Vitamin or mineral supplements for premenstrual syndrome (original) (raw)

Abstract

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To evaluate the effectiveness and safety of vitamin and mineral supplementation for alleviating symptoms in women with a diagnosis of premenstrual syndrome or premenstrual dysphoric disorder.

Background

Description of the condition

Premenstrual syndrome (PMS) is a common health problem for women. Previous studies have shown that up to 90% of women have experienced some form of PMS during their reproductive years (Jarvis 2008). Furthermore, in approximately 5% to 8% of these women, affective symptoms are severe and cause substantial impairment of normal daily functioning (Jarvis 2008). An interaction of gonadal steroid hormone and central nervous system neurotransmitters appears to contribute to development of PMS (Yonkers 2008; Rapkin 2009). In line with this notion, oral contraceptives and selective serotonin reuptake inhibitors (SSRIs) have been shown to reduce the symptoms of PMS (Lopez 2012; Marjoribanks 2013).

PMS occurs during the luteal phase of the menstrual cycle and spontaneously diminishes within a few days after onset of menstruation. Characteristic symptoms of PMS include physical symptoms and psychological and behavioural symptoms. Common physical symptoms include breast tenderness, headaches, musculoskeletal pain, abdominal swelling, swelling of extremities, and weight gain (O'Brien 2011). Common psychological and behavioural symptoms include depression, changes in appetite, fatigue or lethargy, mood swings, irritability, sleep disturbances, tension, social withdrawal, and poor concentration (O'Brien 2011).

Diagnosis of PMS stipulates (1) the presence of at least one of a number of affective symptoms (depression, angry outbursts, irritability, anxiety, confusion, social withdrawal) and at least one somatic symptom (breast tenderness, abdominal bloating, headache, swelling of extremities) during the five days before menses in each of the three prior menstrual cycles; and (2) spontaneous regression of these symptoms within four days of the onset of menses, without recurrence until at least cycle day 13, excluding cases involving pharmacological treatment, hormone intake, alcohol consumption, or socioeconomic performance disability (ACOG 2015). This information should be obtained by prospective collection rather than by retrospective recall (ACOG 2015).

Premenstrual dysphoric disorder (PMDD) is a subtype of PMS. Therefore all women given a diagnosis of PMDD meet the diagnostic criteria for PMS as well, but their symptoms are more severe (Steiner 2000). Appendix 1 presents the standard diagnostic criteria for PMDD as proposed by the American Psychiatric Association (Freeman 2003). Predominant symptoms of PMDD include anger, irritability, and internal tension (Steiner 2000). Throughout this review, we use the term PMS to include PMDD.

The diagnosis of PMS can be established only after exclusion of other possible causes of symptoms, including affective disorders (e.g. depression, anxiety, dysthymia, panic); anorexia or bulimia; and chronic medical conditions such as anaemia, diabetes mellitus, hypothyroidism, or substance abuse (O'Brien 2011).

Description of the intervention

Because the aetiology of PMS is not clear, symptom relief is the goal of treatment. Cochrane Reviews evaluating the efficacy of an SSRI and an oral contraceptive containing drospirenone for management of PMS have shown benefit (Lopez 2012; Marjoribanks 2013). Women presenting with severe PMS symptoms usually are prescribed SSRIs, oral contraceptives, non‐steroidal anti‐inflammatory drugs (NSAIDs), diuretics, or gonadotropin‐releasing hormone (GnRH) agonists, depending on their predominant symptoms (O'Brien 2011). These therapies may be effective for many women with PMS, but they are linked with substantial adverse effects (particularly with long‐term use), which may reduce adherence to treatment (Wang 1995; Sundstrom‐Poromaa 2000; Martin 2014).

Vitamins are defined as any of a group of natural organic substances that are necessary in small amounts and act as coenzymes and precursors of coenzymes in regulating various metabolic processes (Ward 2014). Minerals are defined as chemical elements required as essential nutrients to maintain body functions (Ward 2014). Several vitamins and minerals including vitamin B, vitamin D, calcium, and magnesium are essential for neurotransmitter synthesis and hormonal balance, both of which are potentially involved in the underlying pathogenesis of PMS. Vitamin and mineral supplements may be effective in alleviating PMS symptoms; it has been noted that the incidence of PMS is low among women with diets rich in vitamins or minerals (Rosenstein 1994; Bertone‐Johnson 2005; Chocano‐Bedoya 2011). Reported adverse effects of vitamin and mineral supplements for PMS include nausea, constipation, abdominal discomfort, dizziness, and headache (Whelan 2009). Cochrane systematic reviews of vitamin and mineral supplements used for indications such as subfertility (Showell 2014; Showell 2017), diabetic kidney disease (Raval 2015), and pregnancy (Haider 2015) have not provided evidence of serious adverse effects. However, uncertainty remains regarding the safety of vitamin and mineral supplements owing to poor reporting of adverse events in the included studies.

How the intervention might work

Deficiencies of certain vitamins and minerals including vitamin B, vitamin D, calcium, and magnesium may play a role in PMS. This hypothesis is based primarily on the high incidence of PMS in populations with low levels of these micronutrients (Posaci 1994; Rosenstein 1994; Bertone‐Johnson 2005; Thys‐Jacobs 2007; Chocano‐Bedoya 2011).

Magnesium is essential for the brain's dopaminergic synthesis. Dopamine imbalance can affect mood and can lead to overwhelming anxiety (Li 2001). Previous studies have reported decreased circulating magnesium concentrations during the luteal phase among women with PMS, suggesting that magnesium deficiency may be a key factor in the aetiology of PMS (Posaci 1994; Rosenstein 1994).

Bertone‐Johnson 2005 conducted a substudy of a prospective Nurses’ Health Study, which found that women with high intake of vitamin D and calcium carried lower risk of developing PMS compared with those in the group with low intake, with a risk ratio of 0.59 (95% confidence interval (CI) 0.40 to 0.86) and 0.70 (95% CI 0.50 to 0.97), respectively. A previous study noted that a calcium deficiency during the luteal phase among women with PMS was secondary to the disturbance of calcium‐regulating hormones that follows the rise in ovarian steroid hormone concentrations and vitamin D deficiency (Thys‐Jacobs 2007).

In addition, the risk of developing PMS is lower in women with high dietary intake of vitamin B than in those with low intake (Chocano‐Bedoya 2011). Vitamin B is thought to be involved in various steps of serotonin metabolism including converting tryptophan amino acid to serotonin and generating the active substances required for metabolism of serotonin. Vitamin B deficiency can thus hinder serotonin production, which can result in mood disorders (Hvas 2004; Lewis 2013).

Why it is important to do this review

PMS may have a negative impact on social relationships, professional activities, and healthcare resource utilisation (O'Brien 2011). Thus it is necessary to gather reliable scientific evidence regarding effective interventions for ameliorating PMS symptoms. Research has suggested that PMS is associated with low dietary intake of some select vitamins or minerals (Rosenstein 1994; Bertone‐Johnson 2005; Chocano‐Bedoya 2011); therefore a promising treatment option may consist of supplementation of these vitamins or minerals to achieve optimal status, although available evidence regarding the benefits and harms of vitamin and mineral supplements for PMS is largely inconclusive. It is imperative to establish whether vitamin or mineral supplements are effective and safe for alleviating PMS symptoms ‐ a task that would be best accomplished through a systematic review and meta‐analysis of findings of randomised controlled trials. Accordingly, we will conduct this Cochrane systematic review with the goal of evaluating the effectiveness and safety of vitamin or mineral supplements in alleviating PMS symptoms.

Objectives

To evaluate the effectiveness and safety of vitamin and mineral supplementation for alleviating symptoms in women with a diagnosis of premenstrual syndrome or premenstrual dysphoric disorder.

Methods

Criteria for considering studies for this review

Types of studies

We will include randomised controlled trials (RCTs) irrespective of language of publication, publication status, year of publication, or sample size. We will exclude quasi‐randomised trials (e.g. studies with evidence of inadequate sequence generation such as use of alternate days or patient numbers) and non‐randomised studies as they tend to have high risk of bias. We will include cross‐over trials and cluster‐randomised trials (if any are available), as these designs are valid in this context. However, we will use only first‐phase data of cross‐over trials in our analyses to avoid a carryover effect.

Types of participants

We will include studies of women of reproductive age who met medically defined diagnostic criteria for PMS (including PMDD, which is a severe form of PMS). Diagnosis of PMS requires that symptoms are confirmed by prospective recording for at least two menstrual cycles. Diagnosis must have been made by healthcare professionals before inclusion of women in the study. We will exclude studies that were based solely on self‐diagnosis.

Types of interventions

We will include trials comparing the following interventions.

• Vitamins or minerals or both in any dose and through any route of administration versus placebo or no treatment.
• Vitamins or minerals or both in any dose and through any route of administration versus other treatment.
• Vitamins or minerals or both in any dose and through any route of administration combined with other treatment versus that other treatment alone or that other treatment plus placebo.
• Vitamins or minerals or both in any dose and through any route of administration versus other vitamins or minerals or both in any dose and through any route of administration.

Types of outcome measures

Primary outcomes

• End scores and change scores for all symptoms of PMS, measured via a validated prospective symptom rating tool. Our preferred tools (in order of preference) include Calendar of Premenstrual Experience (COPE); Daily Record of Severity of Problems (DRSP); Moos’ Menstrual Distress Questionnaire (MDQ); and Premenstrual Tension Syndrome Self‐Rating Scale (PMTS‐SR). We will include end scores or change scores from each study, if feasible. We prefer to use end scores and to report change scores as a separate outcome.
• Adverse effects, categorised as:
  • all adverse events per participant;
  • specific adverse effects, which may include digestive symptoms (e.g. diarrhoea, constipation, nausea, abdominal discomfort, gastric upset, dry mouth); neurological symptoms (e.g. headache, insomnia, dizziness); and skin symptoms (e.g. rash, acne); or
  • withdrawals due to adverse effects.

Secondary outcomes

• End scores and change scores for specific PMS symptoms: psychological, physical, and functional symptoms; irritability measured on a single‐item visual analogue scale (VAS).
• Response rate: assessed as the number of participants with improved PMS symptoms from baseline (i.e. complete reduction or improvement vs slightly better or no difference from baseline).
• Rate of use of additional medications (e.g. SSRIs, oral contraceptives, NSAIDs), depending on the participant's predominant symptoms.
• Cost‐effectiveness.
• Quality of life (QoL): end scores and change scores for QoL, provided this information has been recorded in a reproducible and validated format. Our preferred tools (in order of preference) include Pre‐Menstrual Symptoms Impact Survey (PMSIS); 36‐item Short Form (SF 36); and 12‐item Short Form (SF 12).

If data permit, we will analyse outcomes at the following time points: three months (our preferred follow‐up time), six months, and one year from the start of treatment, and at the end of the trial.

We will present a ’Summary of findings’ (SoF) table to report primary outcomes listed in order of priority.

• End scores for all PMS symptoms.
• All adverse effects.
• Specific adverse effects.
• Withdrawals due to adverse effects.

Search methods for identification of studies

We will search for all published and unpublished RCTs in consultation with the Cochrane Gynaecology and Fertility Group (CGFG) Information Specialist, with no restrictions regarding language, publication status, year of publication, or sample size.

Electronic searches

We will search the following electronic databases, trial registers, and websites from their inception to the present.

• Cochrane Gynaecology and Fertility Group (CGFG) Specialised Register of Controlled Trials (Procite platform) (Appendix 2).
• Cochrane Central Register of Studies Online (CRSO) (web platform) (Appendix 3).
• MEDLINE (Ovid platform) (Appendix 4).
• Embase (Ovid platform) (Appendix 5).
• PsycINFO (Ovid platform) (Appendix 6).
• Allied and Complementary Medicine Database (AMED) (Ovid platform) (Appendix 7).
• Cumulative Index to Nursing and Allied Health Literature (CINAHL) (Ebsco platform) (Appendix 8).

We will combine the MEDLINE search with the Cochrane Highly Sensitive Search Strategy for identifying randomised trials, which appears in the Cochrane Handbook for Systematic Reviews of Interventions (Version 5.0.2, Chapter 6, 6.4.11). We will combine Embase, PsycINFO, and CINAHL searches using trial filters developed by the Scottish Intercollegiate Guidelines Network (SIGN) ‐ http://www.sign.ac.uk/methodology/filters.html#random.

Other electronic sources of trials will include the following.

• Trial registries for ongoing and registered trials ‐ ClinicalTrials.gov, a service of the US National Institutes of Health, at http://www.clinicaltrials.gov; and the World Health Organization International Trials Registry platform search portal, at http://www.who.int/trialsearch/Default.aspx.
• Database of Abstracts of Reviews of Effects (DARE), in the Cochrane Library, at http://onlinelibrary.wiley.com/o/cochrane/Cochrane_cldare_articles_fs.html (for reference lists from relevant non‐Cochrane reviews).
• ProQuest Dissertations & Theses (PQDT), at http://www.proquest.com/libraries/academic/dissertations‐theses/ (for unpublished dissertations and theses).
• Conference abstracts and other trials on the Web of Science, at http://wokinfo.com/.
• Web of Knowledge, at http://wokinfo.com/ (another source of trials and conference abstracts).
• OpenGrey, at http://www.opengrey.eu/ (for unpublished literature from Europe).
• Latin American Caribbean Health Sciences Literature (LILACS) database, at http://regional.bvsalud.org/php/index.php?lang=en (for trials from the Portuguese and Spanish speaking world).
• PubMed and Google Scholar (for recent trials not yet indexed in the major databases).

Searching other resources

We will handsearch reference lists of reviews and articles retrieved by the search. We will also handsearch relevant journals and conference abstracts that are not included in the CGFG Register, in liaison with the CGFG Information Specialist.

Data collection and analysis

Selection of studies

We will download all titles and abstracts retrieved through the electronic search to a reference management database (EndNote). After removing duplicates, we will transfer these data to Covidence (Covidence). Two review authors (SK and CK) will independently examine the remaining references. We will exclude studies that clearly do not meet the inclusion criteria. We will obtain copies of full texts of potentially relevant references. Two review authors (SK and CK) will independently assess the eligibility of retrieved reports/publications. We will resolve disagreements through discussion, or, if required, we will consult a third review author (PL). We will identify and exclude duplicates and will collate multiple reports of the same study, so that each study rather than each report is the unit of interest in the review. We will use details regarding the selection process to complete a PRISMA flow diagram and 'Characteristics of excluded studies' tables (Liberati 2009).

Data extraction and management

Two review authors (SK and CK) will independently extract study characteristics and outcome data from included studies using Covidence. We will note any outcome data not reported in a usable way in the 'Characteristics of included studies' tables. We will resolve disagreements by reaching consensus or by involving a third review author (PL). We will correspond with study investigators to request further data on methods and/or results, as required. We will estimate data values from graphs when necessary.

Assessment of risk of bias in included studies

Two review authors (SK and CK) will independently assess risk of bias in included studies by using the criteria available in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011); we will resolve differences by discussion or by appeal to a third review author (PL). We will assess each study on the basis of six categories: selection bias (sequence generation and allocation concealment); performance bias (blinding of participants and personnel); detection bias (blinding of outcome assessment); attrition bias (incomplete outcome data); reporting bias (selective outcome reporting); and other biases (any 'other issues' also considered for assessment). We will judge each item as being at high, low, or unclear risk of bias, as set out in the criteria displayed in Appendix 9 (Higgins 2011). However, we anticipate that the studies included in this review will be highly susceptible to detection and attrition bias owing to the combination of self‐reported outcome measures and the likelihood that dropout might be associated with the individual's condition. We will acknowledge studies without effective blinding of participants, personnel, and outcome assessors as having high risk of performance and detection bias, respectively. If at least 80% of randomised women were included in the analysis, we will rated the study as having low risk of attrition bias.

We will provide in the 'Risk of bias' table a quote from the study report and/or a statement as justification for judgement for each item. We will summarise results in both a 'Risk of bias graph' and a 'Risk of bias summary', if feasible. When interpreting treatment effects and meta‐analyses, we will take into account the risk of bias of included studies that contribute to that outcome. When information on risk of bias relates to unpublished data or correspondence with a trial author, we will note this in the 'Risk of bias' table.

Measures of treatment effect

For dichotomous data (e.g. occurrence of adverse events), we will use numbers of events in control and intervention groups of each study to calculate Mantel‐Haenszel odds ratios (ORs). For continuous data (i.e. end scores and change scores for PMS symptoms), if all studies report exactly the same outcomes, we will calculate mean differences (MDs) between treatment groups. If similar outcomes are reported on different scales, we will calculate standardised mean differences (SMDs). We will reverse the direction of effects of individual studies, if required, to ensure consistency across trials. We will treat ordinal data (i.e. scores obtained from visual analogue scales (VASs) and quality of life scores) as continuous data. We will extract end scores in preference to change scores, when available, and will include them in the 'Summary of findings' table. We will present 95% confidence intervals (CIs) for all outcomes. When data needed to calculate ORs or MDs are not available, we will utilise the most detailed numerical data available that may facilitate similar analyses of included studies (e.g. test statistics, P values). We will compare the magnitude and direction of effects reported by studies with how they are presented in the review, while taking account of legitimate differences.

Unit of analysis issues

The unit of analysis is per woman randomised. In a study with multiple groups, we will combine all relevant experimental intervention groups into a single group to create a single pair‐wise comparison (Higgins 2011). We will include only data from the first phase in cases of cross‐over trials to minimise a carryover effect.

Dealing with missing data

In so far as it is possible, we will carry out analyses on an intention‐to‐treat basis for all outcomes. This means that we will attempt to include in analyses all participants randomised to each group, and we will analyse all participants in the group to which they were allocated, regardless of whether or not they received the allocated intervention. We will attempt to contact study authors to obtain missing data. We anticipate finding data missing from trial reports because of loss to follow‐up; we will attempt to impute missing data for primary outcomes using the 'informative missingness (IM)' approach suggested by Higgins 2008. For continuous outcomes, we will apply the informative missing difference of means (IMDOM), and for dichotomous outcomes, we will calculate the informative missing odds ratio (IMOR) using 'metamiss' or 'metamiss2' in STATA 14 (StataCorp 2015). For secondary outcomes, if we are unable to obtain missing data, we will include only available data.

Assessment of heterogeneity

We will consider whether clinical and methodological characteristics of included studies are sufficiently similar for meta‐analysis to provide a clinically meaningful summary. We will assess statistical heterogeneity using the I² measurement. We will consider I² greater than 50% to indicate substantial heterogeneity (Higgins 2003).

Assessment of reporting biases

In view of the difficulty of detecting and correcting for publication bias and other reporting biases, review authors will aim to minimise the potential impact of biases by ensuring a comprehensive search for eligible studies, and by staying alert for duplication of data. If we include 10 or more studies in an analysis, we will use a funnel plot to explore the possibility of small‐study effects (i.e. the tendency for smaller studies to estimate the intervention effect as more beneficial than reported by larger studies).

Data synthesis

We will carry out statistical analyses with Review Manager 5 software (RevMan 2014), using the Mantel‐Haenszel fixed‐effect model for combining data when included trials examine the same intervention, and when trial populations and methods are acknowledged as sufficiently similar (DerSimonian 1986). We will convert continuous data/standardised mean differences to an interpretable scale/natural units. We will analyse end scores and change scores separately and will not pool these data. We will report separately the results of each comparison listed under Types of interventions. If we identify substantial heterogeneity between included studies, we will summarise findings narratively.

• Vitamins and/or minerals versus placebo or no treatment (stratified by type of comparator and pooled).
• Vitamins and/or minerals versus other treatment (separate comparisons for different comparators).
• Vitamins and/or minerals plus other treatment versus other treatment (± placebo) (separate comparisons for different comparators).
• Vitamins and/or minerals versus other vitamins and/or minerals (separate comparisons for different comparators).

Subgroup analysis and investigation of heterogeneity

When data are available, we will perform subgroup analyses using the RevMan 2014 test for subgroup differences to assess the influence of the following issues on effect size.

• Subgroups by severity of PMS symptoms (with reference to the trial inclusion criteria): mild to moderate PMS versus severe PMS. Severity of PMS will depend on self‐rated scores from rating tools, and PMDD will be defined as severe PMS.
• Subgroups by dosage of vitamins or minerals or both.

If we detect substantial heterogeneity, we will explore possible explanations by performing subgroup analyses and/or sensitivity analyses. We will take any statistical heterogeneity into account when interpreting trial results, especially if we note any variation in the direction of effect.

Sensitivity analysis

We will perform sensitivity analysis to determine the effects of the following factors.

• Repeating the analysis while excluding unpublished studies (if any).
• Repeating the analysis while excluding studies judged to be at 'high' or 'unclear' risk of bias for allocation concealment.
• Repeating the analysis using a random‐effects model.
• As a consequence of the imputation method (informative missingness (IM)) for missing outcome data, we will perform a series of sensitivity analyses to examine the impact of attrition on treatment effect estimates by using a different assumption regarding missing data, an available case analysis (ACA), and imputed case analyses (ICAs), as suggested by Higgins 2008.

Overall quality of the body of evidence: 'Summary of findings' table

We will prepare a 'Summary of findings' table using GRADEpro GDT 2014 software. This table will present the overall quality of the body of evidence according to GRADE criteria for our main comparison (vitamins or minerals or both vs placebo or no treatment) for the primary outcomes including end scores for all symptoms at three months' follow‐up (or closest follow‐up to three months reported), rates of all adverse effects, rates of specific adverse effects, and rates of withdrawal due to adverse effects. These criteria include study limitations (i.e. risk of bias), consistency of effect, imprecision, indirectness, and publication bias. Two review authors (SK and CK) will work independently to determine judgements about evidence quality (high, moderate, or low) and will resolve disagreements by discussion. We will justify, document, and incorporate judgements into reporting of results for each outcome (Schünemann 2011).

Acknowledgements

We thank Helen Nagels, Jane Marjoribanks, and Cindy Farquhar for clinical and editorial advice. We thank Marian Showell for designing the search strategy, and Dylan Southard for assisting with English language presentation.

Appendices

Appendix 1. Standard diagnostic criteria for premenstrual dysphoric disorder (PMDD)

Appendix 2. Cochrane Gynaecology and Fertility Group Specialised Register search strategy

From inception to present (PROCITE platform)

Keywords CONTAINS "premenstrual aggravation" or "premenstrual dysphoria" or "premenstrual dysphoric disorder" or "Premenstrual Syndrome‐Symptoms" or "premenstrual syndrome" or "Premenstrual Tension Scale" or "premenstrual symptoms" or "premenstrual symptom scores" or "premenstrual scores" or "premenstrual pain" or "premenstrual" or "PMDD" or "PMS" or Title CONTAINS "premenstrual aggravation" or "premenstrual dysphoria" or "premenstrual dysphoric disorder" or "Premenstrual Syndrome‐Symptoms" or "premenstrual syndrome" or "Premenstrual Tension Scale" or "premenstrual symptoms" or "premenstrual symptom scores" or "premenstrual scores" or "premenstrual pain" or "premenstrual" or "PMDD" or "PMS"

AND

Keywords CONTAINS "antioxidants" or "antioxidant" or "antioxidant levels" or "vitamin" or "vitamin A" or "vitamin B" or "Vitamin‐B‐12" or "Vitamin‐B‐12‐Therapeutic‐Use" or "vitamin B6" or "vitamin C" or "Vitamin D" or "vitamin E" or "vitamins" or "selenium" or "folic acid" or "*Calcium" or "potassium" or "sodium" or "Copper" or "Manganese" or "Magnesium" or "iron" or "minerals" or "Mineral" or" ascorbic acid" or "zinc" or "fatty acids" or "oil" or "fish oils" or "plant extracts" or "tocopherol" or "multivitamins" or "alpha tocopherol" or "melatonin" or "dietary supplement" or "nutritional supplement" or "nutritional supplements" or "Myo‐inositol" or "evening primrose oil" or "chromium supplementation" or "Pyridoxine" or Title CONTAINS "antioxidants" or "vitamin" or "vitamin B" or "Vitamin‐B‐12"or"vitamin B6" or "vitamin C" or "Vitamin D" or "vitamin E" or "vitamins" or"*Calcium" or ”potassium" or "sodium" or "Copper" or "Manganese" or "Magnesium" or "iron" or "minerals" or "Mineral" or "Pyridoxine"

Appendix 3. CENTRAL Register of Studies Online (CRSO) search strategy

From inception to present (Web platform)

#1 MESH DESCRIPTOR Premenstrual Syndrome EXPLODE ALL TREES

#2 (premenstrual syndrome):TI,AB,KY

#3 (pmt or pms):TI,AB,KY

#4 #1 OR #2 OR #3

#5 MESH DESCRIPTOR Vitamin B Complex EXPLODE ALL TREES

#6 MESH DESCRIPTOR Vitamins EXPLODE ALL TREES

#7 MESH DESCRIPTOR Minerals EXPLODE ALL TREES

#8 mineral*:TI,AB,KY

#9 vitamin*:TI,AB,KY

#10 MESH DESCRIPTOR Antioxidants EXPLODE ALL TREES

#11 antioxidant*:TI,AB,KY

#12 MESH DESCRIPTOR Calcium Carbonate EXPLODE ALL TREES

#13 (calcium or manganese):TI,AB,KY

#14 MESH DESCRIPTOR Manganese EXPLODE ALL TREES

#15 (iron or copper):TI,AB,KY

#16 MESH DESCRIPTOR Copper EXPLODE ALL TREES

#17 MESH DESCRIPTOR Sodium, Dietary EXPLODE ALL TREES

#18 MESH DESCRIPTOR Sodium EXPLODE ALL TREES

#19 sodium:TI,AB,KY

#20 zinc:TI,AB,KY

#21 (dietary supplement*):TI,AB,KY

#22 MESH DESCRIPTOR Dietary Supplements EXPLODE ALL TREES

#23 Nutriceutical*:TI,AB,KY

#24 MESH DESCRIPTOR Melatonin EXPLODE ALL TREES

#25 melatonin:TI,AB,KY 1371

#26 MESH DESCRIPTOR Ascorbic Acid EXPLODE ALL TREES

#27 MESH DESCRIPTOR Magnesium EXPLODE ALL TREES

#28 magnesium:TI,AB,KY

#29 multivitamin*:TI,AB,KY

#30 MESH DESCRIPTOR Fatty Acids EXPLODE ALL TREES

#31 (fatty acid*):TI,AB,KY

#32 omega:TI,AB,KY

#33 selenium:TI,AB,KY

#34 (ascorbic acid):TI,AB,KY

#35 (evening primrose):TI,AB,KY

#36 chromium:TI,AB,KY

#37 #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35 OR #36

#38 #4 AND #37

Appendix 4. MEDLINE search strategy

From 1946 to present (OVID platform)

1 exp Premenstrual Syndrome/ 2 PMS.tw. 3 luteal phase disorder$.tw. 4 premenstrual dysphoric disorder$.tw. 5 PMDD.tw. 6 premenstrual aggravation.tw. 7 premenstrual tension$.tw. 8 Premenstrual Syndrome$.tw. 9 PMT.tw. 10 or/1‐9 11 exp antioxidants/ or free radical scavengers/ 12 (antioxidant$ or radical scavengers).tw. 13 exp vitamins/ or exp ascorbic acid/ or exp dehydroascorbic acid/ or exp vitamin a/ or exp vitamin e/ or exp vitamin u/ or exp alpha‐tocopherol/ or exp beta carotene/ or exp beta‐tocopherol/ or exp gamma‐tocopherol/ 14 vitamin$.tw. 15 exp Minerals/ or mineral$.tw. 16 exp Zinc/ 17 Potassium.tw. 18 exp potassium/ 19 (zinc or selenium).tw. 20 exp Selenium/ 21 sodium.tw. 22 exp sodium/ 23 copper.tw. 24 exp copper/ 25 manganese.tw. 26 exp manganese/ 27 iron.tw. 28 exp Iron/ 29 exp Glutathione Peroxidase/ or exp folic acid/ 30 (Glutathione$ or folate).tw. 31 exp Ubiquinone/ 32 (ubiquin$ or folic acid).tw. 33 coenzyme q10.tw. 34 exp Carnitine/ 35 (carnitine$ or carotenoid$).tw. 36 (astaxanthin$ or lycopene$).tw. 37 multivitamin$.tw. 38 (betacarotene$ or beta carotene$).tw. 39 ascorbic acid.tw. 40 n‐acetylcysteine.tw. 41 exp Acetylcysteine/ 42 alpha‐tocopherol$.tw. 43 (fish adj2 oil$).tw. 44 omega$.tw. 45 exp fatty acids/ or exp fish oils/ or exp cod liver oil/ or exp fatty acids, omega‐3/ or exp plant oils/ 46 fatty acid$.tw. 47 (plant adj4 oil$).tw. 48 primrose oil$.tw. 49 l‐arginine$.tw. 50 flavonoid$.tw. 51 riboflavin$.tw. 52 pycnogenol$.tw. 53 lutein$.tw. 54 lipoic acid$.tw. 55 n acetyl cysteine.tw. 56 melatonin.tw. 57 dietary supplement$.tw. 58 nutritional supplement$.tw. 59 micronutrient$.tw. 60 Nutraceuticals$.tw. 61 (myoinositol or mesoinositol or Inositol).tw. 62 exp Inositol/ 63 exp Calcium/ad, tu, th [Administration & Dosage, Therapeutic Use, Therapy] 64 calcium.tw. 65 exp Chromium/ 66 chromium.tw. 67 magnesium.tw. 68 exp Magnesium/ 69 or/11‐68 70 10 and 69 (1313) 71 randomized controlled trial.pt. 72 controlled clinical trial.pt. 73 randomized.ab. 74 randomised.ab. 75 placebo.tw. 76 clinical trials as topic.sh. 77 randomly.ab. 78 trial.ti. 79 (crossover or cross‐over or cross over).tw. 80 or/71‐79 81 exp animals/ not humans.sh. 82 80 not 81 83 70 and 82

Appendix 5. Embase search strategy

From 1980 to present (OVID platform)

1 exp Premenstrual Syndrome/ 2 PMS.tw. 3 luteal phase disorder$.tw. 4 premenstrual dysphoric disorder$.tw. 5 PMDD.tw. 6 premenstrual aggravation.tw. 7 premenstrual tension$.tw. 8 Premenstrual Syndrome$.tw. 9 PMT.tw. 10 or/1‐9 11 exp antioxidants/ or free radical scavengers/ 12 (antioxidant$ or radical scavengers).tw. 13 vitamin$.tw. 14 exp vitamin/ or exp ascorbic acid/ or exp carotenoid/ or exp tocopherol/ 15 Potassium.tw. or exp potassium/ 16 sodium.tw. or exp sodium/ 17 copper.tw. or exp copper/ 18 manganese.tw. or exp manganese/ 19 iron.tw. or exp iron/ 20 exp Zinc/ 21 (zinc or selenium).tw. 22 exp Selenium/ 23 exp Glutathione Peroxidase/ or exp folic acid/ 24 (Glutathione$ or folate).tw. 25 exp Ubiquinone/ 26 (ubiquin$ or folic acid).tw. 27 coenzyme q10.tw. 28 exp Carnitine/ 29 (carnitine$ or carotenoid$).tw. 30 (astaxanthin$ or lycopene$).tw. 31 multivitamin$.tw. 32 (betacarotene$ or beta carotene$).tw. 33 ascorbic acid.tw. 34 n‐acetylcysteine.tw. 35 exp acetylcysteine/ 36 n‐acetyl‐cysteine.tw. 37 alpha‐tocopherol$.tw. 38 (fish adj2 oil$).tw. 39 omega$.tw. 40 fatty acid$.tw. 41 exp edible oil/ or exp castor oil/ or exp cod liver oil/ or exp fish oil/ or exp lyprinol/ or exp olive oil/ or exp safflower oil/ or exp fatty acid/ or exp essential fatty acid/ or exp arachidonic acid/ or exp linoleic acid/ or exp linolenic acid/ or exp gamma linolenic acid/ or exp unsaturated fatty acid/ or exp omega 3 fatty acid/ or exp omega 6 fatty acid/ or exp polyunsaturated fatty acid/ 42 (plant adj4 oil$).tw. 43 l‐arginine$.tw. 44 flavonoid$.tw. 45 riboflavin$.tw. 46 pycnogenol$.tw. 47 lipoic acid$.tw. 48 melatonin.tw. 49 dietary supplement$.tw. 50 micronutrient$.tw. 51 nutritional supplement$.tw. 52 Nutraceutical$.tw. 53 exp inositol/ 54 (Inositol or mesoinositol or myoinositol).tw. 55 exp Pentoxifylline/ or Pentoxifylline$.tw. 56 primrose oil.tw. 57 exp Mineral/ or mineral$.tw. 58 exp calcium/ or calcium.tw. 59 exp magnesium/ or magnesium.tw. 60 exp chromium/ or chromium.tw. 61 or/11‐60 62 10 and 61 63 Clinical Trial/ 64 Randomized Controlled Trial/ 65 exp randomization/ 66 Single Blind Procedure/ 67 Double Blind Procedure/ 68 Crossover Procedure/ 69 Placebo/ 70 Randomi?ed controlled trial$.tw. 71 Rct.tw. 72 random allocation.tw. 73 randomly.tw. 74 randomly allocated.tw. 75 allocated randomly.tw. 76 (allocated adj2 random).tw. 77 Single blind$.tw. 78 Double blind$.tw. 79 ((treble or triple) adj blind$).tw. 80 placebo$.tw. 81 prospective study/ 82 or/63‐81 83 case study/ 84 case report.tw. 85 abstract report/ or letter/ 86 or/83‐85 87 82 not 86 88 (exp animal/ or animal.hw. or nonhuman/) not (exp human/ or human cell/ or (human or humans).ti.) 89 87 not 88 90 62 and 89

Appendix 6. PsycINFO search strategy

From 1806 to present (OVID platform)

1 exp Premenstrual Syndrome/ 2 PMS.tw. 3 luteal phase disorder$.tw. 4 premenstrual dysphoric disorder$.tw. 5 PMDD.tw. 6 premenstrual aggravation.tw. 7 premenstrual tension$.tw. 8 Premenstrual Syndrome$.tw. 9 PMT.tw. 10 or/1‐9 11 exp Antioxidants/ 12 (antioxidant$ or radical scavengers).tw. 13 exp Vitamins/ 14 vitamin$.tw. 15 exp Zinc/ 16 (zinc or selenium).tw. 17 (Glutathione$ or folate).tw. 18 (ubiquin$ or folic acid).tw. 19 coenzyme q10.tw. 20 (carnitine$ or carotenoid$).tw. 21 multivitamin$.tw. 22 (betacarotene$ or beta carotene$).tw. 23 ascorbic acid.tw. 24 n‐acetylcysteine.tw. 25 alpha‐tocopherol$.tw. 26 (fish adj2 oil$).tw. 27 omega$.tw. 28 exp Fatty Acids/ 29 fatty acid$.tw. 30 l‐arginine$.tw. 31 melatonin.tw. 32 dietary supplement$.tw. 33 nutritional supplement$.tw. 34 micronutrient$.tw. 35 Nutraceuticals$.tw. 36 (Pentoxifylline or myoinositol or inositol).tw. 37 mineral$.tw. 38 exp POTASSIUM/ 39 potassium.tw. 40 exp SODIUM/ 41 exp COPPER/ 42 copper.tw. 43 sodium.tw. 44 manganese.tw. 45 exp IRON/ 46 iron.tw. 47 exp Dietary Supplements/ 48 exp CALCIUM/ 49 calcium.tw. 50 primrose oil.tw. 51 chromium.tw. 52 magnesium.tw. 53 myo inositol.tw. 54 or/11‐53 55 10 and 54 56 random.tw. 57 control.tw. 58 double‐blind.tw. 59 clinical trials/ 60 placebo/ 61 exp Treatment/ 62 or/56‐61 63 55 and 62

Appendix 7. AMED search strategy

From 1985 to present (OVID platform)

1 exp Premenstrual syndrome/ 2 premenstrual syndrome.tw. 3 PMS.tw. 4 premenstrual dysphoric disorder.tw. 5 PMDD.tw. 6 premenstrual tension.tw. 7 PMT.tw. 8 1 or 2 or 3 or 4 or 5 or 6 or 7 9 exp Vitamins/ or exp Minerals/ 10 (vitamin$ or mineral$).tw. 11 antioxidant$.tw. 12 exp Calcium/ 13 calcium.tw. 14 chromium.tw. 15 copper.tw. 16 exp Copper/ or exp Iron/ 17 exp Magnesium/ or exp Potassium/ 18 magnesium.tw. 19 (iron or potassium).tw. 20 exp Sodium/ 21 sodium.tw. 22 manganese.tw. 23 primrose oil.tw. 24 exp Antioxidants/ or exp Free radicals/ 25 exp Ascorbic acid/ 26 vitamin$.tw. 27 exp Zinc/ 28 (zinc or selenium).tw. 29 (Glutathione$ or folate).tw. 30 exp Selenium/ 31 (ubiquin$ or folic acid).tw. 32 coenzyme q10.tw. 33 exp Carnitine/ 34 (carnitine$ or carotenoid$).tw. 35 multivitamin$.tw. 36 ascorbic acid.tw. 37 n‐acetylcysteine.tw. 38 Acetylcysteine.tw. 39 alpha‐tocopherol$.tw. 40 (fish adj2 oil$).tw. 41 omega$.tw. 42 exp Fatty acids/ 43 exp Fish oils/ 44 fatty acid$.tw. 45 (plant adj4 oil$).tw. 46 l‐arginine$.tw. 47 flavonoid$.tw. 48 riboflavin$.tw. 49 pycnogenol$.tw. 50 micronutrient$.tw. 51 nutriceutical$.tw. 52 dietary supplement$.tw. 53 Pentoxifylline$.tw. 54 (myoinositol or inositol).tw. 55 melatonin.tw. 56 exp Dietary supplements/ 57 or/9‐56 58 8 and 57 59 randomized controlled trials/ 60 randomized controlled trial.pt. 61 controlled clinical trial.pt. 62 placebo.ab. 63 random*.ti,ab. 64 trial.ti,ab. 65 groups.ab. 66 or/59‐65 67 58 and 66

Appendix 8. CINAHL search strategy

From inception to present (EBSCO platform)

Appendix 9. Risk of bias assessment

Assessment of risk of bias will be based on Chapter 8 of Higgins 2011.

• Random sequence generation.
• • Low risk of bias, e.g. participants assigned to treatments on the basis of a computer‐generated random sequence or a table of random numbers.
  • High risk of bias, e.g. participants assigned to treatments on the basis of date of birth, clinic ID‐number or surname, or no attempt to randomise participants.
  • Unclear risk of bias, e.g. not reported, information not available.
• Allocation concealment.
• • Low risk of bias, e.g. when the allocation sequence could not be foretold.
  • High risk of bias, e.g. allocation sequence could be foretold by patients, investigators, or treatment providers.
  • Unclear risk of bias, e.g. not reported.
• Blinding of participants and personnel.
• • Low risk of bias if participants and personnel were adequately blinded.
  • High risk of bias if participants were not blinded to the intervention that the participant received.
  • Unclear risk of bias if this was not reported or was unclear.
• Blinding of outcomes assessors.
• • Low risk of bias if outcome assessors were adequately blinded.
  • High risk of bias if outcome assessors were not blinded to the intervention that the participant received.
  • Unclear risk of bias if this was not reported or was unclear.
• Incomplete outcome data: We will record the proportion of participants whose outcomes were not reported at the end of the study. We will code a satisfactory level of loss to follow‐up for each outcome as follows.
• • Low risk of bias, e.g. if fewer than 20% of participants were lost to follow‐up and reasons for loss to follow‐up were similar in both treatment arms.
  • High risk of bias, e.g. if more than 20% of participants were lost to follow‐up or reasons for loss to follow‐up differed between treatment arms.
  • Unclear risk of bias, e.g. if loss to follow‐up was not reported.
• Selective reporting of outcomes.
• • Low risk of bias, e.g. review reports all outcomes specified in the protocol.
  • High risk of bias, e.g. it is suspected that study outcomes have been selectively reported.
  • Unclear risk of bias e.g. it is unclear whether outcomes have been selectively reported
• Other bias.
• • Low risk of bias, e.g. review authors do not suspect any other source of bias and the trial appears to be methodologically sound.
  • High risk of bias, e.g. review authors suspect that the trial was prone to an additional bias.
  • Unclear risk of bias, e.g. review authors are uncertain whether an additional bias may have been present.

Contributions of authors

Srinaree Kaewrudee (SK) conceived the review question and developed and completed the protocol.

Chumnan Kietpeerakool (CK) conceived the review question and developed and completed the protocol.

Porjai Pattanittum (PP) edited a portion of the protocol and advised on a portion of the protocol.

Pisake Lumbiganon (PL) edited the protocol and advised on the protocol.

All review authors approved the final version of the protocol before submission.

Sources of support

Internal sources

• Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Thailand.
• Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen University, Thailand.
• Cochrane Thailand, Thailand.

External sources

• Thailand Research Fund (Distinguished Professor Award), Thailand.
• Long term institutional development HUBs (LID‐HUBs), the Human Reproduction Programme (HRP) Alliance for Research Capacity Strengthening, World Health Organization, Switzerland.

Declarations of interest

SK: none known.

CK: none known.

PP: none known.

PL: none known.

New

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