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Case Study: Melanie’s PMS Hell

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A smart woman in her mid forties, Melanie had written “Bad PMS” neatly on our patient intake form, and then gone on to trace the word “Bad” several times with her pen and underlined it.

Until about ten years ago, the odds were stacked against women like Melanie, trying to get help from their doctors for that Pandora’s box of hardships known as premenstrual syndrome. Doctors, both male and female, had been taught in med school that symptoms of any sort required following up as they related to disease, which could only be diagnosed using tests.

If you have bad PMS, there’s no disease and nothing much shows up on tests. Women of a certain age surely have heard a doctor tell them “that’s just part of being a woman.” In fact, the first medical description of PMS didn’t appear in a medical journal, but in an advice column of the Ladies’ Home Journal.

The situation with doctors is better today, but it wasn’t for Melanie. She couldn’t remember when she hadn’t had PMS, with the full range of symptoms affecting both body and mood. Now, in her mid-40s, everything seemed to be getting worse. Her symptoms included headache, breast tenderness, bloating, constipation, fluid retention, and a blush of acne.

In addition, she told me she’d start her two-week PMS nightmare weepy if someone looked at her cross-eyed and ended it like the famous Francisco Goya painting Saturn Devouring his Children. She also said her only good week was the one immediately following her period, and even that seemed to be getting shorter.

I explained to Melanie that there are two aspects of PMS–estrogen dominance and serotonin insufficiency:
In the second half of your cycle (assuming fertilization doesn’t occur), both estrogen and progesterone, produced by your ovaries, start to fall. The amount of estrogen should be lower than progesterone, but often the opposite occurs. This is not disease, it’s just you, and the excess estrogen stimulates estrogen-sensitive areas like your breasts while also causing fluid retention and headaches.

The rise and fall of stress-buffering serotonin parallels that of estrogen. If your estrogen drops, so does your serotonin, and down goes your stress buffer. You cry at what you know is a marginal movie on Lifetime and later make rage into an art form.

For Melanie, in the foothills of perimenopause, declining estrogen levels were resetting her serotonin even lower, so with each passing year, her mood-related PMS issues got a bit worse.

Melanie’s previous doctor had run thyroid and blood tests and found them normal, so we could start therapy immediately. First her diet. She needed to reduce her intake of all sugars (including high fructose corn syrup), refined white-flour products, and meats high in saturated fats, increasing lean protein like fish and chicken breast and emphasizing complex carbohydrates, including all fruits and vegetables as well as half-cup servings of oatmeal in the morning and kidney beans or brown rice at other meals. Regular exercise and being in the sunlight (walking outside at lunchtime) would bump up her feel-good serotonin.

She could make real headway using two herbs: Vitex (also called chasteberry) to balance her hormones and St. John’s wort to raise her serotonin. Since vitex can take 3 to 4 cycles to work, she could speed the process using over-the-counter progesterone cream, a quarter teaspoon applied twice daily from about the 10th day of her cycle (when her symptoms began) and stopping when she started her period.

I asked her not to expect much of anything for the first month, but to hang in there. By the second month her mood improved and her breasts were less tender, and by the third month, she reporter a much happier Melanie.

Be well,
David Edelberg, MD

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