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Premenstrual Syndrome

Also indexed as: Menstrual Cramps, PMS, PMT, Premenstrual Tension

Illustration

Know your body and find your balance despite PMS. Because every woman is different, no single treatment effectively relieves all symptoms in all women. According to research or other evidence, the following self-care steps may be helpful:

What you need to know

  • Check out calcium and magnesium
  • A daily supplement of 1,000 to 1,200 mg of calcium and 200 to 400 mg of magnesium to reduce the risk of mood swings, bloating, headaches, and other symptoms
  • Eat right
  • Emphasize low-fat, high-fiber foods and plenty of fruits and vegetables to improve hormone metabolism
  • Stay active
  • Aim for regular aerobic exercise to help reduce symptoms
  • Balance your body chemistry with vitex
  • 20 mg a day of a concentrated herbal extract for up to three months may help balance hormones
  • Try vitamin B6
  • Take 100 to 200 mg per day regularly to help reduce symptoms

These recommendations are not comprehensive and are not intended to replace the advice of your doctor or pharmacist. Continue reading the full premenstrual syndrome article for more in-depth, fully-referenced information on medicines, vitamins, herbs, and dietary and lifestyle changes that may be helpful.

About premenstrual syndrome

Premenstrual syndrome (PMS) is a poorly understood complex of symptoms occurring a week to ten days before the start of each menstrual cycle.

PMS is believed to be triggered by changes in progesterone and estrogen levels.

Product ratings for premenstrual syndrome

Science Ratings Nutritional Supplements Herbs
3Stars

Calcium

Vitamin B6

Vitex

2Stars

Evening primrose oil

Magnesium

Multiple vitamin-mineral

Potassium gluconate

Vitamin E

 
1Star

Fiber

Progesterone

Soy

Vitamin A (see dosage warnings)

Vitamin B-complex

Black cohosh

Dong quai

Ginkgo

Peony

Yarrow

See also:  Homeopathic Remedies for Premenstrual Syndrome
3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star For an herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support and/or minimal health benefit.

What are the symptoms?

Many premenopausal women suffer from symptoms of PMS at different points in their menstrual cycle. Symptoms include cramping, bloating, mood changes, and breast tenderness tied to the menstrual cycle.

Medical options

Over the counter pain medications, such as ibuprofen (Motrin®, Advil®), naproxen (Aleve®), aspirin (Bayer®, Ecotrin®, Bufferin®), and acetaminophen (Tylenol®), may provide relief from premenstrual pain.

Prescription drug treatment is directed primarily at relieving symptoms. Commonly prescribed drugs include birth control pills (Ortho-Novum®, Loestrin®, Mircette®, Triphasil®); pain relievers, such as ibuprofen (Motrin®) and naproxen (Anaprox®, Naprosyn®); diuretics, such as hydrochlorothiazide (HydroDIURIL®); antidepressants, such as fluoxetine (Prozac®); and anti-anxiety drugs, such as lorazepam (Ativan®) and alprazolam (Xanax®).

Dietary changes that may be helpful

Women who eat more sugary foods have been reported to have an increased risk of PMS.1 Some doctors recommend that women with PMS cut back on sugar consumption for several months to see if it reduces their symptoms. However, no trials have yet to study the isolated effects of sugar restriction in women with PMS.

Alcohol can affect hormone metabolism, and alcoholic women are more likely to suffer PMS than are nonalcoholic women.2 Some doctors recommend that women with PMS avoid alcohol for several months to evaluate whether such a change will reduce symptoms.

In a study of Chinese women, increasing tea consumption was associated with increasing prevalence of PMS.3 Among a group of college students in the United States, consumption of caffeine-containing beverages was associated with increases in both the prevalence and severity of PMS.4 Moreover, the more caffeine women consumed, the more likely they were to suffer from PMS.5 A preliminary study showed that women with heavy caffeine consumption were more likely to have shorter menstrual periods and shorter cycle length compared with women who did not consume caffeine.6 Some doctors recommend that women with PMS avoid caffeine.

Several studies suggest that diets low in fat or high in fiber may help to reduce symptoms of PMS.7 Many doctors recommend diets very low in meat and dairy fat and high in fruit, vegetables, and whole grains.

Lifestyle changes that may be helpful

Women with PMS who jogged an average of about 12 miles a week for six months were reported to experience a reduction in breast tenderness, fluid retention, depression, and stress.8 Doctors frequently recommend regular exercise as a way to reduce symptoms of PMS.

Vitamins that may be helpful

Many,9 10 11 12 13 though not all,14 clinical trials show that taking 50–400 mg of vitamin B6 per day for several months help relieve symptoms of PMS. A composite analysis of the best designed controlled trials shows that vitamin B6 is more than twice as likely to reduce symptoms of PMS as is placebo.15 Many doctors suggest 100–400 mg per day for at least three months. However, intakes greater than 200 mg per day can cause side effects and should never be taken without the supervision of a healthcare professional.

Women who consume more calcium from their diets are less likely to suffer severe PMS.16 A large double-blind trial found that women who took 1,200 mg per day of calcium for three menstrual cycles had a 48% reduction in PMS symptoms, compared to a 30% reduction in the placebo group.17 Other double-blind trials have shown that supplementing 1,000 mg of calcium per day relieves premenstrual symptoms.18 19

Women with PMS have been shown to have impaired conversion of linoleic acid (an essential fatty acid) to gamma linolenic acid (GLA).20 Because a deficiency of GLA might, in theory, be a factor in PMS and because evening primrose oil (EPO) contains significant amounts of GLA, researchers have studied EPO as a potential way to reduce symptoms of PMS. In several double-blind trials, EPO was found to be beneficial,21 22 23 24 whereas in other trials it was no more effective than placebo.25 26

Despite these conflicting results, some doctors consider EPO to be worth a try; the amount usually recommended is 3–4 grams per day. EPO may work best when used over several menstrual cycles and may be more helpful in women with PMS who also experience breast tenderness or fibrocystic breast disease.27

Women with PMS have been reported to be at increased risk of magnesium deficiency.28 29 Supplementing with magnesium may help reduce symptoms.30 31 In one double-blind trial using only 200 mg per day for two months, a significant reduction was reported for several symptoms related to PMS (fluid retention, weight gain, swelling of extremities, breast tenderness, and abdominal bloating).32 Magnesium has also been reported to be effective in reducing the symptoms of menstrual migraine headaches.33 While the ideal amount of magnesium has yet to be determined, some doctors recommend 400 mg per day.34 Effects of magnesium may begin to appear after two to three months.

A preliminary, uncontrolled trial found that women with severe PMS who took potassium supplements had complete resolution of PMS symptoms within four menstrual cycles.35 Most participants took 400 mg of potassium per day as potassium gluconate plus 200 mg of potassium per day as potassium chloride for the first two cycles, then switched to solely the gluconate form (600 mg potassium per day) for the remainder of the year-long trial. Without exception, all of the women found their symptoms (i.e., bloating, fatigue, irritability, etc.) decreasing gradually over three cycles and disappearing completely by the fourth cycle. Controlled trials are needed to confirm these preliminary observations.

The amino acid, L-tryptophan has been shown to help relieve PMS symptoms. In a double-blind trial, women with premenstrual discomfort received 6 grams per day of L-tryptophan or placebo for 17 days.36 Those who took L-tryptophan had significant improvement of symptoms, including mood swings, tension, irritability, breast sensitivity, water retention, and headache. There was a slight reduction in premenstrual depression, but it was not statistically significant. L-tryptophan is available only by prescription. It has not been determined whether 5-hydroxytryptophan (5-HTP, a metabolic byproduct of L-tryptophan that is available without prescription) has similar effects.

In a double-blind trial, supplementing with soy protein (providing 68 mg of isoflavones per day) for two menstrual cycles was significantly more effective than a placebo at relieving premenstrual swelling and cramping.37 The placebo used in this study was cow's milk protein. Some doctors believe that cow's milk, because of its estrogen content, can worsen premenstrual symptoms. If that is the case, then the beneficial effect of soy protein may have been overestimated in this study.

Although women with PMS do not appear to be deficient in vitamin E,38 a double-blind trial reported that 300 IU of vitamin E per day may decrease symptoms of PMS.39

Some of the nutrients mentioned above appear together in multivitamin-mineral supplements. One double-blind trial used a multivitamin-mineral supplement containing vitamin B6 (600 mg per day), magnesium (500 mg per day), vitamin E (200 IU per day), vitamin A (25,000 IU per day), B-complex vitamins, and various other vitamins and minerals.40 This supplement was found to relieve each of four different categories of PMS symptoms. Related results have been reported in other clinical trials.41 42

Most well-controlled trials have not found vaginally applied natural progesterone to be effective against the symptoms of premenstrual syndrome.43 Only anecdotal reports have claimed that orally or rectally administered progesterone may be effective.44 Progesterone is a hormone, and as such, there are concerns about its inappropriate use. A physician should be consulted before using this or other hormones. Few side effects have been associated with use of topical progesterone creams, but skin reactions may occur. The effect of natural progesterone on breast cancer risk remains unclear; some research suggests the possibility of increased risk, whereas other research points to a possible reduction in risk.

Very high amounts of vitamin A—100,000 IU per day or more—have reduced symptoms of PMS,45 46 but such an amount can cause serious side effects with long-term use. Women who are or who could become pregnant should not supplement with more than 10,000 IU (3,000 mcg) per day of vitamin A. Other people should not take more than 25,000 IU per day without the supervision of their doctor. As yet, no trials have explored the effects of these safer amounts of vitamin A in women suffering from PMS.

Many years ago, research linked B vitamin deficiencies to PMS in preliminary research.47 48 Based on that early work, some doctors recommend B-complex vitamins for women with PMS.49

Are there any side effects or interactions?
Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful

Vitex has been shown to help re-establish normal balance of estrogen and progesterone during the menstrual cycle. Vitex also blocks prolactin secretion in women with excessive levels of this hormone; excessive levels of prolactin can lead to breast tenderness and failure to ovulate. A double-blind trial has confirmed that vitex reduces mildly elevated levels of prolactin before a woman’s period.50 Studies have shown that using vitex once in the morning over a period of several months helps normalize hormone balance and thus alleviate the symptoms of PMS.51 A preliminary trial52 and a double-blind trial53 have found that women taking 20 mg per day of a concentrated vitex extract for three menstrual cycles experience a significant reduction in symptoms of PMS.

Vitex has been shown to be as effective as 200 mg vitamin B6 in a double-blind trial of women with PMS.54 Two surveys examined 1,542 women with PMS who had taken a German liquid extract of vitex for their PMS symptoms for as long as 16 years.55 With an average intake of 42 drops per day, 92% of the women surveyed reported the effectiveness of vitex as “very good,”“good,” or “satisfactory.”

Some healthcare practitioners recommend 40 drops of a liquid, concentrated vitex extract or one capsule of the equivalent dried, powdered extract once per day in the morning with some liquid. Vitex should be taken for at least four cycles to determine efficacy.

A double-blind trial has shown that standardized Ginkgo biloba extract, when taken daily from day 16 of one menstrual cycle to day 5 of the next menstrual cycle, alleviates congestive and psychological symptoms of PMS better than placebo.56 The trial used 80 mg of a ginkgo extract two times per day.

In Traditional Chinese Medicine, dong quai is rarely used alone and is typically used in combination with herbs such as peony (Paeonia officinalis) and osha (Ligusticum porteri) for menopausal symptoms as well as for menstrual cramps.57 However, no clinical trials have been completed to determine the effectiveness of dong quai for PMS.

Black cohosh is approved in Germany for use in women with PMS.58 This approval appears to be based on historical use as there are no modern clinical trials to support the use of black cohosh for PMS.

Based on anecdotal evidence, yarrow tea has been used by European doctors when the main symptom of PMS is spastic pain.59 Combine 2–3 teaspoons of yarrow flowers with one cup of hot water, then cover and steep for 15 minutes. Drink three to five cups per day beginning two days before PMS symptoms usually commence. In addition, 1–3 cups of the tea added to hot or cold water can be used as a sitz bath.

Are there any side effects or interactions?
Refer to the individual herb for information about any side effects or interactions.

References:

1. Rossignol AM, Bonnlander H. Prevalence and severity of the premenstrual syndrome. Effects of foods and beverages that are sweet or high in sugar content. J Reprod Med 1991;36:131–6.

2. Halliday A, Bush B, Cleary P, et al. Alcohol abuse in women seeking gynecologic care. Obstet Gynecol 1986;68;322–6.

3. Rossignol AM, Zhang J, Chen Y, Xiang Z. Tea and premenstrual syndrome in the People’s Republic of China. Am J Public Health 1989;79:67–6.

4. Rossignol AM. Caffeine-containing beverages and premenstrual syndrome in young women. Am J Public Health 1985;75(11):1335–7.

5. Rossignol AM, Bonnlander H. Caffeine-containing beverages, total fluid consumption, and premenstrual syndrome. Am J Public Health 1990;80:1106–10.

6. Fenster L, Quale C, Waller K, et al. Caffeine consumption and menstrual function. Am J Epidemiol 1999;149:550–7.

7. Werbach MR. Nutritional Influences on Illness, 2d ed. Tarzana, CA: Third Line Press, 1993, 540–1 [review].

8. Prior JC, Vigna Y, Sciarretta D, et al. Conditioning exercise decreases premenstrual symptoms: a prospective, controlled 6-month trial. Fertil Steril 1987;47(3):402–8.

9. Barr W. Pyridoxine supplements in the premenstrual syndrome. Practitioner 1984;228:425–7.

10. Gunn ADG. Vitamin B6 and the premenstrual syndrome. Int J Vitam Nutr Res 1985;Suppl 27:213–24 [review].

11. Kleijnen J, Riet GT, Knipschild P. Vitamin B6 in the treatment of the premenstrual syndrome—a review. Br J Obstet Gynaecol 1990;97:847–52 [review].

12. Williams MJ, Harris RI, Deand BC. Controlled trial of pyridoxine in the treatment of premenstrual syndrome. J Int Med Res 1985;13:174–9.

13. Brush MG, Perry M. Pyridoxine and the premenstrual syndrome. Lancet 1985;i:1399 [letter].

14. Hagen I, Nesheim B-I, Tuntland T. No effect of vitamin B6 against premenstrual tension. Acta Obstet Gynecol Scand 1985;64:667–70.

15. Wyatt KM, Dimmock PW, Jones PW, Shaughn O’Brien PM. Efficacy of vitamin B-6 in the treatment of premenstrual syndrome: systematic review. BMJ 1999;318:1375–81.

16. Rossignol AM, Bonnlander H. Premenstrual symptoms and beverage consumption. Am J Obstet Gynecol 1993;168:1640 [letter].

17. Thys-Jacobs S, Starkey P, Bernstein D, et al. Calcium carbonate and the premenstrual syndrome: Effects on premenstrual and menstrual symptoms. Am J Obstet Gynecol 1998;179:444–52.

18. Thys-Jacobs S, Ceccarelli S, Bierman A, et al. Calcium supplementation in premenstrual syndrome. J Gen Intern Med 1989;4:183–9.

19. Penland JG, Johnson PE. Dietary calcium and manganese effects on menstrual cycle symptoms. Am J Obstet Gynecol 1993;168:1417–23.

20. Horrobin DF, Manku MS, Brush M, et al. Abnormalities in plasma essential fatty acid levels in women with premenstrual syndrome and with nonmalignant breast disease. J Nutr Med 1991;2:259–64.

21. Puolakka J, Makarainen L, Viinikka L, Ylikorkola O. Biochemical and clinical effects of treating the premenstrual syndrome with prostaglandin synthesis precursors. J Reprod Med 1985;30:149–53.

22. Ockerman PA, Bachrack I, Glans S, Rassner S. Evening primrose oil as a treatment of the premenstrual syndrome. Rec Adv Clin Nutr 1986;2:404–5.

23. Massil H, O’Brien PMS, Brush MG. A double blind trial of Efamol evening primrose oil in premenstrual syndrome. 2nd International Symposium on PMS, Kiawah Island, Sep 1987.

24. Casper R. A double blind trial of evening primrose oil in premenstrual syndrome. 2nd International Symposium on PMS, Kiawah Island, Sep 1987.

25. Khoo SK, Munro C, Battisutta D. Evening primrose oil and treatment of premenstrual syndrome. Med J Aust 1990;153:189–92.

26. Collins A, Cerin A, Coleman G, Landgren B-M. Essential fatty acids in the treatment of premenstrual syndrome. Obstet Gynecol 1993;81:93–8.

27. McFayden IJ, Forrest AP, Chetty U, Raab G. Cyclical breast pain - some observations and the difficulties in treatment. Br J Clin Pract 1992; 46:161–4.

28. Abraham GE, Lubran MM. Serum and red cell magnesium levels in patients with premenstrual tension. Am J Clin Nutr 1981;34:2364–6.

29. Sherwood RA, Rocks BF, Stewart A, Saxton RS. Magnesium and the premenstrual syndrome. Ann Clin Biochem 1986;23:667–70.

30. Nicholas A. Traitement du syndrome pre-menstruel et de la dysmenorrhee par l’ion magnesium. in First International Symposium on Magnesium Deficit in Human Pathology, ed. J Durlach. Paris: Springer-Verlag, 1973, 261–3.

31. Facchinetti F, Borella P, Sances G, et al. Oral magnesium successfully relieves premenstrual mood changes. Obstet Gynecol 1991;78:177–81.

32. Walker AF, De Souza MC, Vickers MF, et al. Magnesium supplementation alleviates premenstrual symptoms of fluid retention. J Womens Health 1998;7:1157–65.

33. Facchinetti F, Sances G, Borella P, et al. Magnesium prophylaxis of menstrual migraine: effects on intracellular magnesium. Headache 1991;31:298–301.

34. Werbach MR. Premenstrual syndrome: magnesium. Int J Alternative Complementary Med 1994;Feb:29 [review].

35. Takacs BE. Potassium: A new treatment for premenstrual syndrome. J Orthomolec Med 1998;13:215–22.

36. Steinberg S, Annable L, Young SN, Liyanage N. A placebo-controlled clinical trial of L-tryptophan in premenstrual dysphoria. Biol Psychiatry 1999;45:313–20.

37. Bryant M, Cassidy A, Hill C, et al. Effect of consumption of soy isoflavones on behavioural, somatic and affective symptoms in women with premenstrual syndrome. Br J Nutr 2005;93:731–9.

38. Chuong CJ, Dawson EB, Smith ER. Vitamin E levels in premenstrual syndrome. Am J Obstet Gynecol 1990;163:1591–5.

39. London RS, Sundaram GS, Murphy L, Goldstein PJ. The effect of alpha-tocopherol on premenstrual symptomatology: a double blind study. J Am Coll Nutr 1983;2(2):115–22.

40. London RS, Bradley L, Chiamori NY. Effect of a nutritional supplement on premenstrual symptomatology in women with premenstrual syndrome: a double-blind longitudinal study. J Am Coll Nutr 1991;10:494–9.

41. Stewart A. Clinical and biochemical effects of nutritional supplementation on the premenstrual syndrome. J Reprod Med 1987;32:435–41.

42. Chakmakjian Z, Higgins C, Abraham G. The effect of a nutritional supplement, Optivite for women, on premenstrual tension syndrome: effect of symptomatology, using a double-blind crossover design. J Appl Nutr 1985;37:12.

43. Freeman E, Rickels K, Sondheimer SJ, Polansky M. Ineffectiveness of progesterone suppository treatment for premenstrual syndrome. JAMA 1990;264:349–53.

44. Martorano JT, Ahlgrimm M, Colbert T. Differentiating between natural progesterone and synthetic progestins: clinical implications for premenstrual syndrome and perimenopause management. Comp Ther 1998;24:336–9.

45. Block E. The use of vitamin A in premenstrual tension. Acta Obstet Gynecol Scand 1960;39:586–92.

46. Argonz J, Abinzano C. Premenstrual tension treated with vitamin A. J Clin Endocrinol 1950;10:1579–89.

47. Biskind MS. Nutritional deficiency in the etiology of menorrhagia, metrorrhagia, cystic mastitis and premenstrual tension: treatment with vitamin B-complex. J Clin Endocrinol Metabol 1943;3:227–34.

48. Biskind MS, Biskind GR, Biskind LH. Nutritional deficiency in the etiology of menorrhagia, metrorrhagia, cystic mastitis and premenstrual tension. Surg Gynecol Obstet 1944;78:49–57.

49. Piesse JW. Nutritional factors in the premenstrual syndrome. Int Clin Nutr Rev 1984;4(2):54–80 [review].

50. Milewicz A, Gejdel E, Sworen H, et al. Vitex agnus castus extract in the treatment of luteal phase defects due to latent hyperprolactinemia: Results of a randomized, placebo-controlled double-blind study. Arzneimittelforschung 1993;43:752–6 [in German].

51. Dittmar FW, Böhnert KJ, et al. Premenstrual syndrome: Treatment with a phytopharmaceutical. Therapiwoche Gynäkol 1992;5:60–8.

52. Loch EG, Selle H, Boblitz N. Treatment of premenstrual syndrome with a phytopharmaceutical formulation containing Vitex agnus castus. J Women Health Gender-Based Med 2000;9:315–20.

53. Schellenberg R. Treatment for the premenstrual syndrome with agnus castus fruit extract: prospective, randomized, placebo controlled study. BMJ 2001;20:134–7.

54. Lauritzen C, Reuter HD, Repges R, et al. Treatment of premenstrual tension syndrome with Vitex agnus castus. Controlled, double-blind study versus pyridoxine. Phytomed 1997;4:183–9.

55. Dittmar F. Das pramenstruelle Spannungssyndrome. Jiatros Gynakologie 1989;5:4–7.

56. Tamborini A, Taurelle R. Value of standardized Ginkgo biloba extract (EGb 761) in the management of congestive symptoms of premenstrual syndrome. Rev Fr Gynecol Obstet 1993;88:447–57 [in French].

57. Qi-bing M, Jing-yi T, Bo C. Advance in the pharmacological studies of radix Angelica sinensis (oliv) diels (Chinese danggui). Chin Med J 1991;104:776–81.

58. Blumenthal M, Busse WR, Goldberg A, et al., eds. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998, 90.

59. Weiss RF. Herbal Medicine. Gothenburg, Sweden: Ab Arcanum and Beaconsfield, UK: Beaconsfield Publishers Ltd, 1988, 315.

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