By Dr. Nicole Sundene
PMS symptoms can be debilitating to not just women, but also to their husbands. PMS and hormone imbalance can sadly destroy marriages when not properly addressed and treated as it almost happened to my patient Jenny and her husband.
Googling for PMS symptoms, doctors and treatments are what triggered Jenny’s husband to drive her from California to Scottsdale for Hormone Testing. This is when he kindly brought to my attention that “Dr. Sundene is the #1 BEST PMS Doctor in all of California and Arizona” which is why he now calls me the “PMS Queen of the Southwest” and thanks me for saving their marriage. He began to notice a monthly cyclical pattern to their fighting, and after failed marriage counseling for a year, he began to lose hope until he started to research more about PMS symptoms.
While it is hilarious to me to find out I am #1 for PMS on his Google list…. it also makes sense since I am a Naturopathic Hormone Doctor. I know very well from my 8 years of working in regular Family Medicine how many of the conventional medications for PMS we will discuss today truly fail women. Medications to mask PMS symptoms can only get you so far with hormone imbalance which is why we need to treat hormone imbalance at the root cause. Otherwise many women with PMS end up on antidepressants, anti-anxiety medications, and birth control pills while still not feeling quite right. Or even worse their doctor tells them that PMS is normal and to just learn to live with it.
Patients with PMS need a solid Naturopathic approach to balance their hormones and prevent PMS which can take at least 3 months or “3 cycles” as the eggs releasing imbalanced hormones that are being made today have not yet undergone treatment with a Naturopathic approach with herbs and nutrition and therefore will continue to release imbalanced hormones until we address the impaired egg quality with nutrition and impaired liver detox pathways from genetic mutations such as COMT and MTHFR causing estrogen dominance. This is why Naturopathic Medicine is by far superior to conventional medicines and also why PMS symptoms tend to worsen with age. I often refer to Perimenopause as “Permanent PMS” to my patients in their 40’s while they nod their heads and agree, which is why intervening sooner than later with PMS can save a woman’s mental health.
As much as I love to joke around about PMS it is truly no laughing matter as it affects around 90% of menstruating women and is the most common condition impacting a woman's menstrual cycle. Studies report that PMS affected around 47.8% of women worldwide. PMS is a set of medical symptoms, including physical, psychological, and behavioral symptoms that occur before the beginning of each menstrual cycle in women typically days 21-25 of the menstrual cycle. These symptoms often last for a few days to 2 weeks typically between days 14-28 .
Severity of PMS
Did you know that 20% of women reported severe PMS symptoms that disrupted their daily life activities? 1 in 5 women are experiencing very disruptive symptoms to their physical and mental health. In comparison, the rest of the women showed mild to moderate symptoms. Epidemiological studies reported that the prevalence rate of PMS among university students is 80-90%. 
PMS is characterized by the following symptoms that appear during the second half or luteal phase of the menstrual cycle. The severity of symptoms ranges from mild to moderate, disrupting the daily life activities and relationships with family, partner, coworkers and friends. The consumption of alcohol aggravates or increases the risk of developing PMS symptoms. [1, 2, 3]
It is important to note that when PMS symptoms get severe and cause mental illnesses like depression and anxiety, it is called premenstrual dysphoric disorder (PMDD).
Diagnostic criteria for PMS
Diagnosis of PMS involves assessment of symptoms and patient history. The PMS diagnostic criteria are based on the presence of at least one physical (Somatic) and emotional (Affective) signs during the 05 days before a period in each of the three previous menstruations. [3, 7]
Different treatment interventions, including both pharmacological agents and non-pharmacological approaches, help the symptoms of PMS. However, hormonal medications are commonly prescribed in the treatment of PMS symptoms. Other medications include painkillers, anti-anxiety agents, antidepressants, and diuretics.
Oral contraceptives such as progestin drospirenone and estrogen can reduce PMS symptoms. Studies reported that these synthetic hormonal medications can decrease PMS symptoms, improve daily life activities, social communication, and help poor mood in women with PMS. Although some women experience worsening of their PMS and mood swings and cannot tolerate hormonal contraceptives. The possible side effects include breast tenderness, increased risk of blood clotting, gastrointestinal symptoms, and breakthrough bleeding. [2, 4]
Plus, hormonal contraceptives are contraindicated in case of pregnancy or women who want to conceive. Always consult with your physician first because there are limited research studies about the best and most effective hormonal contraceptive agents for PMS symptoms. [2, 4]
Antidepressants such as Selective serotonin reuptake inhibitors (SSRIs) can be useful for treating depression and anxiety associated with PMS. These are the first-line treatment options that increase the serotonin concentration in the brain and help women with psychological and behavioral symptoms. [2, 4]
SSRIs include Sertraline (Zoloft), paroxetine (Paxil), fluoxetine (Prozac), citalopram (Celexa), and escitalopram (Lexapro).
It is recommended to take SSRIs for at least three months to become effective during the second half of the cycle. Most treatments for PMS will require long term dedication. The side effects of SSRIs include nausea, weight gain, dry mouth, sleep disturbances, and low libido. [2, 4]
NSAID medications such as aspirin and ibuprofen can provide anti-inflammatory and analgesic effects. This class of drugs can relieve inflammation and pain associated with PMS. They help with headaches, body aches, muscle aches, backaches, period pain, and other physical symptoms of PMS. The side effects associated with NSAIDs include gastrointestinal distress, ulcers and drowsiness. [2, 4]
Diuretics can help with edema swelling and swollen breasts during PMS. Diuretics whether natural or prescription work to increase water release from the body and help edema. The side effects associated with diuretic drugs include nausea and headaches. [2, 4]
Gonadotropin-releasing hormone agonists:
Gonadotropin-releasing hormone (GnRH) analogs are rarely prescribed for the management of severe PMS symptoms. They interfere with hormone production in the ovaries. Side effects with GnRH agonists include hot flashes, insomnia, and depressed mood. These agents are not recommended for more than six months and are contraindicated in women who want to become pregnant. It is important to mention that there are minimal studies about their clinical effectiveness. [2, 4]
Progesterone can be beneficial during PMS when used correctly and can help balance the “Estrogen Dominance” occurring when estrogen is too high and progesterone is too low during PMS. Research studies however have shown no significant effect of progesterone on PMS symptoms compared to placebo. Plus, they can impair regular periods when not used cyclically as a withdrawal from hormones . Progesterone gel in Germany is approved to use for premenstrual breast tenderness. [2, 4]
Herbal and Dietary supplements
In addition to the medication, certain herbs and dietary supplements also help PMS symptoms. Naturopathic Doctors use nutrients like magnesium, pyridoxine (vitamin B6), calcium, turmeric, chaste tree extracts, evening primrose oil, St. John's wort, peppermint, angelica root, tangerine leaf, and Ginkgo biloba to ease their patient’s PMS symptoms. However, minimal data currently suggest the use of these herbs and nutrients in the management of PMS symptoms. While natural medicines for PMS do not have significant research their side effects are generally minimal and well tolerated to help women manage their symptoms. [2, 4] Many natural remedies and counseling can also be beneficial for women struggling with PMS. There is no solid research evidence about the use of cognitive-behavioral therapy (CBT), homeopathic medicines like Pulsatilla or Sepia, acupuncture, and reflexology massages to manage PMS symptoms. [2, 4]
Research suggests certain lifestyle modifications such as intake of high fluid, regular exercise, and meditation, the addition of nutrients, taking enough sleep, and avoiding high sugar, salts, caffeine, and alcohol may help PMS symptoms. Keeping a period tracker app to plan for expected mood swings and shift in energy can also help women minimize their symptoms and target their natural remedies for PMS to the appropriate time in their menstrual cycle when PMS symptoms will be expected to be at their worst. 
If you would like my help with your PMS simply pop over to my SCHEDULE page to treat yourself to a Naturopathic visit! Remember that the medicine I provide to women is in the form of nutritional changes, taking herbs and supplements in capsules, tinctures, or teas. So if that type of thing does not work for you please do not sign up to work with me as I will not be able to help you. Otherwise, if you are open to using Naturopathy and herbal medicine I would be happy to help!
Dr. Nicole Sundene, NMD
Dr. Sundene is a Naturopathic Doctor in Scottsdale, Arizona, and is considered a Female Hormone Expert in Women's Health and Bioidentical Hormones. She specializes in Holistic Women's Health for Menopause, Thyroid, Hashimotos, PMS, Perimenopause, Autoimmune, Postpartum, Chronic Fatigue, Depression, Anxiety, Food Allergies, Digestion, Dermatology , Acne, Psoriasis, Eczema and Adrenal Hormonal Conditions. In 1999 she began working for a Hormone Doctor prior to starting Naturopathic Medical School. With over 22 years of experience in both Prescription and Natural women's health and hormones she presents to women the best integrated health solutions for their Chronic Disease. She has been an Herbalist for over 27 years and enjoys teaching women how to use herbs to balance their hormones, nutrition and optimize their health. Dr. Sundene relies on blood testing for her hormone metrics. The hormone testing is covered per the patient's insurance plan and conducted at certain points in the woman's menstrual cycle. To learn more about Hormone Testing for Women Visit: Bioidentical Hormones. Follow Dr. Sundene on Instagram, Twitter and Facebook for more tips on Women's Health, Female Hormones and Naturopathy!