PMS Symptoms, Causes, and Treatment: Why Premenstrual Syndrome Is Still Medically Underestimated
“Why so irritable?” … Sound familiar? Such dismissive comments (whether in professional or private contexts) lead affected women to tolerate PMS symptoms sometimes, while the underlying biological mechanisms are insufficiently considered by medical professionals.
In today’s article, we address the scientifically described causes of PMS, typical symptoms, diagnostic particularities, as well as the conventional medical and naturopathic classification of treatment. Particular attention is given to natural substances with proven efficacy.
PMS Causes: Neuroendocrine Sensitivity Rather Than a “Hormonal Imbalance”
Affected persons often do not exhibit abnormal estrogen or progesterone levels. Research shows that in many cases PMS does not arise from pathological hormone levels, but from an increased sensitivity of the central nervous system to normal cyclical hormonal fluctuations. There is an altered neurobiological response to physiological endocrine changes, which is why PMS is classified as a neuroendocrine regulatory process. Physical, psychological, and cognitive symptoms typically occur in the second half of the cycle — especially in the luteal phase after ovulation — and subside with the onset of menstruation. During this phase, neurosteroidal metabolites of progesterone influence neurobiological processes that modulate mood, irritability, and stress processing (Yonkers et al., 2008; Rapkin & Akopians, 2012).
PMS Symptoms: Typical Complaints in Premenstrual Syndrome
The clinical symptomatology of PMS is multidimensional and includes physical, psychological, and cognitive complaints that occur in a cycle-dependent manner and decrease with the onset of menstruation (Yonkers et al., 2008).
The most common PMS symptoms include:
· emotional lability
· depressed mood
· anxiety and inner restlessness
· fatigue and reduced resilience
· sleep disturbances
· breast tenderness (mastodynia)
· fluid retention and a feeling of tension
· headaches
· concentration difficulties.
These complaints can impair quality of life, work capacity, and psychological stability—even in moderate cases, and particularly in severe courses (Yonkers et al., 2008).
PMS Diagnosis: Why Cycle-Based Tracking Is Crucial
It is recommended to document symptoms over at least two menstrual cycles in order to reliably capture the cyclical dynamics of the complaints and differentiate them from other conditions (American College of Obstetricians and Gynecologists ACOG, 2023).
In clinical practice, however, this structured documentation is not always consistently implemented, which is why PMS symptoms are often classified as non-specific or attributed to other psychological or somatic disorders, despite a clear cyclical association (Yonkers et al., 2008).
Conventional Medical Treatment of PMS: Largely Symptom-Oriented
Conventional medical treatment of PMS primarily focuses on symptom relief.
Evidence-based standard therapies include:
· selective serotonin reuptake inhibitors (SSRIs)
· hormonal contraceptives to suppress ovulation
· analgesics for pain-associated complaints.
Guidelines from the American College of Obstetricians and Gynecologists identify SSRIs and hormonal therapies in particular as central treatment options for clinically relevant premenstrual disorders (ACOG, 2023).
These therapies can be effective, but they mainly address symptoms and do not necessarily target the underlying neuroendocrine sensitivity to hormonal fluctuations, which plays a central role in the pathophysiology of PMS. Regulatory analyses of large randomized studies also show that antidepressants — including selective serotonin reuptake inhibitors (SSRIs) — may be associated, particularly in individuals under 25 years of age, in early phases of treatment or during dose changes, with an increased risk of suicidal thoughts and suicidal behavior. Hardly desirable when the aim is to treat depressive mood or depression! Authorities and published guidelines emphasize that this effect as age-, phase-, and indication-dependent and requiring careful benefit–risk assessment as well as close clinical monitoring, rather than a blanket negative evaluation of the drug class (FDA, 2004; EMA, 2005). A more decisive stance in the interest of patients can, unfortunately, rarely be expected from international authorities and conventional medical “guidelines.”
Treating PMS Naturally: Evidence-Based Micronutrients in a Scientific Context
For a naturopathic approach, it is essential that only those substances are considered that have actually been specifically studied in PMS:
o Calcium: A Nutritional Medicine Approach to PMS Complaints
Particularly in the areas of mood, appetite, and fluid retention, study results show a significant reduction in premenstrual symptoms (Thys-Jacobs et al., 1998).
Calcium from supplements is best absorbed in single doses of ≤ 500 mg; therefore, e.g., two doses per day are reasonable.
o St. John’s Wort (Hypericum perforatum): Plant-Based Support for PMS-Associated Mood Fluctuations
St. John’s wort (Hypericum perforatum) is traditionally used in the context of affective complaints and is pharmacologically known in particular for its effects on serotonergic, dopaminergic, and noradrenergic signaling pathways. These neurotransmitter systems also play a role in premenstrual mood swings, irritability, and depressive mood, which is why St. John’s wort has been studied not only in depression but also in PMS-associated psychological symptoms.
In a randomized, placebo-controlled study, St. John’s wort showed a significant improvement in mental and physical complaints compared with placebo, particularly in mood, irritability, and functional impairment. The authors classify St. John’s wort as a potentially relevant phytotherapeutic option in mild to moderate premenstrual complaints, with effects primarily attributed to modulation of central neurotransmitters and stress-related regulatory mechanisms (Canning et al., 2010).
For standardized St. John’s wort preparations, the European Medicines Agency (EMA) and the Committee on Herbal Medicinal Products (HMPC) describe typical daily doses in the range of 600–1,800 mg/day (depending on the preparation), often 900 mg/day as a single dose for certain products (EMA/HMPC, 2022).
It is essential to note that St. John’s wort can have significant interactions. Professional clarification is advisable, e.g., in the case of hormonal contraception, anticoagulants, immunosuppressants, and many psychotropic medications (EMA/HMPC Assessment Report, 2022).
o Magnesium: A Mineral for Fluid Retention and Neuromuscular PMS Complaints
Magnesium is an essential mineral of central importance for neuromuscular regulation, stress physiology, and electrolyte balance — factors that are regularly discussed in connection with premenstrual complaints. It is not classified as a general PMS therapy per se, but is specifically investigated with regard to individual symptom clusters such as premenstrual fluid retention, tension states, and other physical complaints.
Supplementation with 200 ml daily showed a significant reduction in premenstrual fluid retention and associated physical complaints in placebo-controlled studies. In particular, the role of magnesium in electrolyte and fluid balance as well as neuromuscular stability is discussed (Walker et al., 1998).
In cases of a sensitive gut, better-tolerated forms of magnesium (e.g., citrate or glycinate) are recommended.
o Chaste Tree (Vitex agnus-castus): Phytotherapeutic Intervention for Numerous PMS Complaints
Chaste tree (Vitex agnus-castus) is one of the best-studied plant-based active substances in the context of premenstrual syndrome. Its pharmacological effect is associated, among other things, with dopaminergic effects and indirect modulation of the hypothalamic–pituitary axis, which can influence hormonal and cycle-related complaints.
Studies confirm a significant improvement in overall PMS symptomatology under Vitex extract. Several trials also show that Vitex agnus-castus can lead to a significant reduction in typical PMS symptoms such as irritability, breast tenderness, mood swings, and headaches (Verkaik et al., 2017; Schellenberg, 2001).
A dose of 200 mg dry extract daily for a duration of at least three cycles is recommended.
Due to these direct study data, chaste tree is repeatedly classified in the scientific literature as an evidence-based phytotherapeutic approach for premenstrual complaints, particularly in cycle-dependent, hormonally associated symptom complexes.
o Omega-3 Fatty Acids: Relief of Inflammation-Associated PMS Complaints
Omega-3 fatty acids, particularly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are polyunsaturated fatty acids with inflammation-modulating and neurobiological properties. Since inflammatory processes, prostaglandin dynamics, and neurochemical changes are among the described pathophysiological factors in PMS, omega-3 fatty acids are discussed in the literature as a nutritionally plausible approach in multifactorial PMS complaints (Rapkin & Akopians, 2012).
Supplementation with omega-3 fatty acids resulted in a significant reduction in premenstrual symptoms, including depression, anxiety, concentration difficulties, and somatic complaints, compared with placebo. Study authors attribute these effects, among other things, to inflammation-modulating mechanisms as well as the involvement of omega-3 fatty acids in neuronal membrane processes and neurotransmitter regulation (Behboudi-Gandevani et al., 2018).
The applied dosage was 1 g per day for a duration of three cycles/months. As you may expect, longer-term intake is recommended. Omega-3 capsules or oils are usually combined with a meal for better tolerability, although omega-3 fatty acids can also be obtained through food.
o Vitamin B6 (Pyridoxine): A Micronutrient for the Relief of Psychological PMS Symptoms
Vitamin B6 (Pyridoxine) can significantly improve psychological symptoms such as irritability, depressive mood, and mood swings.
The applied — and recommended — dose was a maximum of 100 mg daily (Wyatt et al., 1999).
Gender Data Gap: PMS Long Underestimated — With Consequences
For a long time, clinical studies were predominantly conducted without differentiated consideration of hormonal cycle phases, which meant that cycle-dependent complaints such as PMS were investigated less systematically. This contributed to premenstrual symptoms, despite their high prevalence and significant impact on quality of life, being medically classified for a long time as non-specific or secondary (Yonkers et al., 2008; Rapkin & Akopians, 2012).
Only with the increase in sex-sensitive research has it become clearer that hormonal sensitivity, neurobiological stress responses, and cycle-dependent symptom patterns require specific scientific consideration. As a result, PMS is now classified more differentially as an independent, clinically relevant symptom syndrome—and is gradually receiving corresponding attention.
PMS: Complex Causes Require Differentiated Strategies
Premenstrual syndrome is multifactorial, with neuroendocrine, neurobiological, and individual regulatory components.
A purely symptom-oriented therapy may provide short-term relief, but it falls short if the underlying mechanisms — particularly neuroendocrine sensitivity, cycle-dependent regulation, and individual vulnerability — are not taken into account. Complementary medicine can offer supportive approaches here.
And now to ...
FAQ — (Further) Frequently Asked Questions About PMS
1. Can alternative treatment methods such as yoga or acupuncture be useful for PMS?
Non-pharmacological methods such as acupuncture and yoga are increasingly being scientifically investigated in the context of premenstrual syndrome (PMS), particularly with regard to stress regulation, pain processing, and emotional stability. Since PMS is associated with neuroendocrine stress axes, affective symptoms, and physical tension states, mindfulness-based and body-oriented interventions are considered supportive approaches for cycle-dependent complaints (Rapkin & Akopians, 2012).
Randomized studies show that yoga interventions, when a specific yoga program is followed, can contribute to a significant reduction in PMS symptom severity and pain, with particular effects described on emotional regulation (Rakhshaee, 2011).
Systematic reviews of randomized studies indicate that acupuncture can reduce premenstrual complaints — both somatic and affective (Armour et al., 2018).
2. Why is PMS often treated only symptomatically?
Guidelines primarily focus on evidence-based symptom reduction, for example through SSRIs or hormonal therapies, while the underlying neuroendocrine sensitivity is not directly addressed causally (ACOG, 2023; Rapkin & Akopians, 2012).
3. Ist PMS dasselbe wie PMDS (prämenstruelle dysphorische Störung)?
PMS and PMDS differ primarily in severity and dominant symptom patterns. Both PMS and PMDS include physical and psychological symptoms, including irritability, mood swings, anxiety, and depressive mood. The decisive difference lies in the severity and duration of symptoms and the degree of impairment they cause. In PMDS, pronounced affective symptoms are in the foreground and significantly impair daily life, work capacity, or interpersonal relationships, whereas PMS describes a broader spectrum of cycle-dependent complaints of varying intensity (Yonkers et al., 2008).
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Sources:
· Yonkers, K. A. et al. (2008): “Premenstrual syndrome,” The Lancet.
· Rapkin, A. J.; Akopians, A. L. (2012): “Pathophysiology of premenstrual syndrome and premenstrual dysphoric disorder,” Menopause International.
· American College of Obstetricians and Gynecologists (2023): “Management of Premenstrual Disorders: ACOG Clinical Practice Guideline,” Obstetrics & Gynecology.
· U.S. Food and Drug Administration (FDA): “Suicidality in Children and Adolescents Being Treated With Antidepressant Medications.”
· European Medicines Agency (EMA): “Serotonin-specific reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) – safety review on suicidal behaviour in children and adolescents.”
· Thys-Jacobs, S. et al. (1998): “Calcium carbonate and the premenstrual syndrome: Effects on premenstrual and menstrual symptoms,” American Journal of Obstetrics and Gynecology.
· Canning, S. et al. (2010): “The efficacy of Hypericum perforatum (St John’s wort) for the treatment of premenstrual syndrome: a randomized, double-blind, placebo-controlled trial,” CNS Drugs.
· European Medicines Agency (EMA), Committee on Herbal Medicinal Products (HMPC): “European Union herbal monograph on Hypericum perforatum L., herba (traditional use),” EMA/HMPC/745582/2009 Revision 1, 2017.
· European Medicines Agency (EMA), Committee on Herbal Medicinal Products (HMPC): “Assessment report on Hypericum perforatum L., herba (traditional use),” EMA/HMPC/745583/2009 Revision 1, 2017.
Available at: https://www.ema.europa.eu/en/documents/herbal-report/final-assessment-report-hypericum-perforatum-l-herba-revision-1_en.pdf
· Walker, A. F. et al. (1998): “Magnesium supplementation alleviates premenstrual symptoms of fluid retention,” Journal of Women’s Health.
· Verkaik, S. et al. (2017): “The treatment of premenstrual syndrome with preparations of Vitex agnus castus: a systematic review and meta-analysis,” American Journal of Obstetrics and Gynecology.
· Schellenberg, R. (2001): “Treatment of the premenstrual syndrome with agnus castus fruit extract: prospective, randomised, placebo controlled study,” BMJ.
· Behboudi-Gandevani, S. et al. (2018): “The effect of omega-3 fatty acid supplementation on premenstrual syndrome and health-related quality of life: a randomized clinical trial,” Journal of Psychosomatic Obstetrics & Gynecology.
· Wyatt, K. M. et al. (1999): “Efficacy of vitamin B-6 in the treatment of premenstrual syndrome: systematic review,” BMJ.
· Rakhshaee, Z. (2011): “Effect of three yoga poses (cobra, cat and fish poses) in women with premenstrual syndrome: a randomized clinical trial,” Journal of Alternative and Complementary Medicine.
· Armour, M. et al. (2018): “Acupuncture and acupressure for premenstrual syndrome: a systematic review and meta-analysis of randomised controlled trials,” BMC Complementary and Alternative Medicine.