Premenstrual syndrome is a psychoneuroendocrine
condition characterized by a cyclical recurrence of a constellation
of symptoms during the week before and a few days after the onset
of menses. These symptoms include nervousness, irritability, emotional
instability, anxiety, depression and possibly headaches, edema and
mastalgia. To qualify as a DSM IV diagnosis of PMS (late luteal phase
dysphoric disorder), symptoms must seriously interfere with work or
usual social activities.1 PMS is a non-specific disease process with
a constellation of symptoms and an often unpredictable course. A multi-prong
treatment involving education, Chiropractic adjustments, exercise,
diet and nutrition supplementation incorporating the best available
evidence will always prove more effacious than any specific cure-all
approach.
Education
Critical to the management of any condition is education and reassurance.
PMS is no exception. Education should be focused on information regarding
the high incidence of PMS in women during their reproductive years,
common symptoms, the female menstrual cycle, and the importance of
stress reduction, adequate rest and quitting smoking. Coping techniques
can include scheduling activities during low symptom periods, reading
self help books, and eating low calorie snacks during periods of low
concentration, irritability and fatigue.5 Relationship skills can
be taught focusing on assertiveness training and talking about their
feelings or PMS symptoms with their loved ones. As a last resort,
although not too consoling, educate the patient that if all else fails
symptoms definitely abate with menopause.4
Spinal Manipulative Therapy
(SMT)
Walsh et al (1994) conducted a preliminary study evaluating the
effect of Chiropractic full spine SMT and soft tissue techniques
on reducing the symptoms of PMS. They reported decreased symptoms
in PMS sufferers with Chiropractic treatment which supported previous
anecdotal evidence.6 This study was followed up in 1999 in the form
of a prospective, randomized, placebo-controlled, crossover clinical
trial. In this study, Walsh et al (1999) evaluated the benefits
of high velocity low amplitude osseous SMT and soft tissue therapy
two to three times per week during the week prior to menses. This
was compared to a sham activator technique. They concluded that
the symptoms associated with PMS can generally be reduced with Chiropractic.7
Reported SMT methods include distractive decompression SMT in patients
with sacral nerve root compression, SMT of L1, L2, L5 and bilateral
SI joints, SMT to reduce the sacral base angle, and low force techniques
to relieve anxiety and irritability.5
Exercise
Women participating in regular physical exercise report fewer symptoms
of PMS than do those women who do not. It is the frequency, not
intensity, of exercise during the premenstrual period that results
in this decreased symptomatology.3 Recommendations include a daily
light aerobic activity, such as a brisk walk. Theories for this
beneficial response to exercise include decreased estrogen and catecholamine
levels, increased glucose tolerance and endorphin levels, and stimulation
of the immune symptom.3,4,5 In addition, exercise may help decrease
bloating.4
Diet
Studies indicate women suffering from PMS consume significantly
increased refined sugars and carbohydrates, dairy products, and
sodium. However, their intake of manganese, B vitamins, and iron
is lower versus women without PMS.2,3 High fiber and low fat diets
may reduce blood estrogen levels by acting at the gastrointestinal
level to suppress the ability of bacteria to deconjugate estrogen
which enhances fecal excretion.3 General dietary recommendations
include eating small regular meals (decreases postprandial rebound
hypoglycemia); limiting red meats, dairy, fried foods, caffeine
(decreases irritability, tension and headaches), refined sugar,
salt, and alcohol (prevents decreased glucose levels); increasing
consumption of water, lean meat, fresh fruit and vegetables, and
complex carbohydrates (increases tryptophan thus elevating mood);
and screening for possible food allergies (wheat, yeast).2,3,4,5
Specifically, many women report lowered premenstrual mastalgia after
reducing or eliminating caffeine3 and salt2 as well as eating a
high complex carbohydrate and low fat diet2.
A documented four phase dietary intervention has been used at the
University College London Hospital's PMS clinic. This approach may
require a long term treatment period, thus participants require
patience and will power. Clients’ diets are first screened
with a questionnaire to assess suitability for the program. They
are then advised of a healthy diet which they are to follow for
3 months. If poor results are found, phase II is entered whereby
they are then to exclude refined sugars and eat a starchy meal or
snack every 3-4 hours for one month. Phase III is reached if no
significant results are achieved. At this point, the client begins
to consume a daily vitamin and mineral cocktail for 3-5 months.
If no improvement is attained, the supplemental approach should
be discarded and Phase IV begins. This consists of special investigations
for other underlying medical problems including allergies, intolerances,
diabetes, anemia, and irritable bowel syndrome. Obvious benefits
of this approach are a controlled hierarchical method of addressing
dietary intervention as well as the worse case scenario of improved
general well-being while still suffering from PMS symptoms.2
Nutrition
Trials have suggested decreased mood and somatic symptoms during
the luteal phase in women suffering from PMS while taking calcium
(1200 mg per day)3, magnesium (200 mg3 or 400-1000 mg per day5),
vitamin B6 a.k.a. pyridoxine (50 mg3 to 500 mg3 per day), and/or
vitamin E (300-600 IU2) supplements. Botanical supplementation has
also been advocated for the treatment of PMS. Chastetree (20 mg
of dried vitex per day), black cohosh (80 mg per day), ginkgo biloba,
St. John's wort (300 mg per day), and kava (100-200 mg of 30% standardized
kavalactones three times per day) have been studied and have shown
positive effects. Other botanicals recommended but requiring further
investigation include blue cohosh, wild yam, black haw and pulsatilla.3
Evening primrose oil supplementation for mastalgia (1000-2000 mg
per day5)2,3, as well as flaxseed oil5 and borage oil5 for PMS symptoms
has been shown to have unequivocal results.
Conclusion
It is important to remember that PMS is a constellation of symptoms
with an often unpredictable course and not a specific disease process.
Therefore, a multi-prong treatment approach incorporating the best
available evidence will always prove more effacious than any specific
cure-all approach.
References
1. Beers MH & Berkow R. (Editors).
The Merck Manual of Diagnosis and Therapy. 1999; 1932-1933.
2. Bussell G. Pre-menstrual syndrome and diet. Journal of Nutritional
and Environmental Medicine 1998; 8: 65-76.
3. Dog LT. Integrative treatments for premenstrual syndrome. Alternative
Therapies in Health and Medicine. 2001; 7: 32-40.
4. Harvard Women's Health Watch. New approaches to PMS. 1998; 5:
6-7.
5. Oyelowo TA. Diagnosis and management of premenstrual syndrome
in Chiropractic office. Topics in Clinical Chiropractic 1997; 4:
60-67.
6. Walsh MJ, Chandraraj S, Polus BI. The efficacy of Chiropractic
therapy on premenstrual syndrome: A case series study. Chiropractic
Journal of Australia 1994; 24: 122-128.
7. Walsh MJ, Polus BI. A randomized, placebo-controlled clinical
trial on the efficacy of Chiropractic therapy on premenstrual syndrome.
Journal of Manipulative and Physiological Therapeutics 1999; 22:
582-585.
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Ciropractic
 Chiropractic
for the Relief of Premenstrual Syndrome
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