This blog aims to look at the evidence behind what, if any, impact nutrition can have on improving the symptoms of PMS.

Premenstrual Syndrome (PMS) is a common and often challenging collection of symptoms that affects many women during their reproductive years. Due to their cyclical nature, PMS symptoms could potentially have a detrimental impact on around 25-50% of a woman’s life during that time – not exactly a small percentage. 

WHAT ACTUALLY CAUSES PMS?

The aetiology of PMS remains unclear; appearing to be linked to the body’s inflammatory response to hormonal changes and resultant oxidative stress, though research is very limited.¹ Over 200 symptoms of PMS have been identified,² which can have far-reaching negative effects on women’s health; both mental and physical. PMS can affect overall quality of life, academic performance and athletic performance.³

Symptoms can include:²

• Trouble sleeping
• Irritability and mood swings
• Breast tenderness
• Headaches
• Changes in appetite

Many women report experiencing at least one of these symptoms in the weeks prior to their period, usually around the luteal phase of the menstrual cycle, as progesterone peaks.⁴

Interestingly, there appears to be cultural and geographic links between rates of PMS (or at least rates of reporting PMS), with some research highlighting that France notes a ~12% rate of PMS whilst Iran reports ~98%.⁵

LIFESTYLE AND PMS

As you might imagine, with something that affects approximately half of the population, monitoring and attempting to adapt to our menstrual cycle to improve symptoms is not a new idea. It has been around for centuries in medical literature and PMS-like symptoms have been described since the time of Hippocrates.⁶

Recently though, interest has piqued through a pushback against the use of hormonal contraceptives and a rise in interest in apps to monitor menstrual cycles.⁷ This has led to a surge in interest in ‘cycle-syncing’ and similar. ‘Cycle syncing’ is actually a term which has been coined and trademarked by the company Flo Living, which involves adapting diet and levels or types of physical activity according to different phases of the menstrual cycle.⁸

DIET AND PMS

Research into PMS and diet is fairly limited, with a noticeable lack of high-quality intervention studies. Some research has been conducted that suggests a link between intermittent fasting (IF) and PMS. A very small interventional study (n=7) has highlighted a potential for a lowered stress effect via reduced salivary cortisol levels and improved parasympathetic activity.⁹ This was linked with fasting patterns during the luteal phase, though much more research is needed to elucidate on this further.¹⁰

Other results appear to contradict this, however, showing no statistically significant link between macronutrient composition of the diet and PMS symptoms. As such, more high-quality evidence is needed to specify what, if any, the macronutrient composition of the diet can have on PMS symptoms.^11,12

WHAT ABOUT MICRONUTRIENTS AND PMS?

Calcium

Serum calcium levels appear to be lower in research participants with PMS and supplementation appears to have the potential to improve symptoms.13 An intervention study looking at calcium supplementation showed a significant difference in mood with a 500mg supplement, though it’s unclear whether the participants were deficient in calcium at baseline.¹⁴

Other studies have shown improvements in calcium supplements of 1000mg/day and with calcium and vitamin D combined.^13,15 More dose-response trials are needed before any recommendations can be made.

Vitamin D

The importance of vitamin D to female reproduction is becoming apparent. Vitamin D deficiency is a risk marker for adverse pregnancy outcomes and reduced fertility.^16,17 As such, it has been highlighted as being important in the female reproductive cycle overall.

Some research in vitamin D deficient adolescents has shown that therapeutic treatment with vitamin D can bring improvements in PMS symptoms. A small Iranian intervention study showed promising/significant improvements/results for vitamin D supplementation in women who were deficient at baseline.18

Overall, vitamin D supplementation appears to be beneficial for those who are deficient, but the benefit of therapeutic doses in those who are vitamin D replete needs further research.

Magnesium

Links have been made between serum magnesium status and symptoms⁴ and a quick Google search will pull up a lot of advice around supplementing with magnesium for PMS. However, the actual evidence base is scant.

A 2017 literature review has shown that it may be beneficial in managing both PMS and menstrual migraine. However, dose-response rates are unclear and better quality studies are required.¹⁹

Zinc

Zinc supplementation/repletion has been linked with a reduction in both physical and psychological PMS symptoms, potentially due to antioxidant, anti-inflammatory and/or antidepressant effects.²⁰ Once again, though, the benefits of additional supplementation versus repletion remain unclear.

THE TAKEAWAYS

• At this time, there doesn’t appear to be one intervention that will benefit everyone.
• PMS symptoms have a negative impact on the lives of many women throughout their reproductive lives.
• There does appear to be something that can be done with diet, yet there is a massive lack of intervention studies.
• Ensuring a balanced, nutritionally complete diet, paying attention to ensuring personalised dietary advice, which includes adequate calcium and vitamin D intake, appears to be helpful.
• Current research into ‘cycle-syncing’ is severely lacking, although it is potentially worth being informed about the theory so that clients/patients who may be interested in finding out more can be supported.

Jessica English, RD

Freelance dietitian with interests in IBS, maternal and
child health, publichealth.

Instagram: @meals.for.motherhood
Website: www.mealsformotherhood.com

References

1. Granda D, Szmidt MK, Kaluza J. Is Premenstrual Syndrome Associated with Inflammation, Oxidative Stress and Antioxidant Status? A Systematic Review of Case-Control and Cross-Sectional Studies. Antioxidants (Basel). 2021;10(4):604. Published 2021 Apr 14. doi:10.3390/antiox10040604
2. Matsumoto T, Asakura H, Hayashi T. Biopsychosocial aspects of premenstrual syndrome and premenstrual dysphoric disorder. Gynecol Endocrinol. 2013;29(1):67-73. doi:10.3109/09513590.2012.705383
3. Takeda T, Imoto Y, Nagasawa H, Muroya M, Shiina M. Premenstrual Syndrome and Premenstrual Dysphoric Disorder in Japanese Collegiate Athletes. J Pediatr Adolesc Gynecol. 2015;28(4):215-218. doi:10.1016/j.jpag.2014.07.006
4. Siminiuc R, Ţurcanu D. Impact of nutritional diet therapy on premenstrual syndrome. Front Nutr. 2023;10:1079417. Published 2023 Feb 1. doi:10.3389/fnut.2023.1079417
5. Costanian C, Akiki Z, Rabah Z, Daou S, Assaad S (2018) Factors Associated with Premenstrual Syndrome and its Different Symptom Domains among University Students in Lebanon. Int J Womens Health Wellness 4:068. doi.org/10.23937/2474-1353/1510068
6. King S. Premenstrual Syndrome (PMS) and the Myth of the Irrational Female. 2020 Jul 25. In: Bobel C, Winkler IT, Fahs B, et al., editors. The Palgrave Handbook of Critical Menstruation Studies [Internet]. Singapore: Palgrave Macmillan; 2020. Chapter 23. Available from: https://www.ncbi.nlm.nih.gov/books/NBK565629/ doi: 10.1007/978-981-15-0614-7_23
7. Earle S, Marston HR, Hadley R, Banks D. Use of menstruation and fertility app trackers: a scoping review of the evidence. BMJ Sex Reprod Health. 2021;47(2):90-101. doi:10.1136/bmjsrh-2019-200488
8. Flo Living app site - ‘cycle-syncing’ definition available online at: https://floliving.com/blog/luteal-phase#:~:text=The%20Flo%20Living%20Cycle%20Syncing,certain% 20supplements%20each%20phase%20too. (Accessed 01/10/2023)
9. Ohara K, Okita Y, Kouda K, Mase T, Miyawaki C, Nakamura H. Cardiovascular response to short-term fasting in menstrual phases in young women: an observational study. BMC Women's Health. 2015;15:67. Published 2015 Aug 28. doi:10.1186/s12905-015-0224-z
10. Hooshiar SH, Yazdani A, Jafarnejad S. Effect of modified alternate day fasting diet on the severity of premenstrual syndrome and health-related quality of life in women with overweight or obesity: a trial study protocol. BMJ Open. 2023;13(5):e066740. Published 2023 May 4. doi:10.1136/bmjopen-2022-066740
11. Houghton SC, Manson JE, Whitcomb BW, et al. Carbohydrate and fiber intake and the risk of premenstrual syndrome. Eur J Clin Nutr. 2018;72(6):861-870. doi:10.1038/s41430-017-0076-8
12. Houghton SC, Manson JE, Whitcomb BW, et al. Protein intake and the risk of premenstrual syndrome. Public Health Nutr. 2019;22(10):1762-1769. doi:10.1017/S1368980018004019
13. Arab A, Rafie N, Askari G, Taghiabadi M. Beneficial Role of Calcium in Premenstrual Syndrome: A Systematic Review of Current Literature. Int J Prev Med. 2020;11:156. Published 2020 Sep 22. doi:10.4103/ijpvm.IJPVM_243_19
14. Shobeiri F, Araste FE, Ebrahimi R, Jenabi E, Nazari M. Effect of calcium on premenstrual syndrome. A double-blind randomized clinical trial. Obstet Gynecol Sci. 2017;60(1):100-105. doi:10.5468/ogs.2017.60.1.100
15. 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;165(11):1246-1252. doi:10.1001/archinte.165.11.1246
16. Pilz S, Zittermann A, Obeid R, et al. The Role of Vitamin D in Fertility and during Pregnancy and Lactation: A Review of Clinical Data. Int J Environ Res Public Health. 2018;15(10):2241. Published 2018 Oct 12. doi:10.3390/ijerph15102241
17. Shahrokhi SZ, Ghaffari F, Kazerouni F. Role of vitamin D in female reproduction. Clin Chim Acta. 2016;455:33-38. doi:10.1016/j.cca.2015.12.040
18. Heidari H, Amani R, Feizi A, Askari G, Kohan S, Tavasoli P. Vitamin D Supplementation for Premenstrual Syndrome-Related inflammation and antioxidant markers in students with vitamin D deficient: a randomised clinical trial. Sci Rep. 2019;9(1):14939. Published 2019 Oct 17. doi:10.1038/s41598-019-51498-x
19. Moslehi M, Arab A, Shadnoush M, Hajianfar H. The Association Between Serum Magnesium and Premenstrual Syndrome: a Systematic Review and Meta-Analysis of Observational Studies. Biol Trace Elem Res. 2019;192(2):145-152. doi:10.1007/s12011-019-01672-z
20. Jafari F, Amani R, Tarrahi MJ. Effect of Zinc Supplementation on Physical and Psychological Symptoms, Biomarkers of Inflammation, Oxidative Stress, and Brain-Derived Neurotrophic Factor in Young Women with Premenstrual Syndrome: a Randomized, Double-Blind, Placebo-Controlled Trial. Biol Trace Elem Res. 2020;194(1):89-95. doi:10.1007/s12011-019-01757-9