Treatment of premenstrual syndrome

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1 Journal of Medicinal Plants Research Vol. 5(26), pp , 16 November, 2011 Available online at ISSN Academic Journals DOI: /JMPR Review Treatment of premenstrual syndrome Muhammad Akram 1 *, Naveed Akhtar 2, H. M. Asif 1, Pervaiz Akhtar Shah 3, Tariq Saeed 3, Arshad Mahmood 4 and Nadia Shamshad Malik 5 1 Department of Basic Medical Sciences, Faculty of Eastern Medicine, Hamdard University, Karachi, Pakistan. 2 Faculty of Pharmacy and Alternative Medicine, The Islamia University of Bahawalpur, Pakistan. 3 University College of Pharmacy, The University of Punjab Lahore, Pakistan. 4 Department of Pharmaceutical Sciences, COMSATS Institute of Information Technology, Abbottabad, Pakistan. 5 School of Pharmacy, The University of Lahore, Islamabad Campus, Islamabad, Pakistan. Accepted 26 September, 2011 Premenstrual syndrome (PMS) is characterized by a spectrum of physical and mood symptoms, which appear during the week before menstruation and usually resolve within a week after the onset of menses. Most women in their reproductive years experience some premenstrual symptoms. In some women, the symptoms can badly affect quality of life before periods. The treatment of PMS is a changing area as research continues to clarify which treatments actually work and to try to find better treatments. The main objective of the present article is to review the potential treatment for premenstrual disorders. Various treatments have been advocated for PMS. Treatment strategies include either eliminating the hormonal cycle associated with ovulation or treating the symptom(s) causing the most distress to the patient. Herbal drugs are effective and well tolerated treatment for the relief of symptoms of the premenstrual syndrome. Key words: Premenstrual syndrome, research study, treatment option. INTRODUCTION A syndrome that occurs in many women from two to fourteen days before the onset of menstruation is known as premenstrual syndrome (PMS). It is a collection of physical, psychological, and emotional symptoms related to a woman's menstrual cycle. PMS is now viewed as a complex psychoneuroendocrine disorder (Jarvis et al., 2008). Premenstrual syndrome affects emotional and physical well being of women (Halbreich, 1995). Premenstrual syndrome is not a single disorder, but a group of menstrually related disorders and symptoms (Braverman, 2007). Premenstrual syndrome is the constellation of emotional, behavioral, and physical symptoms that occur during the premenstrual (luteal) phase of the menstrual cycle and resolve after the start of menses (Whitehead et al., 1986). A premenstrual symptom affects daily life. PMS most commonly affects women aged 30 to 40 years. Preliminary studies suggest that up to 40% of women with symptoms of PMS have a significant decline in their circulating serum levels of beta-endorphin (Bancroft et al., 1994). Many treatments have been suggested for PMS, including diet or lifestyle changes, and other supportive means. Different treatments have been advocated for PMS. The treatment of PMS is a changing area as research continues to clarify which treatments actually work and to try to find better treatments (Facchinetti et al., 1994). By staying up to date with current research on premenstrual disorders and new management options, physicians can help women to better understand their symptoms and benefit from a rational, individualized treatment plan (Halbreich et al., 1993). The main objective of this study is to review the potential treatment for premenstrual disorders, data are obtained from published articles identified using the search terms premenstrual syndrome (PMS) and premenstrual syndrome symptoms and treatment. Pubmed gives 1231 hits with the search terms Premenstrual syndrome, symptoms, and treatment. *Corresponding author. makram_0451@hotmail.com. Tel: Fax: ETIOLOGY OF PREMENSTRUAL SYNDROME The true etiology of PMS is the consequence of complex

2 Akram et al and poorly understood interactions between ovarian hormones, endogenous opioid peptides, neurotransmitters, prostaglandins, and the circadian, peripheral, autonomic, and endocrine systems. Secondary causes of deficient corpus luteum production are defective liver, heart, or kidney function and hyperprolactinemia. Hormonal changes Hormone levels may fluctuate due to the decreased production of sex hormones after ovulation has taken place (Freeman et al., 1997). Brain chemicals Fluctuations of serotonin in the brain may lead to mood swings and depression. Opioid peptides These are also brain chemicals that fluctuate in response to the hormones. Other possible causes may include a poor diet, mineral and vitamin deficiency, and stress. Sign and symptoms of premenstrual syndrome (Lopez et al., 2009) (1) Bloating and weight gain (2) Breast swelling, tenderness (3) Mood swings (4) Depression and anxiety (5) Skin problems (6) Changes in appetite, food cravings (7) Changes in interest in sex (8) Headaches, backaches, cramps (9) Not being able to concentrate, loss of interest in usual activities, confusion. Management of premenstrual syndrome Common pharmacologic treatments include the use of natural progesterone and synthetic progestins, diuretics for edema, antiprostaglandins, bromocriptine, a dopamine receptor agonist, and pyridoxine, a watersoluble B vitamin for PMS. Nonpharmacologic interventions such as cognitive therapy, relaxation responses, reflexology, and massage therapy result in effective PMS control. Allopathic prescription Fluoxetin (prozole), setraline (zoloft), paraxetin (paxil), citalophara (celexa), certain selective serotonin reuptake inhibitor (SSRI). Progesterone suppositories/ pessaries Progesterone suppositories/ pessaries are used for the treatment of the pre-menstrual syndrome including premenstrual tension and depression. Progesterone vaginal gel Progesterone vaginal gel is prescribed for the management of disorders associated with progesterone deficiency such as premenstrual syndrome. Norethisterone tablets Norethisterone tablets are used for treatment of premenstrual syndrome including premenstrual mastalgia. Dydrogesterone tablets Dydrogesterone tablets are prescribed for treatment of premenstrual syndrome, 10 mg twice daily from day 12 to 26 of cycle. Levonorgestrel Levonorgestrel is prescribed in premenstrual tension. Bromocriptine Bromocriptine is usually prescribed in cyclical benign breast disease/ cyclical pronounced mastalgia. In the premenstrual syndrome there is some evidence that other symptoms such as headache, mood changes and bloatedness may be alleviated. Gamolenic acid It is prescribed for symptomatic treatment of premenstrual cyclical mastalgia and non-cyclical breast pain. Danazol It is prescribed for treatment of severe cyclical breast pain.

3 6124 J. Med. Plants Res. Bendroflurazide It is prescribed in premenstrual oedema. Hydrochlorothiazide It is prescribed in premenstrual edema (James et al., 2007). Mefruside It is prescribed in premensterual edema (Auld et al., 1971). Ayurvedic treatment Saraca indica, Cyperus rotundas, Mesua ferrea, Lotus flower. anti-inflammatory activity. Majoon dabeed ul warid contains Cymbopogon jawarancusa, Aqeullaria agallocha, Valariana officinalis, Bambusa arundinaceae, Cichorium intybus, Apium graceolens, Commiphora stocksiana, Cinnamomum cassia, Aristolochia indica, Saussurea cappa, Rosa damascene, Delphinium zalil, Laccifer lacca, Rubia cordifolia, Crocus sativus, Pistacia lentiscus (Barrero, 2005). Treatment of appetite changes in premenstrual syndrome Jawarish Kamoni is herbal coded formulation that is prescribed for indigestion. It helps in digestion and increases appetite. Jawarish Kamoni contains Ruta graveolens, Armenian bole, Zingiber officinale (Kawai, 1994), Corum carv and Piper nigrum. Direction: To be taken in the morning or after principal meals. Dose: 5 to 10 g Complementary and alternative therapies A comprehensive treatment plan for PMS may include a range of complementary and alternative therapies (Moline et al., 2005). Herbal treatment There are different types of Unani medicine dosage forms which are being prescribed for the treatment of premenstrual syndrome. The dosage form prescribed is categorized as follows: aqueous extract (Joshanda), pills (Hab), tablet (Qurs), electuary (Majun), ointment (Marham). The different prescriptions are delineated herewith. Further the proprietary herbal medicine are prescribed according to sign and symptoms. All these are described alongwith the component and composition (Eisenberg et al., 1998). Herbs used in uteritis Marham dakhlioon is usually prescribed in uteritis. It contains Plantago ovata seeds, Linum usitattisimum seeds, Althae officinale seeds, Phyllanthus emblica seeds, Trigonella foenum graecum, Sesamum indicum oil, Ricinus communis, honey bee wax (Blumenthal et al., 2000; Nosal ova et al., 1992). Majoon dabeed ul warid Majoon dabeed ul warid is prescribed for liver disorders. It is also effective in premenstrual syndrome due to its Treatment of insomnia in premenstrual syndrome Somina is a herbal formulation that is usually used fro treatment of insomina. Somina contains Prunus amygdalus (Badam), Lagenaria vulgaris (Kaddu), Papaver somniferum (Khaskhash), S. indicum (Til), Lactuca serriola (Kahu) Freeman et al., 2010; Kest et al., 2001; Medina et al., 1997). Treatment of anxiety in premenstrual syndrome Sherbet Ahmed Shah is usually used for treatment of anxiety. Sharbat Ahmed Shah contains Cuscuta reflexa (Aftimun), Lavandula stoech as (Ustukhuddus), Nepeta hindostana (Badrang Boya), Cassia senna (senna), Polypodium vulgare (Bisfaij), Nymphea alba (Nilofar), Rosa damascena (Gulab), Ocimum basilicum (Franjmushk), Terminalia belerica (Halilah Siyah), Viola odorata (Banafshah), Onosma echoides (Gaozaban) (Mustafa et al., 1990; Paladini et al., 1999). Treatment of depression in prementrual syndrome Selective serotonin reuptake inhibitors (SSRIs) may be prescribed continuously throughout the menstrual cycle, or may be given in intermittent fashion during the luteal phase of the cycle. Muffareh Shaikh-al-Rais is Unani formulation. It has been used as a brain tonic since centuries. Muffareh Shaikh-al-Rais contains Aquillaria agallocha (agar), Onosma echioides (gaozaban), Elettaria cardamomum (Ilaichi Khurd), Santalum album (Sandal Safaid), Pterocarpus santalinus Sandal Surkh), Bambusa arundinacea (Banslochan), Centurea behen

4 Akram et al Behman Safaid), Lactuca serriola (Kahu), Rosa damascene (Gulab), Doronicum hookeri (Daronj Aqrabi), Portulaca oleracea (Khurfa Siyah), L. vulgaris (Kaddu), Curcuma zeddoria (Zaranbad), Scilla serrata (Crab), Cucumis melo (Khurbuza), Cucumis sativus (Khiyarain), Cinnnamomum camphora (Kafur), Coralium rubrum (Marjan, Coral), Bombyx moris (Abresham Muqraz), Crocus sativus (Zafran), mixed with honey, apple, Pyrus cydonia (Behi) juices (Kulkarni et al., 1996). Treatment of pain in premenstrual syndrome Thus, the management of PMS is important for women s health. However, there is considerable debate regarding the nature and extent of PMS symptoms. Barshaasha is Unani formulation that is usually prescribed in pain. Barshaasha contains Valeriana walichii (Balchar), Hyoscymus niger (Ajwain khurasani), Papver somniferum, (Khaskhash), Violoa odorata (Banafshah), Onosma echoides (Gaozaban), Anacyclus pyrethrum (Aqarqrah), P. nigrum (Filfil Siyah), Euphorbia caudicifolia (Halima, 2004). PMS and traditional Chinese medicine (TCM) One of the most commonly used TCM formulas, employing the roots of bupleurum (Bupleurum Chinense), dong quai (Angelica sinensis), peony (Paeonia lactiflora), and licorice (Glycyrrhiza glabra), focuses on liver function and strengthening the blood (Dhingra et al., 2006). example, premenstrual syndrome, painful or heavy menstruation, hot flashes during menopause, emotional and physical symptoms during and after pregnancy, candidiasis, and a sagging and prolapsed uterus (Steven, 1997). Exercise Not more than 30 min and thrice a week if aerobic activity is practiced it can lighten up mood swings, internal frustration could be minimized and tendency to tolerate could be increased. Physical activity like exercise can reduce body aches, fluid retention and tenderness of breast. Production of endorphin is increased by exercise endorphin which relevantly soothes mild depression (Wyatt et al., 2000). Nutrients 1. Vitamin E- 400 IU/day- Breast tenderness 2. Vitamin B-6-50 mg/day- Premenstrual syndrome, 50 to 100 mg daily 3. Magnesium- 200 mg/day- Deficient in PMS, muscle relaxant 4. Calcium- 200 mg/day- Deficient in PMS, water retention, mood 5. Chromium- 200 mcg/day- Sugar cravings 6. Borage oil- 150 mg/day- Cramps, breast tenderness 7. 5-HTP- 100 mg before bed- Depression, PMDD (Daugherty, 1998). Homeopathy for premenstrual syndrome Current treatments for premenstrual syndrome (PMS) appear to offer, at best, a 25 to 50% reduction in symptoms. Homeopathic treatments work to stimulate the body into righting any emotional or physical upsets that produce PMS symptoms. It uses highly diluted doses of natural substances that would cause PMS symptoms if given in full strength to a healthy person. The substances are from plant, mineral, and animal sources (including snakes). A remedy is individualized to each patient and depends on her particular mix of emotional and physical symptoms, as well as her general state of emotional and physical health (Klein-Laansma et al., 2010). For example, if a woman with PMS easily becomes weepy, she may be prescribed one of several remedies, including, Pulsatilla nigricans of Pulsatilla have been used to treat reproductive problems such as premenstrual syndrome and epididymitis. Other applications of this plant include uses as a sedative and for treating coughs (Ernst, 2005). Sepia, a cuttlefish ink acts on the uterus, ovaries, and vagina and is mainly used for gynecological problems, for DISCUSSION Premenstrual syndrome (PMS) is a condition of cyclical and recurrent physical and psychological discomfort occurring 1 to 2 weeks before menstrual period. More severe psychological symptoms have been described for the premenstrual dysphoric disorder (PMDD). No single treatment is universally recognised as effective and many patients often turn to therapeutic approaches outside of conventional medicine. It has been suggested that some of the symptoms typically attributed to menopause may be more related to premenstrual syndrome (PMS) than menopause, as perimenopausal women appear to be more prone to PMS-like symptoms, or at least to tolerate them less well (Van Die et al., 2009). Increased levels of the hormone prolactin are often responsible for menstrual irregularities and pre-menstrual syndrome; agnus-castus has been shown to inhibit its production and clinical trials have demonstrated that this can help regularise the menstrual cycle, improving symptoms such as breast tenderness, mood swings, fluid retention and headache. Agnus-castus may also be used to treat acne with a hormonal cause (Atmaca et al.,

5 6126 J. Med. Plants Res. 2003). Retrospective community surveys estimate that some 30 to 90% of women have suffered from premenstrual symptoms (Chung et al., 1996; Jeong et al., 2001; Lee et al., 1994). Antidepressants called SSRIs (for example, Prozac) are usually in the treatment of severe PMS where the symptoms are mostly depression, mood swings, irritability (Brown et al., 2009). Hormonal contraceptive methods suppress ovulation; thus, combined oral contraceptive pills or a progestin-only contraceptive agent may provide relief of PMS. Diuretic like spiranolactone is effective for treatment of fluid retention. Several nonsteroidal anti-inflammatory drugs (NSAIDs) are effective for treatment of dysmenorrhea, and their use has been recommended for other perimenstrual discomforts (Woods et al., 1985). Extra estrogen (one of the female hormones) via patches or implants can suppress ovulation and reduce the naturally occurring hormone fluctuations (Lopez et al., 2009). Danazol (for example, Danol) is a synthetic hormone based on the male hormone testosterone. Its use in PMS is supported by scientific studies (Yonkers et al., 1997). Recommended daily dosage includes calcium 1,000 mg, magnesium 400 mg, manganese 6 mg and Vitamin E 400 IU. A study was carried out to evaluate the efficacy of Agnus castus for treatment of premenstrual syndrome. It was observed that dry extract of Agnus castus fruit is an effective and well tolerated treatment for the relief of symptoms of the premenstrual syndrome (Schellenberg, 2001). Calcium supplementation is a simple and effective treatment in premenstrual syndrome, resulting in a major reduction in overall luteal phase symptoms (Thys et al., 1998). A study was carried out that shows a yearly decrease in the number of prescriptions linked to diagnoses for premenstrual syndrome. Progestogens including progesterone, are the most commonly prescribed treatment for premenstrual syndrome despite the lack of evidence demonstrating their efficacy (Katrina et al., 2002). CONCLUSION Herbal medicines are effective for managing the symptoms of PMS. Premenstrual symptoms are complex but highly treatable disorders. Premenstrual syndrome (PMS) can be successfully managed with lifestyle changes, dietary modifications, complementary therapies and prescription medications. Lifestyle changes to manage PMS include regular exercise, not smoking, cutting back on alcohol and caffeine and getting more sleep. Nutritional supplements are helpful in reducing symptoms of premenstrual syndrome. Although some women report relief of PMS symptoms with the use of herbs such as evening primrose oil and saffron, few scientific studies prove the effectiveness of herbs thought to help reduce the effects of PMS. REFERENCES Atmaca M, Kumru S, Tezcan E(2003). 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