PMS, Prozac and Civlized Behavior

Hello dear readers,

I am, on a daily basis, asked to deal with PMS.

Since I have been in practice ( 27 years, yikes!) I have struggled with this diagnosis. When I was first in practice, and the only female gyn for many miles in any direction, I was prevailed upon to diagnose and treat PMS. It was a young problem. An English physician, Katarina Dalton, had at that time, successfully argued PMS as a murder defense in London, and this diagnosis was brought to the world stage.

Since it is a syndome, it is comprised of a number of symptoms. No objective findings are apparent for a definitive diagnosis. Calendars were kept, vitamins, exercise and every hormone in the book was used. All to no real avail. PMS is the witch within, waiting to pounce on unsuspecting males, coworkers, children, and the public.

The dawn of what I call modern mental health began when Prozac was brought to market. Here was a drug that had little toxicity, and could successfully treat depression and anxiety. The world changed. Even though your insurance company did not cover you for "nervous and mental disorders" it was worth it.

No longer was bad behavior tolerable. Self control, and its attendant civility crept into society. The behavior seen in The Honeymooners, was now considered abusive.

Your body only has so many finite resources to deal with your day to day activities. In biology, we define stress as adaptation to change. There are internal stressors, your body functions, and overall health. There are external stressors in your life. When a woman has a menstrual cycle, there are hormonal changes that are normal that occur, but contribute to internal stress. In my opinion, this is the straw that breaks the camel's back of civility, and the inner witch emerges. She is irritable, bitchy, not a nice person, sharp tongued, and quick to anger. We teach our children, not to pick up their shoes, but that women are crazy and not to be trusted.

There are three basic treatment methods for PMS. One is to control the menstrual cycle to lessen the burden of internal stress, another is to reduce external stressors from your life, and the third is to increase your stress management resources. Go to the mountaintop and commune with nature, do yoga, exercise, meditate, deep breathe, read a book. Remove yourself from society. Turn off the cell phone, TV, and don't watch the news.
Those are starters.

If a patient is unable or unwilling, or too wacky, I will offer her fluoxetine, the active ingredient in Prozac. It has been shown to be very helpful, and can be taken just around the menses. I ususally advisea woman if she feels good on the days she is taking the medicine, and then feels a let down the other days of the month, I advise her to take it every day. No sense only having a few good days.Manipulation of menstrual cycles will work, especially in adolescents, and young adults. I am always hesitant to prescribe psychotropic medications to this age group.

The bottom line is that the inner witch is no longer allowed to come out. She must be controlled, or you will wind up alone. Nobody wants to be around her. Your children will want to live with your ex husband. So my advice is to get a grip. There are lots of ways to get to being a civil person. Pick one or many, but do it.

Until next time..............

HOT FLASHES, HORMONES and CELEBRITIES

.

My last post introduced menopause as a transitional period into the third phase of the human female experience. It's an experience alright! You can see why men steer clear from "women of a certain age" and attribute all ununderstandable behavior to "hormones". Since this is a predictable event, it is expected for a woman to more or less be troubled by the symptoms of menopause, such as poor sleep and its corollary, bad moods. In my opinion, improving sleep is a critical part of managment of menopause. It removes the tendency for grouchy

We know that replacing ovarian hormones alleviates the symptoms of menopause. Indeed, all hormones were originally gleaned from animal by products such as insulin, thyroid and growth hormone. By the 1970's it was determined that replacing estrogen alone placed a woman at higher risk for endometrial cancer for those women who had a uterus. In the 1980's combined therapy was introduced. The use of estrogen in the form of combined equine estrogen and progestin in the form of medroxyprogesterone acetate and others was used. This is not the same formulation as birth control pills. Varying regimens were developed from cycling women to mimic normal menstrual cycles, to combined continuous hormones, meaning both estrogen and progestin every day. Everybody was happy. Women took hormone replacement therapy, hot flashes disappeared. With the continuous combined regimen, periods disappeared as well. This was the cure all for everything, old age, heart disease, osteoporosis, some theorized Alzheimer's disease and Colon Cancer and age related eye disease.

Fast forward to the Women's Health Initiative Study. It was designed to test whether or not hormone replacement could be used as primary prevention for heart disease. That means it asked the question,
"Should you use hormone replacement to prevent heart disease in women?".
Women were recruited into the study from ages 50-70.  The average age of women in the study was 63, and most were no longer symptomatic for menopause. Lots of women were recruited, many many thousands doing their altrustic duty for science. My mother was a participant. She called me one evening to say that the study nurse had called her to stop taking her pills. On July 9, 2002 the announcement was made that the study had been halted prior to its closure date. The observations has shown that the risk of cardiac events, stroke and breast cancer were increased. What you did not hear was that the risk of colon cancer, and hip fracture was decreased.

Good drug? Bad drug? Well in the eight years since that finding was released, the world of menopausal medicine has changed. Many women stopped taking HRT. Many women have a fear of HRT. Many women fear that HRT causes breast cancer. The actual numbers were very small. In the WHI study the expected number of breast cancers in the general population per year is 30 per ten thousand women. In the Prempro users the observed number was 38. There were an additional 8 breast cancers observed after 5.2 years of use. The observation came between years 4 to 5 years of use.

The Premarin only ladies had a different outcome. The same number of expected breast cancers 30/10,000/yr, but they observed 16 cancers. FOURTEEN  LESS? Yes, this is where it gets very interesting. So now it seems that there is a conflict.  How can this drug be good and bad?

Current thinking, according the the North American Menopause Society states that the confounding factors appear to be timing and whether or not a combination of hormones was used. Oh MY!.
I will leave you today with yet another layer in the mix of celebrity hormone promotion.

 Suzanne Somers appeared on Oprah and made a huge impact promoting her hormone related regimen.

http://www.huffingtonpost.com/2009/01/29/suzanne-somers-daily-rout_n_162342.html


Next post will help to clear up the mess................

Menopause and Beyond

You are 50 years old. Your periods have been somewhat irregular for a year or so. They are now lighter, and you've missed a few. Your internal thermostat has gone on the fritz. One minute you are hot the next, sweaty and cold. You don't sleep well at all with frequent waking at night, and you are a miserable grouch during the day.

Welcome to Menopause

The truth is that life expectancy in 1900 was 47 years. Aristotle wrote that women stopped bearing children in the fifth decade of life. You are an experiment in living beyond reproductive life. Most other animals die when their reproductive capacity ends. You are in THE CHANGE.

So what does this mean for you? Looking in the mirror you look pretty good. Oh well, a few grey hairs here and there and some wrinkles are beginning to creep up, but you feel like you are young. What's happening?

Menopause is defined as the time when a year has passed and a woman no longer has periods. This becomes tricky because as soon as ten months pass,you have another period, and start the clock over. This drives me crazy as a physician, because my patients are asking when this is going to end. Reality states that this is a process, not a time and date. Patience and understanding are needed to see you through, plus some girlfriends and maybe a hormone or two! Today's entry is designed to introduce the topic of the third stage of life, living beyond reproduction, or as a postmenopausal woman.

Current thinking divides life into three stages, 0-30 years when growing physically, intellectually, and gaining financial independence is achieved, then 31-60 in your maturity when family building, career climbing, and acquisiton is important, and the third from 61-90 as a post reproductive life when divesting, giving back, and spirituality gain importance.

Actual menopause occurs around age 51 in most US women. It may be variable with < 35 years of age considered pathologic, and I have had women up to 59 still having regular menses. You are born with all the eggs you will ever have. The eggs in the ovaries are where your reproductive hormones are produced. You make estrogen every day, and then after ovulation you make estrogen and progesterone. Now the object of ovulation is pregnancy, so if you are pregnant, you will make estrogen and progesterone until delivery. If you are not pregnant you continue to make estrogen but stop making progesterone from the ovary after about 14 days. This change in hormonal production destablalizes the uterine lining, and a period occurs.

So what is it I feel? Not eveybody is symptomatic in the menopause. Some women, about 25% don't have much in the way of hot flashes. That leaves the majority with some symptoms. These vary in intensity from bothersome to disruptive. Many remedies are available, and work quite well for women. They have been used for a long time with some results. Soy products are weak naturally occuring estrogens, and afford relief, thus marking a difference in reportable symptoms among East Asian women who consume lots of soy products.Caution is advised, however because they do demonstrate pharmacologic effects on the breast.Good sources of information can be found at http://www.menopause.org/, the North American Menopause Society publishes a great website with lots of great factual information. The other is http://www.acog.org/, the American College of Obstetricians and Gynecologists who have patient education literature for review.

Until next time

Ladies' Doctor