TABLE OF CONTENTS
1. Symptoms and Prevalence of PMS
2. Potential Hormone Fluctuations Seen in PMS
3. Underlying Contributors to PMS
- 3.1. Stress
- 3.2. Blood Sugar Regulation
- 3.3. Gut Health
5. Nutrition and Lifestyle Support for PMS‡
- 5.1. Diet
- 5.2. Exercise
- 5.3. Stress
7. Pure Encapsulations® Nutrient Solutions
SYMPTOMS AND PREVALENCE OF PMS
The menstrual cycle reflects a woman’s overall health status and has been considered her fifth vital
sign.1 For some women, their menstrual cycle is a dreaded time of the month, bringing with it a
cyclic pattern of pain and discomfort that impacts their daily life.
In fact, approximately 90% of cycling females report that they experience at least one mood related or physical
symptom in the luteal phase of their menstrual cycle.2
When a woman experiences one or more symptoms in the five days prior to the onset of her menses, this is known as
PMS, or premenstrual syndrome.3
Up to 30% of reproductive-age women experience PMS and report a number of emotional and physical
symptoms:3
POTENTIAL HORMONE FLUCTUATIONS SEEN IN PMS
While the cause of PMS is multifactoral, the fluctuation of estrogen and progesterone levels during the menstrual
cycle play a role. In some individuals, excess or depletion of these hormones can contribute to symptoms.
Since progesterone is required to balance estrogen’s activity, elevated estradiol should be viewed relative to
progesterone levels. The natural fluctuation of estrogen can contribute to PMS symptoms and can occur
when:4
- Progesterone is low
- Both estrogen and progesterone are in normal ranges, but estrogen is higher than progesterone
- Phase I detoxification metabolites are elevated
- Estrogen is elevated outside the luteal phase
While hormonal fluctuations can be a contributing factor to PMS symptoms, research suggests that in some women
PMS may be caused by a heightened sensitivity to the normal rise and fall of estrogen and progesterone during
the luteal phase of the menstrual cycle, impacting the serotonergic and GABAergic systems.2, 5
UNDERLYING CONTRIBUTORS TO PMS
Owing to the complex interactions between the hormones, body tissues, cells and the gut microbiome that
coordinate the menstrual cycle, a practitioner may be uncertain which system to address first in patients with
PMS. While there are many approaches, there are three underlying contributors and strategies that can help move
the needle in caring for patients with PMS: stress, blood sugar regulation and gut health.
STRESS
High stress is a contributing factor to PMS symptoms, as a bidirectional relationship exists between the
hypothalamic-pituitary-gonadal (HPG) axis and hypothalamic-pituitary-adrenal (HPA) axis.
The paraventricular nucleus in the brain, which contains several neurons that regulate the HPG axis and
expression of gonadotropin-releasing hormone (GnRH), also contains neurons which regulate the HPA axis and
expression of corticotropin-releasing-factor (CRF).6 This area of the brain is also ubiquitous with
GABAergic and serotonergic neurons. The neural overlap of these regulating systems is one contributing factor to
their interactions, as both the HPG and HPA axes are vulnerable to hormones produced by the other.6,
7
In animal studies, various stress models and exogenous cortisol have been shown to suppress GnRH and luteinizing
hormone (LH) secretion.6 Corticotropin-Releasing Factor, released in response to stress, can increase aromatase
production in the brain and promote increased estrogen levels.8 Conversely, progesterone and its
metabolite, allopregnanolone, are able to modulate HPA axis function due to their interaction with GABAergic
neurons.6 Estradiol can positively and negatively impact HPA axis reactivity, hypothesized to be due
to the distribution of both Erα and ERβ receptors in the parts of the brain responsible for HPA axis
regulation.6, 7
Credit: Schweizer-Schubert S et al. Front Med (Lausanne). 2021 Jan 18;7:479646. doi:
10.3389/fmed.2020.479646. PMID: 33585496; PMCID: PMC7873927.
A controlled study conducted by Hou et al. attempted to determine basal HPA axis activity in women with PMS by
measuring salivary cortisol levels mid-follicular and mid-luteal phase. Compared to healthy controls, women with
PMS exhibited an attenuated cortisol awakening response, a potential indicator for HPA axis dysregulation when
combined with markers of HPA axis function and other factors.9, 10 These findings align with previous
experiments in women with premenstrual symptoms that found hypoactivity of the HPA axis in response to
stress.11, 12
BLOOD SUGAR REGULATION
Fluctuations with glucose metabolism may occur during the luteal phase in some women with PMS. Decreased tissue
sensitivity to insulin and a worsening of glycemic control in the luteal phase have been reported in women with
higher estradiol or progesterone levels, compared to the follicular phase.13, 14, 15, 16
Higher circulating levels of insulin can impact production of Sex Hormone Binding Globulin, or SHBG, and can
elevate estrogen production by increasing aromatase.17 A transport protein, SHBG binds to sex
hormones like estrogen and testosterone and regulates their bioavailability. When SHBG production is decreased,
more hormones are available in their active form to reach target tissues and cause symptoms. In addition, low
plasma SHBG can be an early indicator of insulin resistance.18
GUT HEALTH
In a survey examining premenstrual emotional and GI symptoms in 156 healthy women, over 70% of the women surveyed
listed one or more GI symptom in the five days prior to their menses, including pain, bloating and altered bowel
habits—typically in the form of occasional diarrhea.19
Fluctuations in prostaglandins and hormones throughout the menstrual cycle can impact numerous functions of the
gut, including motility, pain sensitivity and immune function, contributing to the common GI symptoms seen in
PMS.
Sex hormones in the gut also communicate with neurotransmitters involved in signaling along the gut-brain axis,
often leading to co-existing emotional and GI symptoms in women with PMS.18
The gut microbiome plays a critical role in the regulation of estrogen metabolism. Microbes in the gut encode
enzymes responsible for the biotransformation of estrogen and its elimination through the stool. Altered gut
microbiota can increase activity of β- glucuronidase enzymes that engage in deconjugation of estrogens and
restore their biological activity.20 Reactivated estrogens can then be reabsorbed into the
bloodstream where they are free to reach target tissues.
The relationship between the gut microbiota and estrogen is bidirectional, however; estrogen levels can influence
the composition and diversity of the gut microbiota, and reduced diversity of gut microbiota can affect estrogen
levels.19
ASSESSMENTS FOR PMS
Assessments for PMS should explore hormone levels during the luteal phase, gut health, blood sugar regulation,
HPA axis function, nutrient status and neurotransmitter function.
NUTRITION AND LIFESTYLE SUPPORT FOR PMS
Nutrition and lifestyle play crucial roles in managing PMS because they can influence hormonal balance, energy,
mood and overall well-being. Making positive changes in diet, stress management and physical activity may help
alleviate the severity of PMS symptoms for many individuals.
DIET
Diet plays a significant role in moving the needle for individuals with PMS.
Cross-sectional studies have identified that most women experience food cravings during their luteal cycle,
particularly for high-calorie, high-sugar, high-fat, and high-salt foods, and that severity of PMS symptoms is
positively correlated with intake of these types of foods.21, 22
Due to the influence of insulin, stress, and the gut microbiome on menstrual health, a phytonutrient-rich,
preferably organic, whole foods diet should be emphasized for women with PMS. The Mediterranean diet, comprised
of a high intake of fruits and vegetables, whole grains, legumes, nuts and olive oil can be beneficial for women
with PMS.
A 2022 cross-sectional study examined dietary patterns and PMS symptoms in 262 women ages 20-49. A lower
prevalence of PMS was found in women who adhered to a Mediterranean diet, and a higher prevalence of PMS was
found in women who had low adherence to a Mediterranean diet and higher intake of snacks and
breads.23 The consumption of sugar has also been significantly associated with an increase in nervous
tension symptoms in PMS.24
Encouraging fermented foods and adequate fiber can support motility, stool consistency, and balance in the
patient’s gut microbiome, as well as support the excretion of excess estrogen.
EXERCISE
Regular physical activity can have a positive effect on both emotional and physical PMS symptoms. Exercise
increases endorphins, helps regulate cortisol and ovarian hormone levels, and can reduce prostaglandin
levels.2, 25 A randomized, controlled trial examined the effects of 20 minutes of aerobic exercise
three times a week on PMS symptoms in 65 women and found that the intervention group experienced a significant
reduction in headaches, nausea, bowel changes and appetite changes after 8 weeks, compared to
controls.26 In a systematic review of 17 randomized and nonrandomized studies that included over
8,800 women, regular exercise was shown to reduce nervous tension, anger, general pain and occasional
constipation symptoms.27 Forms of exercise included strength training, yoga, Pilates and aerobic
exercise. While many studies have demonstrated significant improvement in PMS symptoms after 8 weeks, some women
may experience a benefit after just one menstrual cycle, especially if they are new to exercising.28
The American College of Obstetricians and Gynecologists endorses routine exercise to help manage physical and
affective premenstrual symptoms and highlights yoga as a beneficial option to reduce overall PMS
symptoms.2
STRESS
In a 2022 meta-analysis of 77 studies that examined factors associated with prevalence and severity of
menstrual-related symptoms, stress was determined to be significantly associated with prevalence of
PMS.24 Stress in a patient raises cortisol, impacts glycemic control and insulin sensitivity and
increases prostaglandins.24, 29
There are numerous recommendations the practitioner can make for a patient needing to manage stress, including
relaxation techniques, aerobic exercise, meditation and yoga. Interestingly, Cognitive Behavioral Therapy (CBT)
has been the most studied psychosocial practice for addressing PMS symptoms and is endorsed by the American
College of Obstetrics and Gynecologists as a recommended option. CBT has been shown to provide statistically
significant reductions in symptom scores compared to controls in nervous tension, low mood, negative behavioral
changes, symptom intensity and interference with daily life.21
NUTRIENT SUPPORT
Along with dietary and lifestyle changes, nutrients that support blood sugar balance, emotional well-being, GI
health and healthy prostaglandin and eicosanoid levels can help improve patient outcomes.30, 31, 32, 33,
34
Vitamin B6 has a positive effect on premenstrual mood and may enhance the effect of
magnesium.30‡
Healthy intracellular magnesium levels have been associated with maintaining positive mood
during the luteal phase.31 Magnesium also plays an important role in nervous system sensitivity,
providing support for muscle comfort, breast comfort and emotional well-being associated with the menstrual
cycle.32
Calcium promotes healthy smooth muscle function and menstrual comfort.33
Vitamin D supports healthy smooth muscle function and menstrual comfort, due to its ability to
promote healthy calcium levels, cyclic hormone function and neurotransmitter activity.34‡
Omega-3 Fatty Acids moderate prostaglandin and leukotriene production, supporting healthy
connective tissue.35 Research suggests that omega-3 fatty acids may also play a role in maintaining
gastrointestinal cell health by supporting healthy eicosanoid production.‡
Eleuthero is a highly recognized adaptogen thatpromotes physiological balance and
moderatesoccasional stress. In part, it helps moderate the production of adrenocorticotrophic hormone (ACTH) and
corticosterone activity.36‡
Rhodiola supports energy and mental function.37
Chaste tree/Vitex has been traditionally used and clinically studied for the beneficial support
it provides to the hypothalamus and pituitary.38‡
l-Theanine may be helpful for premenstrual support and promote alpha wave production in the
brain, an indication of relaxation.39, 40‡
PURE ENCAPSULATIONS® NUTRIENT SOLUTIONS
Pure Encapsulations provides products designed to complement your supplement plans for patients who need overall
support. We offer nutrients individually and in combination to meet all your patient’s unique needs when it
comes to supporting healthy stress response, moderating food cravings, encouraging healthy mood, and promoting
healthy GI and cyclic hormone function. Pure Encapsulations can help you move the needle toward your patient’s
overall menstrual comfort.‡
PMS Essentials
supports the health and activity of the adrenal glands and promotes physiological balance and moderates
occasional emotional stress. It also promotes optimal energy reserves and healthy immune function.‡
O.N.E.TM
Multivitamin supports overall wellness with vitamins, minerals and
antioxidants.‡
O.N.E.TM Omega
promotes joint and connective tissue integrity and cardiovascular health.‡
Magnesium
(glycinate) encourages healthy cognitive and neuromuscular function and helps with calcium
metabolism and bone mineralization.‡
l-Theanine promotes
relaxation without causing drowsiness and offers premenstrual support, including supporting a healthy
mood.‡
CarbCrave Complex
moderates carbohydrate intake and helps lessen appetite by supporting neurotransmitter function.‡
Phyto-ADR supports adrenal
gland health and promotes physiological balance and moderates occasional emotional stress. Supports optimal
energy reserves and promotes immune function. May help to moderate mild fatigue under stressful
conditions.‡
Best-Rest Formula
provides support for occasional sleeplessness, encourages the onset of sleep as well as healthy sleep quality
and supports natural relaxation of the nervous system.‡
PureGG 25B is our highly
researched Lactobacillus rhamnosus GG supplement that supports immune, G.I. and overall health across all ages.
Our PureGG 25B is a human origin strain, selected for its resistance to gastric acidity, adhesion properties and
ability to support healthy gut microflora.‡
Pure Encapsulations only uses premium ingredients backed by verifiable science, so you can be confident you are
recommending products with quality, purity, and potency.
SUMMARY
There is moderate evidence that supports the use of pharmaceuticals like SSRIs for the treatment of PMS symptoms.
The rate of relapse is high in patients that stop SSRIs and most patients need to maintain use of them until
menopause.2
Certain medications, such as SSRIs, may be appropriate and should be used under the recommendation of your
healthcare professional for managing chronic, long-term, and/or more serious symptoms related to PMS. Dietary
supplements are not intended to replace the use of such medications.
However, if looking for a way to potentially manage common PMS symptoms, the supplement recommendations mentioned
may be appropriate, along with other dietary and lifestyle changes.
The practitioner who can provide support and lifestyle recommendations that address the root causes of patient
specific PMS symptoms can provide care that makes a difference for female patients, while also improving their
overall health.
RESOURCES
PMS
Protocol:‡ This protocol offers focused interventions to support menstrual
comfort in patients with premenstrual syndrome.‡
Nutrient
Solutions to Complement the 5R Protocol: This blog post covers nutrient solutions that
supplement the 5R Protocol and addresses factors related to leaky gut and other GI concerns.
Drug-Nutrient Interactions
Checker: Offers scientifically supported, clinically relevant information that’s easy to
understand with product suggestions based on verifiable science.
You can also explore Pure Encapsulations® to
find On-Demand Learning,
Clinical
Protocols, and other resources developed with our medical and scientific advisors.
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