmacy and Edited by Michelle Violi, PharmD – Women’s International Pharmacy.
Adapted from Premenstrual Syndrome: Understanding PMS from Puberty to Menopause A Connections publication of Women’s International Pharmacy
Materials provided by:
Content may be edited for style and length.
This article is not intended to provide medical diagnosis, advice, treatment, or endorsement
- Dalton K. Once a Month: Understanding and Treating PMS. 6th Alameda, CA; Hunter House, Inc.: 1999.
- Frackiewicz EJ, Shiovitz TM. Evaluation and Management of Premenstrual Syndrome and Premenstrual Dysphoric Disorder. J Am Pharm Assoc. 41(3): May/June 2001.
- Hahn L. PMS: Solving the Puzzle, Sixteen Causes of Premenstrual Syndrome and What to Do About It. Evanston, IL; Chicago Spectrum Press: 1995.
- McCormick K. PMS: From Puberty to Menopause. Connections. Women’s International Pharmacy; 2003.