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Venturing beyond the prescription pad

Dr Karine Nohr looks at all the options available to treat premenstrual syndrome - including those you might not have thought of.

A significant proportion of women experience pre-menstrual symptoms that seriously impact on their quality of life. Despite this there is a lack of understanding of the causes of PMT, and inevitably this is reflected the inadequate armory we have to treat it.

The dynamic interplay of our environment and social systems, spirit, and physiology suggests that an integrated biopsychosocial approach may be the most therapeutic strategy.

As always, we need to be very patient-centred in this approach, finding where the patient is at in terms of making changes, what obstacles they identify, how they might address those obstacles and enabling them to identify how they might institute those changes. Advice is most useful when a person can problem-solve for themselves, with us having simply a role in enabling that process.

The first discussion may be centred on lifestyle, in particular: diet, exercise and stress management. Thirty minutes of daily exercise leads to fewer symptoms of PMT and improved sense of wellbeing and improved mood.

Meditation, breathing, yoga and CBT are all routes by which a person may develop a greater sense of their own agency, which in itself may lead to a reduction of symptoms of PMT.

Reduced caffeine intake in the luteal phase has been found to improve breast tenderness and reduce irritability.

If these measures are not enough to gain satisfactory symptom control, what prescribable options are there?

In conventional medicine, drugs used have included NSAIDs, antidepressants, contraceptive pills and spironolactone. The only one with some trial-based evidence behind them are SSRI's. Progestone use in the luteal phase is not backed by evidence.

However, there is evidence that calcium supplements, given for three months, leads to a significant reduction of PMT symptoms. Considering that adequate calcium intake is an important aspect of a good diet, this may be a useful intervention, at a dosage of 500mg bd. Though there may be many other explanations to consider, (we can only work with the information that we have at our disposal) the Nurse's Health Study 2 showed that those with vitamin D intake in the highest quartile had a relative risk of 0.59 of PMT as compared with those in the lowest quartile, and as we need vitamin D to absorb the calcium, a combination supplement could be given.

A double blind placebo controlled crossover trail of magnesium in PMT demonstrated reduced swelling of extremities, mastalgia and abdominal bloating. Magnesium can also be useful for menstrual migraine and uterine cramps. Magnesium can be found in green leafy vegetables, tofu, legumes, nuts, seeds, and whole grains, as well as many multivitamin preparations.

Vitamin B6 and evening primrose have been used for negative mood symptoms (B6) and mastalgia (EPO) but the evidence for this isn't there.

Herbal approaches include vitex agnus castus(chasteberry), actea racemosa (black cohosh), St John's Wort, angelica (Dong Quai) and ginkgo baloba.

The name agnus castus (chaste lamb) refers back to its use by monks to curb their libido. I have been really quite impressed by the use of vitex for PMT in some of my patients. It has a long history of use for menstrual disorders. Usual dosage is 40-60mg/d.

The properties of black cohosh include muscle relaxant, sedative and relief of menopausal symptoms, the German health authorities endorse its use for dysmenorrhoea, menopause and premenstrual discomfort (dosage 40-160mg/d).

In traditional Chinese medicine, PMT implies probable liver Qi stagnation (the liver is failing to circulate the Qi and it is getting blocked). TCM can be very effective for the treatment of this problem.

Dr Karine Nohr is a GP in Sheffield

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Dr Karine Nohr


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