Dr. Michael Ruscio, DC is a clinician, Naturopathic Practitioner, clinical researcher, author, and adjunct professor at the University of Bridgeport. His work has been published in peer-reviewed medical journals and he speaks at conferences around the globe.
Fatigue is among the more than 150 physical, behavioral, or psychological symptoms of premenstrual syndrome, or PMS. PMS and PMS fatigue are often signs that the hormones responsible for women’s menstrual cycles are imbalanced.
The two most common underlying factors that can lead to hormonal imbalances in women are stress and poor gut health. The great news is that we can do something about both of these. Taking simple steps to reduce stress and improve digestion may be the ticket to less fatigue and fewer symptoms overall in the week or two before your period.
First, let’s unravel PMS and the fatigue that often comes with it.
What Is PMS?
Premenstrual syndrome describes the collection of symptoms that many women experience between ovulation and menstruation.
Globally, about half of all women of reproductive age experience PMS . About 20% of those women have symptoms that disrupt their daily activities . Furthermore, around 2.5-3% of women with PMS have a severe form called premenstrual dysphoric disorder, or PMDD .
How Does the Menstrual Cycle Work?
If you’re interested in understanding the hormonal shifts that take place during the menstrual cycle, here’s a simple overview.
Follicular Phase (First Half of Cycle)
At the start of menstruation (your period), these four hormones are low:
Luteinizing hormone (LH)
Follicle-stimulating hormone (FSH)
A few days after your period ends, Estrogen levels start to rise, peaking a couple of days before ovulation.
The peak in estrogen causes both LH and FSH levels to surge. This triggers the ovary to release an egg (ovulation). This is the stage where conception can happen.
Luteal Phase (Last Half of Cycle)
If the egg is not fertilized by sperm at ovulation, LH levels drop. Progesterone and estrogen levels decrease in the late part of the luteal phase. This triggers the endometrium (inner layer of the uterus that would provide nutrients to a fertilized egg) to slough off and results in menstrual blood loss, or menstruation.
PMS symptoms occur in the final days of the luteal phase, as hormone levels drop.
Symptoms of PMS
The most common PMS symptoms include the following :
Appetite changes and food cravings
Water retention (overall bloating) and weight gain
Muscular aches and pains, especially in the lower back
Breast tenderness and swelling
Restlessness and poor concentration
Mood swings and heightened emotions
What Causes PMS?
The exact causes of PMS are not clear, but it may develop as a result of imbalanced hormone levels [4, 5, 6], poor diet [5, 6], and certain genetic predispositions [7, 8, 5, 6]. Some women may also be more sensitive to normal fluctuations of estrogen and progesterone and are therefore more likely to experience PMS [6, 9]. Alcohol use  and cigarette smoking  may increase the risk of developing PMS.
Stress and poor gut health can trigger hormone imbalances, leading to symptoms of PMS. Thankfully, there’s much you can do to reduce stress, improve gut health, and resolve your PMS symptoms, including PMS fatigue.
What Causes PMS Fatigue?
One likely cause of fatigue in the days leading up to your period isthe low level of estrogen. This hormonal change causes a drop in several neurotransmitters (the body’s chemical messengers) that are important for preventing insomnia, fatigue, and depression .
One of those neurotransmitters is serotonin, your happy-mood chemical that comes from a dietary amino acid called tryptophan. Tryptophan is abundant in protein-rich foods such as chicken, fish, and milk. When all is well in your gut, tryptophan from food gets converted into serotonin, which lifts your mood and energy levels.
However, when too much stress and a poor diet cause gut inflammation, the tryptophan that comes with your food gets converted to inflammatory proteins instead of serotonin, robbing your brain of happy chemicals [11, 12].
In a nutshell, if low estrogen levels before your period reduce your serotonin and you’re dealing with gut inflammation from stress and poor diet, you won’t have enough serotonin to give you the positive outlook and energy you had before ovulation, when your estrogen was high. In other words, you’ll find yourself saddled with PMS fatigue.
However, as mentioned before, there is much you can do to reduce or eliminate PMS symptoms, including fatigue.
How To Relieve PMS and PMS Fatigue
Many studies and my clinical experiences have shown that simple lifestyle changes, such as practicing stress-relieving techniques and improving your diet, can go a long way in improving PMS symptoms. For those who need a little more help, adding specific nutrients or herbs can tip the scales toward PMS freedom.
Let’s explore a three-pronged approach to overcoming PMS by reducing stress, improving gut health, and balancing hormones.
The following activities can go a long way toward reducing your PMS symptoms and premenstrual fatigue:
Moderate exercise to relieve PMS-related pain, constipation, breast tenderness, anxiety, and anger [13, 5]
Identifying stressful events and doing your best to avoid them, particularly in the two weeks leading up to menstruation
What you eat and the composition of your gut microbiome (the community of microorganisms that regulates your digestive health and immune system) impacts your blood sugar, levels of inflammation, and hormonal balance. Here are two ways to improve your gut health:
Make dietary changes to replace processed foods with healthy, whole foods. The Paleo Diet [18, 19, 20, 21] is a good choice for stabilizing blood sugar and supporting a healthy gut microbiome.
Probiotics are the cornerstone of improving gut health, with the power to correct imbalances in the gut microbiome and reduce inflammation that may undermine your hormones. The most effective approach to using probiotics is to use one quality probiotic from each of these categories [22, 23]: 1) a blend of Lactobacillus and Bifidobacteria; 2) Saccharomyces boulardii (a beneficial yeast); and 3) a soil-based probiotic.
Certain nutrients and herbs can be very helpful in nudging your hormones back into balance. Keep in mind that supplements are most effective when used together with a healthy diet and lifestyle changes.
Research suggests that certain herbs can be helpful for PMS symptoms . Chasteberry, also called vitex, is well-studied and has been shown to be effective for PMS and PMDD in several clinical trials . One meta-analysis (highest quality of research evidence) found that women who took vitex were 2.57 times more likely to stop having PMS symptoms  when compared to controls.
Women with low dietary intake of the B vitamins thiamine (B1) and riboflavin (B2) may be more susceptible to PMS symptoms . Eating higher amounts of whole grains, meat, and fish could reduce the risk of developing PMS by 35% . Another B vitamin found to help with PMS is vitamin B6 (pyridoxine) , but supplements containing only B6 may be less effective than multivitamins containing all B vitamins at reducing PMS symptoms .
Vitamin D levels are sometimes low in women with PMS and may contribute to symptoms . A moderate daily dose of sunlight or a vitamin D supplement (balanced with vitamin K2) can reduce PMS symptoms in some women .
Calcium levels may also be low in women with worse PMS symptoms. Calcium supplements or high-calcium foods, such as dairy products or canned salmon , can raise calcium levels and reduce PMS symptoms .
Magnesium levels are not necessarily low in women with PMS , but some evidence suggests that magnesium supplements may help treat PMS-related anxiety .
Your Plan for Relieving PMS Fatigue
In summary, your plan for relieving PMS fatigue and other symptoms should include stress reduction, dietary changes, and a simple supplement protocol:
Anyone struggling with PMS fatigue probably knows it can feel impossible to make changes to daily life when you’re exhausted. So, I recommend using the days during your cycle when your energy levels are higher to start implementing your PMS relief plan. For many women, energy levels are highest the week or so after their period ends.
Ideally, you’ll start to see improvements in your PMS symptoms within the first few menstrual cycles.
What To Do If PMS Persists
If you have intense PMS or PMDD (the most severe form of PMS) that doesn’t resolve after making diet and lifestyle changes, consider reaching out for professional support from a healthcare provider. Options include:
A gynecologist who can diagnose more complex gynecological conditions that may contribute to your symptoms
A health coach who can help you to stay on track with dietary and lifestyle changes
Life Is Better Without PMS
PMS symptoms are disruptive and can be debilitating. However, there’s much you can do to prevent monthly episodes of PMS fatigue, mood swings, and other troublesome symptoms.
I have observed in my clinic that most women can significantly reduce symptoms of PMS within one or two cycles. Reduce your stress levels, improve your diet, and take a few key supplements, and you’ll be on your way to living PMS-free.
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