The days leading up to one’s period can be positively dreadful. Your mood goes up and down as if it were on a roller coaster, you feel bloated and you just can't seem to stop eating chocolate. You’re not alone in feeling this way. Almost 70 percent of women experience these typical symptoms of premenstrual syndrome (PMS). In fact, symptoms can become so severe that they prevent some women from being able to get through their daily routine — and this phenomenon happens month after month [1; 2]. Fortunately, PMS is no longer considered to be an exaggerated ‘hysteria’ invented by women in need of attention, as some history books like to claim. It is a real and at times very stressful condition. The good news is that natural ingredients like monk’s pepper (Vitex agnus-castus L., also known as agnus castus fruit and chaste tree) might be able to help make that time of the month feel a little more bearable.

 Where hormones come in

Without hormones, quite simply, nothing in our body works. It’s as if they operate in a sort of remote-controlled communication system in which a high-level control centre in the hypothalamus and pituitary gland of the brain uses hormones to send messages to the rest of the body. At the same time, the brain can also receive hormones from the rest of the body in a kind of feedback loop about the state of the body. That way, the brain always knows exactly which hormones are called for in any given moment. Everything in our body, including the communication between cells, is controlled by hormones and messenger substances such as neurotransmitters to affect our mood, behaviour, weight, appearance and organ functioning.

The high sensitivity of hormones 

The hormonal system is very clever, yet also very sensitive — and it can make PMS affect each person differently. Imagine for a moment that hormones were like keys that fit into locks called receptors, located on cells throughout the body. Whereas sometimes the key fits perfectly into the lock, other times a tiny piece of dirt or grime might alter the fit, as other substances tend to bind to receptors and thus block, imitate or strengthen the effect of the key. Essential oils, for example, can sometimes mimic the effect of the hormone oestrogen.

Premenstrual syndrome (PMS) 

PMS is when our hormonal system gets out of balance, even though that’s precisely what the brain and body are supposed to regulate. Hormones start to yoyo about 4-14 days before our actual period begins. The result? Our body, mood and even our behaviour can change. The first symptoms can often be felt immediately after ovulation. Once menstruation (bleeding) begins, our levels stabilise again – until the next ovulation begins. All in all, our period occupies up to at least 14 days per month. That adds up to a lot of time, which can have a decisive influence on our quality of life [2].

What are the symptoms of PMS?

It sounds unbelievable but PMS can present itself in a variety of different ways. Here’s a selection of what you might feel…

… physically:

• tenderness in the breasts
• weight gain
• headaches / migraines
• issues with circulation
• fluid and water retention (oedema)
• back pain
• nausea and diarrhoea
• lower abdominal pain

… mentally:

• anxiety
• depression
• fatigue
• irritability
• mood swings

… behaviourally:

• listlessness
• hunger pangs or cravings for certain foods
• difficulty concentrating
• difficulty sleeping
• social withdrawal

Symptoms, of course, vary in type and severity from person to person, and can even vary from month to month within the same person. No matter how any of these symptoms affect you, they can be quite a bother and difficult to put up with every month.

Causes of PMS

When the hormonal ‘control centre’ in the brain is disturbed, it affects all of the physical control circuits throughout the body. This includes, for example, our energy reserves, acid-base balance and the hormonal balance that can make us feel happy. 

During ovulation, there tends to be an increase in the hormone prolactin, which is responsible for initiating and sustaining lactation. Production of prolactin also increases in response to stress in both men and women [S1].

Prolactin levels can remain high as the body transitions into the luteal phase, though that’s also when the hormones oestrogen and testosterone reach their maximum and begin to decline as the body produces more of the hormone progesterone, which can have a calming effect on the body. People with lower levels of progesterone might experience stronger PMS symptoms.

In addition to hormonal fluctuations, this phase of menstruation also coincides with fluctuations of the neurotransmitter serotonin, which is believed to play a key role in mood states. Insufficient levels of serotonin might set off PMS symptoms, as well as contribute to fatigue, food cravings and issues with sleep. 

As if this wasn’t already enough of a roller coaster for our mind and body, diet and lifestyle habits can affect the symptoms of PMS too.

What are PMDD and endometriosis?

Have you ever wondered if your PMS was abnormally severe? Are you worried that something might be wrong with your body? Modern science hasn’t yet nailed down why the female body can be particularly sensitive to hormone fluctuations. It could be that your body is naturally over-sensitive to sex hormones and that’s nothing to be ashamed about.

That being said, there’s a severe form of PMS called premenstrual dysphoric disorder (PMDD) that often goes untreated. There are very few diagnostic tests to distinguish PMDD from PMS, however genetic variations and family history of PMDD, smoking, trauma and stress are believed to be possible factors in the development of this serious condition.

There’s another severe long-term condition called endometriosis which occurs when womb lining tissue begins to develop in other places of the body, such as in the ovaries and fallopian tubes, and it can affect a woman’s ability to bare children. Endometriosis also often goes untreated because the condition can only be confirmed via laparoscopy and because the symptoms can vary and many of the common symptoms such as abdonimal pain, general feelings of sickness, constipation and diarrhoea overlap with those of PMS and PMDD. 

Many find it helpful to keep a diary of symptoms over the course of several months. If you believe you might be at risk of PMDD or endometriosis, make sure to consult your doctor.

Monk’s pepper: What is it?

The use of monk's pepper (Vitex agnus-castus L., also known as agnus castus fruit and chaste tree) to treat hormone fluctuations is not new. It’s said that thousands of years ago the plant was used by monks to help them remain chaste. Nowadays women might use it to get a more regular cycle or help with infertility.

The monk’s pepper plant has fan leaves that look much like those of the hemp and tends to be found in the Mediterranean region, Central Asia and India. Monk's pepper tastes a bit like black pepper, which is why it’s sometimes used as a spice. Therapeutic preparations of monk's pepper are ‘obtained by drying and powdering the fruit or by putting the plant material in a solvent (such as ethanol) to dissolve compounds and form a liquid extract. The solvent is then evaporated to obtain a dry extract’. [7] Monk’s pepper is rich in essential oils, flavonoids, bitter substances and unsaturated fatty acids.

How monk’s pepper works

Researchers still aren’t sure how the plant affects the human body. They suspect that it influences the brain’s hormonal ‘control centre’, which might counteract the hormone imbalance that tends to occur leading up to menstruation [7]. The linchpin of PMS might be those elevated prolactin levels during the ovulation and luteal phase of the menstrual cycle, as mentioned earlier. Monk's pepper can stimulate the production of the neurotransmitter dopamine, which acts as an antagonist of prolactin and means that it can help suppress prolactin to previous levels [1].

Monk's pepper can also act on additional receptors such as those that work with:

• endorphins
• histamine
• oestrogen
• opioids

According to the Committee on Herbal Medicinal Products (HMPC) of the European Medicines Agency, ‘one particular dry extract preparation of agnus castus fruit can be used continuously over 3 months for the treatment of premenstrual syndrome (symptoms that occur in the days before a woman's menstrual period).’ The HMPC also concluded that ‘on the basis of their long-standing use, the other agnus castus fruit preparations can be used for relief of minor symptoms in the days before a woman’s period.’ [7]

Science to support the use of monk’s pepper

During an open study without controls that took place in 2000 with 1634 patients suffering from premenstrual syndrome symptoms, ‘93% reported a decrease in the number of symptoms or even cessation of PMS complaints’ after three months of taking a solid preparation from an extract of the fruit of monk’s pepper [S5]. Another study with PMDD patients compared treatment with monk’s pepper (referred to as ‘Vitex agnus castus (VAC)’) as compared to the SSRI antidepressant fluoxetine and concluded: ‘This study confirms the data reported in the literature regarding the effectiveness of VAC therapy with no side effects’. [1; 2; S6]

The HMPC concluded that there’s a ‘well-established use’ for the treatment of premenstrual syndrome using the agnus castus fruit dry extract for are based on ‘bibliographic data providing scientific evidence of effectiveness and safety when used in this way, covering a period of at least 10 years in the EU’. For the use of other agnus castus preparations to relieve minor PMS symptoms, the HMPC concluded, are based on their ‘traditional use’, which means ‘although there is insufficient evidence from clinical trials, the effectiveness of these herbal medicines is plausible and there is evidence that they have been used safely in this way for at least 30 years (including at least 15 years within the EU). Moreover, the intended use does not require medical supervision’. [7]

What form does monk’s pepper come in?

Monk's pepper is typically available as:

• tea
• drops
• tablets
• capsules
• seeds and
• ointments [1].

Perhaps some of these forms will work better for you than others. It’s also important to make sure the product is of high-quality when it comes to the following factors:

• plant cultivation
• chemical composition and possible additives
• concentration of the extract
• product packaging

It's best to consult your doctor and/or gynacologist before trying any preparation of monk’s pepper.

How to use monk's pepper

Very important: If you suffer from severe abdominal cramps or unusually heavy bleeding, make sure you speak with your doctor first. 

As mentioned previously, the HMPC advises that monk’s pepper be taken for at least three months. This is the only way to build up an effective level in your blood [4]. If you have little to no mild symptoms, you might consider discontinuing use [5].

The ideal dosage

Here, too, it is best to ask your doctor or gynaecologist for a dosage recommendation. What we can say, however, is that dosing really does matter.

In a multicenter, double-blind, placebo-controlled, parallel-group study, 162 female patients with PMS were assigned at random to take either placebo or different doses of Vitex agnus castus L. (VAC) extract Ze 440 over three menstrual cycles. While ‘each of the treatments was well tolerated…. Improvement in the total symptom score (TSS) in the 20mg group was significantly higher than in the placebo and 8 mg treatment group. The higher dose of 30 mg, on the other hand, did not significantly decrease symptom severity compared to the 20mg treatment, providing a rational [sic] for the usage of 20mg’. [S7].

Side effects and precautionary measures

Those who have cancer in the genitals, endometriosis or are pregnant or breastfeeding are not advised to take monk’s pepper [1]. If you are taking any other medication, please discuss with your doctor in advance of trying monk’s pepper to avoid possible interactions. Otherwise monk’s pepper is generally well tolerated. If you are particularly sensitive and the dosage is too high, the following side effects might occur:

• weight gain
• skin rash
• headache
• gastrointestinal complaints
• dry mouth
• hypersensitivity reactions [S8]. 

 If you experience any of these adverse effects, skin rashes or itching in particular, it’s advised to stop using monk’s pepper immediately [4]. 

How long do I have to live with PMS?

PMS can be an issue for as long as you are capable of getting pregnant. Even hormonal contraceptives don't always protect against PMS. These hormonal fluctuations tend to disappear with pregnancy and might come back with different symptoms when you return to menstruating. Sometimes symptoms continue into or evolve into another set of symptoms during the onset menopause. The good news is that they will likely decrease when menopause is over.

What else you can do for PMS

Much like other processes in our body, hormones react to our lifestyle and diet. The strength of the PMS symptoms can be influenced by our stress level, diet, and certain medications (such as laxatives). It might be worth exploring whether PMS symptoms are affected by changes to those factors, such as with the introduction of new activities like:

• acupuncture [S9]
• healthier sleep routine
• improved stress management
• high-carbohydrate, low-protein and low-salt diet
• relaxation exercises
• regular physical exercise
• abstention from coffee, sugar, alcohol and nicotine 
• heat therapy

References: 

[1] Monk’s pepper - Effect on the desire to have children and PMS, in the central health insurance company, accessed on 11/10/2020 https://www.krankenkassenzentrale.de/wiki/moenchspfeffer#

[2] Dr. Fessler, Beate, Bitchy in the second half of the cycle, Deutsche Apothekerzeitung, accessed on November 102020 from https://www.deutsche-apotheker-zeitung.de/daz-az/2017/daz-10-2017/wenn-regelschmerzen-die-regel-sind

[3] Neubauer, Sylvia, Eat bitter and you feel good!, July 10, 2019 in Healthy: Nutrition, accessed on November 15, 2020 from https://www.gesund.at/ernaehrung/bitterstoffe-gesund/

[4] Monk’s pepper, January 19, 2020 in PharmaWiki, accessed on November 15, 2020 from https://www.pharmawiki.ch/wiki/index.php?wiki = M% C3% B6nchspfeffer

[5] Wolf, Elke, The ups and downs of hormones determine a woman’s month, March 8, 1999 in Pharmazeutischer Zeitung, accessed on November 15, 2020 from https://www.pharmazeutische-zeitung.de/ inhalt-10-1999 / titel-10-1999 /coach

[6] Monk’s pepper, micronutrient coach accessed on November 15, 2020 from https://www.mikronaehrstoffcoach.com/de/at/mikronaehrstoffe/micronutrient.moenchspfeffer.html

[7] Agni casti fructus, February 25, 2020 in European Medicines Agency, accessed on November 15, 2020 from https://www.ema.europa.eu/en/medicines/herbal/agni-casti-fructus

Relevant studies: 

[S1] Wuttke, W. et. al., Chaste tree (Vitex agnus-castus) - pharmacology and clinical indications, May 2003 in Phytomedicine; 10 (4): 348-57, accessed on November 15, 2020 https: //pubmed.ncbi.nlm.nih. gov / 12809367 /

[S2] Zamani, Mehrangiz et. al., Therapeutic effect of Vitex agnus castus in patients with premenstrual syndrome, 2012 in Acta Med Iran; 50 (2): 101-6, accessed on November 15, 2020 https://pubmed.ncbi.nlm.nih.gov/22359078/

[S3] Webster, Donna E. et. al., Opioidergic mechanisms underlying the actions of Vitex agnus-castus L, January 1, 2011 in Biochem Pharmacol; 81 (1): 170-7, accessed on November 15, 2020 https://pubmed.ncbi.nlm.nih.gov / 20854795 /

[S4] Saberivand, A. et. al., The effects of Cannabis sativa L. seed (hempseed) in the ovariectomized rat model of menopause, 09/2010 in Methods Find Exp Clin Pharmacol. 2010 Sep; 32 (7): 467-73, accessed on November 15, 2020 https://www.ncbi.nlm.nih.gov/pubmed/21069097

[S5] Loch, EG et. al., Treatment of premenstrual syndrome with a phytopharmaceutical formulation containing Vitex agnus castus, April 2000 in J Womens Health Gend Based Med; 9 (3): 315-20, accessed on November 15, 2020 https://pubmed.ncbi.nlm.nih.gov/10787228/

[S6] Ciotta, L. et. al., Psychic aspects of the premenstrual dysphoric disorders. New therapeutic strategies: our experience with Vitex agnus castus, June 2011 in Minerva Ginecol; 63 (3): 237-45, accessed on November 15, 2020 from https://pubmed.ncbi.nlm.nih.gov/21654609/

[S7] Schellenberg, Rüdiger et. al., Dose-dependent efficacy of the Vitex agnus castus extract Ze 440 in patients suffering from premenstrual syndrome, November 15, 2012 in Phytomedicine; 19 (14): 1325-31, accessed on November 15, 2020 https: //pubmed.ncbi .nlm.nih.gov / 23022391 /

[S8] Daniele, Claudia et. al., Vitex agnus castus: a systematic review of adverse events, 2005 in Drug Saf; 28 (4): 319-32, accessed on November 15, 2020 from https://pubmed.ncbi.nlm.nih.gov/15783241/

[S9] Kim, SY et. al., Acupuncture for premenstrual syndrome: a systematic review and meta-analysis of randomized controlled trials, July 2011 in BJOG; 118 (8): 899-915, accessed on November 15, 2020 https: //pubmed.ncbi.nlm. nih.gov/21609380/