23 Nov 2016
Tips for Menstrual Problems
I previously attended an event curated by ‘Binti International’, an organisation dedicated to designing community projects that manufacture reusable and disposable sanitary products.
As a doctor championing ‘food as medicine’ I was asked to talk about the link between diet and common menstrual problems. Is there anything women can eat or change in their lifestyle to help with menstruation issues?
This is my attempt at trying to answer that question as best as possible using the available evidence and a pragmatic approach to novel theories.
But first .. DISCLAIMER ALERT! This post is not intended to treat, override the decision of your personal doctor or cater for all problems you may have. I strongly advise everyone, particularly those with diagnosed conditions, to discuss the below suggestions with their personal physician. I believe everyone is a unique case and a one-size fits all approach to medicine, diet or exercise is naïve. ESPECIALLY if you are taking medications it is exceptionally important to discuss everything with your practitioner.
I encourage you to look at the research (a selection of which I’ve included at the end) and be sceptical of anything anyone tells you on the internet … and yes that includes me! What I encourage is a holistic view of disease and healthcare in general. There is no single cause of menstrual related problems but I believe the tips below are simple and safe for the majority of patients.
Rather than talking about the number of follicles you start with and how they decline from birth, the wonders of hormone control, the pharmaceutical approaches to menstrual health etc I want to start by focusing on the main issues we see as GPs surrounding menses and what options we have in clinic. An in depth description of the menses is beyond the scope of this post. For an overview of the menstrual cycle, the nature of hormone changes and what is supposed to happen please see the attached links below:
Menstruation and Disorders
NHS Info on Periods
What I want to reiterate at the start is how incredibly complex a topic this is and how symptoms may not always be related to menstruation even if it seems like periods are the likely culprit. It’s very important to discuss unusual symptoms or changes to your cycles with your physician. I try and keep a holistic approach as much as possible. The impact of menses on cardiovascular risk, gut microbiome population, mental health and even cancer going onto later life is a difficult topic to approach.
COMMON PROBLEMS WITH MENSTRUATION
Pain (Dysmenorrhoea) is one of the commonest complaints we see as GPs. ‘Primary Dysmenorrhoea’ is from periods themselves whilst ‘Secondary Dysmenorrhoea’ is pain related to something other than just periods, like fibroids, Pelvic Inflammatory Disease or Ovarian cysts.
Heavy Bleeding (Menorrhagia) is prolonged or excessive bleeding which can be associated with ‘flooding’ episodes or passing of persistent clots.
Infrequent/Irregular Bleeds are defined as greater than 35 days apart and we as doctors are particularly mindful of intermenstrual bleeds which can be associated with STDs and cervical abnormalities including cancer.
Premenstrual Symptoms are usually the butt of many jokes but this is a constellation of physical and mental symptoms ranging from low mood, anxiety, bloating and fatigue that can be severely distressing for a lot of women.
Whenever faced with a set of symptoms we’re trained to assess the ‘differential’. This is why it’s important to discuss any problems with your doctor. After taking a detailed history your physician will deliberate whether this is menstrual cycle related or a presentation of a gastrointestinal problem, a potential infection or even related to underlying mental stressors. Modern medicine has a multitude of approaches to common menstrual problems ranging from:
Many of these interventions unfortunately have side effects and during a consultation both the doctor and patient weigh up these options in terms of risk benefit. I’m not anti-medications, I’m a practicing GP in the NHS and use drugs on a daily basis (not personally), but what I advocate is getting a solid foundation in nutrition in place before we turn to pharmaceutical methods of dealing with problems. I want patients to understand the phenomenal impact of lifestyle medicine BEFORE we trial medications.
1. The Basics
In the literature there are clear links between smoking, obesity, stress and alcohol on ALL common menstrual problems. Particularly for PMS; mindfulness therapies, meditation and CBT are all non invasive and effective means of improving symptoms during this stressful time and I wholeheartedly encourage it. Try an app, YouTube channel or class. The jury is out on coffee, but from what we understand about how caffeine can raise cortisol, adrenaline and cause anxiety my advice would be to remove it and see if symptoms improve. Here’s a lighthearted article detailing my thoughts on coffee.
2. Remove Sugar, Refined Carbohydrates and Processed Foods
Sometimes I feel like I’m beating an old drum, but this is really important. Before I start talking about food to increase the intake of, we need to address the problem of processed foods right at the start. The compounds created as a result of high sugar diets affect a multitude of pathways involved in common menstrual problems. Plus there are so many other benefits of removing sugar from your diet ranging from microbiome rebalance, weight loss and reducing your risk of diabetes.
3. Nutrient Dense Varied Diet
The anti-inflammatory effect of a diet rich in a variety of colourful plantbased foods is demonstrated in multiple research studies. Colourful plants including dark green leafy vegetables, peppers, onion and garlic are rich in phytochemicals that exert these effects. Pathways that are involved in painful periods, bleeding etc are thought to be attenuated by introducing these types of foods onto your plate. This could explain the link between a diet solely based on plants and reduced PMS symptoms. Have a look at this spectrum of foods to see how varied your diet can be. VARIETY is key and it’s why my dishes are so colourful .. it’s not just filters! Check out some of my quick recipes on YouTube. The other byproduct of diets rich in these foods are their effect on the microbiome which I’ve talked more about here.
4. Diet Choice?
As discussed earlier, fat (adipose) tissue particularly around the waist is problematic for women and may be the cause of menstrual problems. There is a strong association between weight and dysmenorrhoea, heavy bleeding etc. and there are a number of reasons why this may be the case. But there in lies the question … How do I lose weight?
Unfortunately there is no quick answer to this. Everyone is individual and the reason why one person is overweight can be completely different to anothers. There was an interesting studythat compared different diets and their effectiveness on weight loss. Turns out whatever diet the participants followed (low carb, Atkins, plant based, etc) they tended to lose weight. Atkins appeared to fare the best, however I’d be cautious about ‘blanket’ recommending a restricted carbohydrate diet for women with menstrual health issues.
My personal belief is that if you stick to the principles of removing refined carbohydrates, increasing plant protein, introducing quality fats and maintaining defined eating times you will be successful. I’ve talked about my favourite strategies for sugar and weight control here.
Whenever I get asked about the efficacy of supplements, nutritional adjuncts and herbal medications I always start by referring to the guidelines that the colleges of respective specialities (e.g O&G, General Practice etc) have provided to practitioners. Fortunately, the Royal College of Obstetrics and Gynaecology (UK) have reviewed the literature a few years ago looking at the efficacy of non-medicine therapies for common menstrual problems. It’s due an update but worth a look. You’ll find research and advice for supplementation for common menstrual problems all over the internet, the main ones include:
Generally the studies are non-existent or too small to make generalisations from, but I’ve found a few that I find particularly interesting. Magnesium supplementation has been shown to alleviate common symptoms of PMS in a small number of studies. The same has been found with B vitamins (particularly B6) and one of the most interesting theories surrounding mood change during menstruation is the potential fluctuation of calcium and vitamin D levels due to the shifts in oestrogen and progesterone. I’m guessing people want the conclusion … do I recommend supplements? Not necessarily.
If you look at the amounts of minerals and vitamins used in the studies (with the exception of B6 and D3) they’re achievable doses we can gain from a diet rich in colourful plant foods. Th 200mg Magnesium tablet used, for example, is equivalent to a 1 1/2 cups of spinach and pumpkin seeds are full of Mg. The best calcium sources include sesame, tofu and dark leafy greens. I’m an advocate for getting your nutrition from food as much as possible. I take very much a wholistic view of nutrition and the complexity of minerals, phytochemicals and micronutrients found in food is no match for a simple tablet. Plus, the additional benefits of getting your requirements from food include incredible compounds that fight inflammation, cancer and improve the functioning of your gut microbes.
However, what I would ensure is adequate Vitamin D level (that your doctor can check), Omega 3 in your diet (from oily fish, or an algae based supplement) and potentially a vitamin B6 supplement (50mg starting dose) if you suffer PMS symptoms. Combined with meditation, talking therapies and other coping practices it’s a winning formula for many women.
6. Complementary Medicine
There’s a whole guideline on the use of Chinese Herbal Medicine and acupuncture for the treatment of Chronic pelvic pain. The college concluded, “The use of acupuncture as a potentially effective and safe intervention for pain management without the risk of adverse gastrointestinal effects from NSAIDs, warrants further investigation” and the same was essentially said for the use of Chinese herbs. Although this was specifically looking at chronic pelvic pain, I think there is a lot of crossover with dysmenorrhea and patients may find these useful. I can’t condone the use of specific herbs used in the practice (there are so many variations depending on what practitioner you see) however my advice would be to only visit ‘registered’ practitioners with the UK ‘Association of Traditional Chinese medicine’.
There are reports of adverse effects from using these medications, so again it must certainly be discussed with your physician who can weigh up any safety concerns. The studies looking at sham versus real acupuncture are part of a wider debate of whether acupuncture should be advised at all and beyond the scope of this post. I think we have to weigh up these variables on a case by case basis, but I certainly have had patients that swear by it. As long as people entertain complementary medicine practices safely, they do no harm and they find it cost effective, I welcome it.
7. Movement and Meditation
It’s very well documented that stress and lack of exercise are associated with menstrual problems. Whilst I’m not one to talk about how uncomfortable periods can be, a lot of patients describe the benefits of less intense yoga practices during menstruation. As I alluded to before, ‘Mindfulness‘ is a practice I recommend to everyone. In our fast paced lives, never before has meditation been so useful and necessary.
8. Medicinal foods
I owe a lot to Dr Michael Greger on this section. I was introduced to a lot of information from his amazing website www.nutritionfacts.org. It’s heavily biased toward plant based living (with a lot of good reasons) and I admire his dedication to the field of nutrition in medicine. The studies demonstrating effectiveness of these ingredients are again few and far between to make generalisations from, but considering the potential benefits and lack of side effects from taking food it’s certainly worth a shot.
Flax/High Fibre Diet
A fantastic ingredient with a nutty flavour, it’s a source of protein, fatty acids and considered a therapy for cyclical breast pain (mastalgia). Another reason to take flax is it’s fibre content. Fibre improves the transit of stool through the bowels that reduces exposure of oestrogens to the gut lining. This may also explain why flax in the diet appears to protect against breast cancer. I put it in smoothies or blended with spices as a delicious salad topper.
A fascinating study (that is yet to be repeated and compared to leading antifibrinolytic agents like tranexamic acid) demonstrated ginger to be a highly effective agent for reducing the heavy bleeding in patients suffering menorrhagia. They used 250mg capsules ginger capsules which one can easily substitute with a thumb size piece of ginger grated into hot water and given the lack of side effects (especially compared to the medications I prescribe) I would encourage patients to at least try this. It’s also a well known anti-nausea agent and the gingerols are known to be cancer suppressors. I have ginger all the time!
A versatile aromatic vegetable and it’s seeds are fantastic at transforming the most bland of dishes! Fennel extract was found to be as effective as a common non steroidal anti-inflammatory medication for pain control in a small study. I can’t find the exact dose that was used (30 drops of fennel extract is all that the paper states) but 30mg of Foeniculum vulgare (fennel) has been used with encouraging results in other studies. Again, another intervention much safer than the medications I have in my arsenal, that are worth trialling before turning to drugs.
9. Everything else …
There is a lot more to talk about in the future ranging from sleep disturbance, exposure to endocrine disrupting compounds and the shifts in microbiome due to hormonal change. I believe the use of sleep hygiene, probiotics and other therapies have a role, but I’m going to have to save this discussion for another day when I can actually gather the available evidence and read through the literature!
The purpose of this article isn’t to recommend supplements, herbs and acupuncture over pharmaceuticals. I want to encourage patients to get the basics in place before we start relying on medications. In many cases the answers to menstrual issues, and other medical problems, are diet and lifestyle related. There are many ways in which to approach this difficult and complicated topic but I sincerely believe the basics of:
With perhaps some flax, ginger and experimenting with other ingredients to improve your microbiome.
I’d love to know about your experiences and if you found this article useful share it and comment 🙂
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