Diet and Premenstrual Syndrome
6 Sep 2007
Dr Pamela Mason, Pharmaceutical and Nutrition Writer and Consultant looks at diet and PMS.The following article was first published in Complete Nutrition (2007); 7(3): 16-1.
Premenstrual syndrome (PMS) describes a range of symptoms that regularly recur, specifically during the luteal phase (ie, the second half) of the menstrual cycle, and resolve by the end of menstruation. Although more than 200 symptoms have been associated with PMS, the classic symptoms include irritability, depression, mood swings, breast tenderness, backache, bloating, changes in appetite and food cravings.1 Some women with severe PMS, who have predominantly emotional and behavioural symptoms, which interferes with their day to day functioning or relationships, may have premenstrual dysphoric disorder (PMDD).
Between 85% and 97% of women of reproductive age experience some symptoms during the premenstrual phase of the cycle, and the symptoms are severe enough to significantly disrupt everyday life for 3-5% of women.2 A survey of 300 women in the UK, who reported PMS symptoms, found that 13% of those who worked, had taken time off in the previous year because of PMS.3
The underlying mechanisms leading to the symptoms of PMS are unknown, but it is recognised that symptoms only occur during an ovulatory cycle.4 In the past, it was thought that PMS was caused by progesterone deficiency but this theory is unproven.5 The most probable physiological factor is a disturbance in the equilibrium between the ovarian hormones and the central neurotransmitters, particularly serotonin.4 The diversity of presenting symptoms has led to many drug and non-drug approaches, none of which has proven to be successful in all women with these disorders.
Several aspects of diet, including energy and carbohydrate, and specific vitamins and minerals (e.g. vitamin B6, vitamin E, calcium, magnesium and zinc) have been considered. In addition, there has been interest in gamma-linolenic acid (GLA), an omega-6 fatty acid found in evening primrose oil, borage oil and blackcurrant oil and also in isoflavones found in soya and other plants, such as red clover.
Energy and macronutrients
Variations in energy and macronutrient intake across the menstrual cycle have been observed, the highest intakes of energy usually being observed premenstrually during the luteal phase.6, 7 A study in overweight women found an increase in premenstrual intake of energy and all macronutrients in those with PMS while those with no PMS reported a rise in energy and fat intake, but all other macronutrients, including non-milk extrinsic sugars were similar between the phases.8 However, a more recent study in women of healthy weight found that consumption of energy and macronutrient intake were similar between the phases of the cycle in women with PMS, while intakes were usually greater premenstrually in the control women. Exceptions were with non-milk extrinsic sugars and alcohol, which were both consumed in greater amounts in the premenstrual phase in women with PMS.9
Carbohydrate
Some women who suffer from PMS experience carbohydrate craving, particularly for sweets and chocolates. It has been suggested that these food cravings are related to abnormal serotonin activity in the brain, which may in turn affect food and appetite.10 Eating small, frequent meals, high in carbohydrate is sometimes recommended to women with PMS to improve symptoms such as anxiety and depression.
In a placebo-controlled study, a single dose of a drink mix containing dextrose and maltodextrin (200 calories/dose) produced an increase in self-reported recognition memory in women with PMS three hours after the dose was given. Whether this has any advantage over changing eating patterns is unclear.11
Vitamin B6
Perhaps one of the most widely held nutritional theories concerning PMS is that it is caused by a deficiency of vitamin B6. During the 1970s and early 1980s supplementation with vitamin B6 was frequently discussed in the popular press for potentially reducing the symptoms of PMS. Since vitamin B6 is a co-factor for several enzymes, and is associated with low levels of the neurotransmitter serotonin and depression,12 there is a reasonable basis for it having a role in mood symptoms related to PMS.
However, clinical trials have produced mixed results. A review published in 1990 of 12 controlled trials found three with positive results, five with ambiguous results and four with negative results. All except one of the trials were small, with fewer than 50 subjects in the treatment groups and all suffered from methodological problems. A more recent review, published in 1999, of nine randomised controlled trials (RCTs), found that vitamin B6 reduced overall and depressive symptoms of PMS. However, there was no dose response relationship and trials were of poor quality.
Despite the lack of clear evidence, women may choose to take vitamin B6 supplements, but they need to be aware that high doses can cause peripheral neuropathy. Most reported cases of neuropathy associated with vitamin B6 supplementation have involved intakes of at least 500mg/day for two or more years, or larger doses for shorter periods of time.13 A few cases of neuropathy have been reported in individuals taking lower doses of vitamin B6, but these studies have been disputed.4 Several authorities have set upper levels (ULs) for vitamin B6 ranging from 10-100mg/day,14-16 though the UK Expert Vitamin and Mineral (EVM) group agreed a UL of 200mg/day for short-term use only.16
Vitamin E
Vitamin E has been implicated in PMS because of its effects on PMS symptoms through regulation of prostaglandin synthesis.17 A double-blind trial evaluated the effects of vitamin E supplementation (400 IU/day) in PMS. Significant improvements in some symptoms (eg, breast tenderness) were observed in the vitamin E group.17
Magnesium
Deficiency of magnesium has been suggested to cause PMS.18 Magnesium is involved in the activity of serotonin and other neurotransmitters and in cell membrane stability, vascular contraction and neuromuscular function, which offers several mechanisms by which magnesium might influence PMS.
Moreover, a substantial proportion of women in the UK have low intakes. The National Diet and Nutrition Survey (NDNS) in British adults found that 74% of women failed to achieve the Reference Nutrient Intake (RNI) for magnesium while 13% of women have intakes below the Lower Reference Nutrient Intake (LRNI). In women aged 19-24, these figures were 85% and 22% respectively.
Serum magnesium levels may vary across the menstrual cycle. Erythrocyte and leucocyte magnesium levels have been reported to be lower in women with PMS than in women without PMS, but plasma levels do not demonstrate this pattern.12, 18-21
Three small double-blind RCTs have investigated the effect of magnesium supplementation in PMS. A trial in 38 women with relatively mild PMS found that a daily supplement of 200mg of magnesium reduced one out of six studied symptom categories. Fluid retention was significantly reduced in the second, but not the first month of use, but there were no significant effects on emotional symptoms.22 Supplementation with magnesium 360mg/day in 32 women significantly reduced total PMS symptoms, specifically those related to mood,23 while in another trial in 20 women with premenstrual migraine, the same dose of magnesium significantly reduced the number of days with headache.24
In addition, a combination of daily supplementation with magnesium 200mg and vitamin B6 50mg significantly reduced anxiety related premenstrual symptoms during treatment of 44 women for one menstrual cycle.25 A yeast-based supplement providing 400mg/day of magnesium also reduced premenstrual distress.26 Magnesium is usually well tolerated at the doses described above. However, doses of 350-400mg daily have been associated with diarrhoea. ULs set by different authorities range from 250-400mg daily.14-16
Calcium
Calcium status has been associated with the menstrual cycle since 1930 when a study found that plasma calcium levels were lower in the premenstrual period than in the week following menstruation.27
Several reports anecdotally suggest symptom relief. In 1989, a small randomised crossover trial demonstrated a significant reduction in premenstrual symptoms after supplementation with calcium 1000mg/day.28 In 1993, a controlled dietary study demonstrated reduced premenstrual and menstrual symptoms in women consuming diets providing 1,336mg calcium/day compared with 587mg/day.29 These trials were followed by a large US multicentre clinical trial in which 466 women with PMS received 1,200mg calcium or placebo for three menstrual cycles. By the third treatment cycle those receiving calcium showed an overall 48% reduction in total symptom scores compared with a 30% reduction in the placebo group.30 Doses used in these studies are well within safety limits. ULs set by different authorities range from 1500-2500mg daily.14-16
More recently, a case-control study within the Nurses’ Health Study II cohort found that women with the highest intakes of calcium from food (median=1,283mg/day) and vitamin D (median=706IU/day) had a lower risk of PMS than those with the lowest intakes.31
Evening primrose oil
Evening primrose is a rich source of gamma-linolenic acid (GLA), a long chain fatty acid, which is a precursor in the synthesis of prostaglandins. The use of evening primrose oil is based on the hypothesis that women with PMS have a relative deficiency of GLA that may result in abnormalities in prostaglandin synthesis, which may in turn contribute to PMS. However, a systematic review of seven placebo-controlled trials (n=329) found that there was not enough evidence to demonstrate the efficacy of evening primrose oil in PMS.32 It may have a small effect but large trials are needed to confirm this.
Isoflavones
Isoflavones, which are phytoestrogenic compounds found in plants such as soya and red clover, might prove effective in reducing some premenstrual symptoms because they have the ability to act as antioxidants, regulate neuro-endocrine activity and exhibit weak oestrogenic and anti-oestrogenic effects. A high intake of isoflavones has been inversely associated with PMS symptoms in Korean women living in the US.33 A clinical trial found that 68mg/day of soy isoflavones reduced headache, breast tenderness, cramps and swelling, but not total symptoms in women with PMS, compared with a milk protein placebo.34
Caffeine
Anecdotally, some women find that caffeine reduction results in improvement in PMS symptoms. One study found that consumption of caffeine was strongly related to the prevalence of PMS. In women with more severe symptoms, the effect was greater, and the authors suggested that women with PMS consider eliminating caffeine from their diets and then evaluate any changes in their symptoms after several months. A more recent trial found no significant difference in total caffeine intake or in the individual caffeine containing beverages consumed during the premenstrual period. Women with PMS were more likely to be heavy consumers of decaffeinated coffee and herbal tea than controls.35
Herbal products
A variety of herbal products, including black cohosh, blue cohosh, wild yam root, agnus castus (chasteberry), St John’s wort and dong quai have been suggested for the reduction of PMS symptoms. With the exception of chasteberry, no controlled trials have demonstrated efficacy of these herbs in PMS.
Chasteberry is approved in Germany for the treatment of PMS. A placebo-controlled trial in Germany involving 170 women found that 20mg of agnus castus daily significantly improved PMS symptoms and was well tolerated.36 However, it is unclear whether similar efficacy and tolerability will be seen with all preparations available in the UK.
Dietary recommendations
Currently, there is no definitive evidence that diet can eliminate PMS symptoms. However, dietary change may help some women. This could include:
- Eating more complex carbohydrates, particularly those with a low glycaemic index (GI)
- Avoiding or limiting caffeine, which can increase tension and irritability
- Limiting salt and salty food to help prevent bloating
- Eating small, frequent meals and snacks
- Choosing low fat foods to help maintain a healthy weight.
Regular exercise plays a beneficial role in PMS. Studies show that women who are physically active tend to suffer less from PMS.
Dietary supplementation may be of value in reducing symptoms of PMS. All women who could become pregnant are recommended to take folic acid 400mg/day to minimise their risk of bearing a child with a neural tube defect. The use of a multivitamin supplement containing folic acid 400mg could therefore be a useful strategy in the reduction of PMS even though rigorous evidence of efficacy is lacking. Among the variety of specific supplements recommended for PMS, the greatest evidence of benefit is for calcium and a calcium supplement could be tried by women with PMS. (Multivitamins contain only small quantities of calcium so a separate product is required).
Further information on www.nutrition2me.com
References: 1. Freeman EW. Premenstrual syndrome and premenstrual dysphoric disorder: definitions and diagnosis. Psychoneuroendocrinology 2003;28 Suppl 3:25-37. 2. Kraemer GR, Kraemer RR. Premenstrual syndrome: diagnosis and treatment experiences. J Womens Health 1998;7(7):893-907. 3. Hylan TR, Sundell K, Judge R. The impact of premenstrual symptomatology on functioning and treatment-seeking behavior: experience from the United States, United Kingdom, and France. J Womens Health Gend Based Med 1999;8(8):1043-52. 4. The American College of Obsterics and Gynecology (ACOG) Committee on Practice Bulletins. Clinical management guidelines for obstetrician-gynecologists: Premenstrual syndrome. . ACOG Practice Bulletin 2000;15:1-8. 5. Ling FW. Recognizing and treating premenstrual dysphoric disorder in the obstetric, gynecologic, and primary care practices. J Clin Psychiatry 2000;61 Suppl 12:9-16. 6. Dye L, Blundell JE. Menstrual cycle and appetite control: implications for weight regulation. Hum Reprod 1997;12(6):1142-51. 7. Reimer RA, Debert CT, House JL, Poulin MJ. Dietary and metabolic differences in pre- versus postmenopausal women taking or not taking hormone replacement therapy. Physiol Behav 2005;84(2):303-12. 8. Cross GB, Marley J, Miles H, Willson K. Changes in nutrient intake during the menstrual cycle of overweight women with premenstrual syndrome. Br J Nutr 2001;85(4):475-82. 9. Bryant M, Truesdale KP, Dye L. Modest changes in dietary intake across the menstrual cycle: implications for food intake research. Br J Nutr 2006;96(5):888-94. 10. Rapkin AJ. The role of serotonin in premenstrual syndrome. Clin Obstet Gynecol 1992;35(3):629-36. 11. Sayegh R, Schiff I, Wurtman J, Spiers P, McDermott J, Wurtman R. The effect of a carbohydrate-rich beverage on mood, appetite, and cognitive function in women with premenstrual syndrome. Obstet Gynecol 1995;86(4 Pt 1):520-8. 12. Rose DP. The interactions between vitamin B6 and hormones. Vitam Horm 1978;36:53-99. 13. Bendich A, Cohen M. Vitamin B6 safety issues. Ann N Y Acad Sci 1990;585:321-30. 14. Institute of Medicine Food and Nutrition Board. Dietary reference intakes for thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin and choline. Washington DC: The National Academies Press, 2000. 2000. 15. European Food Safety Authority. Tolerable upper intake levels for vitamins and minerals. Scientific Committee on Food. Scientific Panel on Dietetic Products, Nutrition and Allergies. February 2006. Available at http://www.efsa.europa.eu/en/publications/scientific.html. Accessed 07/04/07. 16. Expert Group on Vitamins and Minerals. Safe uper levels for vitamins and minerals. London: Food Standard Agency;2003. Available at www.food.gov.uk 2003. 17. London RS, Murphy L, Kitlowski KE, Reynolds MA. Efficacy of alpha-tocopherol in the treatment of the premenstrual syndrome. J Reprod Med 1987;32(6):400-4. 18. Abraham GE, Lubran MM. Serum and red cell magnesium levels in patients with premenstrual tension. Am J Clin Nutr 1981;34(11):2364-6. 19. Facchinetti F, Borella P, Valentini M, Fioroni L, Genazzani AR. Premenstrual increase of intracellular magnesium levels in women with ovulatory, asymptomatic menstrual cycles. Gynecol Endocrinol 1988;2(3):249-56. 20. Posaci C, Erten O, Uren A, Acar B. Plasma copper, zinc and magnesium levels in patients with premenstrual tension syndrome. Acta Obstet Gynecol Scand 1994;73(6):452-5. 21. Mira M, Stewart PM, Abraham SF. Vitamin and trace element status in premenstrual syndrome. Am J Clin Nutr 1988;47(4):636-41. 22. Walker AF, De Souza MC, Vickers MF, Abeyasekera S, Collins ML, Trinca LA. Magnesium supplementation alleviates premenstrual symptoms of fluid retention. J Womens Health 1998;7(9):1157-65. 23. Facchinetti F, Borella P, Sances G, Fioroni L, Nappi RE, Genazzani AR. Oral magnesium successfully relieves premenstrual mood changes. Obstet Gynecol 1991;78(2):177-181. 24. Facchinetti F, Sances G, Borella P, Genazzani AR, Nappi G. Magnesium prophylaxis of menstrual migraine: effects on intracellular magnesium. Headache 1991;31(5):298-301. 25. De Souza MC, Walker AF, Robinson PA, Bolland K. A synergistic effect of a daily supplement for 1 month of 200 mg magnesium plus 50 mg vitamin B6 for the relief of anxiety-related premenstrual symptoms: a randomized, double-blind, crossover study. J Womens Health Gend Based Med 2000;9(2):131-9. 26. Facchinetti F, Nappi RE, Sances MG, Neri I, Grandinetti G, Genazzani A. Effects of a yeast-based dietary supplementation on premenstrual syndrome. A double-blind placebo-controlled study. Gynecol Obstet Invest 1997;43(2):120-4. 27. Okey R, Stewart J, Greenwood M. Studies of the metabolism of women. IV. The calcium and inorganic phosphorus in the blood of normal women at the various stages of the monthly cycle. Journal of Biological Chemistry 1930;87:91-102. 28. Thys-Jacobs S, Ceccarelli S, Bierman A, Weisman H, Cohen MA, Alvir J. Calcium supplementation in premenstrual syndrome: a randomized crossover trial. J Gen Intern Med 1989;4(3):183-9. 29. Penland JG, Johnson PE. Dietary calcium and manganese effects on menstrual cycle symptoms. Am J Obstet Gynecol 1993;168(5):1417-23. 30. Thys-Jacobs S, Starkey P, Bernstein D, Tian J. Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Premenstrual Syndrome Study Group. Am J Obstet Gynecol 1998;179(2):444-52. 31. Bertone-Johnson ER, Hankinson SE, Bendich A, Johnson SR, Willett WC, Manson JE. Calcium and Vitamin D Intake and Risk of Incident Premenstrual Syndrome. Arch Intern Med 2005;165(11):1246-1252. 32. Budeiri D, Li Wan Po A, Dornan JC. Is evening primrose oil of value in the treatment of premenstrual syndrome? Control Clin Trials 1996;17(1):60-8. 33. Kim HW, Kwon MK, Kim NS, Reame NE. Intake of dietary soy isoflavones in relation to perimenstrual symptoms of Korean women living in the USA. Nurs Health Sci 2006;8(2):108-13. 34. Bryant M, Cassidy A, Hill C, Powell J, Talbot D, Dye L. Effect of consumption of soy isoflavones on behavioural, somatic and affective symptoms in women with premenstrual syndrome. Br J Nutr 2005;93(5):731-9. 35. Caan B, Duncan D, Hiatt R, Lewis J, Chapman J, Armstrong MA. Association between alcoholic and caffeinated beverages and premenstrual syndrome. J Reprod Med 1993;38(8):630-6. 36. Schellenberg R. Treatment for the premenstrual syndrome with agnus castus fruit extract: prospective, randomised, placebo controlled study. Bmj 2001;322(7279):134-7.
© Complete Media & Marketing Limited
