Nutritional management of premenstrual syndrome: The current evidence
Premenstrual syndrome (PMS) is a cyclical condition that occurs during the luteal phase of the menstrual cycle (that is 1-2 weeks before menstruation). Symptoms of PMS vary between and within individuals and may include mood swings, increased appetite, irritability, carbohydrate and/or alcohol cravings, breast tenderness, bloating and headaches. These symptoms are usually relieved by the onset of, or during menstruation. Women with chronic conditions such as diabetes, irritable bowel syndrome or allergies, may have a low threshold for developing PMS. Good control of such medical conditions can reduce the severity of PMS symptoms.
Aetiology of PMS
The actual cause of PMS is unknown, but it is believed to be due to the increased sensitivity to circulating hormone progesterone and its metabolites. It has also been suggested that a lack of prostaglandin E1 (PGE1) production from omega-6 fatty acids may also be a contributing factor.
There is no universally recognised single treatment for PMS. Most women often use diet, drugs including selective serotonin reuptake inhibitors (SSRIs), supplements, cognitive behavioural therapy (CBT), and/or alternative approaches (i.e. reflexology) to relieve PMS symptoms. With regards to supplement use, only calcium and vitamin D have good quality evidence to support their use for the management of PMS. There is not enough evidence to support the use of any other supplement for the management of PMS. For mild to moderate symptoms, healthy lifestyle changes including adopting a healthy and balanced diet, regular physical activity and stress reduction techniques, can substantially reduce, if not alleviate the symptoms. For women who are treated with drugs, a healthy lifestyle approach may also help make the treatment more successful.
Many women report an increase in appetite during the luteal phase. In a recent study, women with PMS have been shown to eat significantly more fat, carbohydrates and simple sugars premenstrually. Obesity is associated with PMS, and as such, adopting a healthy diet and increasing physical activity levels to at least 45 minutes for 5 times a week, is an effective strategy for weight reduction in overweight and obese women, and a way to manage PMS symptoms. Also, it has been shown that increasing dietary fiber intake can help reduce the constipation that may occur premenstrually, and this can be of particular importance for women with IBS-induced constipation. Isoflavones in soy may also benefit premenstrual migraine, but the evidence is still equivocal and further data are needed before recommendation. Alcoholics are prone to PMS and alcohol has been shown to aggravate PMS symptoms.
Calcium and Vitamin D
A diet rich in calcium and vitamin D is associated with a significantly lower incidence of PMS. Specifically, taking calcium and vitamin D at 1000mg/day and 10μg/day respectively may be useful in reducing premenstrual pain and emotional symptoms associated with PMS. You can get this amount by taking a daily supplement of calcium combined with vitamin D. You should also consume foods rich in calcium including:
Low-oxalate greens like bok choy, broccoli, Chinese cabbage, collards, and kale
Fruit juices fortified with calcium citrate malate
Bread and anything made with calcium fortified flour
Milk and dairy foods
Calcium-fortified non-dairy beverages and yogurts like soy, rice or almond milk
Fish where you eat with bones such as sardines and pilchards
Most of your vitamin D should be made in your body from exposure to sunlight. You can achieve this by leaving your face and forearms uncovered in the sun for about 20 minutes a day between the hours of 10am and 3pm, between April and October. You may also consume foods rich in vitamin D including eggs, and fortified margarines, fruit juices and breakfast plant milks and cereals. If you are vegan, vitamin D2 supplements that provide 10mcg of vitamin D can be useful.
Magnesium, B complex vitamins and vitamin E
For these supplements the evidence to support their use for PMS is equivocal. Specifically, low intake and low blood levels of magnesium have been identified in PMS sufferers, and an improvement in PMS symptoms has been observed following magnesium supplementation; however, in recent views it was concluded that there is little evidence to support the effectiveness of magnesium in PMS. Vitamin B6 supplements were used in the past for the treatment of PMS, but a pharmacological dose of 50-100mg was required to produce any effect. Such high doses may induce neuropathy, and as such in the UK supplements are only sold in 10mg, which is an ineffective dose. Finally, some studies have shown that vitamin E combined with evening primrose oil may be effective in reducing premenstrual breast pain; however further and good quality research needs to be undertaken before strong conclusions can be made.
Although herbal medicines are often used for the management of PMS, their effectiveness has not been fully evaluated in randomized control trials – the gold standard in research. Single trials of Jingqianping, Vitex agnus castus, Ginko biloba and Crocus sativus have shown some efficacy; however more clinical trials are needed to provide reliable recommendations.
The actual cause of PMS is unknown, but is believed to be due to increased sensitivity to circulating hormone progesterone and its metabolites
Obesity is directly linked to the PMS, and alcohol has been shown to exacerbate symptoms of the syndrome.
A healthy and balanced diet that provides adequate amounts of dietary fiber, calcium and vitamin D, combined with regular exercise, drug use (on medical advice) and other therapies such as cognitive behavioral therapy, can significantly reduce the symptoms of PMS.
The evidence to support the use of supplements such as magnesium, B-complex vitamins and vitamin E, or herbal therapies for the management of PMS is at the moment equivocal.
Gandy, J. (2014). Manual of dietetic practice. (5th ed.). London: Wiley-Blackwell.