Download PMS

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PMS – Am I Crazy or Hormonal?
An Integrative Approach
Andrea Gordon, MD
Sept 6, 2014
•Who gets this? What is it? My greatest fear is that this isn’t PMS andI’m just a bitch.”
-Affects 30% of women with regular menstrual cycles.
-ACOG definition of clinically significant PMS: at least one symptom associated with “economic or
social dysfunction” in the five days before onset of menses and present in at least three consecutive
menstrual cycles
Symptoms are broken into physical and affective/ cognitive
Physical may include:
Affective/ cognitive may include:
Acne or hives
• Mood swings, irritability, depressed mood
• Menstrual migraines
• Forgetfulness, confused or fuzzy thinking
• Abdominal and pelvic pain & cramps
• Fatigue, insomnia
• Bloating, weight gain, breast tenderness
• Difficulty concentrating
• Dizziness, worsened coordination, palpitations
• Cravings (sweet/salty)
• Worsening chronic conditions (arthritis,
• Tearfulness, angry outbursts
epilepsy or asthma) A
“Why is this happening?!”
Theories include:
Increased estrogen
Endorphin withdrawal
Decreased B6
Hypothyroidism,
Increased prolactin
Decreased serotonin
Decreased glucose
Increased monoamine oxidase
Fluid retention
Hormone allergy,
Prostaglandin abnormalities
Cyclic manifestations of underlying psychopathology
We don’t know! But we do know what can help.
First- make the diagnosis. You need:
• The nature, timing, and severity of the symptoms (do they stop with menses?)
• Detailed accounting of stress levels, diet, exercise
• Present and past medical problems
• Alcohol/drug use? Diet?
• Rule out other mood disorders, although they can be superimposed
Track symptoms and improvement:
• Recording specific symptoms and severity on a 1-10 scale
(can also help assess effectiveness of treatment)
• In general, a 50% decrease in symptoms translates into a noticeably improved quality of life for women
with PMS (Borenstein, 2007)
Yup, it’s PMS- now what?
Exercise:
not a lot of studies but those done show improved symptoms and mood. One study looked at 30 min/day
of moderate activity. (Stoddard,2007)
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Diet:
Frequent small meals, Less caffeine
More fiber; Slower bowel motility may mean more reabsorption of estrogen via enterohepatic
circulation
• Low fat, less red meat
• More chicken, fish or omega 3s
– Crossover study showed decreased symptoms in women on low fat vegetarian diet
Also showed increase sex-hormone binding globulin (Barnard, et al, Obstet Gynecol. 2000)
Nutritional supplements
Calcium 1,200 mg/day can reduce pain, cramping, mood swings
Magnesium 200-400 mg/day can reduce headache, fluid retention, mood changes
Vitamin E 400 units/day (especially for mastalgia)
Vitamin B6 50-100 mg daily (or a good B50 supplement)
Vitamin D 800 IU daily (or check levels and replace as needed for level >40)
(See other handout for research info)
Herbs:
Start with Vitex agnus chastus – Chastetree Berry.
• Studies showed 93% of patients reported decrease in number of symptoms or even
cessation of PMS complaints (Loch EG,2000)
• Another study showed effects equivalent to fluoxetine (Atmaca M, 2003)
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Dosing depends on form of herb:
– 500 mg/d of dried chastetree fruit.
• Extracts often standardized to agnuside or casticin and come in 20-40 mg tablets.
– Dosed at 40-60 mg taken each morning.
–
Black Cohosh- it’s not just for menopause anymore
Anti-inflammatory activity makes it useful for dysmenorrhea.
• Binding to serotonin receptors indicates that it may help with mood symptoms
• The dose is typically 40-160 mg/d of an extract made from the dried root and rhizome
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St. John’s Wort
• Can be helpful for mood, but also food cravings, swelling, and pain
• A small prospective trial found that 2 cycles led to a 51% reduction in symptoms for more
than 65% of subjects (Stevinson C, Ernst E. 2000)
• Usual dose is 300 mg. of 0.3% hypericin extract three times daily
•
Also consider:
• Evening Primrose Oil Mixed studies- some showed benefit, one review did not (Khoo et al, 1990)
– Traditionally used for mastalgia
• Ginkgo -One study showed helpful for mastalgia, but not other sx. (Tamborini A, Taurelle R. 1993)
• Saffron - Small study showed effectiveness of 15 mg b.i.d. (Agha-Hosseini et al, 2008)
Mind-Body Approaches
• Relaxation Response –58.0% improvement, vs 27.2% for reading group vs 17.0% for charting
group. (Goodale,1990)
• Guided Imagery - Lengthened cycle and decreased PMS sx. (Groër, Ohnesorge, 1993)
• CBTstudies show benefit alone, (Blake, 1998) or with relaxation response (Morse, 1991) or with
coping skills training (Kirkby, 1994)
• Also some evidence for light therapy, yoga and reflexology. Anecdotal responses to acupuncture
have been good.
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A different view
• Is this when the truth comes out?
• Is it a reflection of the need to withdraw, relax, reflect, look inside?
• Getting in touch with a more assertive part of oneself, the “Darkly Feminine” (Sara
Avent Stover)
A time to receive rather than nurture?
– Note that it happens after ovulation that did not end in pregnancy
• Suggestions: encourage journaling, time for self, asking partner or family for what they need, try
to decrease demands on herself
ACOG guidelines for treatment of PMS: Step 1:
• Supportive therapy
• Lifestyle modifications
– Diet changes and exercise
– Improve sleep habits
• Nutritional supplements
– Calcium 1,200 mg/day can reduce pain, cramping, mood swings
– Magnesium 200-400 mg/day can reduce headache, fluid retention, mood changes
– Vitamin E 400 units/day (especially for mastalgia)
• Spironolactone 100 mg/day for 2 weeks before menses; may reduce water retention, breast
tenderness, weight gain
Step2:
• SSRIs - “ for women who do not respond, consider an anxiolytic for specific symptoms, such as
alprazolam”
Step 3:
• 3: OCPs - monophasic pills may be less likely to cause mood changes
“For severe cases unresponsive to other therapies” 0- 0GnRH agonists (leuprolide, goserelin)
See powerpoint for more research references.
Can refer patients to more holistic approach in books like The Wisdom of Menopause by
Dr. Christiane Northrup or Our Bodies, Ourselves: Menopause