Management of a Patient With Premenstrual Syndrome Using Acupuncture, Supplements, and Meditation: A Case Report

Abstract

Objective

The purpose of this case report was to describe a multimodal approach for the treatment of premenstrual syndrome (PMS).

Clinical Features

A 36-year-old nulliparous woman presented to a free clinic for veterans and their spouses. She received a PMS diagnosis at age 18. She was previously prescribed hormonal birth control and nonsteroidal anti-inflammatory drugs, which minimally affected her condition. She stopped using conventional medicine therapies at age 27. Laboratory results showed that her progesterone was below 0.5 ng/mL. Her symptom score was 50 out of 60 on the Treatment Strategies for PMS assessment tool. During her menses, she experienced low back pain and stiffness, bloating, swelling, weight gain, breast tenderness, swelling, and pain, and she felt overwhelmed and stressed.

Intervention and Outcome

Traditional Chinese medicine acupuncture was administered in conjunction with 100 mg of coenzyme Q10 (ubiquinol) and a B-100 complex once a day and 400 mg of magnesium citrate, 1000 mg of flaxseed oil (Linum usitatissimum), and 1000 mg of turmeric (Curcuma longa) twice a day. Five days before the onset of her menstrual period, she was to ingest a B-100 complex twice a day and 400 mg of magnesium citrate, 1000 mg of flaxseed oil, and 1000 mg of turmeric 3 times a day. Mindfulness meditation was encouraged twice a day for 10 minutes to reduce stress. After 12 treatments over 3 months, her symptom score decreased to 18 out of 60 and remained below 20 for an additional 32 weeks.

Conclusion

This patient with PMS symptoms positively responded to a multimodal approach using traditional Chinese medicine–style acupuncture, dietary supplements, and mindfulness meditation.

Introduction

Premenstrual syndrome (PMS) is a condition that occurs during the luteal phase of the menstrual cycle and dissipates upon cessation of menstruation and is characterized by persistent psychological and/or physical symptoms.¹ The predominant psychological symptoms include anxiety, restlessness, irritability, depression, difficulty concentrating, short-temperedness, and crying, with the physical symptoms manifesting as abdominal, back or low back pain, nausea, constipation, bloating, headaches, fatigue, breast tenderness, and appetite changes.^{1, 2, 3, 4} It is estimated that 95% of women of reproductive age experience PMS.¹ A majority of women with PMS have mild to moderate symptoms, yet around 20% are afflicted with severe symptoms that interfere with their activities of daily life.³

The primary mechanism that is believed to contribute to the development of PMS is a fluctuation in hormone levels.^2,3 Hormonal fluctuations creating estrogen dominance and progesterone deficiency are common models thought to result in PMS symptoms.³ Another possible explanation is the interaction between progesterone and neurotransmitters, such as gamma-aminobutyric acid, serotonin, opioids, or catecholamines.³ This seems possible, as research shows that progesterone can bind to gamma-aminobutyric acid receptors, altering their configuration and inhibiting its activity.⁵ A deficiency of serotonin, in combination with a greater sensitivity to progesterone, may account for PMS symptoms.³ Another cause of PMS could be elevated levels of prolactin, resulting in a hormonal imbalance.³ A dysfunction of glucose metabolism and insulin resistance has been correlated with PMS symptoms.³ Abnormal function of the hypothalamic-pituitary-adrenal axis is another possible mechanism.³ Stress and higher levels of prooxidants and inflammatory mediators can exacerbate PMS symptoms.^3,6,7

One treatment option is a cyclic hormonal contraceptive with monophasic, biphasic, or triphasic regimens.⁸ These pharmaceuticals disperse estrogen or progesterone derivatives or a combination of the 2 hormones.⁸ The possible adverse events that women using hormonal therapy experience are abnormal menstrual bleeding, amenorrhea, nausea, breast tenderness, headaches, and mood swings.⁹ In one study, 18.5% of participants withdrew due to the undesirable effects of hormonal contraceptive therapy.¹⁰ In another study, the prevalence of PMS symptoms in patients prescribed hormonal contraceptives was analyzed. Of the 205 participants enrolled, 182 patients experienced PMS symptoms accounting for 88.8% of participants.¹¹ Consequently, women utilizing hormonal contraceptives as a form of therapy may still experience PMS symptoms. In addition, hormonal contraceptives increase the risk of breast cancer by 20%.¹² Thus, some patients may avoid these treatments.

Selective serotonin reuptake inhibitors are another form of treatment available. Physicians may administer selective serotonin reuptake inhibitors to patients as an alternative to hormonal therapy.¹³ These medications impede the presynaptic reuptake by prolonging its action on the postsynaptic neuron.¹⁴ Selective serotonin reuptake inhibitors can cause side effects that result in the discontinued use of the medication.¹³

Evidence about alternative therapies for the treatment of PMS is limited; however, traditional Chinese medicine (TCM)–based acupuncture, flaxseed oil (Linum usitatissimum), coenzyme Q10 (ubiquinol), and turmeric (Curcuma longa) may have a positive impact on PMS symptoms.^{15, 16, 17, 18} In addition, acupuncture, flaxseed oil (L usitatissimum), coenzyme Q10 (ubiquinol), magnesium, turmeric (C longa), and B vitamins have promise to reduce PMS symptoms.^{19, 20, 21, 22, 23, 24} Meditation and acupuncture aim to control stress and psychological symptoms associated with PMS.^25,26

Women utilizing hormonal medications may still experience PMS symptoms, and there is an increased risk of breast cancer with the use of hormonal contraceptives; thus, some patients seek other therapeutic modalities to control PMS symptoms.^11,12 Therefore, the purpose of this case report is to describe a multimodal, natural medicine treatment plan using acupuncture, flaxseed oil (L usitatissimum), coenzyme Q10 (ubiquinol), magnesium, turmeric (C longa), and B vitamins for the treatment of a patient with PMS.

Case Report

A 36-year-old nulliparous woman presented with symptoms of PMS to a free acupuncture clinic for veterans and their spouses. Her menses began at age 12, and her PMS symptoms onset at age 18. Her gynecologist prescribed her an oral hormonal birth control medication at that time. Birth control minimally improved her PMS symptoms. She was prescribed several different hormonal birth control medications from the onset of her symptoms until age 27. She tried over-the-counter nonsteroidal anti-inflammatory drugs in conjunction with hormonal therapy, which did not alleviate her symptoms. Due to minimal improvement, she discontinued the use of conventional medicine therapies.

On September 24, 2020, laboratory results revealed that her levels of follicle-stimulating hormone, luteinizing hormone (LH), estradiol, estrone, and testosterone were within normal reference ranges. However, her progesterone was abnormal at less than 0.5 ng/mL. She was employed as a nurse for a home care facility. As a nurse, especially during the coronavirus pandemic, she considered her job to be stressful. Her cycle was regular, lasting 28 days without intermittent bleeding or spotting. A week prior to the onset of her menses, she would feel anxious in anticipation of the pain and discomfort that she experienced. She had a heavy menstrual flow with clots for 5 days.

During her menses, she reported that she experienced moderate to severe PMS symptoms. The Treatment Strategies for PMS form is a clinical assessment checklist of the major symptoms presenting in patients with PMS. The tool has been used to evaluate therapeutic approaches for PMS treatment for over 20 years and is considered efficacious for measuring clinical improvement.²⁷ The Treatment Strategies for PMS form ranged from 1 to 6, with 1 signifying no change from normal and 6 representing a severe presentation of symptoms. The assessment tool had a minimum score of 10 and a maximum score of 60. Her most intense symptoms were low back pain and stiffness, which was rated at a 6 out of 6 according to the assessment tool. Her other prominent symptoms were feeling bloated with water retention, swelling, and puffiness contributing to weight gain. Each of these symptoms was ranked at a 6 out of 6 on the scale. She rated her breast tenderness, swelling, and pain at a 5 out of 6. Her stress level was a 4 out of 6, and her feeling of being overwhelmed was a 5 out of 6. Her stress exacerbated her emotional symptoms, such as sadness, irritability, and short-temperedness, which were all rated at a 4 out of 6. Lastly, she rated her abdominal pain and discomfort at a 4 out of 6. Her initial score, according to the assessment tool, was 50 out of 60. A diagnosis of PMS was confirmed based on her medical history and presenting symptoms.

Traditional Chinese medicine theory based on historical context was used to formulate an Eastern medicine diagnosis. She experienced gas and bloating with loose stool occasionally and craved sweet foods. Her pulse was wiry on the right and choppy on the left at the spleen position. Her tongue was swollen and quivering. Her TCM diagnosis based on her history and clinical presentation was kidney and spleen qi deficiency.

The treatment strategy using TCM theory was to reinforce kidney function and foster spleen qi. Manual acupuncture therapy was performed using DBC Spring Singles. The depth of needle insertion was 0.25 to 0.5 cun, depending on the location of the point. The Chinese gauge was 38 for 15- × 0.18-mm needles, which were employed in the head, wrists, ankles, and feet. The torso and larger portions of the extremities were treated with 30- × 0.25-mm needles with a Chinese gauge of 32. The acupuncture points selected for her treatment were SP3 (Tai Bai) right (R), SP4 (Gong Sun) left (L), SP6 (San Yin Jiao) B/L, GB21 (Jian Jing) B/L, GB34 (Yang Ling Quan) L, UB11 (Da Zhu) bilateral (B/L), UB20 (Pi Shu) B/L, UB23 (Shen Shu) B/L, UB57 (Cheng Shan) B/L, ST36 (Zu San Li) L, KD3 (Tai Xi) L, KD6 (Zhao Hai) R, KD10 (Yin Gu) B/L, LI11 (Qu Chi) R, GV16 (Feng Fu), GV20 (Bai Hui), PC4 (Xi Men) B/L, LR 2 (Xing Jian) B/L, and HRT 7 (Shen Men) B/L.

The patient was advised to take a combination of supplements 2 times a day. The supplement regimen consisted of 100 mg of coenzyme Q10 (ubiquinol) and a B-100 complex (100 mg thiamin HCl, 100 mg riboflavin, 100 mg niacinamide, 100 mg pyridoxine HCl, 100 mg calcium-D pantothenate, 100 μg folic acid, 100 μg cyanocobalamin, 100 μg biotin, 100 mg inositol, 100 mg para-aminobenzoic acid, and 100 mg choline bitartrate) once a day, and 400 mg of magnesium citrate, 1000 mg of flaxseed oil (L usitatissimum), and 1000 mg of turmeric (C longa). In addition, 5 days prior to the onset of her menstrual period, she was to ingest a B-100 complex twice a day in conjunction with 400 mg of magnesium citrate, 1000 mg of flaxseed oil (L usitatissimum), and 1000 mg of turmeric (C longa) 3 times a day. It was recommended that the patient practice mindfulness meditation 2 times a day for 10 minutes each session to control her stress. The meditations were available through a free mobile application.

Response to Care

Her symptom score, according to the Treatment Strategies for PMS assessment tool, was 50 out of a total possible 60 at baseline. Her first menses after 4 weeks of treatment was recorded at 35 out of 60, indicating that her symptoms were almost one-third lower than when she started. After 6 weeks of treatment, she reported that she felt less stressed and anxious on a daily basis, and she no longer felt anxious prior to her menstrual period. At 8 weeks after her second period, her total symptom score dropped to 29. The length of her menstrual period did not change. However, the patient described her menstrual period as less intense. During the first 3 days of her menses, she experienced a moderate flow with a few clots and a light flow the 2 subsequent days. At the 12-week mark of her treatment, her symptom score was 18, and with the exception of week 16, it remained below 20 according to the assessment tool for the remainder of her treatment. This signified that her overall symptom score was 60% lower than baseline and was sustained at that level for 44 weeks. Her symptoms, according to the Treatment Strategies for PMS assessment tool, are available in Table 1.

Table 1.

PMS Symptom Score

	Pain, tenderness, enlargement or swelling of breasts	Feeling unable to cope or overwhelmed by ordinary demands	Feeling under stress	Feeling sad or blue	Backaches, joint and muscle pain, or joint stiffness	Outbursts of irritability or bad temper	Weight gain	Relatively steady abdominal heaviness, discomfort or pain	Edema, swelling, puffiness or water retention	Feeling bloated	Total score
Baseline	5	5	4	4	6	4	6	4	6	6	50
4 weeks	4	3	4	3	4	4	4	3	3	3	35
8 weeks	4	3	4	3	3	3	3	2	2	3	29
12 weeks	3	2	2	1	2	2	2	2	1	1	18
16 weeks	3	2	2	2	2	2	2	1	2	2	20
20 weeks	2	1	2	1	1	2	1	2	1	1	14
24 weeks	2	1	1	2	2	1	1	2	1	2	15
28 weeks	2	3	3	1	3	1	1	1	1	1	17
32 weeks	2	1	2	1	1	1	2	1	1	1	13
36 weeks	2	1	2	1	2	1	2	2	1	2	16
40 weeks	2	2	2	1	1	1	1	1	1	1	13
44 weeks	2	1	1	1	1	1	1	1	1	1	11

*Most severe symptoms 6; Least Severe 1; Maximum score of 60; Minimum symptom score 10.

At 28 weeks, she received a promotion and had to learn the responsibilities of a new job position, which caused more stress than usual. As a result, she experienced a slight exacerbation of symptoms, characterized by a minimal increase in her overall level of stress and her ability to cope with ordinary demands. She also had more intense backaches, joint and muscle pain, and joint stiffness. Overall, her PMS symptoms were marginally impacted by this change, and her symptom score increased from 15 to 17. She was able to adapt to the situation and cope with her stress more efficiently than in the past, and her subsequent menses was recorded at a 13, according to the Treatment Strategies for PMS assessment tool, indicating that her exacerbation of symptoms subsided. She remarked that her menses at week 32 was the most well-tolerated she had experienced since adolescence. At week 36 of treatment, on April 13, 2022, her primary care physician performed laboratory testing and determined that her progesterone increased to normal at 7.4 ng/mL. Treatment was administered for 44 weeks. At 44 weeks, her treatment score, according to the assessment tool, was 11 with the lowest score possible being a 10. The patient provided consent for the publication of this case report.

Discussion

This case presentation reflects a case of PMS in which a patient did not respond to standard therapy using conventional medicine and may have responded favorably to natural medicine therapies. This case is unique as this combination of therapies has not been previously utilized to treat PMS symptoms in a patient that did not respond to pharmaceuticals. In addition, human trials evaluating the ability of these therapeutic modalities to raise progesterone in patients with PMS are limited.

The modalities and supplements were selected to raise progesterone, reduce the inflammatory process, increase antioxidant status, and alleviate cramping pain. The primary agent selected to reestablish progesterone levels was flaxseed oil (L usitatissimum).¹⁶ Coenzyme Q10 (ubiquinol) and turmeric (C longa) were incorporated into the treatment strategy for their anti-inflammatory and antioxidant properties.^19,21,23 Several B-vitamins can diminish the inflammatory process and augment antioxidant function.²¹ As a spasmolytic, magnesium was utilized to relieve her cramping pain.²¹ Acupuncture can elevate progesterone, suppress the inflammatory process, and eliminate prooxidants.^15,21,22 To alleviate the stress-related amplification of her PMS, meditation was incorporated into her treatment plan.²⁸

The dosage of flaxseed oil (L usitatissimum) and turmeric (C longa) were based on the reference ranges provided by the Physician's Desk Reference for Herbal Medicine.²⁹ The dosage of the B vitamins and magnesium was based on a case report that alleviated dysmenorrhea in a patient with endometriosis.²¹ A dosage of 100 mg of coenzyme Q10 (ubiquinol) is considered safe and effective for therapeutic purposes.^{30, 31, 32}

In this case, one possible explanation for the reduction in the severity of her symptoms was the normalization of her progesterone levels. In 2020, her progesterone levels were deficient, below 0.5 ng/mL, while the levels of her other hormones were normal. After treatment for 36 weeks, her progesterone levels elevated to 7.4 ng/mL. This could explain the favorable outcome observed.

Although there are no human clinical trials demonstrating the efficacy of flaxseed oil (L usitatissimum) for the treatment of PMS, flaxseed oil (L usitatissimum) can influence progesterone levels. In this case, a progesterone deficiency was observed, which is a possible cause of PMS.³ In animal trials, flaxseed oil (L usitatissimum) elevated progesterone levels, which may have accounted for the rise in her progesterone from 2020 to 2022.^16,33,34 Unfortunately, human trials evaluating the effects of flaxseed oil (L usitatissimum) on progesterone are lacking. The mechanism responsible for the elevation of progesterone is not conclusive.

The treatment approach was multimodal; thus, other treatment strategies may have contributed to the positive results. In 2 studies, supplementing with coenzyme Q10 (ubiquinol) raised progesterone levels. A human trial conducted by Thakur et al administered 150 mg of coenzyme Q10 (ubiquinol) to women between the ages of 20 and 40 with amenorrhea. According to the results, there was a nonsignificant rise in progesterone, while the levels of LH doubled.¹⁷ Increasing LH may have raised progesterone levels.¹⁷ However, a cell culture study determined that supplementing with coenzyme Q (ubiquinol) augmented mitochondrial function, nutrient uptake, and progesterone synthesis in cumulus granulosa cells.³⁵ One animal study indicated that turmeric (C longa) could increase progesterone levels potentiating the follicular phase of the menstrual cycle.¹⁸ The action of these nutraceuticals may have contributed to the positive outcome observed in this case.

Several B vitamins can lower homocysteine levels. Michels et al suggested that hyperhomocysteinemia decreased the concentration of progesterone.³⁶ Folic acid, riboflavin, niacin, pyridoxal 5-phosphate (PLP), and cobalamin are involved in homocysteine metabolism.^20,37 In addition, supplementation with folic acid and inositol as monotherapies increased serum progesterone levels.^34,38 Consequently, these micronutrients may have weakly assisted with the progesterone elevation. Unfortunately, the homocysteine levels of the patient were not obtained, so this finding is unknown.

Traditional Chinese medicine acupuncture treatment has been shown to affect progesterone levels in rats.¹⁵ An explanation for this may be an increase in circulating LH that has been observed after acupuncture therapy.¹⁵ LH stimulates progesterone synthesis.³⁹ Acupuncture may also up-regulate the activity of progesterone by increasing the generation of progesterone receptors.⁴⁰ Progesterone receptors are responsible for regulating the physiologic effects of progesterone.⁶

Other considerations related to the pathophysiology of PMS are the levels of inflammatory mediators and oxidative stress. The concentration of interleukins (IL) has been elevated in cases of PMS, indicating that inflammation can impact the presentation of the condition.⁷ Specifically, IL-1β, IL-6, IL-8, and tumor necrosis factor (TNF) α were elevated.⁴¹ Oxidative stress may be amplified in women with PMS, which is thought to be caused by an inflammatory response due to the potential of prooxidants to induce tissue damage.^7,20 Heidari et al advocated attenuating inflammation through the suppression of nuclear factor-κB (NF-κB) and oxidative stress for the treatment of patients with PMS.⁷ Consequently, diminishing inflammation and increasing antioxidant status may have helped improve symptoms in the patient.

Several of the supplements employed could have decreased the inflammatory response. The agents used in this case may down-regulate NF-κB in rats are PLP, folic acid, magnesium, turmeric (C longa), flaxseed (L usitatissimum), and coenzyme Q10 (ubiquinol).^{19, 20, 21} Acupuncture can attenuate NF-κB expression as well.^42,43 In addition, acupuncture may augment the therapeutic benefits of vitamins and herbs.^{44, 45, 46} The combination of the nutraceuticals with acupuncture may have acted synergistically to mitigate inflammation.

Reducing the generation of other inflammatory mediators may have had an impact on this case. Coenzyme Q10 (ubiquinol), flaxseed oil (L usitatissimum), turmeric (C longa), and acupuncture can decrease the generation of IL-1β, IL-6, IL-8, and TNF-α.^{19,47, 48, 49, 50, 51, 52, 53, 54, 55, 56} Pyridoxal 5-phophate and niacin may diminish the release of TNF-α, while PLP and para-aminobenzoic acid can down-regulate IL-6.^{57, 58, 59}

It has been proposed that oxidative stress can aggravate the inflammatory state and the severity of the symptoms in patients with PMS. Thus, it is proposed that decreasing the production of prooxidants could have had a positive effect in this case. Nutraceuticals and acupuncture are hypothesized to eliminate the formation of free radicals and reactive oxygen species. Thiamin, riboflavin, niacin, inositol, and cobalamin can eradicate prooxidants and reactive oxygen species.^{60, 61, 62} Riboflavin, niacin, inositol, and cobalamin can enhance the regeneration of glutathione, while PLP may augment the activity of glutathione peroxidase and superoxide dismutase (SOD).^60,61,63 Folic acid can increase the antioxidant potential of SOD, catalase, and glutathione s-transferase.^{64, 65, 66} The antioxidant effects of SOD, glutathione peroxidase, and catalase can be elevated by turmeric (C longa), coenzyme Q10 (ubiquinol), flaxseed oil (L usitatissimum), and acupuncture treatment.^{22, 23, 24,67, 68, 69, 70, 71}

The inflammation and oxidative stress that occurs during menstruation may potentially exacerbate mental symptoms.^7,21 In this case, she had feelings of stress, irritability, short-temperedness, depression, and feeling overwhelmed by ordinary demands. Acupuncture and mindfulness meditation aimed to diminish these symptoms.^25,26,72,73

Limitations

The primary limitation of this report is that this is a single case using this therapeutic approach. Other patients may not respond to the treatment in a similar manner. Another limitation is that multiple modalities were incorporated into her treatment plan. Consequently, it is not possible to determine the type of therapy that produced positive results or if the combination of treatment strategies was synergistic. Lastly, the symptoms, in this case, were subjective and not measured with a diagnostic instrument.

Conclusion

A patient with PMS symptoms responded positively to a combination therapy utilizing acupuncture, meditation, flaxseed oil (L usitatissimum), coenzyme Q10 (ubiquinol), magnesium, turmeric (C longa), and B vitamins.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Contributorship Information

Concept development (provided idea for the research): B.R.M.

Design (planned the methods to generate the results): B.R.M.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): B.R.M., J.W.

Data collection/processing (responsible for experiments, patient management, organization, or reporting data): B.R.M.

Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): B.R.M.

Literature search (performed the literature search): B.R.M., J.W.

Writing (responsible for writing a substantive part of the manuscript): B.R.M., J.W.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): B.R.M.

Other (list other specific novel contributions): B.R.M.

Practical Applications.

• •This study found that acupuncture, turmeric (Curcuma longa), flaxseed oil (Linum usitatissimum), coenzyme Q10 (ubiquinol), magnesium, and B vitamins helped to reduce the symptoms of premenstrual syndrome.
• •After 12 treatments over 3 months, the patient's symptom score decreased.
• •The combination of therapies seemed to be helpful for this patient.

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