Often, when I ask my clients if they have PMS, they jokingly respond, “you should ask my husband!” It is well accepted that women can be more “sensitive” around their menses but why? Although PMS is accepted as the “norm” in our society, to naturopathic doctors it points to an underlying imbalance in the body. Our job as clinicians is to investigate further and find a solution that brings equilibrium.
Although estrogen dominance has become a prominent phrase in the clinical world of treating hormone imbalances, this doesn’t entirely capture the whole aspect of hormone imbalance with respect to PMS and other women’s health issues. It is worth noting, hormonal balance comes from an orchestrated balance between many organs such as the hypothalamus, pituitary, ovaries, thyroid, liver and adrenals.4 As clinicians, our job is to look at the symptoms and objective testing and treat accordingly, keeping in mind this fine balance of organs in the hormonal orchestration.
Assessment: The Hormone Orchestration- what affects this fine balance?
As stated above, the most important aspect is how estrogen and progesterone are in relationship with one another. Estrogen dominance could be from a low progesterone level or a high estrogen level or an estrogen high RELATIVE to progesterone. Progesterone might be in normal levels but estrogen concentration may be high relative to progesterone, leaving an estrogen dominant picture. Or progesterone may be decreasing (common in peri-menopausal years) and therefore estrogen that is unopposed by progesterone acts as if it is at a higher level. To simplify- they work in tandem with each other.
Estrogen dominance can be caused from a variety of reasons. Exogenous estrogens from our environment such as xenoestrogens could be contributing to excess estrogen. Xenoestrogens are chemicals that are manmade and have an estrogenic effect in the body. Wildlife studies have shown now that some fish are even changing gender due to high levels of estrogens in our water sources.4 Other sources of xenoestrogens include fat-soluble estrogen from livestock or poultry, organochlorides, PCB’s, PVC’s – various man-made chemicals found in our households.4 High endogenous estrogen occurs with obesity as fat cells tend to hold onto estrogen. Lastly, our liver has to metabolize and break down the estrogen, therefore liver function needs to be optimal in order to do this.
When we are stressed, the stress hormones cortisol and adrenaline increase. Progesterone is a precursor hormone in the production of cortisol, hence with increased demand of stress hormones, lower progesterone levels may result.4 This theory supports the need to support the adrenal glands with various naturopathic therapies – adaptogenic herbs, nutritional supplementation and lifestyle modification (routine, dietary blood sugar balance and stress management). Stress can also affect a woman’s other hormones including testosterone, leading women to feel tired and sometimes a low libido.4 This demonstrates the need to look at all hormones and consider the whole orchestration of hormonal balance in PMS.
Dietary factors can play a large role in producing PMS symptoms. A low nutrient diet full of junk food, fried foods, low fiber and few vegetables will not provide the nutrients to prevent PMS. Calcium and magnesium deficiencies are suspected in the etiology of PMS. Serotonin deficiency is also a suspected cause of PMS symptoms. Without sufficient protein in our diet, we are unable to attain the amino acid tryptophan, needed to produce serotonin. Lastly, blood sugar balance through diet is also needed to help with PMS symptoms such as anxiety, depression, insomnia and headaches.
Removing exogenous estrogens from the patient’s environment is critical. Advising patients as to where such chemicals occur, how levels build up in the body and how to remove them is essential.
Estrogen is conjugated through various pathways in the liver and various nutritional/herbal natural health products (NHPs) will help with this conjugation. Estrogen’s oxidative metabolism is mediated through the liver’s cytochrome p450 system. 2-hydroxylation of estrogens is induced by indole-3-carbinol (I3C), a nutrient found in cruciferous vegetables like broccoli and cabbage. In one study, I3C was given to 10 women for 2 months and 7 men for 1 week. Urinary samples were taken from individuals to monitor estrogen excretion through gas chromatography-mass spectrometry assessment. Results showed a significant increase in urinary excretion of C-2 estrogens.7 Hence, when looking at an estrogen excess picture, I3C or other NHPs that work on this pathway can help in balancing estrogen and progesterone through conjugation of the excess estrogen. When we decrease the body burden of estrogen, progesterone concentration relative to estrogen will increase and therefore symptoms of PMS will decrease. Although, this is just a theory (to my knowledge) and more research is needed on this. Anecdotally, I think we could agree that many of us naturopathic doctors, including myself, have seen this work for PMS clinically.
From a Traditional Chinese Medicine (TCM) theory, we know the emotion of the liver is irritability and it is necessary for the liver energy to “run smoothly” prior to the menses cycle. If not, this can lead to a host of PMS symptoms including irritability and anger. We also know that, from a TCM perspective, our emotions/stress can impact the liver energy, supporting the observation that emotion affects the physical and vice versa.
With PMS symptoms, especially with irritability and mood fluctuations, I have seen time and time again where liver herbs like milk thistle, dandelion, globe artichoke, calcium-d-glucarate and I3C can really help. Many of my clients don’t want to go off their liver herbs!
This is primarily a central nervous system (CNS) adaptogenic herb. Rhodiola has been shown to influence neurotransmitters such as serotonin, norepinephrine and dopamine. It has been reported to prevent stress-induced depletion of catecholamines. Rhodiola is viewed as a herb to use for sleep disturbances due to physical or intellectual stress and also has been shown to decrease salivary cortisol levels.10 Rhodiola is a good candidate to supplement when a patient has a high-stress history, to prevent the decrease in progesterone levels through shunting into cortisol.
Vitamin B6, B12 and B3 are all needed as co-factors for serotonin production. A B-Complex supplement can be helpful in aiding serotonin production and as a support for stress.
Hence, addressing diet or adding supplementation to ensure adequate intake of calcium and magnesium is a baseline treatment strategy for PMS.
The hormone orchestration of PMS is an involved process that needs a thorough investigation on the clinician’s part to unwind the etiology and to work with these symptoms. With diligence and application of naturopathic principles supported by scientific evidence, naturopathic doctors have a diverse tool kit to help our patients.
Pinkerton, J. Premenstrual syndrome (PMS). Merck Manual Professional Website. http://www.merckmanuals.com/professional/gynecology-and-obstetrics/menstrual-abnormalities/premenstrual-syndrome-pms. Last reviewed November 2015. Accessed August 2, 2016.
Wuttke W, Jarry H, Christoffel V, et al. Chastetree (Vitex agnus-castus)- Pharmacology and Clinical Indications. Phytomedicine. 2003;10(4):348-57.
Momoeda, M, Sasaki H, Tagashira E, et al. Efficacy and safety of Vitex agnus-castus extract for treatment of premenstrual syndrome in Japanese patients: a prospective, open-label study. Ther. 2014;31(3):362-73.
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Canning S, Waterman M, Orsi N, et al. The efficacy of Hypericum perforatum (St John’s Wort) for the treatment of premenstrual syndrome: a randomized, double-blind, placebo-controlled trial. CNS Drugs. 2010;24(3):207-25.
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Saeedian, K. Amani R., Cheraghian B. The Association between the Risk of Premenstrual Syndrome and Vitamin D, Calcium, and Magnesium Status among University Students: A Case Control Study. Health Promot Perspect. 2015; 5(3):225-30.
Akhlaghi F, Hamedi A, Javadi Z, Hosseinipoor F. Effects of calcium supplementation on premenstrual syndrome. Razi Journal of Medical Sciences. 2004;10:669-675. [In Persian].
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Dr. Jennifer Bunzenmeyer, ND is a registered Naturopathic Doctor, Medical Advisor, and consultant with over 1 1 years clinical experience in Calgary, AB. She is recognized highly in the women’s and mental health fields; having been interviewed in leading lifestyle magazines including Chatelaine, Alive, Fresh Juice and Avenue.
Having held a presidential position for a Toastmasters club, she speaks regularly for corporations, school boards and small businesses. She has excellent Clinic Management, Operational and Leadership experience in running a successful clinic. She is currently working towards her Professional Coaching Certification in order to assist clients and corporations achieve their best self.