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PMS (Premenstrual Syndrome) 

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PMSWhat Is PMS (Premenstrual Syndrome)?

[dropcap]P[/dropcap]remenstrual syndrome is a menstrual disorder that occurs regularly during the last week of the luteal phase of the menstrual cycle and starts to subside a few days before menstruation begins and is absent the week following menstruation. It is characterized by distressing mental, emotional, and physical features.

Symptoms must occur most months in the year previous to diagnosis. Currently, the American Psychiatric Association terms this disorder “premenstrual dysphoric disorder” (PMDD).

What Is Premenstrual Syndrome In Celiac Disease and/or Gluten Sensitivity?

  • Relationship between premenstrual syndrome and celiac disease. Premenstrual syndrome is an atypical symptom of celiac disease and may be an uncommon presenting feature of untreated celiac disease.
  • Relationship between premenstrual syndrome and malabsorption. PMS is the effect of multiple nutritional deficiencies caused by malabsorption in celiac disease, including, calcium, vitamin D, magnesium, EPA (omega-3 fatty acid), and tryptophan amino acid.

How Prevalent Is  Premenstrual Syndrome In Celiac Disease and/or Gluten Sensitivity?

Premenstrual syndrome has increased frequency in celiac disease.

What Are The Symptoms Of  Premenstrual Syndrome?

Premenstrual syndrome is marked by five or more of the following mental/emotional symptoms:

  • A greatly depressed mood, such as feeling sad, hopeless, or self-deprecating.
  • Possible suicidal thoughts.
  • Anxiety (feeling tense or on edge).
  • Emotional lability interspersed with tearfulness.
  • Persistent irritability, anger and increased interpersonal conflicts largely caused by aggression.1,2
  • Decreased interest in usual activities.
  • Difficulty concentrating.
  • Fatigue or lack of energy.
  • A subjective feeling of being overwhelmed.
  • Food cravings.

Physical symptoms include:

  • Sensation of bloating.
  • Weight gain.
  • Breast tenderness or swelling.
  • Body edema (tight rings, shoes, clothes).
  • Joint or muscle pain.

How Does Premenstrual Syndrome Develop In Celiac Disease and/or Gluten Sensitivity?

  • Premenstrual syndrome results from nutritional deficiencies caused by malabsorption in celiac disease which include calcium, magnesium, vitamin D, EPA (an omega-3 fatty acid)3, vitamin B6, and the amino acid tryptophan.
  • Omega-3 fatty acid deficiency explains some features of PMS. After 90 days from starting the treatment with omega-3 fatty acid, the average severity of depression, anxiety, lack of concentration, nervousness and the duration of depression, nervousness, anxiety, lack of concentration, bloating, headache and breast tenderness were all lower in the case group.4
  • Magnesium deficiency, as one of the components of the pathogenesis of premenstrual disorders, is a reason of the different forms of clinical presentation, structural and functional disorders of nervous system and development of psychopathological constituent of premenstrual disorders in clinics.5,6
  • Calcium and vitamin D deficiencies explain some features of PMS. Ovarian hormones influence calcium, magnesium and vitamin D metabolism. Estrogen, produced by the ovaries, regulates calcium metabolism, intestinal calcium absorption and parathyroid gene expression and secretion, triggering fluctuations across the menstrual cycle. Alterations in calcium homeostasis (hypocalcemia and hypercalcemia) have long been associated with many affective disturbances. PMS shares many features of depression, anxiety and the dysphoric states. The similarity between the symptoms of PMS and hypocalcemia is remarkable. Clinical trials in women with PMS have found that calcium supplementation effectively alleviates the majority of mood and bodily symptoms. Evidence to date indicates that women with luteal phase symptoms have an underlying calcium dysregulation with a secondary hyperparathyroidism and vitamin D deficiency. This strongly suggests that PMS represents the clinical manifestation of a calcium deficiency state that is unmasked following the rise of ovarian steroid hormone concentrations during the menstrual cycle.7
  • Tryptophan depletion is a cause of aggression.8,9

Does Premenstrual Syndrome Respond To Gluten-Free Diet?

Yes. celiac disease-related PMS responds to a gluten free diet containing adequate calcium, vitamin D, EPA, magnesium, and tryptophan.

6 Steps To Improve Premenstrual Syndrome In Celiac Disease and/or Gluten Sensitivity:

  • [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both PMS and gut health.

  • Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
  • A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
  • Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

  • Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
  • Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

  • Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
  • Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.10
  • The intestinal lining may take up to a year to heal.[/box]
  • [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

  • Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.11
  • Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
  • Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.11
  • Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.11.
  • Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.11
  • Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
  • Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.11
  • Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.11[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

  • Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
  • Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes green leafy vegetables such as lettuce and kale, also onion, broccoli, garlic, and others.
  • High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
  • Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
  • Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
  • Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
  • Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
  • Protective Herbs and Spices.  See below #6 below for examples.[/box]
  • [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

  • [dropcap]4[/dropcap] Manage Your Medications Safely:

[box type=”shadow” ]

Certain medications deplete one or more of these nutrients that promote PMS: calcium, magnesium, vitamin D, vitamin B6, EPA (omega-3 fatty acid), and tryptophan. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

This is not a complete listing.

ANTACIDS / ULCER MEDICATIONS

  • Pepcid®, Tagamet®, Zantac® deplete Calcium, Vitamin D, Magnesium.
  • Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete Calcium, Vitamin D, Magnesium.
  • Alka Seltzer®, Baking Soda deplete Magnesium.

ANTIBIOTICS disrupt intestinal permeability which complicates celiac disease.

  •  Tetracyclines deplete Calcium, Magnesium, Vitamin B6.

ANTI-INFLAMMATORIES disrupt intestinal permeability which complicates celiac disease.

  • Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Calcium, Vitamin D, Magnesium, Vitamin B6.
  • Aspirin and Salicylates deplete Calcium.

ANTICONVULSANTS

  • Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Calcium, Vitamin D.

ANTIVIRAL AGENTS

  • Foscanet depletes Calcium, Magnesium. 

CARDIOVASCULAR DRUGS

  • Antihypertensives (Catapres®, Aldomet) deplete Vitamin B6.

DIURETICS

  • Thiazide Diuretics (Hydrochlorothiazide, Enduron®, Diuril®, Lozol®, Zaroxolyn®, Hygroton® and others) deplete Magnesium.
  • Loop Diuretics (Lasix®, Bumex®, Edecrin®) deplete Calcium, Magnesium, Vitamin B6.
  • Potassium Sparing Diuretics (Midamor®, Aldactone®, Dyrenium® and others) deplete Calcium.

FEMALE HORMONES disrupt intestinal permeability which complicate celiac disease.

  • Oral Contraceptives (Norinyl®, Ortho-Novum®, Triphasil®, and others) deplete Vitamin B3 (body can make trytophan from this), Magnesium, Vitamin B6.
  • Oral Estrogen/Hormone Replacement (Evista®, Prempro®, Premarin®, Estratab® and others) deplete Magnesium, Vitamin B6. [/box]
  • [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

  • Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
  • Calcium citrate is the best absorbed of calcium supplements. Calcium carbonate is a poor choice.
  • Vitamin D3 as prescribed following blood test for status.
  • Chelated magnesium  as prescribed but do not take at same time as calcium because they compete for absorption.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

  • [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

  • Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
  • If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
  • Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
  • What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

  • Raspberry.
  • Carrot is also a cleansing digestive tonic.
  • Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
  • Redbeets also stimulate and improve digestion and are easily digested.
  • Cabbage also stimulates and improves digestion and is also a liver decongestant.
  • Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
  • Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

  • Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
  • Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
  • Parsley also relieves indigestion.
  • Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
  • Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

  • Cloves are also antispasmodic.
  • Nutmeg is also useful for indigestion.
  • Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Premenstrual Syndrome In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Evaluation of the effect of omega-3 fatty acids in the treatment of premenstrual syndrome: a pilot trial.” This study designed to evaluate the effect of omega-3 fatty acids on the treatment of PMS reports that omega-3 fatty acids may reduce the psychiatric symptoms of PMS including depression, nervousness, anxiety, and lack of concentration and may also reduce the somatic symptoms of PMS including bloating, headache and breast tenderness. These good effects increased by longer duration of treatment .

A randomized double blind controlled trial was performed on eligible women who then were randomly assigned into two groups.  There were no significant differences between the two groups according to age, BMI, level of education, and the severity and duration of primary symptoms. In the case group  of 70 women, omega-3 in an amount of 2 g was prescribed for a one per day basis on a single dosage (two 1 g pearls), and in the control group of 69 women, placebo soft gel, which were completely similar to omega-3 soft gels, were prescribed. The severity and duration of each of the symptoms were compared in both groups 1.5 and 3 months after the beginning of treatment.

After 45 days from starting omega-3 capsules, the  average severity of depression, anxiety, lack of concentration and bloating in the case group, were all significantly lower than in the control group taking placebo. The duration of depression and bloating in the case group were less than in the control group. After 90 days from starting the treatment, the average severity of depression, anxiety, lack of concentration, nervousness and the duration of depression, nervousness, anxiety, lack of concentration, bloating , headache and breast tenderness were all lower in the case group.4

“Cyclical changes in calcium metabolism across the menstrual cycle in women with premenstrual dysphoric disorder.” This study investigating abnormalities in calcium  metabolism  as a cause of some affective and physical symptoms in women with premenstrual syndrome,  concluded that the lack of responsiveness in vitamin D metabolism  resulting in a decline in 1,25(OH)(2)D during the luteal phase of the menstrual cycle may serve as the biological trigger for the classical features of PMDD.

Researchers measured fluctuations and group differences in calcium-regulating hormones across the menstrual cycle in women with and without premenstrual dysphoric disorder (PMDD). Calcium-regulating hormones varied significantly across the menstrual cycle in both groups. Total serum, ionized and urine calcium, pH, intact PTH, and 1,25-dihydroxyvitamin D [1,25(OH)(2)D] varied significantly over the menstrual cycle. The PMDD group, when compared with controls, had significantly lower ionized calcium at phase 1 (menses) (1.166 +/- 0.072 vs. 1.182 +/- 0.087 mmol/liter), significantly lower urine calcium excretion at three of the five phases (late follicular phase 2, midcycle phase 3, and early luteal phase 4), and significantly lower 1,25(OH)(2)D at luteal phase 4 (45.0 +/- 27.5 vs. 50.6 +/- 33.8 pg/ml).12

“Calcium and vitamin D intake and risk of incident premenstrual syndrome.” This study investigating whether taking the nutrients calcium and vitamin D may prevent the initial development of PMS found that a high intake of calcium and vitamin D may reduce the risk of PMS.

Researchers conducted a case-control study nested within the prospective Nurses’ Health Study II cohort. Participants were a subset of women aged 27 to 44 years and free from PMS at baseline in 1991, including 1057 women who developed PMS over 10 years of follow-up and 1968 women reporting no diagnosis of PMS and no or minimal menstrual symptoms. Intake of calcium and vitamin D was measured in 1991, 1995, and 1999 by a food frequency questionnaire.

After adjustment for age, parity, smoking status, and other risk factors, women in the highest quintile of total vitamin D intake (average dose of 706 IU/d) had a relative risk of 0.59 compared with those in the lowest quintile (average dose of 112 IU/d). The intake of calcium from food sources was also inversely related to PMS; compared with women with a low intake (average dose of 529 mg/d), participants with the highest intake (average dose of 1283 mg/d) had a relative risk of 0.70. The intake of skim or low-fat milk was also associated with a lower risk. Large-scale clinical trials addressing this issue are warranted. Given that calcium and vitamin D may also reduce the risk of osteoporosis and some cancers, clinicians may consider recommending these nutrients even for younger women.13

“Tryptophan depletion increases aggression in women during the premenstrual phase.” This study, in consideration of published research showing that reducing serotonin by the method of tryptophan depletion has led to increased aggression in men, was designed to evaluate the effects of tryptophan depletion on aggression in women in the late luteal phase of their menstrual cycle. Findings show that decreased serotonergic neurotransmission increases aggression in women, as well as, men.

Healthy women were recruited and randomly assigned to an amino acid drink either depleted or with a balanced amount of tryptophan. At 4.5 h later, they competed on the competitive reaction time task. Women who had received the tryptophan depletion drink showed more behavioural aggression in response to provocation.14

“Magnesium and the premenstrual syndrome.” In this study, plasma and erythrocyte (red blood cell) magnesium were measured in 105 patients with premenstrual syndrome (PMS) using a simple atomic absorption spectroscopy method. The erythrocyte magnesium concentration for the patients with PMS was significantly lower than that of a normal population. The plasma magnesium did not show this difference.6

Sources:
  1. Bond AJ, Wingrove J, Critchlow DG. Tryptophan depletion increases aggression in women during the premenstrual phase. Psychopharmacology (Berl). 2001 Aug;156(4):477-80. [↩]
  2. Dougherty DM, Moeller FG, Bjork JM, Marsh DM. Plasma L-tryptophan depletion and aggression. Adv Exp Med Biol. 1999;467:57-65. [↩]
  3. Krause’s Food, Nutrition, & Diet Therapy. 10th Edition. Kathleen Mahan, Sylvia Escott-Stump. 2000. W.B. Saunders Company. [↩]
  4. Sohrabi N, Kashanian M, Ghafoori SS, Malakouti SK. Evaluation of the effect of omega-3 fatty acids in the treatment of premenstrual syndrome: “a pilot trial”.Complement Ther Med. 2013 Jun;21(3):141-6. doi: 10.1016/j.ctim.2012.12.008. [↩] [↩]
  5. Ventskivs’ka IB, Senchuk AIa. Role of magnesium in the pathogenesis of premenstrual disorders. Lik Sprava. 2005 Dec;(8):62-5. [↩]
  6. Sherwood RA, Rocks BF, Stewart A, Saxton RS. Magnesium and the premenstrual syndrome. Ann Clin Biochem. 1986 Nov;23 ( Pt 6):667-70. [↩] [↩]
  7. Thys-Jacobs S. Micronutrients and the premenstrual syndrome: the case for calcium. J Am Coll Nutr. 2000 Apr;19(2):220-7. [↩]
  8. Bond AJ, Wingrove J, Critchlow DG. Tryptophan depletion increases aggression in women during the premenstrual phase. Psychopharmacology (Berl). 2001 Aug;156(4):477-80. [↩]
  9. Tryptophan depletion is a cause of aggression and in premenstrual females. ((Dougherty DM, Moeller FG, Bjork JM, Marsh DM. Plasma L-tryptophan depletion and aggression. Adv Exp Med Biol. 1999;467:57-65. [↩]
  10. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
  11. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
  12. Thys-Jacobs S, McMahon D, Bilezikian JP. Cyclical changes in calcium metabolism across the menstrual cycle in women with premenstrual dysphoric disorder. J Clin Endocrinol Metab. 2007 Aug;92(8):2952-9. [↩]
  13. Bertone-Johnson ER, Hankinson SE, Bendich A, Johnson SR, Willett WC, Manson JE. Calcium and vitamin D intake and risk of incident premenstrual syndrome. Arch Intern Med. 2005 Jun 13;165(11):1246-52. [↩]
  14. Bond AJ, Wingrove J, Critchlow DG. Tryptophan depletion increases aggression in women during the premenstrual phase. Psychopharmacology (Berl). 2001 Aug;156(4):477-80. [↩]
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