Case 2 – Women’s Health: Pre-Menstrual Syndrome

by Danny Siegenthaler

 

Introduction

Over 40% of women suffer premenstrual symptoms which as a group are referred to as Premenstrual Syndrome (PMS) (Habek, Habek, & Barbir, 2002) , or Premenstrual tension (PMT). This condition is attributed with over 150 physical and psychological symptoms (Cho & Kim; Halbreich, 2003) that include breast tenderness and/or distension, headache, low back pain, lack of energy, anxiety, irritability, depression, food cravings, bloating, abdominal cramps, and others (Campagne & Campagne, 2007; Cho & Kim; Freeman, 2003; Halbreich, 2003; Kaptchuk, 1983, p. 227; 1998; Roberts, McCarty, & Severino, 2001) . However, PMS is not present before puberty, during pregnancy or after the menopause (Salamat, Ismail, & O' Brien, 2008) , and associated symptoms are usually relieved by the onset of the menstrual period, although, in some cases, some or all of the symptoms persist during the period and can even extend beyond (Maciocia, 1998, p. 339) .

Premenstrual Dysphoric Disorder (PMDD) is an extension of PMS where severe physiological symptoms can lead to impairment of social/psychological behaviours (Campagne & Campagne, 2007; Cho & Kim) and may result in angry or violent outbursts (Maciocia, 1998, p. 339) . This condition is more defined and requires at least 5 of the following symptoms to be present in order for a biomedical diagnosis of PMDD to be confirmed (Pinkerton, 2010) :

• Feelings of sadness, hopelessness, or self-depreciation
• Feeling ‘on edge’ or anxious
• Frequent mood changes with tearfulness
• Irritability or anger that persists, leading to increased interpersonal conflicts
• Loss of interest in daily activities, possibly causing withdrawal
• Decreased concentration
• Fatigue, lethargy, or lack of energy
• Changes in eating habits, including binge-eating
• Insomnia
• Feelings of being overwhelmed or out of control
• Physical symptoms associated with PMS

Despite the large number of women suffering PMS, there is a paucity of studies that investigate the effect of Acupuncture or Chinese herbal medicine on PMS (Chou, Morse, & Xu, 2008; Jing, Yang, Ismail, Chen, & Wu, 2009) . In terms of Western medicine (WM), this condition is not well understood (Chou & Morse, 2005) and there is no clear definition of PMS (Campagne & Campagne, 2007; Indusekhar, Usman, & O'Brien, 2007; Knaapen & Weisz, 2008; Maciocia, 1998, pp. 356-357; Roberts, et al., 2001) .

 

Traditional Chinese Medicine (TCM) and Biomedical Aetiology and Treatment

TCM:

The aetiology of PMS is primarily due to Liver Qi stagnation, resulting from emotional stress, inappropriate diet, overwork and/or excessive sexual activity (Lyttleton, 2004, pp. 93-94; Maciocia, 1998, pp. 339-340) , or prolonged use of drugs including oral contraceptives, recreational or prescription drugs (Lyttleton, 2004, p. 94) . In addition, Liver Qi stagnation may lead to Fire and when combined with Phlegm creates Phlegm-Fire; while excessive sexual activity and/or overwork weaken the Kidney- and Liver-Yin, which in turn results in Liver Qi stagnation as a secondary condition (Maciocia, 1998, p. 340) .

Maciocia (1998, p. 340) divides the pathophysiology of PMS into either resulting from a Full or Empty aetiology and lists the following TCM patterns involved in PMS:

Full

• Liver-Qi stagnation: as a direct result of emotional stress.
• Phlegm-Fire harassing upwards: resulting from underlying Liver Qi stagnation combined with inappropriate dietary intake of excessive dairy products and/or greasy foods.

Empty

• Liver-Blood deficiency: a deficiency of Liver Blood can lead to Liver Qi stagnation as a secondary pattern.
• Liver- and Kidney-Yin deficiency: overwork and/or excessive sexual activity can lead to this underlying condition, which in turn can lead to stagnation of the Liver Qi, thus Liver Qi stagnation is not the primary cause of the PMS and the underlying patterns must be the focus of treatment.
• Spleen- and Kidney-Yang deficiency: this pattern is cold in nature and lack of Kid/Sp Yang (Heat) fails to facilitate movement, thus cold and damp accumulate and cause stagnation of Liver Qi.

Specific symptomatology associated with each of these patterns is described in detail in Maciocia (1998) , chapter 18.

It must be remembered that PMS is not of itself a disorder or disease, rather it is a time when changes in hormone levels, or changes in the energy cycle associated with the menstrual cycle, present an additional stress to a woman’s physiology which in turn highlights pre-existing/underlying excesses or deficiencies.

 

Biomedical:

The pathophysiology of PMS in WM is not well understood and is controversial (Campagne & Campagne, 2007; Chou, et al., 2008; Freeman, 2003; Maciocia, 1998, p. 356; Roberts, et al., 2001) . Halbreich (2003) (Fig.1) provides a diagrammatic representation of the aetiology and pathophysiology of PMS.

Fig. 1 provides an overview from the biomedical perspective into the aetiology and phathobiology of PMS pointing at five causalities:

• Genetic predisposition;
• Dynamically evolving vulnerability;
• Current luteal phase changes in gonadal hormones;
• Environment at a given state; and
• Perception and coping mechanisms.

Each of these causes, ranging from genetic to psychological, have an effect on the symptoms and disorders for which treatment is prescribed (From Halbreich (2003) ).

Symptoms associated with PMS (Table 1) must occur during the luteal phase (Freeman, 2003) and can range in number from a few to several hundred (Halbreich, 2003) .

Physical symptoms of PMS may include:

Breast engorgement and tenderness

Abdominal bloating

Constipation or diarrhoea

Headache and migraine

Swelling of the hands or feet

Weight gain

Clumsiness

Nausea and vomiting

Muscle and joint aches or pains

Emotional and behavioural symptoms of PMS may include:

Depression (severe depression before menstruation, called premenstrual dysphoric disorder, occurs in about 5% of women with PMS)

Anxiety and panic attacks

Insomnia

Change in sexual interest and desire

Irritability

Hostility and outbursts of anger

Increased appetite often with specific food cravings (especially salt and sugar)

Mood swings

Inability to concentrate

Lethargy and fatigue

Table 1 lists commonly reported symptoms associated with PMS (Simon, 2009) .

Symptoms must be present for at least 2 consecutive months and diagnosis is a clinical judgement rather than arrived at through blood tests or similar (Roberts, et al., 2001) . According to Maciocia (1998, pp. 357-358) and others (Halbreich, 2003) , scientific investigation has focused on deficiencies in progesterone, Vitamins, as well as prostaglandins and aldesterone, but without finding a conclusive cause for PMS.

Biomedical management of PMS focuses primarily on the use of hormonal and other pharmacological drugs, but these appear to have only limited effect in the management of PMS (Maciocia, 1998, p. 357) . Halbreich (2003) proposes suppression of ovulation as an effective treatment to eliminate PMS. He reports that if ovulation was suppressed PMS was eliminated, however, when using hormonal contraception to prevent ovulation, results where mixed and dosage dependant.

According to Pinkerton (2010) treatment of PMDD using Vitamins (specifically B₆ and D), minerals, such as Calcium, and sometimes SSRIs (Selective serotonin reuptake inhibitors (SSRIs)) or hormonal manipulation, provided mixed results.

 

Treatment of PMS using Chinese herbal medicine and/or Acupuncture

Detailed treatment approaches using Chinese herbal medicine and/or Acupuncture are described in Maciocia (1998, pp. 340-356) and are reproduced in Table A1. At this time there are very few studies in the English literature that have investigated the effectiveness of Chinese herbal medicine or Acupuncture for the treatment of PMS. Some of these studies (Habek, et al., 2002; Kong, Lee, & Shin, 2009) investigated the effects of Acupuncture on PMS, and their results suggest that Acupuncture is an effective treatment for PMS. One German study by Chou, et al., (2008) investigated the effectiveness of Chinese herbal medicine, in particular Xiao Yao San, on PMS and showed that Chinese herbal therapy was effective in the treatment of PMS.

 

Patient History, Diagnosis (both TCM & Biomedical), Treatment Principles (TCM) and Treatment (TCM)

Medical History & Presenting Symptomatology

Had 1^st baby, with excessive blood loss, 2 yrs ago.

Menstruation recommenced in the last 3 months

30-35 day cycle

Clots in menstrual flow prior to pregnancy, not since.

Lower abdominal premenstrually and during menses.

Nature of pain: dull, aching, and quite severe.

Not sleeping well (child still wakes at night and crying wakes parents)

Difficulty in falling asleep (insomnia)

Postural dizziness

Some shortness of breath (S.O.B.), without exertion

Itchy skin since giving birth.

PMS

Onset of premenstrual symptoms up to 14 days before menses

Increasing irritability from the time of ovulation to onset of menstruation

Blurred vision

Mood swings, with increasing severity premenstrually

Tender breasts, relieved with onset of menses

Dysmenorrhoea before period, as well as during menses

Other s+s:

Tendency to cold hands and feet

Gastro-intestinal symptoms: Changed since birth of child

Foul smelling flatus

Bloating

Stool slightly loos

Acid reflux, sometimes severe (not after every meal, almost to the level of vomiting)

Tongue: Pale with white coating & strawberry (very slight) spots on body.

Pulse: Deep, weak and slightly wiry

Pharmaceutical prescriptions: None

TCM Diagnosis

1)    Liver / Heart Blood Deficiency

2)    Liver Qi Stagnation, and Liver Qi invades St/Sp with Sp Qi/Yang Xu.

 

Biomedical Diagnosis and Aetiology

WM Diagnosis

1)    Based on the symptomatology this case would be clinically diagnosed as Premenstrual syndrome. It does not comply with the PMDD diagnostic parameters, although some symptoms do fit the criteria. However, as the minimum number of symptoms for a diagnosis of PMDD has not been met, the diagnosis would be PMS.

2)    In addition, IBS (irritable bowel syndrome) may also be diagnosed, as key symptoms for IBS are:

• Acid reflux
• Changes in bowel motions – loose or constipation
• Bloating – flatus
• Pain, usually lower Left-quadrant (but not necessarily)
• Worse premenstrually.

Aetiology according to WM

Luteal phase changes in gonadal hormones, such as per Fig.1, would appear to be the most likely aetiology according to WM.  CNS (central nervous system) symptomatology during the luteal phase may include: mood swings, tender/distension of breasts, bloating, etc.

 

TCM Treatment Principles

1)    Tonify Liv/Ht Blood

2)    Resolve Liv. Qi Stagnation

3)    Sooth Stomach/Spleen

TCM Herbal Prescription

1)    Xiao Yao San @ 10 pills 3x daily (Black Pearl Brand)

2)    Shi Quan Da Bu Wan 10 pills 3x daily (BP Brand)

Acupuncture

CV. 3, CV.4 & CV.6 (moxa box for 10 minutes), ST.36, GB.34, SP.6, Liv.3 and PC.6

Treatment Rationale

Chinese herbal formulae:

1)    Xiao Yao San is indicated for both Liver Blood deficiency as well as Liver Qi stagnation, which is supported by Maciocia (1998, p. 340 & 349) and Bensky (1990, pp. 147-148) .

Chi hu, Sheng Jiang and Bo He disperse Liver Qi stagnation; Bai Shao and Dang Gui nourish Liver Blood and calm the mind; Fu Ling and Gan Cao tonify the Spleen (Reid, 2007, p. 146) .

2)    Shi Quan Da Bu Wan, tonifies Qi & Blood and warms the Yang. This is in part supported by Maciocia (1998, p. 350) in that he suggests using Ba Zhen Wan. Shi Quan Ba Bu Wan is Ba Zhen Wan with the addition of two warming herbs - Huang Qi and Rou Gui.

Huang Qi, Dang Shen, Bai Zu, Fu Ling and Zhi Gan Cao tonify the Spleen Qi. Bai Shao, Shu Di Huang, Dang Gui and Chuan Xiong nourish Liver Blood. Bai Zu and Fu Ling dispel damp, while Dang Gui, Chuan Xiong activate the Blood and dispel stasis. Rou Gui warms the Spleen and Kidney, promoting circulation of Qi and Blood (Reid, 2007, p. 103) .

Acupuncture

Maciocia (1998, p. 340 & 349) provides the following rational for the points used in the treatment of this patient:

CV.4 & CV.6: CV.4 nourishes the Blood and regulates the Conception Vessel, while CV.6 in combination with GB.34 moves Qi in the lower abdomen.

ST.36 & SP. 6 nourish Blood. Sp.6 also moves Liver-Qi and calms the Mind.

Liv.3 in conjunction with GB.34 soothes the Liver and eliminates stagnation.

PC.6: moves Liver-Qi, cams the Mind and settles the Ethereal Soul.

 

Ongoing Treatment of Patient

2^nd Appointment (2 weeks after initial consultation):

The patient’s second visit (25/03/2010) was two weeks after her first consultation, which was day 27 of her menstrual cycle. She reported a marked decrease in her usual symptoms associated with PMS. However there was still a dull abdominal ache and some irritability to a much lesser extent.

The above TCM prescription and Acupuncture treatment was continued unchanged.

 

3^rd Appointment – 31/03/2010:

Day-3 (started period on day 29).

Symptoms prior to period:

Irritability only on the day before.

Very little in terms of mood swings

No tenderness of breasts

No dysmenorrhoea.

No S.O.B.

No postural dizziness.

Occasional night sweats

Acid reflux is still occurs after most meals

Itchy skin improved to some extent

Bloating better, but flatulence is the same

Bowel motions continue to be slightly loose, but have improved.

Tongue: Still pale, virtually no coat.

 

4^th Appointment – 16/04/2010:

(Day 20)

PMS:

No symptoms of PMS as yet.

GIT:

No actual reflux, but some heartburn.

Bloating decreased

Decreased flatulence, but is still malodorous

Tongue: Still pale; no coating.

 

Prognosis and Treatment Response

At this stage no changes have been made to the Acupuncture or TCM prescriptions as the next period is about 8-10 days away. However, if symptoms continue to improve and if PMS symptoms do not reappear, her condition and treatment approach will be reassessed.

It is anticipated that this patient will be free of symptoms associated with PMS and that her GIT symptoms will be relieved. It has further been suggested that she start on a regular exercise regime, such as Yoga or Tai Chi.

The patient’s diet is very good and she adheres to a vegetarian diet, which includes eating some fish and dairy foods.

 

Integration between TCM and Western Medicine

Reports on integration between TCM and WM in the literature is sparse, however, one review (Girman, Lee, & Kligler, 2003) that looked at an integrative approach found that many women return to alternative medical approaches outside the biomedical system. Griman, et al., (2003) reviewed several categories of  Complimentary and Alternative Medical (CAM) approaches to the treatment of premenstrual syndrome, which included:

§       Conventional pharmaceuticals;

§       Psychotherapy;

§       Botanical and nutritional supplements;

§       Dietary manipulation;

§       Acupuncture;

§       Homeopathy;

§       Mind-body approaches i.e.: visualization, biofeedback, and hypnotherapy;

§       Chiropractic manipulation; and

§       Massage.

He concludes that: “…In the case of PMS, particularly given its multifactorial aetiology and its tendency to present in different ways in different women, this approach is well suited and will provide benefit for many patients”.

References

Bensky, D., Barolet, R. (1990). Chinese Herbal Medicine: Formulas & Strategies. Seattle, Wasington: Eastland Press, Inc.

Campagne, D. M., & Campagne, G. (2007). The premenstrual syndrome revisited. [doi: DOI: 10.1016/j.ejogrb.2006.06.020]. European Journal of Obstetrics & Gynecology and Reproductive Biology, 130(1), 4-17.

Cho, S.-H., & Kim, J. Efficacy of acupuncture in management of premenstrual syndrome: A systematic review. [doi: DOI: 10.1016/j.ctim.2009.12.001]. Complementary Therapies in Medicine, In Press, Corrected Proof.

Chou, P. B. Y., & Morse, C. A. (2005). Understanding premenstrual syndrome from a Chinese medicine perspective. Journal of Alternative & Complementary Medicine, 11(2), 355-361.

Chou, P. B. Y., Morse, C. A., & Xu, H. (2008). A controlled trial of Chinese herbal medicine for premenstrual syndrome. J Psychosom Obstet Gynaecol, 29(3), 185-192.

Freeman, E. W. (2003). Premenstrual syndrome and premenstrual dysphoric disorder: definitions and diagnosis. [doi: DOI: 10.1016/S0306-4530(03)00099-4]. Psychoneuroendocrinology, 28(Supplement 3), 25-37.

Girman, A., Lee, R., & Kligler, B. (2003). An integrative medicine approach to premenstrual syndrome. [doi: DOI: 10.1067/mob.2003.403]. American Journal of Obstetrics and Gynecology, 188(5, Part 2), S56-S65.

Habek, D., Habek, J. C., & Barbir, A. (2002). Using acupuncture to treat premenstrual syndrome. Arch Gynecol Obstet, 267(1), 23-26.

Halbreich, U. (2003). The etiology, biology, and evolving pathology of premenstrual syndromes. [doi: DOI: 10.1016/S0306-4530(03)00097-0]. Psychoneuroendocrinology, 28(Supplement 3), 55-99.

Indusekhar, R., Usman, S. a. B., & O'Brien, S. (2007). Psychological aspects of premenstrual syndrome. [doi: DOI: 10.1016/j.bpobgyn.2006.10.002]. Best Practice & Research Clinical Obstetrics & Gynaecology, 21(2), 207-220.

Jing, Z., Yang, X., Ismail, K. M., Chen, X., & Wu, T. (2009). Chinese herbal medicine for premenstrual syndrome. Cochrane Database of Systematic Reviews(1).

Kaptchuk, T. J. (1983). Chinese Medicine: The Web that has no Weaver. London: Rider.

Knaapen, L., & Weisz, G. (2008). The biomedical standardization of premenstrual syndrome. [doi: DOI: 10.1016/j.shpsc.2007.12.009]. Studies in History and Philosophy of Science Part C: Studies in History and Philosophy of Biological and Biomedical Sciences, 39(1), 120-134.

Kong, J. C., Lee, M. S., & Shin, B. C. (2009). Randomized clinical trials on acupuncture in korean literature: a systematic review. Evid Based Complement Alternat Med, 6(1), 41-48.

Lyttleton, J. (2004). Treatment of Infertility with Chinese Medicine. Edinburgh: Churchill Livingstone.

Maciocia, G. (1998). Obstetircs and Gynecology in Chinese Medicine. Edinburgh: Elsevier Churchill Livingstone.

Pinkerton, J. V. (2010, January, 2010). Premenstrual Syndrome (PMS)(Premenstrual Tension). from http://www.merck.com/mmpe/sec18/ch244/ch244g.html#sec18-ch244-ch244f-178

Reid, T. (2007). Essential Formulae: Practitioner's Clinical Guide (1st ed.). Melbourne: China Books.

Roberts, L. W., McCarty, T., & Severino, S. K. (2001). Premenstrual Syndrome Treatment Interventions. In S. F. Howard (Ed.), Assessment and Therapy (pp. 245-260). San Diego: Academic Press.

Salamat, S., Ismail, K. M. K., & O' Brien, S. (2008). Premenstrual syndrome. [doi: DOI: 10.1016/j.ogrm.2007.11.006]. Obstetrics, Gynaecology & Reproductive Medicine, 18(2), 29-32.

Simon, H. (2009). Premenstrual syndrome - Symptoms.   Retrieved 27/04/2010, 2010, from http://www.umm.edu/patiented/articles/who_gets_premenstrual_syndrome_000079_5.htm

Appendices

Appendix 1

Table A1 provides treatment approaches used in TCM for patterns associated with PMS. It provides TCM herbal prescriptions and Acupuncture points as prescribed by Maciocia (1998, pp. 340-356) .

TCM Pattern	TCM Herbal Prescription	Acupuncture
Liver-Qi stagnation	Xiao Yao San Yue Ju Wan Chai Hu Shu Gan Tang	Liv.3, GB.34, GB.41, SP.6, TH.6, PC.6. Reducing or even method.
Phlegm-Fire harassing upwards	Sheng Tie Luo Yin Wen Dan Tang Clear The Moon (Women’s Treasure remedy)	PC.7, ST.40, ST.8, Du.24, CO.11, Sp.4 (on the right) and PC.6 (on the left), CV.12, BL.20. Use reducing or even method on all except for CV.12 and BL.20 which should be reinforced.
Liver-blood deficiency	Xiao Yao San Gui Shao Di Huang Tang Ba Zhen Wan	CV.4, Lu.7 (on the right) and Kid.6 (on the left), SP.6, ST.36, GB.34, PC.6, CV.6, Liv.8, BL.20, BL.18. Reinforcing method except for GB.34, PC.6 and CV.6 which should be needled with even method. Moxa can be used.
Liver- & Kidney-Yin deficiency	Yi Guan Jian Qi Ju Di Huang Wan Nourish the Root (Three Treasures remedy)	Liv.8, CV.4, SP.6, Liv.3. Reinforcing method on all except Liv.3 which should be needled with even method.
Spleen- & Kidney-Yang deficiency	You Gui Wan Strengthen the Root (Three Treasures remedy)	BL.23, BL.20, Cv.4, ST.36, SP.6, Kid.3, Lu.7 (on the right) and Kid.6 (on the left). Reinforcing method, moxa should be used.