Premenstrual Syndrome

The following essay on pre menstrual syndrome is provided to give you an understanding of this condition. Massage therapists see cases of pre menstrual syndrome in their offices every day. It is important to make sure that everyone, whatever their sex or gender, have a good understanding of pre menstrual syndrome so they can detect if they or a loved one are having any signs or symptoms. Women, transmen, and intersex individuals with ovaries and uterus can all experience PMS, though most research has focussed on cis-women. PMS affects every aspect of life; work productivity, relationships, and self-image.

Definition:

Also known as Premenstrual Dysphoric Disorder or Premenstrual Tension Syndrome. Pre-Menstrual Syndrome (PMS) is a disorder mainly affecting menstruating individuals during the last week of the leuteal phase of the menstrual cycle. It is a very common disorder, affecting 60% of North American Women between the ages of 20 and 50. It is of importance to note the difference between the normal physiological changes in a leuteal phase and the severity of true PMS. PMS used to be dismissed as a general diagnosis for discomfort affecting women, but the increasing awareness and education in the medical field and society in general has changed this attitude into one of professionalism and compassion for people with this disorder. The fact that a high percent of menstruating individuals suffer from PMS has contributed to fear and negative attitudes towards the menstruating years. It is important to recognise the debilitating effects of PMS, as it can affect not only general well being, but also productivity and quality of life- and in many cases this may be easily avoided.

Etimology:

There are many factors, both externally and internally, that play a role in the onset of this disorder: age, nutritional habits, hormone imbalances, and overall reproductive/sexual health can all be elements to consider. The risk for PMS increases in individuals over thirty years of age, with most of the severest symptoms, occurring in those aged thirty to forty.

Nutritional habits seem to be one of the most modifiable causes, and most of the research has been done in this area of PMS. Diets of concern include a daily consumption of dairy products, caffeine, animal flesh and/or fats, refined sugar/flour and over-processed foods in general. Caffeine found in coffee, black or green tea, colas and chocolate has been seen to contribute to breast tenderness. Thirty percent of women with breast tenderness as a symptom of PMS reported relief upon eliminating caffeine. Caffeine also increases anxiety, and depletes the body’s stores of Vitamin B – thus interfering with the liver and metabolism. Animal flesh/fats have been shown to lead to increased levels of the hormone prostaglandin F2, which in excess causes uterine contractions and cramping. Consuming animal products also causes the excessive estrogen/low progesterone levels that are often found with PMS.  It is also interesting to note here that women who choose a vegetarian and/or vegan diet have been shown to excrete 2 -3 times the amount of estrogens in their feces than non-vegetarians. In addition, studies have shown that these women have 50% less plasma levels of unconjugated estrogens than women who eat meat. Some further common nutritional characteristics include low levels of Vit. C, E, Selenium, Magnesium, (which, along with Vit B is needed by the liver to metabolize estrogens) and Essential Fatty Acids.

Other factors that increase the risk of PMS include emotional stresses in daily life and/or poor stress management techniques, alcohol use and/or abuse, unstable body weight, obesity, being in a relationship, having children, past pregnancies terminated or complicated by toxemia, low exercise levels, having grown up in an alcoholic family, complications during or recent discontinuation of oral contraceptives, and tubal ligations, especially if done by unipolar electrocautery (which was mostly done in the 70’s and is no longer used).

In patients with PMS, a relatively high blood level of estrogens is found; this may be either from increased intake or decreased elimination of these substances. This imbalance is also associated with Vit B deficiencies. As well, a relatively low blood level of progesterone is secondary to the high levels of estrogens. Excessive body weight increases the chances of hyperestrogenism and PMS. The progression of symptoms may be a downward spiral, for example; when blood-sugar levels dip, the result often is headaches, dizziness, mood swings, cravings and heart palpitations. One of the food cravings may be for salt, and the salt intake may lead to further increasing of the water retention and weight gain, which for some may lead to emotional distress and guilt over eating habits. The perfect balance of estrogen and progesterone is important in regular and symptom free menstrual cycles. When balanced, estrogen has been shown to stimulate production of endorphins, and progesterone has been shown to have an opiate-like effect, when these two hormones drop suddenly before menstruation time, the body has a reaction close to drug withdrawal. Also found in blood tests of PMS sufferers are higher than normal levels of prolactin. This particular hormone imbalance may be the cause of breast tenderness and cysts associated with PMS.

Clinical Manifestations:

The signs and symptoms of PMS are very numerous and affect every system in the body. More common symptoms can include: persistent irritability, anxiety, mood swings, severe cravings, hypersomnia, joint pain/swelling, muscle pain, tearfulness, aggression, suicidal thoughts, violent thoughts or behaviors, heart palpitations, food binges, rage, lethargy, nausea, emotional ability, alcohol intolerance, sexual desire changes, insomnia, depression, headache, backache, migraine, acne, water retention, decreased interest in activities, social withdrawal, less frequent urination, decreased immune system, breast soreness/swelling, constipation, cramps, extreme fatigue, and dizziness.

Patients often report over ten symptoms. 

Treatment:

Some aspects of western medicine are still searching for the direct cause and direct cure of PMS, and this may not be found unless a holistic approach to treatment is implemented.

Since this syndrome is influenced by many factors, it has presented a particular challenge for some practitioners of modern medicine. The effects of the emotions, mind, diet, relationships, childhood traumas, exercise and heredity must not be overlooked when treating PMS. Common medical treatments include non-steroidal anti-inflammatory drugs (NSAIDS), Fluexotine (Prozac), Indocin, Motrin, Ponstel, oral contraceptives, diuretics, and anti-anxiety medication, but these often mask the problem and create even more dysfunction in the body. Recent studies have shown that estrogens are directly related to seratonin levels, and as estrogen naturally decreases just prior to ovulation, so does seratonin, this may be why PMS sufferers respond well to anti-depressant medications (SSRI’s). It is of interest to note that many anti-depressant drugs actually increase other PMS symptoms, reduce sexual interest, and can make it difficult to achieve orgasm. The pharmaceutical Parlodel (bromocryptine mesylate) is used to inhibit prolactin production and has been shown to decrease breast pain, depression and bloating, but often has negative side effects.

One area of interest is the use of progesterone as a treatment. When high levels of estrogen are unopposed by progesterone, the effect tends to be irritation of the nervous system. Progesterone can come form a natural or a synthetic source. Natural sources include soy, yam or animal derived. It is available as an injection, sublingual drops, suppository, or a skin cream/oil. The use of natural progesterone has been praised mostly for its effect on premenstrual migraines. These headaches often start with the gradual change in estrogen and progesterone levels that tend to occur in the years preceding menopause. It is important to note that synthetic progesterone (progestins) has very different qualities. This synthetic hormone has been shown to have a list of negative side effects including bloating; headache, weight gain, and can actually increase PMS.

More holistic treatments include elimination of meat, dairy, caffeine, refined sugar/flour and other health-reducing foods, which often has a positive response in as little time as one cycle. Alternatives are gaining popularity as awareness increases, such as the fact that goat’s cheese is more easily emulsified in the body or that carob is high in calcium. These healthy choices are reducing the rates of PMS dramatically in our society. Other dietary changes are incorporating Essential Fatty Acids into the daily meals, and increasing levels of Vit C, E, magnesium, selenium, zinc, and B vitamins. The intake of evening primrose oil in the leuteal phase of the menstrual cycle has been shown to decrease the emotional aspects of PMS dramatically (I can personally vouch for this!) Adding miso to the diet is an excellent part of treatment, as it has all eight of the essential amino acids, as well as between 12 and 20% protein, compared to cows milk at 3%. Miso also contains acidophilus and other digestive enzymes and is a useful source of Vit B12, often recommended in a vegetarian diet. The complete elimination of alcoholic beverages is one aspect of treatment, as alcohol is directly toxic to liver cells and therefore disrupts the liver’s ability to metabolize hormones, possibly causing a higher than normal estrogen level. Alcohol also depletes the body of Vit. B and minerals. Stress reduction and stress management techniques play a major role in treatments, including yoga, meditation, counseling, and relaxation massage, visualization and breathing techniques. Herbal Medicine is gaining much recognition in the treatment of many disorders, and has had substantial results in the treatment of PMS. Nervine herbs such as valerian and chamomile help to tone the nervous system and restore balance. Red raspberry leaf and vitex are well known for their balancing effect on women’s’ hormones, as well as burdock, black cohosh and blessed thistle. Ginger, cramp bark and pennyroyal are useful in cases of dysmennoria accompanying PMS as they gently relax and tone the reproductive system as a whole.

Prognosis:

The outcomes of treating PMS are extremely variable, due to the wide range of treatments available, and the combinations of them used. Finding relief of one’s symptoms depends somewhat on the amount of energy and conscious thought put into the treatment. For example it may take extra time and a strong will to have a big change in diet and counseling may have to be part of the program when dealing with addictions. Most sufferers find some form of improvement within one cycle from many of the lifestyle changes listed prior, and this continues to improve over time. Since most individuals choose to try smaller scale and less harmful treatments first, it may take longer to see results if the therapy chosen is ineffective or the dosages need to be increased.

There are so many new treatments gaining medical approval and public awareness that the majority of outcomes from PMS treatments are very positive, and these lifestyle changes may in fact be temporary. For example if the key problem is the liver’s inability to metabolize the hormones due to a build up of toxins, the initial treatment may include fasting or a liver cleanse program with a following of an only slightly modified diet in the long term. Although many different areas of treatment may need to be explored to see which type suits that particular patient, most individuals find relief from some form(s) of treatment and this disorder is easily managed throughout their life. Very rarely is this disorder life threatening, or untreatable.

Implications for the Massage Therapist:

It is important for therapists to be aware of any PMS symptoms during the client’s menstrual cycles, whether they have been clinically diagnosed or not. It is an important part of case history taking to find out what part of the cycle the client is at for each treatment. The massage therapy treatment may have to be modified depending on what signs and symptoms are presenting that particular day. PMS affects the body systematically; therefore, it is important to take into account what these changes are having on the person as a whole. From a physiological level, the treatments may include release of any trigger points found within Quadratus Lumborum, Iliopsoas, or Erecter Spinae as well as any other muscles or muscle groups that may refer pain to the areas most commonly affected by menstrual cramps. The therapist can play an important part in breaking the pain-spasm cycle by increasing the parasympathetic nervous system. Massage therapy techniques that increase circulation can help flush the system of excessive build up of hormones and substances associated with prolonged stress responses happening in the body.

Relaxation massage has an important effect of decreasing the stress level. Therapists have the opportunity to teach clients stress reduction/management techniques such as diaphragmatic breathing, visualization etc. These techniques can be used as part of a treatment with the client as well as taught as home care enabling the client to have some control over situations that may arise.

References:

  • Premenstrual Syndrome Self Help Book – Susan Lark M.D.
  • Our Bodies Our Selves – Boston Womens’ Health Collective
  • Womens’ Bodies, Womens’ Wisdom – Christiane Northup M.D.
  • Womens’ Herbs, Womens’ Health – Christopher Hobbs, Kathi Keville
  • Taber’s Cyclopedic Medical Dictionary – F.A. Davis
  • Holistic Herbal – David Hoffman

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