Premenstrual Syndrome (PMS) was originally described by Frank in 1931. In this paper he described a constellation of symptoms consisting of swelling, weight gain, and emotional disturbances before the beginning of menses. Frank attributed this syndrome to an excess of estrogen that occurs during this part of the menstrual cycle. It is estimated that 5-10% of woman will have symptoms strongly suggestive of premenstrual syndrome. Although historically PMS has been reported to occur in woman of 30-45 years of age, more recent data demonstrates that it is evenly distributed across age groups in the reproductive years. In many instances, adolescent irritability and perimenopausal depression may be attributed to PMS. In addition premenstrual syndrome may occur in woman who are not menstruating as long as ovarian function is preserved. In spite of strong scientific evidence for a biological bases for PMS many woman who have this syndrome have been told that there is nothing wrong with them or it is "all in the head". This is unfortunate since this only adds to the frustration that these women are experiencing. The problem with PMS is that most of the physical and psychological symptoms are non-specific in nature and may be attributed to many other causes including stress. The following list illustrates the great diversity of symptoms: Fatigue, abdominal bloating, headache, feeling hot or cold, breast tenderness, weight gain, nausea, pain in pelvic region, depression, confusion, diminished sex drive, and anxiety. As can be seen, the above list is not very specific and anyone or even several of the above symptoms may occur in people who do not have PMS. The defining element of PMS is not the presence of any particular symptoms but on their cyclic nature in relation to the menstrual cycle. As such PMS can be defined as "recurring physical and/or psychological complaints that interfere with normal activity – or result in deterioration of interpersonal relationships – and that are consistently related to the luteal phase of the patient's menstrual cycle". The luteal cycle is the part of the menstrual cycle that precedes menstruation and is hormonally dominated by estrogen as compared to progesterone. For this reason, the diagnosis is extremely dependent on temporal relationships and it is imperative to keep a chart of symptoms in relation to the menstrual cycle. Basal body temperatures should also be recorded, particularly in woman with irregular menstrual cycles since it too can indicate when a woman is in the luteal phase. During this phase the temperature will increase. It is important that such records are kept since studies have indicated that 25-50 per cent of cases actually experiences symptoms throughout the menstrual cycle and therefor should not be given the diagnosis of PMS. The exact cause of PMS has been debated over the years but it is clear that there is a strong hormonal component to it, since PMS only occurs in woman in their reproductive years. Its onset always occurs after puberty and it will disappear after menopause. Also woman that have PMS and have their ovaries removed will have remission of the PMS symptoms. It has been difficult to define the exact roles of estrogen and progesterone in the evolution of PMS since studies do not show a clear difference in the levels of these hormones in woman with and without PMS. Although the absolute levels of estrogen and progesterone is often normal, the ratio between these two hormones may not be in balance with estrogen relatively increased to progesterone in woman with PMS. This hormonal imbalance can lead to impaired liver function that can inhibit detoxification, reduce serotonin levels and decrease the activity of vitamin B6, resulting in depression and increase aldosterone which in turn can contribute to retention of water and increased prolactin levels manifesting in breast tenderness. There may also be disturbances in thyroid function, adrenal function, prolactin and FSH, levels in woman with PMS. The corpus luteum develops from the ovarian follicle after ovulation and is responsible for secreting progesterone for the purpose of preparing the uterus for the implantation of the fertilized egg. If fertilization does not occur, the corpus luteum degenerates and the menstrual cycle starts again. Measuring blood levels of progesterone three weeks after the onset can indicate if the corpus luteum is secreting insufficient progesterone. In addition to PMS Corpus luteal insufficiency has been linked to excessive blood loss and other menstrual irregularities as well as hypothyroidism. More recent research indicates that the hormonal changes that occur during the luteal phase of the cycle are not the primary cause of PMS but they unmask deficiencies in nutritional status resulting in psychological and physical changes. If this is the case these borderline deficiencies need to be addressed in order to effectively treat PMS. Studies have consistently demonstrated that there are cyclic changes in mineral metabolism during the menstrual cycle. For example, calcium levels fell before and during ovulation while magnesium, zinc, selenium and maganese were highest during menstruation. These findings give some support to the practice of using nutritional supplements for the treatments of PMS. Magnesium seems to have a positive affect on woman with PMS. Studies have shown that the red blood cell magnesium (a more accurate test than the standard serum levels) is often lower in woman with PMS. Magnesium supplementation of 360mg/day has been shown to reduce total symptom scores. The largest effect was noted with breast tenderness and weight gain, which were both reduced by over 90%. Other studies have confirmed these results. As mentioned before there is a strong positive interaction between vitamin B6 and magnesium. When these nutrients are combined results can be dramatic with a 70% reduction in both premenopausal and post menopausal symptoms. Vitamin E has also been used to treat PMS. Although it seems that a wide variety of symptoms are ameliorated it is best known for its positive effects on breast tenderness. Vitamin E should be taken in a natural form as mixed tocopherols to maximize absorption and effectiveness. When prolactin levels are elevated and a potential cause of PMS, zinc has been effective in reducing the levels of this hormone, since it can suppress excretion of prolactin. Interestingly zinc levels are often lower in woman with PMS. Zinc should not be used in doses of greater than 50mg/day. Some of the most conclusive studies of a nutritional basis for PMS involve calcium. Numerous studies have correlated low calcium levels with PMS. Interestingly many of the symptoms of hypocalcemia are the same as PMS such as, fatigue, anxiety, depression, poor concentration, and muscle cramps. Several studies have shown calcium is effective as a treatment for PMS. In one study, woman with PMS were given 1000mg of calcium per day for 3 months. The results showed a 73% improvement in woman who took the calcium as compared to placebo. In a third study woman with PMS were randomly assigned to receive 1200mg of elemental calcium per day or placebo. By the third month there was an overall decrease of 48% in all symptoms for the group receiving calcium. There is very strong evidence that woman with PMS may have underlying disorders of calcium metabolism. As mentioned earlier it is normal for various hormones and minerals to fluctuate over the course of the menstrual cycle. In woman with PMS these cyclic changes may be much more pronounced. For example, all woman have peak levels of estrogen before their periods with corresponding drops in ionized calcium levels. In woman with PMS the estrogen levels have a tendency to be higher (although this difference did not reach statistical significance) and ionized calcium levels are significantly lower. In addition vitamin D levels were much lower in woman with PMS. Several studies have also found a significant positive correlation between PMS and osteoporosis. In general woman with a history of PMS are much more likely to have lower bone density and osteoporosis. Disorders of calcium regulation have been clearly associates with many of the emotional symptoms common to PMS such as mild personality changes, depression and anxiety. In conclusion, premenstrual syndrome may be successfully addressed with non-pharmacological therapies. Although it has not been conclusively proven that all cases of PMS are caused by disturbances in mineral metabolism, supplementation with moderate doses of calcium and magnesium may provide an inexpensive and nontoxic relief for a large number of woman. Although not specifically discussed in this paper several herbs such as black cohosh and yam extract may also be helpful. In addition, homeopathic remedies can be used to address specific symptoms, such as lac caninum for bloating and breast tenderness. If these initial measures are not helpful it may be advisable to undergo testing for specific hormonal disturbances such as estrogen, prolactin and progesterone levels. 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