What supplements can help alleviate Premenstrual Syndrome (PMS) symptoms?

Supplements for Premenstrual Syndrome (PMS)

Calcium supplementation at 1200-1500 mg daily is the only supplement with strong evidence to reduce PMS symptoms and should be the first-line supplement recommendation. 1, 2, 3

First-Line Supplement: Calcium

• Calcium is the only supplement demonstrated to provide significant benefit in large, rigorous, double-blind, placebo-controlled trials for PMS. 1, 2
• The recommended dose is 1200-1500 mg daily, preferably as calcium carbonate, taken throughout the menstrual cycle. 4
• Calcium supplementation significantly decreases both the number and severity of premenstrual symptoms, including affective symptoms (mood swings, irritability, depression) and somatic symptoms (bloating, mastalgia, fatigue). 4
• This recommendation is supported by consistent, high-quality evidence across multiple systematic reviews. 1, 2, 3

Second-Line Supplements with Limited Evidence

Vitamin B6

• Evidence for vitamin B6 is conflicting and inconsistent across trials. 1, 2
• If used, doses should be kept moderate as high doses taken for prolonged periods can cause neurological symptoms and peripheral neuropathy. 1
• Some systematic reviews suggest potential benefit, but the evidence quality is insufficient to make a strong recommendation. 2

Magnesium

• Limited evidence suggests magnesium may be useful, but additional research is needed to confirm these findings. 1
• Specifically, magnesium pyrrolidone showed preliminary benefit in some studies, while magnesium oxide showed no evidence of benefit. 2
• The inconsistency between magnesium formulations makes it difficult to provide a definitive recommendation. 2

Vitamin E

• Preliminary data shows some potential benefit for PMS symptoms. 1, 2
• However, the evidence remains insufficient to recommend vitamin E as a primary treatment option. 1

Herbal Supplements

Chasteberry (Vitex agnus-castus)

• Systematic review evidence suggests chasteberry may be effective for PMS symptoms. 2, 5
• This is the only herbal supplement with reasonably consistent evidence supporting its use. 5
• However, the quality of evidence remains lower than that for calcium supplementation. 2

Evening Primrose Oil

• Evening primrose oil should NOT be recommended for PMS. 1, 2
• The two most rigorous studies showed no evidence of benefit. 1
• Despite its popularity, trials have had conflicting results with the highest quality evidence showing no efficacy. 1, 2

Other Herbal Products

• Preliminary data exists for ginkgo, saffron, St. John's Wort, and soy, but evidence is insufficient to recommend their use. 2
• Sixty-two different herbs, vitamins, and minerals have been advocated for PMS, but randomized controlled trial evidence exists for only 10 of them. 2

Clinical Algorithm for Supplement Recommendations

1. Start with calcium supplementation (1200-1500 mg daily) as the only supplement with strong, consistent evidence. 1, 2, 3, 4

2. If calcium alone is insufficient after 2-3 menstrual cycles, consider adding chasteberry as the only herbal supplement with reasonable supporting evidence. 2, 5

3. Avoid evening primrose oil despite its popularity, as rigorous trials show no benefit. 1, 2

4. Exercise caution with vitamin B6 due to potential neurological toxicity at high doses with prolonged use. 1

5. Consider magnesium pyrrolidone (not magnesium oxide) only if calcium and chasteberry have failed, recognizing the limited evidence. 2

Critical Pitfalls to Avoid

• Do not recommend multiple supplements simultaneously without first establishing whether calcium alone is effective, as this is the only supplement with robust evidence. 1, 2, 3
• Do not suggest evening primrose oil based on popularity alone, as the highest quality evidence demonstrates no benefit. 1, 2
• Do not use high-dose vitamin B6 (>100 mg daily) for extended periods due to risk of peripheral neuropathy and neurological symptoms. 1
• Do not assume all magnesium formulations are equivalent; magnesium oxide showed no benefit while magnesium pyrrolidone showed preliminary positive results. 2
• Recognize that for 62 different supplements advocated for PMS, only 10 have any randomized controlled trial evidence, and only calcium has consistently strong evidence. 2