Who does it affect?
About 3-5% of women have symptoms so severe that it affects their work, education, relationships and/or daily activities. This is equivalent to 500,000 women in the UK alone. The average age of onset of PMS is 26 and it generally gets worse with age, with the most severe form affecting more women in their forties. As women get older they spend more time in the premenstrual phase as the cycle gets shorter and shorter towards menopause, giving rise to more frequent symptoms.
Premenstrual dysphoric disorder
Premenstrual dysphoric disorder (PMDD) is a diagnosis used by psychiatrists and other mental health workers to describe a specific set of particularly pronounced mood symptoms, appearing the week before, and going away a few days after, a period starts. Sometimes it is difficult to differentiate between a true depression and PMS. A telling difference is when your symptoms are only partially relieved when the period starts. In which case, it is worth exploring the possibility of an underlying psychiatric or physical health problem with your doctor or health care professional, as many conditions may give rise to similar symptoms. However, the good news is, once you have ruled out any other underlying condition, and you know that PMS is your problem, you can put an end to these unwanted symptoms after just a few months of following my optimum nutrition principles.
Elaine H is a case in point. She had suffered from PMS for as long as she could remember. Her moods were so bad in the week before her periods that her children would flee and her husband would cower. Here’s what she told me: “My PMS starts a week before a period. For the first two days I can handle it, my stomach starts churning, I get worse and worse, won’t listen to anyone, I go nuts, get breast tenderness, and have heavy painful periods.” Two months later here’s what she said: “I haven’t had any PMT – should be really bad right now. None of my outbursts. I’ve stuck to the diet completely. My energy has gone through the roof. I just feel like a completely different person. I can’t believe it’s happened so quickly. My husband can’t believe the change. No breast tenderness. My middle daughter said “what have you been doing to your skin. You look so much younger?” I’m really enjoying the diet. I’m trying new foods and the taste is great.”
What Causes PMS?
What is known is that PMS does not occur before the onset of the first period, during pregnancy or after natural or surgical menopause. Although the precise cause remains elusive, ovulation appears to be an important factor, with evidence suggesting that the symptoms are generally a result of changes in brain chemistry triggered by fluctuations in ovarian hormones. Both oestrogenOestrogen is one of the main female sex hormones…. and progesteroneProgesterone is one of the main female sex hormones…. levels generally fall sharply before a period and this sudden change is thought to trigger PMS.
Two major brain chemicals (neurotransmitters) seem to be affected by this change – serotoninSerotonin is a hormone found naturally in the brain and digestive tract. It is often referred to as the ‘happy hormone’ as it influences mood…. and gamma-aminobutyric acid (GABA). Serotonin – sometimes called the ‘happy hormone’ has been shown to help control appetite and carbohydrateCarbohydrates are the primary source of energy for the body as they can be broken down into glucose (sugar) more readily than either protein or… cravings. Oestrogen helps to improve mood by keeping up the levels of serotonin. Antidepressants like Prozac and Seroxat are thought to work by helping to maintain levels of serotonin, although there are more natural ways to achieve the same thing (see below).
Similarly a derivative of progesterone enhances the production of GABA, which is a calming neurotransmitterA neurotransmitter is a chemical messenger that carries signals between body cells. They are various types of neurotransmitters which play a major role in everyday… that switches off adrenalin, helping to reduce anxiety and irritability. So falling levels of oestrogen and progesterone before a period could plausibly trigger PMS symptoms. Peri-menopausal and post-natal depression seem to bear this theory out, as in both cases there is a major decrease in both hormones.
DopamineDopamine is a neurotransmitter (chemical messenger) found within the brain. It has a variety of influences on brain function including playing a role in regulating… is another neurotransmitter involved, as you will see later. Having a well-balanced diet is the best way to provide the nutrients needed for all three of these neurotransmitters to work effectively. The proteinProteins are large molecules consisting of chains of amino acids. Proteins are essential nutrients for the human body – they are a building block of… that you eat is made up of amino acidsAmino acids are commonly known as the building blocks of protein. There are 20 standard amino acids from which almost all proteins are made. Nine…, which are vital for many processes in your body, including making hormones, enzymes, and neurotransmitters. There are 22 altogether, eight of which are ‘essential’ which means they cannot be made in the body and therefore must come from the diet.
Tryptophan is one of these essential amino acids and is the raw material from which your body makes serotonin. However, it is the least abundant essential amino acid in food. Meat, beef, game, poultry, eggs and almonds are among the best sources. Dairy products, grains and chocolate also provide good amounts. Although chocolate is a stimulant and the sugar it provides makes it doubly attractive if you are having a blood sugar dip, it would be best not to rely on chocolate for your source of tryptophan.
Tryptophan is also carried into the brain by insulinInsulin is a hormone made by the pancreas. It is responsible for making the body’s cells absorb glucose (sugar) from the blood…. so it is possible that carbohydrate cravings serve the purpose of increasing seorotonin production when needed. Therefore it is possible that low levels of serotonin explain sugar, carbohydrate and chocolate cravings before a period, so make sure your diet contains good sources. Many vitamins and minerals are needed to convert tryptophan to serotonin. Vitamin B6 in its active form – pyridoxal-5-phosphate (P5P) – is perhaps the most well known vitamin required for this conversion. However, the B vitamins niacin (B3), biotinWhat it does: Particularly important in childhood. Helps your body use essential fats, assisting in promoting healthy skin, hair and nerves. Deficiency Signs: Dry skin,… and folate, plus vitamin CWhat it does: Strengthens immune system – fights infections. Makes collagen, keeping bones, skin and joints firm and strong. Antioxidant, detoxifying pollutants and protecting against…, as well as the minerals zincWhat it does: Component of over 200 enzymes in the body, essential for growth, important for healing, controls hormones, aids ability to cope with stress… and ironWhat it does: As a component of red blood cells, iron transports oxygen and carbon dioxide to and from cells. Also vital for energy production…., are also needed. Interestingly, women taking the contraceptive pill are often deficient in B6. This vitamin plays a vital role in controlling mood and depression and was first prescribed in the 1970s to treat women on the pill suffering from depression. It is also needed for clearing oestrogens from the liver.
If oestrogens are not cleared efficiently, symptoms relating to oestrogen excess will be observed. According to the late Dr John Lee, ‘A surplus of oestrogen or a deficiency of progesterone during the two weeks before a period allows an abnormal month-long exposure to oestrogen dominance, setting the stage for the symptoms of oestrogens side effects.’ Too much oestrogen also increases copper levels; high copper can deplete the body of zinc, and both high copper and low zinc are associated with depression.
A low thyroid function may also simulate the symptoms of PMS, and since oestrogen competes with the thyroid hormone thyroxine at hormone receptor sites, oestrogen overload can lead to symptoms of an underactive thyroid. Your doctor or nutritional therapist can recommend and interpret a thyroid function test for you. Vitamin B3 (niacin) is also essential for balancing hormones and helping to prevent PMS. It is needed for energy production and sugar balance in the body.
If your blood sugar levels are unstable, you are more likely to be tired, irritable, depressed and have hot flushes. Only a small amount of dietary tryptophan is converted to serotonin as the majority of tryptophan is used to make vitamin B3. Vitamin B3 is considered an essential nutrient, i.e. it must be eaten in the diet. If your diet is deficient in vitamin B3 then your body has to make it from tryptophan. Vitamin B6 needs zinc to convert into the most active form of B6 (called P5P), which is vital for converting tryptophan to B3. Metabolites of oestrogen have been shown to impair the activity of enzymes converting tryptophan to vitamin B3. Pellagra, a condition caused by vitamin B3 deficiency, occurs much more frequently in women, although overt vitamin deficiencies like pellagra are rare in the Western world. However, mild deficiency of B3 is quite common. Abnormal use of tryptophan converting to B3 has been reported in women using the oral contraceptive pill (OCP). The OCP has been shown to deplete many nutrients including vitamin B6, folate and magnesiumWhat it does: Strengthens bones and teeth, promotes healthy muscles by helping them to relax, also important for PMS, important for heart muscles and nervous…. Insomnia, anxiety and impulsive behaviour are associated with low serotonin levels and all three symptoms are associated with PMS. The body uses serotonin with the aid of magnesium to make a major hormone called melatonin which helps regulate sleep (and is also a very powerful antioxidantAntioxidants are substances that protect cells within the body from damage caused by free radicals. They help to strengthen the body’s ability to fight infection…). Magnesium, known as ‘nature’s tranquiliser’, is a valuable mineral for treating PMS, and magnesium levels are linked with poor appetite, nausea, tiredness, mood swings and muscle cramps.
If you suffer from PMS it is likely you will have lower levels of magnesium than women without symptoms.  As magnesium works together with vitamin B6, we suggest taking magnesium and a B-vitamin complex containing both niacin and the P5P form of vitamin B6. Essential fats, which also improve serotonin status, may also play a role. The most beneficial fatThere are many different types of fats; polyunsaturated, monounsaturated, hydrogenated, saturated and trans fat. The body requires good fats (polyunsaturated and monounsaturated) in order to… for PMS is called GLAGamma Linolenic Acid (GLA) is an essential fatty acid within the omega-6 family. It is found primarily in plant based oils such as evening primrose…, high in evening primrose oil and borage oil. Since we need both omega 3 and omega 6 fats, and more people are omega 3 than 6 deficient, a good starting point is to supplement, on a daily basis, an omega 3 & 6 supplement ideally containing ten times more omega 3, from fish oil, than omega 6, from borage oil.
For example, if you took two capsules providing 750mg of fish oil (giving you about 650mg of active omega 3) plus 250mg of borage oil (giving you about 50mg of GLA) this is a good insurance policy. However, most studies show best effect from supplementing the equivalent of up to 300mg of GLA a day.  That’s the equivalent of six 500mg evening primrose oil capsules, however you can get concentrated GLA capsules using borage oil, containing 150mg or 300mg in one capsule. If a basic change in diet, plus daily omega 3 and 6 combination supplement doesn’t sort out your PMS try taking 150mg or 300mg of GLA in the week before your period.
So, now you know why thousands of women get relief from PMS by supplementing:
High dose B vitamin complexes containing B3 (50mg), B6 (50mg), B12 (10mcg), folic acidWhat it does: Critical during pregnancy for the development of a baby’s brain and nerves. Also essential for brain and nerve function. Needed for utilising… (200mcg) and biotin (50mcg)
Extra vitamin C (1 to 2 grams a day)
Magnesium (300mg a day)
Omega 3 and especially omega 6 essential fats (up to 300mg of GLA)
Supplementation with 5HTP
Tryptophan is converted to the amino acid 5-hydroxytryptophan (5-HTP) and then into serotonin. Many women find that supplementing 5-HTP relieves symptoms. Vitamin B6, biotin and the mineral zinc are still required to convert 5-HTP to serotonin. Supplementing 5-HTP is thought to spare dietary tryptophan for converting to vitamin B3, as described above. It’s best to choose a 5-HTP supplement that also contains these B vitamins, starting with 100mg, up to 300mg a day. 5-HTP is much better absorbed away from a protein-rich meal, ideally with a carbohydrate snack such as a piece of fruit or an oatcake. 5-HTP is not recommended if you are on an anti-depressant drug because many of these block the breakdown of serorotonin, while 5-HTP helps you make more. The combination could theoretically result in serotonin overload. Ensuring adequate dietary tryptophan, and the vitamins and minerals needed for it to function in the body, is very important.
Supplementation with 5HTP does not displace the importance of a balanced diet but could help in the short-term as an aid while you tune up your diet. In the long-term you should be able to be PMS free without relying on 5HTP. Interestingly, animal studies have shown that artificially reducing serotonin levels leads to weight gain and an insatiable appetite. 
Dieting and Stress
Dieting and stress lower the level of tryptophan in the blood and when the level of tryptophan falls in the blood it makes you hungry, especially for carbohydrates.  Weight gain and carbohydrate cravings are common symptoms of PMS.
Supporting Levels of GABA Naturally
GABA is the major relaxing neurotransmitter that works throughout our central nervous system, helping to keep it calm. Benzodiazepine drugs, like Valium, activate GABA neurons and receptor sites in the brain helping to induce a sedative, sleep-promoting, anti-anxiety effect in the body. A new class of ‘non-benzodiazepine’ drugs, also act on GABA. They can be addictive and are therefore only recommended for short-term use. As with serotonin, good quality protein is necessary in the diet to make GABA. The amino acids glutamine and glutamic acid both help make GABA and also work interdependently with GABA and have been described as the Three Musketeers – ‘one for all and all for one’. Vitamin B6 is important for regulating the production of GABA in the brain.
The non-essential amino acid taurine is similar to GABA and also acts as a powerful calming neurotransmitter. Animal produce is the major source of taurine and vegetarian and vegan diets can be short of this amino acid. Two forms of GABA also act as calming neurotransmitters and alcohol has been shown to increase their levels, which may help explain why some people use alcohol as an antidote to stress. One of these two compounds, gamma-hydroxybutyric acid (GHBA), helps to promote sleep.
The function of GABA is also enhanced by a derivative of progesterone called allopregnenelone, which acts like a sedative, decreasing anxiety and irritability. In America you can buy GABA supplements over the counter. 500 to 1,000mg has a relaxing effect. In Europe look for formulas that contain glutamine, taurine, magnesium, and the relaxing herbs passion flower and hops for a natural relaxant effect.
A fundamental principle for managing PMS for most women is to eat meals and snacks providing both protein and carbohydrate.
• Don’t be afraid of carbs. One of the most important dietary factors for balancing hormones is to keep your blood sugar level even. Eat plenty of complex, unrefined carbohydrates such as wholegrains (oats, brown rice, wholegrain bread and pasta, millet), beans (lentils, soya beans, kidney beans etc) and plenty of vegetables. However, do cut out all refined carbohydrates such as white bread, white pasta and rice, cakes, biscuits and sweets and any foods containing added sugar (check labels as this will be more foods than you think – even bread, for example, often has sugar added to it).
• Get the right 5 a day. While eating plenty of fruit and vegetables has many benefits, vegetables such as broccoli and cauliflower are especially beneficial for PMS sufferers as they contain a substance called di-indoly-methane (DIM). DIM has been shown to mop up excess oestrogen and therefore relieve the associated problems such as weight gain, PMS, acne and menopausal symptoms.
• Out with the bad, in with the good. Cut back on ‘bad’ saturated and hydrogenated fats (found in meat, dairy products and processed foods such as cakes, biscuits and junk food) as these have no nutritional value. Replace these fats with the essential fats found in oily fish, nuts, seeds and vegetable oils. These good fats are especially important for menstruating women as they help to prevent inflammation and reduce abnormal blood clotting. Cutting out saturated fats should also help to reduce headaches, menstrual cramps and endometriosis discomfort. In fact it has been shown that diets high in saturated fats increase oestrogen production and prevent the absorption of the beneficial essential fats. 
• Bulk up. Not only does fibreFibre is an important part of a balanced diet. There are two type of fibre; soluble and insoluble. Insoluble fibre helps your bowel to pass… help with digestion and reduce cholesterol levels, but it also plays a key role in balancing female hormones. Fibre found in vegetables, fruit and wholegrains can absorb excess oestrogen in the gut and prevent it from re-entering the blood. Oat fibre of whole oats or rough oat cakes is particularly good.
• Cut the caffeine Caffeine not only removes vital minerals and vitamins from your body due to its diureticA diuretic is a substance that increases the amount of urine produced and therefore makes you urinate more frequently…. effect, but it’s linked to PMS, in particular breast pain and tenderness. Caffeine in tea, coffee, chocolate, soft drinks and headache tablets is a stimulant, which means it will also affect blood sugar levels and lead to rapid peaks and troughs in energy levels. We would recommend cutting out all caffeine and replacing with alternatives such as herbal and fruit teas and coffee substitutes such as Teecino, Caro or Barley Cup.
•…And the alcohol. While it has been all-too-easily accepted that red wine is ‘good for the heart’, research has actually shown that these effects are only evident in women post-menopause. The liver is one of the key organs for controlling and balancing hormones as this is where excess hormones can be removed. If the liver is over-taxed by a poor diet and alcohol, this elimination will not occur.
Fight symptoms with Phytoestrogens
Phytoestrogens are oestrogen-like, plant-derived substances which are found in high amounts in soya products and various vegetables such as peas and beans. However, despite being similar to oestrogens, they can actually reduce the problem of oestrogen dominance. This is because they lock onto and block the body’s oestrogen receptors, so protecting against the negative effects of too much oestrogen. Research has found that soya supplementation can help with many premenstrual symptoms including headache, breast tenderness and cramps. 
Asian women, who typically eat a lot of soya products, have fewer symptoms of the menopause, suggesting a beneficial effect on hormones. Remember to bear in mind though that the majority of soya eaten by Asian women is the fermented kind which is safer and has greater health benefits. The herb red clover also contains several phytoestrogens which may help balance oestrogen dominance. My favourite hormonal health supplements contain phytoestrogens in the form of isoflavonesIsoflavones are naturally occurring compounds – many act as phyto-oestrogens. An example of an isoflavone is Soya Isoflavones…..
Herbal and supplemental help
As well as following a well-balanced diet with the addition of some valuable vitamins and minerals, there are a number of herbs which we recommend to help with hormonal imbalances.
• Black cohosh, originally used by the native North American Indians, may help to counteract excess oestrogen. It may also act on serotonin receptors and raise levels of the ‘happy’ neurotransmitter serotonin. This makes it a useful supplement for treating PMS-related depression.
• Agnus Castus/Chasteberry is a herb which has been shown to increase progesterone, whilst decreasing excess oestrogen levels. In women suffering with PMS, taking Agnus Castus (20mg daily) can reduce symptoms by 42.5%. 
• Another herb I often recommend is Dong Quai (Angelica Sinensis), which is one of the most commonly prescribed herbs in Chinese medicine for female problems. It promotes normal hormonal balance and helps sufferers of menstrual cramps as it has muscle-relaxing qualities.
• If you suffer from water retention, I recommend the natural diuretic Dandelion as it not only helps with removal of fluid, but also supports the liver and can help in the removal of excess hormones. In terms of supplements the most important are vitamin B3, B6, zinc, magnesium and a combination of fish oil omega 3 fats with borage oil for omega 6 fats. If these don’t work, try adding 100mg of 5-HTP.
I cannot stress enough the importance of following a low GL diet as the basis for addressing PMS and other hormone-related problems. Follow a varied, well-balanced diet including plenty of wholefoods, fruits and vegetables (in particular cruciferous vegetables), swap saturated fats for essential fats and cut out all stimulants such as caffeine, alcohol and sugar.
In terms of supplements the most important are vitamin B3, B6, folic acid, B12, zinc, magnesium and a combination of fish oil omega 3 fats with borage oil for omega 6 fats. Good supplements for rebalancing hormones also include isoflavones (phytoestrogens) plus the compound in broccoli, called I3C (indole-3- carbonol) which helps mop up excess oestrogens. This is activated by stomach acid, so a good formula would include some betaine hydrochloride. If these don’t work, try adding 100mg of 5-HTP.
If you are suffering from menstrual cramps, make sure you are getting 300mg of supplemental magnesium, plus the herb Agnus Castus or Dong Quai. For bloating, dandelion can help, either in a tea or in capsule form. If all this doesn’t help, a nutritional therapist can help you to address PMS symptoms more specifically than a trial and error approach. It is very difficult to determine an individual’s exact hormonal imbalance without a simple saliva test. If you are found to be oestrogen dominant, follow all the recommendations in this article for reducing oestrogen levels, including increasing your intake of fibre, ensuring a good intake of phytosterols from beans and B vitamins, eating organically grown produce, limiting exposure to xenoestrogens and reducing consumption of high-fat meat and dairy produce. Also, focus on losing weight since having too many fat cells produces more oestrogens. Most women obtain freedom from PMS within a few cycles.
1. G. Abraham and M. Lubran, ‘Serum and red cell magnesium levels in patients with premenstrual tension’, American Journal of Clinical Nutrition, 1981 Nov.;34(11):2364-6.
2. P. O’Brien, H. Massil. Premenstrual syndrome: clinical studies on essential fatty acidsEssential Fatty Acids (EFAs) are fats that must be taken in through the diet as they cannot be made by the body. Both omega-3 and…. In: Horrobin D, ed. Omega-6 essential fatty acids. Pathophysiology and roles in clinical medicine. New York: Wiley-Liss, 1990:523-45.
3. J. Wurtman, ‘The involvement of brain serotonin in excessive carbohydrate snacking by obese carbohydrate cravers’, Journal of the American Dietetic Association, 1984 Sept.;84(9):1004-7.
4. J. Wurtman, ‘Depression and weight gain: the serotonin connection’, Journal of Affective Disorders, 1993 Oct.;29(2-3):183-92; R. Wurtman and J. Wurtman, ‘Carbohydrate craving, obesity and brain serotonin’, Appetite, 1986;7 Suppl:99-103; R. Wurtman and J. Wurtman, ‘Brain serotonin, carbohydrate-craving, obesity and depression’, Obesity Research, 1995 Nov.;3 Suppl 4:477S-80S.
5. M. Glenville, The Nutritional Health Handbook for Women, Piatkus (2001).
6. M. Bryant et al., ‘Effect of consumption of soy isoflavones on behavioural, somatic and affective symptoms in women with premenstrual syndrome’, British Journal of Nutrition, 2005 May;93(5):731-9.
7. D. Berger et al., ‘Efficacy of Vitex agnus castus L. extract Ze 440 in patients with pre-menstrual syndrome (PMS)’, Archives of Gynecology and Obstetrics, 2000 Nov.;264(3):150-3.
Join the Conversation on our Facebook Page