About premenstrual syndrome
Most women of reproductive age experience at least mild premenstrual symptoms at some time in their lives (O’Brien 1987). However, around 2–10% of women have premenstrual symptoms that severely disrupt daily living (O’Brien 1987, DTB 1992, Wittchen 2002). These more troublesome symptoms are usually termed ‘premenstrual syndrome’ (PMS), if they comprise recurrent psychological and/or physical symptoms that occur specifically during the luteal phase of the menstrual cycle and usually resolve by the end of menstruation (O’Brien 1987).
Diagnosis of PMS is based on the presence of at least five symptoms, including one of four core psychological symptoms, from a list of 17 physical and psychological symptoms (Steiner 2001; Freeman 2001). The 17 symptoms are depression, feeling hopeless or guilty, anxiety/tension, mood swings, irritability/persistent anger, decreased interest, poor concentration, fatigue, food craving or increased appetite, sleep disturbance, feeling out of control or overwhelmed, poor coordination, headache, aches, swelling/bloating/weight gain, cramps, and breast tenderness.
The cause of PMS is unknown, but hormonal and other factors (possibly neuroendocrine) probably contribute (Rapkin 19917; O’Brien 1993). The aim of conventional treatment is to improve or eliminate physical and psychological symptoms; to minimise the impact on normal functioning, interpersonal relationships, and quality of life; and to minimise adverse effects of treatment (Kwan 2009).
Drugs such as spironolactone, valprazolam, metolazone, NSAIDs, buspirone and gonadorelin analogues are used to treat the main physical and psychological symptoms of PMS (Kwan 2009). Surgery is indicated only if there are coexisting gynecological problems.
Freeman EW, Rickels K, Yonkers KA, et al. Venlafaxine in the treatment of premenstrual dysphoric disorder. Obstet Gynecol 2001;98:737–44.
Kwan I, Onwude JL. Premenstrual syndrome. Clinical Evidence. Search date July 2009
Managing the premenstrual syndrome. DTB 1992; 30: 69-72.
O’Brien PMS. Premenstrual syndrome. Oxford: Blackwell Scientific Publications, 1987.
O’Brien PMS. Helping women with premenstrual syndrome. BMJ 1993;307:1471–1475.
Rapkin AJ, Morgan M, Goldman L, et al. Progesterone metabolite allopregnanolone in women with premenstrual syndrome. Obstet Gynecol 1997;90:709–14.
Steiner M, Romano SJ, Babcock S, et al. The efficacy of fluoxetine in improving physical symptoms associated with premenstrual dysphoric disorder. Br J Obstet Gynaecol 2001;108:462–8.
Wittchen H-U et al. Prevalence, incidence and stability of premenstrual dysphoric disorder in the community. Psych Med 2002; 32: 119-32.
How acupuncture can help
A systematic review (Cho 2010) located ten randomised controlled trials and found some evidence to suggest acupuncture reduces PMS symptoms. However, trial quality was generally poor and further studies are needed to confirm this. (See table overleaf.)
Acupuncture may help reduce symptoms of PMS by:
- increasing relaxation and reducing tension (Samuels 2008). Acupuncture can alter the brain’s mood chemistry, reducing serotonin levels (Zhou 2008) and increasing endorphins (Han, 2004) and neuropeptide Y levels (Lee 2009), which can help to combat negative affective states.
- stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz, 1987, Zijlstra 2003, Cheng 2009);
- reducing inflammation, by promoting release of vascular and immunomodulatory factors Kavoussi 2007, Zijlstra 2003).
Cho SH, Kim J. Efficacy of acupuncture in management of premenstrual syndrome: A systematic review. Complementary Therapies in Medicine 2010; 18: 104-11.
A systematic review including 9 randomised controlled trials that assessed the effectiveness and adverse effects of acupuncture for the symptomatic treatment of PMS. Four studies reported a significant difference in reduction of PMS symptoms for acupuncture treatment compared with pharmacological treatment. Two studies reported improvements in primary symptoms within acupuncture and herbal medications groups compared with baseline. Only two trials reported information regarding acupuncture-related adverse events, which included one case of a small subcutaneous haematoma. The reviewers concluded that, although the included trials showed that acupuncture may be beneficial to patients with PMS, there is insufficient evidence to support this conclusion due to methodological flaws in the studies.
|Shin KR et al. The effect of hand acupuncture therapy and hand moxibustion therapy on premenstrual syndrome among Korean women.Western Journal of Nursing Research 2009; 31: 171-86.||A pilot study that compared the effects of hand acupuncture and hand moxibustion therapy with a control group (no treatment) 22 women with PMS. After acupuncture and moxibustion treatment, there were significant reductions in overall symptom reports, and in abdominal pain and bloating, compared with both pre-treatment levels and relative to controls. Rapid mood changes were also reduced in the post-treatment period in both the hand acupuncture and hand moxibustion groups, but not in the control group. The researchers concluded that hand acupuncture and hand moxibustion therapy may be effective strategies for women to reduce PMS symptoms.|
|Research on mechanisms for acupuncture in general|
Cheng KJ. Neuroanatomical basis of acupuncture treatment for some common illnesses. Acupunct Med2009;27: 61-4.
A review that looked at acupuncture treatment for some common conditions. It is found that, in many cases, the acupuncture points traditionally used have a neuroanatomical significance from the viewpoint of biomedicine. From this, the reviewers hypothesize that plausible mechanisms of action include intramuscular stimulation for treating muscular pain and nerve stimulation for treating neuropathies.
|Lee B et al. Effects of acupuncture on chronic corticosterone-induced depression-like behavior and expression of neuropeptide Y in the rats.Neuroscience Letters 2009; 453: 151-6.||In animal studies, acupuncture has been found to significantly reduce anxiety-like behaviour, and increase brain levels of neuropeptide Y, the brain levels of which appear to correlate with reported anxiety.|
|Samuels N et al. Acupuncture for psychiatric illness: a literature review. Behav Med 2008; 34: 55-64||A literature review of acupuncture for psychiatric illness, which presents research that found acupuncture to increase central nervous system hormones, including ACTH, beta-endorphins, serotonin, and noradrenaline. It concludes that acupuncture can have positive effects on depression and anxiety.|
|Zhou Q et al. The effect of electro-acupuncture on the imbalance between monoamine neurotransmitters and GABA in the CNS of rats with chronic emotional stress-induced anxiety. Int J Clin Acupunct 2008 ;17: 79-84.||A study of the regulatory effect of electro-acupuncture on the imbalance between monoamine neurotransmitters and GABA in the central nervous system of rats with chronic emotional stress-induced anxiety. The levels of serotonin, noradrenaline and dopamine fell significantly, while GABA levels were significantly higher in the rats given acupuncture (P<0.05, or P<0.0). The researchers concluded that the anti-anxiety effect of electro-acupuncture may relate to its regulation of the imbalance of neurotransmitters.|
|Kavoussi B, Ross BE. The neuroimmune basis of anti-inflammatory acupuncture. Integr Cancer Ther2007; 6: :251-7.||A review that suggests the anti-inflammatory actions of traditional and electro-acupuncture are mediated by efferent vagus nerve activation and inflammatory macrophage deactivation.|
|Zijlstra FJ et al. Anti-inflammatory actions of acupuncture. Mediators Inflamm 2003;12: 59-69.||A review that suggests a hypothesis for the anti-inflammatory action of acupuncture. Insertion of acupuncture needle initially stimulates production of beta-endorphins, calcitonin gene-related peptide (CGRP) and substance P, leading to further stimulation of cytokines and nitric oxide (NO). While high levels of CGRP have been shown to be pro-inflammatory, CGRP in low concentrations exerts potent anti-inflammatory actions. Therefore, a frequently applied ‘low-dose’ treatment of acupuncture could provoke a sustained release of CGRP with anti-inflammatory activity, without stimulation of pro-inflammatory cells.|
|Pomeranz B. Scientific basis of acupuncture. In: Stux G, Pomeranz B, eds. Acupuncture Textbook and Atlas. Heidelberg: Springer-Verlag; 1987:1-18.|
|Needle activation of A delta and C afferent nerve fibres in muscle sends signals to the spinal cord, where dynorphin and enkephalins are released. Afferent pathways continue to the midbrain, triggering excitatory and inhibitory mediators in spinal cord. Ensuing release of serotonin and norepinephrine onto the spinal cord leads to pain transmission being inhibited both pre- and postsynaptically in the spinothalamic tract. Finally, these signals reach the hypothalamus and pituitary, triggering release of adrenocorticotropic hormones and beta-endorphin.|