Dysmenorrhoea and menstrual complaints

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Chapter 18 Dysmenorrhoea and menstrual complaints

Jon Wardle, ND, MPH

AETIOLOGY AND CLASSIFICATION

Menstrual complaints are often broadly – and sometimes incorrectly – categorised under the broad moniter of premenstrual syndrome (PMS). PMS is defined as a recurrent set of physical and behavioural symptoms occurring cyclically 7–14 days before menstruation (the luteal phase) and are troublesome enough to interfere with some aspects of the female’s life.1 In common clinical usage this has also extended to symptoms (such as dysmenorrhoea) that occur during menstruation and cease by the end of the full flow of menses. Despite its high prevalence PMS remains poorly understood and often not prioritised in medical treatment.1 Multiple aetiologies have been proposed, most prominently those in Table 18.1. In reality a number of these may be responsible for underlying imbalances, even in the same patient. The numerous proposed aetiologies for PMS mean that more than 150 individual symptoms have been associated with the condition. The most common are listed in Table 18.2.1

Table 18.1 Proposed aetiologies of premenstrual syndrome1

CATEGORY EXAMPLE
Fluid and electrolyte balance
• Aldosterone excess
• High sodium:potassium ratio
• Rennin/angiotensin abnormalities

Hereditary factors
• Genetic risk
Hormonal factors
• Oestrogen deficiency
• Oestrogen excess
• High oestrogen:progesterone ratio
• Progesterone deficiency
• High prolactin
Inflammatory mediators
• Prostaglandin excess
• Prostaglandin deficiency
Psychological factors
• Poor coping skills
• Poor self-esteem
• Beliefs about menstrual cycle
Social factors
• Current and former marital and sexual relationships
• Stress
• Cultural and societal attitudes about PMS
• Poor social networks
Biochemical factors
• Various vitamin and mineral deficiencies
• Dopamine deficiency

Table 18.2 The most common symptoms of premenstrual syndrome

Abdominal bloating Depression Lethargy
Anxiety Dizziness Low self-esteem
Back pain Fatigue Mood swings
Breast tenderness Headache Nervousness
Change in appetite Insomnia Social isolation
Clumsiness Irritability Sugar cravings
Constipation Joint pain Water retention

Although diagnosis is difficult given the broad range of possible aetiologies and symptoms, premenstrual dysphoric disorder (PMDD), a more severe form of PMS, is a recent addition to the Diagnostic and Statistical Manual of Mental Disorders IV.2 To be diagnosed with PMDD a woman must have at least five of the following symptoms occurring cyclically at a level serious enough to interfere with normal daily activities:

1. feelings of sadness or hopelessness, possible suicidal thoughts
2. feelings of tension or anxiety
3. mood swings marked by periods of teariness
4. persistent irritability or anger
5. disinterest in daily activities and relationships
6. trouble concentrating
7. fatigue or low energy
8. food cravings or bingeing behaviour
9. sleep disturbances
10. feeling out of control
11. physical symptoms such as bloating, breast tenderness, headaches and joint or muscle pain.

Patients fulfilling the diagnositic criteria for PMDD also fulfil medical diagnostic criteria for PMS, but not necessarily vice versa. However, it may be viewed as disturbing that behavioural aspects form the focus of diagnosis in PMDD, when in clinical practice a vast array of hormonal and physiological interactions take place within a woman’s body around the time of menstruation, resulting in a variety of broader symptoms and forming a more complex basis of underlying aetiology.

Dysmenorrhoea

While PMS is often used as an all-encompassing moniter for menstrual complaints, menstrual symptoms do not occur only prior to menstruation. Dysmenorrhoea is painful menstruation and is the most common menstrual complaint, as well as having the most potential to substantially interfere with patients’ lives. In fact, dysmenorrhoea is the most frequent gynaecological problem in adolescent girls (the prevalence is 80 to 90%). Daily activities are frequently affected and it is the most common cause of regular absenteeism in young women.

Primary dysmenorrhoea classically presents as a cramping lower abdominal pain that usually begins during the day before menstruation. The pain gradually eases after the start of menstruation and is sometimes gone by the end of the first day of bleeding. Primary dysmenorrhoea occurs in a high percentage of young women only in ovulatory cycles and the pain is normally limited to the first 48 to 72 hours of menstruation.1

Secondary dysmenorrhoea may occur during other parts of the menstrual cycle and can be either relieved or worsened by menstruation. Pain from secondary dysmenorrhoea is often described as a dull and aching rather than being spasmodic or cramping in nature. It can occur before menstruation (up to 1 week) or get worse once menstruation starts.

Hormonal and biochemical influences

Endocrine studies have suggested that PMS is not the result of a simple excess or deficiency in certain hormone levels.3 Low progesterone,4 excessive oestrogen5 or normal levels of both6 have not been associated with increasing incidence of PMS. Though prolactin levels have been associated with several symptoms of PMS there has been little hard evidence to suggest that elevated prolactin levels are present in women with PMS.6,7 Similarly while aldosterone is thought to be at least partly responsible for the congestive symptoms of PMS there have been no reports of significant differences between women with and without PMS.5 It has been postulated that PMS is not associated with abnormal hormone levels, but rather an abnormal response to sex hormones8 which may be exacerbated during episodes of stress.9 High blood flow is also associated with an increased instance of dysmenorrhoea.10

It is thought that deviations from normal ovarian function—rather than hormone levels per se—are associated with changes to other body systems (such as neurotransmitters) seen in PMS.11 Serotonin is thought to be particularly affected by changes in hormone levels and responsible for many mood change symptoms associated with PMS.12

It has also been hypothesised that women with PMS may have lower levels of circulating endogenous opiates (or serotonin) or a more sudden withdrawal after the postovulation surge, leaving them more susceptible to depression and more sensitive to pain in the luteal phase.13–15 Prostaglandins are also associated with the PMS symptoms of breast pain, fluid retention, abdominal cramping, headaches, irritability and depression.16 The high levels of the leukotrienes that increase uterine muscle spasm (C4 and D4) in the menstrual blood of women with dysmenorrhoea also support the hypothesis that prostaglandins are an important part of the aetiology.17 Anti-inflammatory prostaglandins may also be associated with reducing the exaggerated effects of prolactin.18

Psychosocial factors can also influence the menstrual cycle. Emotional and physical stressors such as travel, illness, stress, weather changes and other environmental factors can influence the length of the menstrual cycle, ovulation and severity of PMS.19 One study found that 75% of women receiving care for PMS had another diagnosis that could account for their symptom complex—predominantly depression and other mood disorders.20

RISK FACTORS

Epidemiological data observe a strong relationship between smoking or exposure to tobacco products and a higher incidence of dysmenorrhoea.21–23 Obesity is also a risk factor for menstrual disturbances, with women who have a body mass index (BMI) over 30 incurring a threefold risk of developing them.24 Approximately three-quarters of women have a separate diagnosis—particularly mood disorders or other hormone-mediated diagnoses—that contribute significantly to their symptoms.25 High levels of caffeine may be associated with increased prevalence and severity of PMS symptoms,26,27 though this may be due to an additive relationship of sugar with caffeine.28 Many women medicate themselves with caffeine during PMS symptoms, which may exacerbate their symptoms.29

CONVENTIONAL TREATMENT

The basic aim of treatment of menstrual disorders in conventional treatment focuses on symptomatic relief and coping strategies in line with the hormonal dysfunction rather than reliance on medication. Conventional treatment of primary dysmenorrhoea with is usually associated with pain management (such as ibuprofen) or a combined oral contraceptive pill. Secondary dysmenorrhoea is more complex and may be associated with other conditions such as pelvic infection or endometriosis. Common symptomatic relief for dysmenorrhoea with analgesics such as paracetamol or ibuprofen or antiprostaglandin agents such as indomethacin or mefenamic acid may also be recommended. In cases of secondary dysmenorrhoea the conventional treatment is to identify and treat the cause.

Various pharmaceutical agents are used in conventional treatment, including diuretics (such as spironolactone—particularly with fluid retention), vitamins (such as B6), SSRI agents or danazol (particularly with severe mastalgia).30 Hormone therapy is also common, and consists of hormonal agents such as oral contraceptive pill (OCP), progestogens or implants. However, these have little evidence of efficacy in PMS.31 Progesterone treatment is increasingly popular, particularly amongst integrative medical practitioners; however, the evidence for effective treatment with progesterone alone is unclear.32

KEY TREATMENT PROTOCOLS

NATUROPATHIC TREATMENT AIMS

• Remove risk factors.
• Regulate HPO axis function and normalise hormones.
• Reduce inflammation and inflammatory mediators.
• Treat menstrual pain symptomatically.
• Address psychological factors (causations and clinical manifestations).

Although various diagnoses can often present in menstrual disorders, naturopathic treatment focuses not on treatment of particular disorders, but rather the restoration of a normal menstrual cycle. Other chapters in the reproductive section focus on various aspects of hormone normalisation, so this chapter focuses on specific symptoms associated with PMS, particularly dysmenorrhoea as it is often the most encountered symptom in clinical practice. A normal menstrual cycle should be free of the discomfort associated with pathological conditions such as PMS, PMDD or dysmenorrhoea. This eturn to normalcy can be sought through a number of mechanisms, most commonly hormonal regulation via the hypothalamic–pituitary–ovarian (HPO) axis.

HPO-axis regulation

As opposed to conditions specifically linked to certain hormone excesses such as endometriosis (oestrogen) and PCOS (androgen), treatment of broader menstrual disorders focuses on hormone normalisation, often through modulation of the HPO axis. In this sense naturopathic treatments are not necessarily associated with specific actions on hormones, but rather work to restore the appropriate function of the body’s own natural processes that regulate these hormones. For example, while Vitex agnus-castus was initially thought to work on increasing progesterone levels or decreasing prolactin, research is suggesting it has a role even further upstream on the HPO due to its dopaminergic action.

In addition to prescriptive naturopathic medicines, many of which are explored in more detail in other reproductive chapters, a number of different lifestyle factors, discussed below, can disrupt the functioning of the HPO axis.

Dietary factors

Dietary factors may also play a significant role. Women with PMS typically consume more dairy products, refined sugar and high sodium foods than women without PMS.33 Fish, eggs and fruit have been associated with less dysmenorrhoea while wine is associated with more.36 Women following a low-fat, vegetarian diet also had lower incidence

ABRAHAM’S CLASSIFICATIONS

In 1983 Dr Guy Abraham publicised a system for the classification of PMS into four distinct subgroups.33–35 These subtypes have since had a major influence on naturopathic practice. However, while they may be somewhat clinically useful in a broad sense they should be treated as guidelines only as they have not been confirmed by research and patients rarely fit neatly into one group. The subtypes are discussed below.

PMS-A (anxiety)

This is thought to be related to high levels of oestrogen and a deficiency of progesterone. Its symptom complex is irritability, anxiety and emotional lability.

PMS-C (carbohydrate craving)

This is thought to be caused by enhanced intracellular binding of insulin though its exact mechanism is unclear. The symptom complex of this category is increased appetite, carbohydrate craving, headache and heart palpitations.

PMS-D (depression)

This is thought to be due to low levels of oestrogen leading to excessive breakdown of neurotransmitters and could be due to symptoms related to enhanced androgen or progesterone production.

PMS-H (hyperhydration)

This is thought to be caused by elevations of aldosterone due to excessive oestrogen, sodium consumption, adrenal stress or magnesium deficiency. The symptom complex of this subtype is weight gain, breast tenderness and fullness, peripheral swelling and abdominal bloating.

of dysmenorrhoea.22,23,37 This was theorised to be due to increased sex-hormone binding globulin (which was measured in the study) and its effects on oestrogen or arachidonic acid. A diet high in oily fish and avoidance of foods with significant arachidonic acid content reduces the severity of dysmenorrhoea, possibly through improving the synthesis of anti-inflammatory prostaglandins and leukotrienes. Higher amounts of fibre have been associated with lower levels of menstrual pain.38 High intakes of total and saturated fats and low unrefined carbohydrate and fibre consumption were also associated with dysmenorrhoea.39

Regulating blood sugar levels may be important in modulating hormonal status. It has been observed that PMS symptoms are worse in women with abnormal glucose tolerance.40 The body appears more sensitive to insulin during the luteal phase; this has led some researchers to theorise that hypoglycaemia may account for some premenstrual symptoms. Consumption of foods high in sugar content—particularly chocolate—may also increase the severity of menstrual symptoms.28 Regulating eating patterns may therefore help to improve dysmenorrhoea—eating breakfast was associated with a lower incidence of dysmenorrhoea41 as was a history of calorie-restrictive dieting.42 This relationship was also observed irrespective of BMI.43

Other lifestyle factors

Increased or regular exercise is associated with lower incidence of dysmenorrhoea and most other premenstrual symptoms.44–49 This may be due in part to the apparent hormone normalisation role of exercise or increased physical activity,50 or its effects on stress reduction in women with dysmenorrhoea.51 More detailed information on the effects of stress on reproductive function can be found in Chapter 20 on polycystic ovarian syndrome and Chapter 31 on fertility, preconception care and pregnancy.

A study of 380 women found that those with higher levels of stress were twice as likely to experience dysmenorrhoea in their cycle.52 Relaxation therapy through various meditative or relaxation techniques has been demonstrated to improve premenstrual symptoms and dysmenorrhoea.53,54

PMS supplements

Herbal medicines

Vitex agnus-castus has had demonstrated effect in the treatment of a variety premenstrual symptoms.55–58 V. agnus-castus reduces prolactin through its action on dopamine receptors.57–62 However, other studies have suggested a dose-dependent effect, as lower doses (120 mg) were found to increase secretion while higher doses (204–480 mg) were found to decrease secretion.63 It may also have effects on progesterone levels; one study has shown it can normalise progesterone levels in women with hyperprolactinaemia within 3 months61 while another has suggested it can stimulate progesterone receptor expression.64 Recent research has suggested that V. agnus-castus may exert activity in the opiate system, and the activation of mood regulatory and analgesic pathways via this system may be at least partly responsible for its efficacy in menstrual disorders.65

Cimicifuga racemosa is thought to modulate oestrogen levels by reducing LH secretion.66,67 Although no clinical studies are available it has a strong tradition of use in dysmenorrhoea and menstrual disorders and has been approved by Commission E for use in these conditions.34,35,68

Tea from the leaves of Rosa gallica has also been demonstrated to mildly improve dysmenorrhoea and other menstrual symptoms in women.69 Psidii guajavae folium (guava) has been demonstrated to be effective in dysmenorrhoea.70 Matricaria recutita has been commonly used for treatment of dysmenorrhoea.71 Uterine tonic herbs may also be used in PMS treatment (see Chapter 31).

Hypericum perforatum may be useful in women displaying irritability or depression in PMS, and one small pilot trial has demonstrated a significant reduction in PMS symptom scores.72 Other nervine herbs such as Valeriana officinalis, Piper methysticum, Passiflora incarnata and Melissa officinalis have also been traditionally used in PMS for similar circumstances.34,35,68 Ginkgo biloba has also demonstrated improvement in psychosocial aspects of PMS, though it is most effective at reducing congestive symptoms such as breast pain, tenderness and fluid retention.73

Nutritional medicines

Calcium supplementation has been shown to reduce PMS symptoms.74,75 Women who had 1000–1200 mg calcium reported that their menstrual pain reduced by half.74 Magnesium has also been shown to reduce PMS mood and fluid retention symptoms.76,77 Although serum magnesium levels are often normal in women with PMS, they can have lower red blood cell magnesium levels than women without and levels are known to fluctuate throughout the cycle.78–80 Vitamin E can be useful for breast symptoms, tension, irritability and lack of co-ordination in PMS.81–83 Vitamin A also has a long history of use in PMS treatment.84 Zinc levels have also been demonstrated to be low in women with PMS.85

Symptomatic pain relief

Topical application of warmth

There may be an element of clinical truth in the traditional habit of curling up with a hot water bottle. Application of heat to the abdomen has also been demonstrated to be at least as effective as ibuprofen or paracetamol in clinical studies.86,87 Massage with liniments or warming salves (for example ginger) or moxibustion may also offer relief.

Herbal smooth muscle relaxants

Herbs with demonstrated ability to relax smooth muscle, such as Valeriana officinalis (though in animal studies only),88 Lavendula angustifolia,89 Matricaria recutita90 and Foeniculum vulgare91 may be used in the treatment of dysmenorrhoea, usually beginning a few days before menstruation and continuing until bleeding stops. Zingiber officinale has been shown to be equally effective as the NSAIDs ibuprofen and mefenamic acid in the symptomatic treatment of menstrual pain.92 This may be particularly useful in women who experience nausea in conjunction with menstrual pain. It can be taken as an infusion or several preparations—often sold for travel sickness or nausea—are available. F. vulgare was found to reduce the severity of dysmenorrhoea when taken (20 drops of liquid tincture five times per day) during the first 3 days of menses and is thought to be as effective as commonly used conventional analgesics.93

Viburnum opulus and V. prunifolium both have a strong tradition of use as uterine relaxants34,35,68 in addition to many early case reports,94,95 though they are yet to be clinically studied. While these are not symptomatic in the sense that they immediately resolve symptoms, they are effective only in treating the symptoms of dysmenorrhoea and do not address the underlying cause.

Endocrine interactions

In addition to high blood sugar or cortisol, low thyroid function may exacerbate PMS symptoms and low thyroid function has been found in women with PMS.96–98 The menstrual cycle appears to have an effect on thyroid function, with rT3 concentrations found to be higher in the luteal as opposed to follicular phase.97 Given the complex interactions that exist between hormonal systems this is not unusual. Thyroid treatment is expanded in Chapter 17 on thyroid abnormalities.

OTHER THERAPEUTIC CONSIDERATIONS

Although naturopathic philosophy dictates finding the underlying cause for dysmenorrhoea, there is little likelihood of patient compliance (and therefore ultimately clinical success) without addressing symptomatic complaints. This may necessitate either an integrated approach to treatment with conventional medications or a separate prescription for purely symptomatic naturopathic medications.

TRADITIONAL HERBAL REPRODUCTIVE MEDICINE34,35,68

Naturopathy has a rich history in treating disorders of the female reproductive system and it would be remiss from a historical and clinical context to ignore this component. Herbal medicine in particular has a long tradition. Some herbs, such as Vitex agnus-castus, Paeonia lactiflora and Cimicifuga racemosa, have been used as generalist reproductive herbs, and are thought to work predominantly as hormonal regulators rather than having specific activity (it is now thought that they act directly on HPO regulation).

Fluid retention

Diuretics such as Taraxacum officinale have traditionally been used for symptoms of fluid retention.

Oestrogen support

Some herbs have been traditionally considered ‘oestrogenic’ in nature, in that they support oestrogen function in the body, though they may not be intrinsically oestrogenic themselves. Some examples are Chamaelirium luteum and Dioscorea villosa.

Spasmolytic herbs

Spasmolytic herbs have been used traditionally for menstrual cramping. These include Angelica sinensis, Viburnum spp., Ligistium wallichii and Rubus idaeus. Achillea millefolium is specifically used as a spasmolytic that also reduces bleeding.

Antihaemorrhagic

Antihaemorrhagics include Achillea millefolium, Equisetum arvense, Alchemillia vulgaris, Lamium album, Panax notoginseng and uterine antihaemorrhagics such as Capsella bursa-pastoris and Trillium erectum.

Anodyne

Corydalis ambigua, Piscidia erythrina, Tanacetum parthenium and Anemone pulsatilla have been traditionally used for pain management in reproductive disorders.

Uterine tonics

Uterine tonics are herbs that have traditionally been used for their normalising effect on the uterus and assisting with normal uterine function. They include Rubus idaeus, Angelica sinensis, Chamaelirium luteum, Aletris farinose, Caulophyllum thalictroides and more recently Tribulus terrestris.

Emmenagogues

Emmenagogues—or uterine stimulants—are traditionally used when there is a desire to increase the strength of uterine contractions. They are traditionally prescribed to initiate menstruation caused by hormonal irregularities or when the period is slow or delayed. Due to their action they are also contraindicated in pregnancy. Examples are Ruta graveolens, Artemesia vulgaris, Salvia officinalis and Mentha pulegium. Emmenagogues have also been prescribed for certain conditions associated with heavy bleeding due to ‘poor uterine tone’, usually indicated by heavy flow, little pain and significant clotting. They are also used in combination with uterine tonics after miscarriage to adequately expel tissue and promote healing and regeneration.

Circulatory stimulants

Another concept often discussed in various humoral medicines (including traditional Chinese medicine, traditional naturopathy and Ayurvedic medicine) is the concept of warming herbs being used in reproductive conditions that are cold or stagnant in nature. They are used to promote circulation and blood flow and to remove obstruction. Examples are Zingiber officinale and Cinnamomum zeylanicum. Pain is often related to blood or Qi stagnation in traditional Chinese medicine and equivalent ancient naturopathic humoral tradition.

In practice naturopathy is a holistic modality, and also makes use of other various herbal action—nervines, adaptogens and so on—as deemed appropriate for the individual patient. Treatment very rarely makes use of reproductive herbs alone.

The patient should also be counselled on appropriate or sensible dressing to cope with breast tenderness or abdominal bloating (such as loose-fitting clothes around the abdomen or a firm-fitting bra to wear during episodes of PMS).

INTEGRATIVE MEDICAL CONSIDERATIONS

Oral contraceptive use

Vitamin B6 supplementation can restore biochemical values and treat PMS symptoms in women taking oral contraception.99 Hormone supplementation is also commonly used in conventional medicine to treat menstrual symptoms and may affect levels of vitamins A, B2, B3, B5, B12 and folate. OCP use may also reduce the action of Vitex agnus-castus.100

Acupressure

Acupressure has been demonstrated to be an effective treatment for dysmenorrhoea.101,102

Traditional Chinese medicine

Traditional Chinese herbal medicine was found to be more effective than acupuncture in the treatment of dysmenorrhoea103 and a variety of effective herbal treatments are available.104 As prescription is usually determined by a physical state diagnosis based on a classical Chinese understanding of the human body, a comprehensive knowledge of traditional Chinese medicine theory is required to appropriately prescribe many of these herbal formulations.105 Acupuncture has also been found to be moderately effective in the treatment of dysmenorrhoea. This was best seen in patients who committed to weekly treatments and was most effective when combined with herbal and dietary treatments.

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Figure 18.1 Naturopathic treatment decision tree—dysmenorrhoea and menstrual complaints

Chiropractic

A Cochrane review of spinal manipulation in dysmenorrhoea found spinal manipulation to be no better than sham manipulation, though did suggest it was more effective than no treatment.106

Qi gong

Chinese exercise therapy or Qi gong has also had documented encouraging success in alleviating various premenstrual symptoms.107,108

Homoeopathy

A small preliminary pilot study has demonstrated a positive effect of individualised homoeopathic treatment on premenstrual symptoms, with at least 30% improvement in symptoms observed in 90% of patients receiving homoeopathy versus 37.5% of those who were not.109

TENS

Transcutaneous electrical nerve stimulation (TENS) has been demonstrated as a non-invasive, clinically significant intervention for dysmenorrhoea.110 TENS may also reduce cortisol and prolactin levels through the opioid-modulating analgesia system.111

Aromatherapy

Topical application of a 2:1:1 mixture of the aromatherapy oils Lavandula officinalis, Salvia sclarea and Rosa centifolia was demonstrated to be effective in symptomatic treatment of dysmenorrhoea in one small study.112 Other aromatherapy treatments may also be suitable.

Massage

Regular massage may be a useful adjunct therapy in severe perimenstrual disorders. One small trial has demonstrated positive effects on pain and water retention in the longer term but only short-term benefit for mood and anxiety.113 Another small trial of abdominal massage using TCM meridian theory has also shown benefit in regard to perimenstrual symptoms such as pain and bloating.114

Case Study

A 24-year-old woman comes into the clinic presenting with severe menstrual cramping each cycle. The pain is described as ‘acute and stabbing’. Her periods have not become heavier but the pain is getting worse. They are relieved after the first few days. She also gets anxious and ‘moody’ before her cycle begins.

SUGGESTIVE SYMPTOMS

• Uterine cramping
• Behavioural or mood changes or swings
• Abdominal bloating
• Appetite changes
• Breast tenderness

Example treatment

The patient was given a herbal tablet of Vitex agnus-castus to help modulate HPO activity. A combination herbal tablet as in the ‘Herbal formula’ box was also given to provide symptomatic relief. Its rationale is anti-spasmodic, anti-inflammatory and analgesic. The patient was also prescribed 6000 mg of fish oil daily to provide anti-inflammatory action and address nutritional deficiencies.

Herbal formula (tablets)

Vitex agnus-castus taken once 1 tablet daily or once daily 1000 mg
Viburnum combination tablet combining:  
• Corydalis ambigua

600 mg
• Zingiber officinale

400 mg
• Viburnum opulus

400 mg

Taken 3–4 times daily 2 days before period until 2 days after

Nutritional prescription

Omega-3 fish oil 6000 mg daily

The patient was given dietary advice: she was told to initially avoid foods that were commonly associated with inflammatory mediators (wheat and bovine dairy); she was told to increase consumption of foods rich in anti-inflammatory fatty acids such as fish (tuna particularly), avocado and nuts; and was told to increase fibre in her diet, including the addition of legumes and whole grains. Her diet was amended to increase the variety of foods.

The patient had adhered to all prescriptive medicines but had found it difficult to completely remove dairy and wheat. However, her symptoms had still dramatically improved. She was told to continue the V. agnus-castus and try not to take the Viburnum combination for the next cycle, but instead to take a Z. officinale supplement for symptomatic relief. She was told to continue the dietary and lifestyle recommendations and was now free to use dairy and wheat; however, she was counselled on the importance of consuming these as part of a varied diet and taught to focus on wholegrain wheat products and fermented or cultured dairy products.

The patient returned periodically for health visits. After 6 months she was confident enough to cease the V. agnus-castus. Her menstrual cramping does not usually return but can flare up occasionally – during which time she takes the Z. officinale supplement symptomatically. The patient is now often aware of the situations causing these flare-ups and is able to alter diet and lifestyle accordingly.

Expected outcomes and follow-up protocols

Pain reduction in dysmenorrhoea is the most commonly sought treatment in PMS. Many of the other symptoms of PMS are related to the same underlying issue. A symptomatic treatment for menstrual cramping (such as the Viburnum mix) should be given in line with this request; however, eventual HPO modulation or menstrual cycle correction should remain the ultimate goal. Smooth muscle relaxants or uterine tonics alone should never constitute the entirety of treatment. Noticeable improvement should occur within the first cycle and continue throughout the cycles. After a few cycles of noticeably less pain the symptomatic treatments should be ceased and the prescription should focus on HPO modulation and its effectors only.

Table 18.3 Review of the major evidence

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KEY POINTS

• Menstrual problems are not associated with simple hormone excess or deficiency, but rather a complex interconnection of factors that interfere with the HPO axis.
• PMS symptoms are often treated successfully through amelioration of underlying causes with dietary and lifestyle modification—women were not designed to ‘malfunction’ once a month.
• Symptomatic treatment is very important. However, smooth muscle relaxants or analgesics should be considered only a temporary solution and treatment of the underlying factors should be prioritised.
• Treatment of primary dysmenorrhoea should see positive results within the first one or two cycles. Secondary dysmenorrhoea requires treatment of its causative aetiology and is often more complex (see Chapter 19 on endometriosis).

Further reading

Altman G., et al. Increased symptoms in female IBS patients with dysmenorrhea and PMS. Gastroenterol Nurs. 2006;29(1):4-11.

Girman A., et al. An integrative medicine approach to premenstrual syndrome. Am J Obstet Gynecol. 2003;188(5 Suppl):S56-S65.

Hudson T. Women’s encyclopedia of natural medicine. New York: McGraw-Hill, 2008.

Ozgoli G., et al. Comparison of effects of ginger, mefenamic acid, and ibuprofen on pain in women with primary dysmenorrhea. J Altern Complement Med. 2009;15:129-132.

Proctor M., et al. Diagnosis and management of dysmenorrhoea. BMJ. 2006;332(7550):1134-1138.

Trickey R. Women, hormones and the menstrual cycle: herbal and medical solutions from adolescence to menopause. Sydney: Allen & Unwin, 2003.

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