Most women that I see in my Ottawa practice who are in their reproductive years suffer from premenstrual syndrome (PMS) to some extent. Actually, about 75% of women in this demographic experience PMS (Medline Plus, 2016). Does that make it normal? While a low level of discomfort can be expected (after all, there are huge hormonal changes occurring all at once within the week before your period), in many cases, more severe symptoms are pointing to underlying hormone imbalances or deficiencies that should be addressed.
What Is PMS?
PMS is generally defined as a group of symptoms that comes and goes cyclically based on where a woman is in her menstrual cycle. They usually will start in the second half of the cycle (at least 14 days after the start of a period in a woman with a textbook 28 day cycle), and will go away 1-2 days after menstruation starts (Medline Plus, 2016).
Typical PMS symptoms can include one or more of the following:
-Bloating and/or increased gas
-Changes in bowel movements, such as constipation or diarrhea
-Mood changes, such as heightened emotions, irritability, anxiety, or depression
-Skin changes, such as cyclical acne
Paying attention to these sometimes subtle changes can give you a clue about what imbalances you may have.
The 4 Main Types Of PMS
PMS is classified into 4 main types. If you fit primarily into one of these 4 main types, your naturopathic doctor will be able to gain valuable insight just from your symptoms!
1) PMS-A (Anxiety): This type of PMS is characterized by symptoms of increased anxiety, irritability, and emotional lability.
What it means: PMS-A is usually associated with a high estrogen to progesterone ratio. Think of progesterone as the calming hormone between the two. If you don’t have enough of the calming hormone, estrogen will trigger the release of the more stimulating hormones, cortisol and adrenaline, which will make you feel more on edge. As well, if you’re on or have taken birth control pills in the past, you may have excess estrogen in your system, which can worsen these symptoms.
Treatment options: Using natural strategies to increase progesterone (such as the herb Chaste Tree), get rid of excess estrogen, and decrease stress is very helpful for PMS-A sufferers. Increasing magnesium intake can also be helpful. If you have severe PMS-A symptoms, and especially if you are peri-menopausal, you may benefit from cyclical use (post ovulation) of bio-identical progesterone cream (which I can prescribe).
2) PMS-C (Cravings): If you experience strong cravings the week before your period, especially carbohydrate cravings, then you are probably suffering from PMS-C. You may also crave stimulants and chocolate, get heart palpitations, and you may get headaches and energy highs and lows from fluctuating blood sugar levels.
What it means: These symptoms are thought to be due to changes in the way insulin binds. As a response to blood sugar in your bloodstream, your body produces insulin as a signal to bring the sugar into the cells. However, in the days leading up to a period, a woman’s cells become less sensitive to this insulin signal, leading to imbalances in blood sugar regulation. Giving in to sugar cravings can actually make PMS-C symptoms worse, since the body can’t deal with this influx of sugar properly.
Treatment options: Stabilizing blood sugar with a high protein diet low in refined carbohydrates is really important if you suffer from PMS-C. These blood sugar imbalances can also show up as acne in the skin, since high sugar in the blood can lead to more breakouts. Eat small and frequent meals, and avoid alcohol.
3) PMS-D (Depression): If you feel really down before your period, you don’t feel like participating in your regular social activities, you feel grumpy, angry, or have crying spells before your period, you may suffer from PMS-D. If you have pre-existing depression, you might feel like your symptoms are worse leading up to your period. Another feature of this type of PMS is that it may be associated with premenstrual acne.
What it means: The etiology of this type of PMS is like the reverse of PMS-A, with elevated progesterone levels, and low estrogen levels. While progesterone decreases anxiety, too much progesterone relative to estrogen can depress the nervous system, leading to symptoms of depression. As well, the happy neurotransmitter serotonin is decreased when estrogen levels are low, worsening feelings of depression. There also may be elevated testosterone levels, which can lead to increased acne.
Treatment options: Some foods and herbs with phytoestrogenic activity can be used to balance estrogen levels. As well, if you have elevated androgens (hormones such as testosterone and DHT), these can be balanced using natural therapies. Including foods high in tryptophan (the precursor to the feel good hormone, serotonin) can help with mood: sour cherries, turkey, cottage cheese, and oats are all high in tryptophan (Pope, 2016).
4) PMS-H (Hyperhydration): If you routinely gain a few pounds before your period, your abdomen feels swollen, or your breasts get more swollen and tender, you are likely suffering from PMS-H. Rings on your hands may feel tighter if it also affects your extremities.
What it means: The increased extracellular fluid which leads to symptoms of fluid retention is due to higher aldosterone levels. Aldosterone is a hormone produced by the adrenal glands that helps the body retain fluid. This can be compounded with lower dopamine levels typical in the days leading up to the period.
Treatment options: Eating foods high in salt makes the body retain more water, so decreasing your salt intake and processed foods can help decrease the fluid retention. Increasing magnesium intake can also help reduce aldosterone levels and improve symptoms.
What’s A Girl To Do?
If you are tired of dealing monthly with your PMS symptoms, there is a better way than just pushing through it. Prominent PMS symptoms are signs for you to pay attention to the subtle imbalances in your body. The above treatment options will work for some but must be adapted to your particular case. Naturopathic doctors can help you balance your hormones with tools such as liver supporting and hormone balancing herbs, nutritional supplements, dietary changes, and acupuncture. In more complicated cases, we may need to run hormonal testing (blood or salivary) to find out exactly what we’re dealing with.
If you want to get to the bottom of your PMS, I’d love to help. You can get in touch here.
Image from: http://www.123rf.com/profile_rodimovpavel'>rodimovpavel / 123RF Stock Photo
Kaslow JE (2016). Premenstrual Syndromes. Jeremy E. Kaslow, MD. Retrieved from http://www.drkaslow.com/html/premenstrual_syndromes.html.
Pope N (2016). Naturopathic Infertility Treatments Timed With Cycle Charting. Webinar May 15, 2016.
White CD (2016). Premenstrual Syndrome. Medline Plus. Retrieved from https://medlineplus.gov/ency/article/001505.htm.
Published in To Your Good Health, a natural health journal, Winter 2014, Issue #1
Does our gut really have the capacity to “feel”? If you have ever had food cravings when you are feeling down, or digestive upset in anticipation of a stressful event, then the connection certainly appears to be as real as anything else you experience. In fact, research in the growing field of psychoneuroimmunology (which looks at how the fields of psychology, neurology, and immunology blend together) shows that the nervous system of the gut, called the enteric nervous system (ENS), responds to more than 30 neurotransmitters. In fact, the ENS contains approximately 95% of the body’s serotonin, also known as the “feel good hormone” (Hadhazy, 2010). Because of its complex nervous system, the gut is now often referred to as the second brain. It is closely linked to the central nervous system of the brain (CNS) through the peripheral nervous system (PNS), which leaves the spinal cord and connects to different organs, including the gut. Being aware of this strong connection between the brain and the gut, naturopathic doctors typically target both the gut and the brain when managing mental health conditions such as depression, anxiety, autism, and ADHD.
The connection between the brain and the gut is no longer thought of as unidirectional, top-down control (Stasi et al., 2012). Research actually points to a predominance in the other direction: 90% of the nerve fibers in the vagus nerve (the primary nerve connecting the CNS and the ENS) carry information from the gut to the brain (Nibber et al., 2013)! In addition, the 100 trillion microbes residing in the gut are also involved in neurotransmitter production and therefore influence our mental well-being (Nibber et al., 2013). As a naturopathic doctor, optimizing digestive health is an integral part of almost every treatment plan, with the added bonus of its downstream effects on improving mental health. As well, because of the close link between the gut and input from the nervous and endocrine systems, stress management is an important component in helping to address digestive issues.
Food sensitivities can sensitize nerves in the gut, which in turn can trigger changes in the brain (Nibber et al., 2013). These changes can occur so insidiously that it may be difficult for the patient to pinpoint the culprit. This happened in the case of a 43 year old female who presented to my office with chief concerns of weight gain, fatigue, and generalized aches and pains. She was not on any medication at the time, but had a history of depression. Although she had daily bowel movements, her stools were sometimes loose, and she experienced bloating, which she attributed to excessive hunger and overeating. A careful look through her diet diary and questioning revealed that her diet was high in wheat and glutinous grains, and that her chief concerns had become more pronounced after eating more gluten on a regular basis. Within 5 days of removing gluten from her diet, she found that her stools were more solid, she had more energy, and had increased mental clarity. We continued on a gluten-free diet for 3 weeks, along with botanical medicine to support liver detoxification, and nutraceutical adrenal support due to the long-term stress she was under (confirmed by a Koenisburg adrenal urine stress test). At her next follow-up, food cravings had much improved, and she had lost 12 pounds over the previous 5 weeks. The mental clarity which she had originally experienced persisted while she avoided gluten. Physical injuries which had previously lingered on were now healing faster. If occasionally she ingested gluten, she would experience loose stools, nausea, and headaches. This case exemplifies how certain foods can trigger mood and behavioural changes. While gluten is a common culprit, food sensitivities are highly individual and must be properly evaluated, either through careful elimination and re-introduction, or through blood testing where appropriate.
As well, it is important not to forget about the role of commensal bacteria in the gut in helping achieve better mental health. Studies in mice showed that supplementation with specific probiotic strains, Lactobacillus rhamnosus and Bifidobacterium longus, decreased symptoms of anxiety and depression in these mice, through a vagus nerve-dependent mechanism (Grenham et al., 2011). Studies in mice also show that some probiotics increase resistance to stress by decreasing the release of stress-induced corticosterone (Grenham et al., 2011). Although to date we lack large randomized controlled trials in humans, Messaoudi et al. did find that a specific probiotic combination alleviated psychological distress in otherwise healthy volunteers in a small double blind, placebo-controlled, randomized clinical trial (2011). This may explain in part why strain-specific probiotics can be used to alleviate symptoms of conditions with a strong psychogenic link, such as irritable bowel syndrome.
The link between the gut and the brain is complex and multifactorial. For patients with mood and psychological distress, it is often a relief to find out that what they ingest can impact their mental health, and that it’s not all “in their heads”. Obversely, those presenting with digestive disturbances are often surprised by the alertness and mental clarity they experience once the health of their digestive system is improved.
Our first and second brains are in constant communication, and symptoms such as anxiety, depression, mental fog, and digestive upset are red flags to alert us that something is out of balance. Will you listen?
Grenham, S., Clarke, G., Cryan, J.F., and Dinan, T.G. (2011). Brain-gut-microbiome communication in health and disease, Frontiers in Physiology, December 07; 2(94): 1-15.
Hadhazy, A. (2010). Think Twice: How the Gut’s “Second Brain” Influences Mood and Well-Being, Retrieved August 23, 2013, from the Scientific American website:http://www.scientificamerican.com/article.cfm?id=gut-second-brain.
Messaoudi, M., Lalonde, R., Violle, N., Javelot, H., Desor, D., Nejdi, A. et al. (2011). Assessment of psychotropic-like properties of a probiotic formulation (Lactobacillus helveticus R0052 and Bifidobacterium longum R0175) in rats and human subjects, Br J Nutr, Mar; 105(5): 755-64.
Nibber, T., O’Brien, C., McIntyre, C., Dumas, C.A., Chou, M, Al-Kawally, M. (2013). The Gut-Brain Connection, Advances in Orthomolecular Research, 4(3): 4-7.
Stasi, C., Rosselli, M., Bellini, M., Laffi, G., and Milani, S. (2012). Altered neuro-endocrine-immune pathways in the irritable bowel syndrome: the top-down and the bottom-up model,J Gastroenterol, Nov; 47(11): 1177-85.
Dr. Tamar Ferreira is a Naturopathic Doctor in Brampton, Ontario. Her areas of focus include digestive health, hormone balance, and skin conditions.