Prescriptions
Tackle PMS with exercise, diet, calcium
By Landis Lum
If you are a woman who suffers from PMS, what's causing this misery, and what's the best course of treatment? These are common questions patients ask their doctors.
The typical patient I see with PMS, or premenstrual syndrome, is a young woman suffering irritability, breast tenderness, fatigue and increased appetite during the week or so before her period; these symptoms usually diminish as soon as her period starts.
Other symptoms may include bloating, alcohol intolerance, edema, clumsiness, depression, mood swings, food cravings (especially for salt and sugar), inability to concentrate, hostility, and even violence toward self and others.
Women with severe PMS for many years often have marital discord, difficulty maintaining friendships, difficulties with their children, and withdrawal from social activities.
If you have these problems, you're certainly not unique. Up to 40 percent of women of childbearing age have PMS, and about 5 percent of women suffer from a more disabling form of PMS called premenstrual dysphoric disorder, also known as PMDD, in which more severe mood symptoms are present.
Ovulation is necessary for the occurrence of PMS — if ovulation ceases (either naturally, or from certain drugs), then PMS disappears.
Are menstrual cycle hormones to blame? Those hormones do not differ between women with and without PMS; therefore, measuring hormone levels is useless.
The causes of PMS and PMDD are uncertain, but are likely due to a person's exaggerated or hypersensitive responses to the normal hormonal changes of the menstrual cycle. Serotonin (a natural chemical in the brain that promotes a sense of well being) is reduced in many women with PMS, explaining why serotonin-increasing drugs like fluoxetine (Prozac or Sarafem) improve their PMS or PMDD condition. (Yes, Prozac IS safe, despite what you may have heard or read in the media).
Because no test can confirm whether you have PMS or PMDD, your doctor can best make the diagnosis on the basis of a patient-completed daily symptom diary kept for at least two months. Fewer than 50 percent of women complaining of PMS are found to have it — at least by technical medical standards — when a diary is examined and other diseases are ruled out by a doctor.
Many patients ask about herbal or alternative therapies, including magnesium, vitamin E, evening primrose oil, natural progesterone (both vaginal suppositories and oral treatments) and vitamin B6.
Unfortunately, these herbal remedies evidently aren't reliably effective.
The Department of Complementary Medicine at the University of Exeter in England did a systematic review of randomized controlled trials of such therapies for PMS and reported its findings in the July 2001 issue of the American Journal of Obstetrics & Gynecology. Twenty-seven trials were included, investigating herbal medicine (seven trials), homeopathy (one), dietary supplements (13), relaxation (one), massage (one), reflexology (one), chiropractic (one) and biofeedback (two). They found that despite some positive findings, the evidence was not compelling for any of these therapies, with most trials suffering from various methodological problems. Their conclusion was that no complementary/alternative therapy could currently be recommended as a treatment for PMS.
However, my first intervention for PMS patients is indeed a complementary approach. My patients start brisk walking 20 to 30 minutes, four to five days a week. They undertake stress reduction and relaxation, avoid fasting, reduce caffeine, and reduce sugar and other "junk" foods while increasing intake of foods with complex carbohydrates.
I now recommend calcium supplements to all my patients, since a large, well-conducted, randomized trial recently showed that 1000 milligrams of elemental calcium a day improves mood and other PMS symptoms. This will also reduce osteoporosis, hip fractures, and "hunchback." I advise using Tums, which is calcium carbonate, but my wife Judy, who is a pharmacist, feels that calcium citrate (for instance, Citracal) is better absorbed and tolerated. But read the label and be sure you are taking between 100 and 130 percent of the daily calcium requirement each day (1000 to 1300 milligrams); this would be 1 tablet twice a day for Citracal.
If, by three months, those treatments don't provide relief, I then add a serotonin-increasing drug, such as fluoxetine, sertraline, citalopram or paroxetine, starting on either day 15 of the cycle or on the first day of symptoms, and stopping on the first day of menses. If needed, I either increase the patient's daily dose or prescribe the drug to be taken every day of the month. With the above, most of my patients show a gratifying improvement in distressing mood symptoms and social functioning.
Dr. Landis Lum is a family practice physician with Kaiser Permanente, and an associate clinical professor of family and community medicine at the University of Hawai'i's John A. Burns School of Medicine.
Hawai'i experts in traditional medicine, naturopathic medicine, diet and exercise take turns writing the Prescriptions column. Send your questions to: Prescriptions, 'Ohana Section, The Honolulu Advertiser, P.O. Box 3110, Honolulu, HI 96802; e-mail ohana@honoluluadvertiser.com; fax 535-8170. This column is not intended to provide medical advice; you should consult your doctor.
