Cramps
Irregular Periods
Stress & How It Affects Your Menstrual Cycle Heavy Bleeding
Heavy Bleeding
PMS
Vaginal Discharge
Yeast Infections

What causes them?
Each month the lining of the uterus (the endometrium) builds up in preparation for a possible pregnancy. If a pregnancy occurs, the fertilized egg attaches itself to the lining to be nourished as it develops into a baby. If the egg is not fertilized, the lining is not needed. It breaks down and hormones called prostaglandins are released. These trigger the muscles of the uterus to contract and squeeze the lining out. The muscles are the same ones that push a baby out during childbirth, so they are very strong. Some women may have higher levels of prostaglandins and this is thought to be what causes painful muscle spasms.

What sort of pain is it?
You may feel no more than a passing discomfort from your period, or you could be doubled up by it. Usually the pain comes in cramp-like spasms. It could start in the lower abdomen, and may radiate up the spine and down the legs, or center in your lower back. If you get it really badly, you may feel dizzy or nauseous, and get diarrhea or vomit. If this happens you should go and see your doctor. Most women find that the pain usually comes on a few hours before their periods start and begins to ease once the flow begins. But in a few, pain continues into the second and even the third day of their period.

What You Can Do for Yourself?
There are many ways to help relieve menstrual cramps. The trick is to find one that works for you. Lie down if possible at the first sign of pain, and place a warm heating pad on your abdomen.

A relaxing, warm bath may also help. Seek advice from your pharmacist about suitable painkillers. Over-the-counter medications may be very helpful. For maximum relief, take painkillers before the pain gets too bad. Massage can ease menstrual cramps. Gently rub your abdomen, or ask your partner to massage your back. Exercise routines, practiced throughout your cycle, but particularly a few days before the onset of your period may help to reduce pain by lowering your levels of prostaglandins. Exercise also helps to keep the blood flowing in your pelvis, easing that heavy, bloated feeling. Workouts that stretch your body — cycling with your legs up in the air, for example —are best.

What Your Doctor Can Do For You
Hormone treatments: Women who do not ovulate, that is produce a mature egg each month, will rarely have menstrual cramps. Your doctor may prescribe a hormone treatment to stop ovulation.

The birth control pill is often used for this purpose. Anti-prostaglandins: These are drugs that reduce the effect of prostaglandins and your doctor may prescribe them for you. Surgery: In the past, many women with menstrual problems had an operation known as a D & C (dilation and curettage) to remove some of the lining of the uterus. This particular operation is rarely performed today but when a woman’s periods are very heavy as well as painful, her doctor may recommend its modern equivalent, endometrial ablation, which involves treatment with a laser.

Could It Be Something Else?
Menstrual cramps are sometimes caused, or made worse, by other conditions. This is known as secondary dysmenorrhea. If you suddenly start to experience more pain than usual or notice a change in your periods, you should contact your doctor. Older women in particular should consult their doctors if their pain does not respond to treatment.

1. Endometriosis
Occurs when cells from the uterine lining escape into other areas of the body where they cause irritation and pain. Symptoms: Sharp abdominal pains as well as menstrual cramps; painful sexual intercourse. Treatment: Hormone treatment is usual although your doctor may recommend surgery in severe cases.

2. Fibroids
These are non-cancerous growths inside the uterus. Symptoms include dull pain in the abdomen; swollen stomach; and heavy and painful periods. Treatment: Depends on where the fibroids are and how big they are. Sometimes none is needed. Fibroids grow in response to the hormone estrogen, and when this hormone decreases after menopause the fibroids often shrink and practically disappear. Removal of the fibroids or a hysterectomy (surgical removal of the uterus) may be considered if the symptoms are severe.

3. Middle Pain
Experienced by a few women about half way through their menstrual cycle usually 12 - 16 days after a period. The pain is one-sided and sharp, low down in the abdomen. It may last just a few minutes, or rarely several hours. The pain is caused by the egg bursting out of the ovary. If necessary, a mild painkiller may help.

4. Pelvic Inflammatory Disease (PID)
Refers to long-term inflammation of any of the pelvic organs, usually caused by infection. Symptoms include painful intercourse; foul-smelling vaginal discharge; and heavy and painful periods. Treatment: Usually treated with antibiotics.

It is not possible for you to diagnose conditions like these yourself, so see your doctor if you have any of the symptoms. You could be referred to a hospital for a laparoscopy. This involves making a small incision in the abdomen and passing a tiny camera through it that is attached to a viewing tube. The doctor can then look around the pelvis to see what, if anything, is wrong.
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By Dr. Michelle P. Warren
If you’ve experienced menstrual cycles where you bleed at unexpected times, seem to bleed too much, or don't even bleed at all, don’t worry, you're not alone. You’re just going through something that is actually quite common, an irregular period. These occur in about thirty percent of women who are in their “reproductive years”. These are the years when women who are having menstrual periods are capable of becoming pregnant. You may recall being a young teenager (or maybe you are a young teenager) and noticing that your periods were irregular or seemed to take awhile to settle into a "schedule." That's because irregular periods are especially common at the time when menstruation begins in adolescence. A similar syndrome often occurs at the end of the reproductive years when women approach menopause — usually in the mid-to-late forties. Ironically, a menopausal woman can actually be experiencing periods much like those of her teenage daughter. All women, however, should keep in mind that menstrual cycles may vary normally. The time between bleeding can be as short as 25 days and as long as 42 days. Although an occasional cycle of this length shouldn’t be cause for worry, be aware that if cycles continue to be shorter than 25 days or longer than 42, days or are associated with other symptoms, such as pain or heavy bleeding, it's a good idea to consult a doctor. Don’t worry, though, if your cycle does not always last exactly 28 days. Just as most women’s bodies aren't proportioned to fit exactly into one dress size, very few women have menstrual cycles that last precisely 28 days. (You can use our online period calculator and calendar to keep track of your period and see for yourself how long your menstrual cycle is!)

Why do irregular periods even occur? Well, the most common reason that women skip periods is that their bodies have not ovulated during a cycle. Ovulation is the time when the ovary releases an egg. This occurs in the middle of a menstrual cycle. For a variety of reasons, ovulation can sometimes be delayed or even not happen at all. When this happens, your period may be very late or totally absent. To understand how this happens, you need to understand what your period is literally “made of”. When you have your period, what your body is doing is shedding the endometrium, which is the lining of the uterus. The endometrium builds up over the course of the menstrual cycle and receives the signal to shed itself when ovulation occurs and the egg is not fertilized. Heavy bleeding may result if ovulation happens late and more than the usual amount of lining has continued to grow. You may be wondering what keeps the lining from building up when ovulation does occur. The answer lies in a hormone called progesterone, which is made from the ovary. Progesterone acts to stop the growth of the endometrium. The ovary makes progesterone for 14 days, after which the endometrium is shed as a menstrual period. Bet you never realized just how much action goes on in your body in the course of a month!

If you want to get really technical (so you can sound really smart when talking to your girlfriends) you can think about something called a proliferative pattern. This is what happens when your body does not make progesterone and the endometrium builds up so much that it finally outgrows its blood supply. The result is that you have the kind of period in which blood is shed in a disorderly, erratic pattern, and bleeding may last a long time. Although this happens to many women and is quite common, we don't really know what causes it. It’s possible that the reason is related to the kind of stress that comes from dieting, rigorous exercise, or travel where the body clock is thrown out of whack. Remember this very important point, however. Though there are many reasons that you can miss a period or experience erratic bleeding, it's crucial not to ignore the obvious — that you may be pregnant. If you have a period that's abnormal, make sure to ask yourself if this is a possibility.

Irregular periods are sometimes the result of a hormonal imbalance. How do you know if you have a hormonal imbalance? The best way, of course, is to be evaluated by your doctor. If you continue to have irregular periods for longer than three months, you should probably make an appointment with your gynecologist. You may have one of two types of hormonal problems. The first type happens when you have too much of a certain kind of male hormone. This hormone usually comes from the ovary and occasionally comes from the adrenal gland, which sits in the kidney. Since men do not menstruate (wouldn’t it be sweet justice if they did?), too much of this hormone will obviously cause your periods to become irregular or even stop. The second type of hormonal problem occurs when your body literally gets its signals crossed in coordinating the menstrual cycle. This confusion takes place in the brain — where else? And again, if you want to be really brainy about what's going on in your body, think about this: there are three places inside of you where your hormones can be disrupted. These are the hypothalamus, the pituitary gland, (both in the brain) and the ovaries (you remember those, they’re in the lower abdomen.) What happens is that the hypothalamus sends signals to the pituitary gland, which in turn sends signals to the ovary. These signals are sent from the brain in very specific pulses every 60 to 90 minutes. Since you’re reading this on a computer, think of all the signals and connections that must be made just for you to reach this page. Have you ever had trouble logging on to the Internet? Well, things are just as complicated inside your body. So it’s not all that surprising that circuits misfire from time to time

Hormonal problems sometimes come with symptoms that you may not be wild about. Some of these symptoms include acne and excessive hair growth in areas such as the face, the chest, the stomach, and the thighs. In cases where you’re receiving too much of the male hormone, you may find that your hair is thinning in a way that resembles male pattern baldness or that you may be gaining weight. And, as we’ve been discussing, hormonal problems are associated with lack of ovulation, which results in infertility. So aside from all the other discomforts of a hormonal imbalance, you may find yourself unable to get pregnant — though hormonal problems should certainly not be a reason to forgo birth control if you’re sexually active.

In many cases, irregular periods will warrant an ultrasound examination, which allows your doctor to take a look at your ovaries. It may be that your ovaries have a so-called “polycystic appearance”. This means that there are small cysts on your ovaries. Although the ovaries are generally enlarged under these conditions, the cysts do not cause pain and there is no need for surgery. There are things that can be done, however. Many doctors prescribe oral contraceptives (birth control pills) to regulate the periods or, in cases of excess hair growth or other symptoms related to hormonal imbalances, it can be helpful to take prescribed drugs containing progesterone.

You’re probably wondering how you, a full-fledged woman, could ever end up with too much of a male hormone. While no one really knows for sure, recent scientific work suggests that it’s due to increased amounts of insulin, which causes the ovaries to make more male hormones than they should. On rare occasions, a tumor growing in the ovary or adrenal gland can make male hormones — don’t worry, this doesn’t happen very often. Sometimes the adrenal gland may lack enzymes, which cause it to make more male hormone. Again, though, this is technical stuff. The bottom line is that experiencing irregular periods means the signals involved in coordinating the menstrual cycle have been disrupted. The good news is that there are new, promising medications out there that may be able to reverse this syndrome in some women.

There are a few other symptoms of hormonal imbalances that we haven’t yet touched on. One of those is the secretion of milk from the breasts. This can be alarming if you’re not lactating (breast feeding) but it's usually nothing to worry about. Occasionally the pituitary may develop a benign (harmless) tumor, and this can cause secretion of milk from the breasts. Also, if a woman has an eating disorder such as anorexia nervosa or is training very hard for an athletic even such as a marathon, the periods may become irregular or stop altogether. In serious cases (such as severe anorexia) the ovaries may also stop functioning and young women can develop early menopause. One symptom of menopause is hot flashes. If this begins happening to young women it is likely that the problem is diet and exercise related. In many cases, there’s an eating disorder going on. If menopause-like symptoms are happening to you or a friend and you think it might be related to an eating disorder, it is crucial to seek help. In addition to harming your body in other ways, eating disorders can cause the ovaries to shut down, which can lead to osteoporosis.

Of course, women approaching menopause will begin to ovulate less regularly and therefore experience irregular periods. Even menopausal women who are still menstruating may also have hot flashes. Women at this age also often have fibroids, which are benign tumors of the muscular wall of the uterus. Even when ovulation is normal, these fibroids may cause irregular and sometimes very heavy bleeding.

You probably thought you were asking a simple question when you inquired about irregular periods. What you’ve just read is a lot of information to grasp all at once. Just remember that irregular periods are very common and generally easily treated. If you experience one from time to time, don't get upset. If you think you might be pregnant, take a home pregnancy test. If you’re not pregnant and the symptoms persist for more than a few months, see your doctor. Most of these problems reverse on their own. Just remember this very important point: even if you’re periods are not regular, you should always use contraception if you’re sexually active and do not wish to become pregnant. Having irregular periods does not necessarily mean you cannot conceive. Would you like to talk about your own experience with irregular periods? Visit the Always message boards. Don’t worry, there won't be a quiz.

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By Dr. Christina Matera

Among women, it’s very common to experience stress during the normal monthly cycling of ovulation. It is not uncommon and actually almost predictable to have subtle, and not-so-subtle fluctuations in menstruation. It is well known in history that during famines and wartime, fertility rates drop. But such utter devastation is not at all necessary to cause menstrual changes. Many women notice erratic, unpredictable bleeding or a delay of menstruation when they encounter particularly difficult times such as deadlines at work or school, personal illness, or death of a loved one. Physical pressures, such as a continuous and strenuous exercise regime or excessive weight loss often interrupt the normal monthly cycling of a woman. Given an individual woman’s particular threshold, she may even cease to menstruate until stability and tranquility is again achieved.

This shutdown of the menstrual cycle makes perfect adaptive sense when you consider that the major role of the ovulatory cycle is reproduction. It is as if the body is saying, "You have enough on your plate right now! You are not able to deal with the additional strain and energy drain of a pregnancy, much less caring for a newborn infant. This is a sensible adjustment to stress and prevents a woman’s body from being overwhelmed.

Although women intuitively know that their menstrual cycle is susceptible to change given the stresses that they may encounter in their lives, it may seem odd that the ovaries somehow respond to both emotional and physical struggles. It is not until you understand that the monthly ovarian cycle is driven by a well-tuned, tightly run system that actually originates outside the ovary, in a small region of the brain called the hypothalamus. This is the key area that receives input from many different parts of one’s body and also from the environment surrounding the body. It acts as a central station to receive and organize this bombarding information and respond with instructions to the body telling it how to react to all of these stimuli. The hypothalamus is compartmentalized into centers that control thirst, hunger, temperature, and perceptions of light and dark, pain, growth and reproduction. It also plays a role in influencing various forms of behavior in animals, and this is probably also true in people. The hypothalamus also functions as a translation service, helping to decipher the two major forms of communication in the body, the nervous system and the hormone (endocrine) system. Information in the form of electrical neural activity and circulating hormones are received in the hypothalamus, processed, and conveyed to other parts of the brain and body so that the body knows how to respond. The organization of the hypothalamus places reproduction in the midst of all internal and external stimuli. Thus, reproduction will be allowed if the information if the body is in a stable, safe and healthy environment. If there is a perception that a woman is not physically or emotionally capable to sustain a pregnancy and care for a dependent and demanding child, the hypothalamus will issue a shutdown of the ovulation cycle.

In a stable environment, this carefully designed system perpetuates and results in monthly cycles of menstruation. However, any stress can “shake up” this order. What a woman now perceives is an alteration in her monthly flow. The menstrual cycle may lengthen or shorten. There may be erratic, and sometimes continuous bleeding, either heavy or light. A woman may also completely stop menstruating. The dreaded premenstrual symptoms often disappear when ovulation is disrupted. Different women respond in different ways and it is typically unpredictable. To the same stress, one woman may not have a perceptible change and another woman may become totally amenorrheic (without menses). Why this is so is not completely understood, but it appears that all women have their own individual limits as to how much stress they can truly withstand. Fortunately, when the stress is removed, and everything returns to baseline, normal ovulatory function and fertility will return.

Other than the unpleasantness of unpredictable bleeding, the disturbance of the normal ovulatory system can result in anemia (if there is heavy bleeding) and infertility. If the system is so deranged that the ovary doesn’t even produce estrogen, and particularly if this continues for a long period of time, enough bone loss can occur that puts this woman at risk of osteoporosis. Thus, this adaptive process, which helps the body to redirect its focus and energies to issues that are more important at the time, can lead to other problems, if sustained.

Fortunately, an understanding of how the reproductive system works allows us to offer various treatments that may minimize some of the problems when the system goes awry. For example, birth control pills can regulate menstrual flow and reproduce the much-needed estrogen. This, of course, can be utilized as temporary treatment until situations become more stable. Modern medicine can also offer other modalities to help cope with stressful life events until the passage of time allows for healing. A greater understanding and appreciation of the usefulness of non-traditional medicine, such as meditation, massage, acupuncture, and botanicals, also grant alternatives to help cope with stress and to bring our lives and bodies back to a healthy balance.

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What is PMS?

In historical and modern times, many negative connotations regarding menstruation have existed and these may have contributed to some women’s unpleasant expectations of the premenstrual phase. However, Premenstrual Syndrome (PMS) was first noted as a true medical disorder by the American Gynecologist Dr. T. Frank in 1931. The medical community refers to PMS as a condition that is characterized by a constellation of physical and emotional symptoms that have a significant impact on a woman’s day-to-day activities. This is in contrast to the common occurrence of premenstrual symptoms that many women experience. Up to 80% of women experience premenstrual symptoms but only two to five percent actually have PMS. The manifestations of PMS include a set of symptoms that occur during the luteal or premenstrual phase, seven to ten days prior to menstruation. These symptoms must resolve once a woman begins her period. Furthermore, for a woman to have PMS, she must be without symptoms in the follicular or of the menstrual cycle.

The criteria that physicians need to diagnose PMS are as follows: five (or more) of the below symptoms must occur during the luteal phase and be absent after menstruation. Also, at least one symptom must be from Group (A).

Group A
• Depressed mood, feelings of hopelessness
• Anxiety, tension
• Sudden and dramatic mood swings
• Anger, irritability

Group B
• Decreased interest in usual activities
• Difficulty in concentrating
• Fatigue, lack of energy
• Change of appetite, overeating, food cravings
• Sleep disturbances
• Sense of being overwhelmed
• Physical symptoms such as breast tenderness or swelling, headaches, joint or muscle aches, bloating, and weight gain

In addition, for a positive diagnosis of PMS, it is crucial that these disturbances interfere markedly with work, school, or personal relationships. The cyclic nature of these symptoms cannot be relied upon from memory. A woman must chart them on a daily basis for at least two to three months. Finally, these symptoms cannot be a worsening of a psychiatric disorder such as major depression or anxiety disorder. Only 50 percent of women who visit their physician believing that they have PMS actually meet the above criteria and have the diagnosis of PMS confirmed.
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What are the symptoms of PMS?
Different clusters of symptoms appear in different women but in an individual woman, the symptoms tend to be similar from cycle to cycle. The severity, however, may fluctuate from cycle to cycle. Symptoms usually occur seven to ten days before menstruation and may intensify as menstruation approaches. Symptoms can be mild, moderate, or severe, and may include the following:

Symptoms of women suffering from PMS (those with a star are the most common)

Emotional Symptoms
• Anxiety
• Irritability
• Fatigue
• Depression
• Mood swings
• Forgetfulness
• Anger
• Difficulty concentrating
• Tension
• Restlessness
• Over-sensitivity
• Changes in libido
• Low self-image
• Social withdrawal
• Crying spells
• Decreased interest in usual activities

Physical Symptoms
• Abdominal bloating
• Breast swelling and tenderness
• Swollen ankles or fingers from fluid retention
• Increased appetite
• Headaches
• Weight gain
• Acne
• Palpitations
• Food cravings
• Constipation
• Upset stomach
• Joint aches
• Muscle spasms
• Increased thirst
• Clumsiness
• Changes in sleep habits

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Diagnosing PMS
If a woman suspects she has PMS, it is imperative to relate the occurrence of the symptoms to the menstrual cycle. However, it is equally important for a woman to evaluate the stresses in her professional and personal life, since these may have a significant impact on how premenstrual symptoms are expressed.

Some women experience very severe PMS. Symptoms of serious psychiatric problems, such as depression or panic attacks, are often most extreme during the premenstrual phase each month and studies have shown that women’s suicide attempts, psychiatric hospital admissions, and violent criminal acts are most likely to occur in the premenstrual days. If a woman feels that she may hurt herself or someone else, she should seek immediate medical attention. Fortunately, this is extremely rare.

There are no specific physical findings or laboratory tests that can diagnose PMS. There is also no symptom that is unique to PMS. The only way to determine whether or not a woman suffers from PMS is for that woman to record the timing and severity of her symptoms — both emotional and physical — throughout the menstrual cycle on a daily basis for two to three months. We have provided an interactive calendar on this site which can be used to chart your cycle. In addition to the symptoms, monitoring basal body temperature and vaginal secretion will contribute useful information to confirm when ovulation occurs. In order to accurately diagnose PMS, your physician will rely upon this charting. It is also useful to gauge your response to therapy.

When working with a doctor to confirm PMS, other disorders must be eliminated, since many symptoms of PMS resemble those of other underlying conditions. Your doctor may want to do a physical examination and a pelvic exam to rule out gynecologic problems. In cases where fatigue is a major symptom, a blood test may be done to rule out anemia, hypothyroidism, and contributors to chronic fatigue syndrome. It is also important to be aware that more serious psychiatric problems may have a cyclic pattern of worsening emotional symptoms in the premenstrual phase. For example, depression is very common in women and often worsens during premenstrual days.

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Possible causes of PMS
PMS has been called everything from a hormonal dysfunction to a mental illness to the feminist issue of the 80s. Although it is known that PMS is associated with ovulation, the true cause remains unknown. It is clear that two components are essential for PMS to occur. The first is the “trigger”, which is clearly identified as ovulation and the resulting, reproductive hormonal changes. The second is the “vulnerability” to the “trigger” that produces the mood changes of PMS. What makes one women “vulnerable” and another not, is unknown. This is the key to identifying the cause of PMS. Many factors have been suggested, but refuted, as contributors to the “vulnerability”, such as a woman’s social and economic status, number of children, diet, amount of exercise, stress level, personality, and characteristics of the menstrual cycle. However, current data supports serotonin, a chemical in the brain, as having an important role in PMS. While no other cause has been nearly as conclusive as serotonin, other possible factors have been investigated and are interesting to consider. Some theories that have been suggested include:

Serotonin
Serotonin is a neurotransmitter. A neurotransmitter is a chemical that is involved in sending messages along nerves in the brain, spinal cord, and throughout the body. Serotonin affects mood. Impaired serotonin activity has been linked to symptoms of depression, anxiety, impulsivity, aggression and increased appetite. Since depression is also a major symptom of PMS, scientists have questioned the role of serotonin in PMS. Abnormal serotonin levels and activities have been found in women suffering from PMS. Furthermore, drugs that enhance serotonin activity, called specific serotonin reuptake inhibitors (SSRI) (e.g., Prozac, Zoloft, Paxil), are effective in the treatment of PMS.

Cyclic fluctuations in reproductive hormones
While it seemed logical to many that the reproductive hormones involved in the menstrual cycle were the cause of PMS, research has proven that there are no differences in estrogen, progesterone, FSH, LH, prolactin, and testosterone levels between women with and without PMS. This only confirms that ovulation acts as the “trigger” but is not in itself the cause. In the past, progesterone supplementation was supported as a treatment for PMS, but has been proven to be ineffective. As discussed in treatments, the only hormonal therapy that works is a regimen that prevents ovulation from occurring.

Abnormal thyroid function
Thyroid disease is common in women. Symptoms of hypothyroidism, or low activity of the thyroid gland, can resemble symptoms of PMS. For this reason, it was thought that the thyroid gland played a role in the cause of PMS. Any woman who suffers from PMS-like symptoms should get her thyroid checked. However, it is clear that the majority of women with PMS have completely normal thyroid function. Thus, supplementation with thyroid hormone in the treatment of PMS is not helpful and may, in fact, be dangerous.

Endorphin deficiency
Endorphins are opium-like chemicals manufactured by the body. Opium-like chemicals, including endorphins, are involved in the sensation of euphoria and the perception of pain. Thus, some have proposed that PMS is a state of endorphin deficiency. Endorphin levels in the blood do fluctuate. However, these levels are not felt to reflect the activity of endorphins in the brain. Therefore, there is not enough evidence to support this theory.

Vitamins and minerals
Scientific research has not been able to confirm a difference in the levels of vitamins and minerals between those women with symptoms of PMS and those without. One particular vitamin that has received a great deal of attention is Vitamin B6. Vitamin B6 plays an important role in the synthesis of dopamine, a neurotransmitter that may also be involved in physical and emotional well-being. Thus, Vitamin B6 deficiency has been hypothesized as a cause of PMS. Some researchers have shown improvements in PMS symptoms in women taking vitamin B6 daily, while others have not. However, it is important to limit the amount of vitamin B6 that you take, since neural toxicity has been reported. Therefore, Vitamin B6 supplements should only be taken under the supervision of a doctor.

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Possible PMS treatments
It is both important and interesting to understand the processes by which the scientific community researches diseases and their possible treatments. While many remedies have been introduced and advocated for the treatment of PMS, few have been proven truly beneficial. For the medical community to be convinced of a therapy’s effectiveness, a “double blind placebo controlled study” is conducted. This is a highly regarded method of proving the viability of a particular treatment. In this type of study, one group of subjects receives the medication in question, while another group receives a placebo (an inactive pill). The use of a placebo ensures that the study is “controlled”. “Double blind” means that both the treating physician and the patient are unaware of which therapy they are receiving, thus eliminating any possibility of error. Serotonin agents and agents that block ovulation are the only therapies that have been found to be more effective than placebo. It is interesting that a number of patients do respond to placebo in a positive way. This does not mean that the symptoms are not real. It simply represents the lack of understanding as to how or why the placebo works. Perhaps, the belief that a medication will cure a patient, causes a production of chemicals in the brain that improve symptoms. It may also be that a patient is simply have a positive response to a sympathetic caregiver.

Self-Care Tips
If PMS symptoms are severe and having a substantial impact on your life, it is best to see a doctor. We have provided some information in this section as to treatments that a physician may recommend for very severe PMS symptoms. However, for many women who feel basically healthy, some simple tips may provide considerable relief. While poor diet and a lack of exercise have not been found to be a cause of PMS, keeping physically and emotionally well, through adequate sleep, good nutrition and regular exercise may help relieve some symptoms of PMS. The following tips may help:

Diet
A daily diet based on general nutrition guidelines can help in overall well-being as well as PMS control. Eating sweets causes a sudden rise in blood sugar that triggers an insulin response, which results in a subsequent rapid fall in blood sugar levels. Low blood sugar (hypoglycemia) can cause PMS-like symptoms such as irritability and fatigue. To avoid hypoglycemia, eat healthy meals at regular intervals throughout the day and avoid excess sugar. Complex carbohydrates and proteins in healthy foods are digested and absorbed more slowly than refined sugar, insuring a steady, gradual supply of nutrients to the bloodstream. Nutritionists typically advise a diet that consists of 50% carbohydrates, 20% protein and 30% fat. In women with PMS, an attempt to change the diet to a ratio of 60/20/20 is advisable, but can be difficult to accomplish. Avoiding sodium may help control premenstrual fluid retention. Most Americans consume 4,000 to 6,000 mg of salt a day, and if the diet is composed of large amounts of processed foods, salt intake can approach 10,000 mg a day. If fluid retention is a troublesome symptom, restricting salt to 2,000 to 4,000 mg a day is advisable. Use the following basic principles of low-salt nutrition to gradually reduce your salt intake:

• Eliminate table salt (season with herbs, lemon juice or vinegar)
• Don’t add salt in cooking
• Eat fresh rather than processed food
• Read food product labels for sodium amounts
• Change your ordering patterns in restaurants

Exercise
Exercise not only improves general health but it is believed to stimulate the production of endorphins. Aerobic exercise that increases your heart rate by 50% for 30 minutes, should be done three to five times a week. Benefits include cardiovascular fitness, muscle tone, weight control or reduction, decrease in fluid retention, and increase in self-esteem.

Reducing alcohol and caffeine intake
Alcohol and caffeine may aggravate PMS by affecting a person’s moods. Therefore, by minimizing the amount of alcohol and caffeine that you consume during the premenstrual phase, you may feel better. A rapid withdrawal from caffeine may cause symptoms of lethargy and headache. It is therefore, suggested that you decrease your caffeine intake slowly over time. Also, remember that coffee is not the only source of caffeine. It can also be found in tea, soft drinks, chocolate and some over-the-counter medications.

Rest
Most people require about seven hours of sleep each night, but you should get as much rest as feels right for you. Some women find they need extra sleep during the premenstrual week.

Reducing stress
Stress may aggravate PMS. It is often impossible to avoid the day-to-day and the unexpected stressors of life. However, relaxation techniques such as meditation, yoga, and exercise can lower your stress level. Learn what is stressful for you, then try to eliminate it as much as possible, especially on premenstrual days. Also, consider making the time to do something enjoyable. This may make you feel better and happier.

Coping with Emotions
One of the most troublesome aspects of PMS is the intensity of the emotional responses during premenstrual days and the inability to control them. No one wants to be depressed and for many people, anger is an uncomfortable emotion even when it is justified. Identifying sources of anger and conflict in your life can help you to find the strength to make changes. When premenstrual symptoms are more emotional than physical, and self-care tips are not effective, a psychotherapist may help. Depending on where you live, there may also be a PMS support group available. Reassurance that others suffer from similar problems can often help.

Vitamins
Vitamin B6 (pyridoxine), 25 - 50 mg twice a day. Vitamin B6 helps the body synthesize catecholamines, a type of neurotransmitter. Therefore, Vitamin B6 may help with central nervous system-related problems such as depression, anxiety, difficulty concentrating, or other emotional problems. Some doctors feel that vitamin B6 helps certain women. However, it is important to avoid excessive doses, which may be toxic. Serious nerve problems have been reported at high doses, and vitamin B6 should be used only under a physician’s supervision.

Vitamin E (alpha-tocopherol), 400 IU twice a day can be helpful with premenstrual breast tenderness. The method by which vitamin E helps alleviate breast complaints is not understood.

Help from Your Doctor
When your own PMS management efforts aren’t working, it may be time to seek help from your doctor. If your doctor is not an expert in the latest developments and research in PMS, he or she may refer you to someone else. This is perfectly acceptable. Furthermore, you may want to consider visiting a psychiatrist. This is not to suggest that PMS is “all in your head”. Rather, many PMS symptoms overlap with those conditions treated by a psychiatrist. Also, many of the medications that are now recommended for PMS sufferers are often prescribed by a psychiatrist. A collaboration between yourself, your physician, and a psychiatrist can be of tremendous value to you. When visiting your doctor, bring along your cycle charts and food logs. Tell the doctor about any medications, over-the-counter drugs, vitamin/mineral supplements, or herbal remedies that you take.

When PMS symptoms are particularly severe, a doctor may recommend one or a combination of the following:

Serotonin
Currently, serotonin agents are the treatment of choice for PMS. Serotonin, as described earlier, has a great deal to do with moods. Specific serotonin reuptake inhibitors (SSRI) (e.g., Prozac, Zoloft, Paxil) have been confirmed in double blind placebo controlled trials as being the most effective treatment of PMS. These drugs may relieve such symptoms as anxiety, impulsivity, aggression, and increased appetite. Serotonin agents, however, are not generally helpful in alleviating the physical premenstrual symptoms.

Prescription diuretics for fluid retention
If limiting salt intake is not effective, diuretics may be helpful in women experiencing significant cyclic fluid retention which can be manifested as weight gain or leg and ankle swelling. Diuretics increase the kidney’s ability to excrete sodium and water in urine, so the amount of fluid surrounding body tissue cells is diminished. Prescription diuretics are powerful drugs that can cause some serious side effects, so they should always be taken under a doctor’s supervision.

Hormone treatment
Some doctors will try hormone therapy when other treatments have not worked. Progesterone supplementation during the luteal phase is not consistently effective. However, hormone therapy designed to suppress ovulation has some promise. Birth control pills block ovulation, so theoretically, PMS should not exist. However, birth control pills improve PMS symptoms for some women, but others find their symptoms are unchanged or even more severe.

Another form of hormone treatment uses gonadotrophic releasing hormone (GnRH) agonists. GnRH therapy has been used to successfully treat PMS symptoms in very severe cases that have not been helped by other treatments. These agents prevent ovulation by suppressing ovarian function. Thus, estrogen and progesterone levels remain low. Since low estrogen levels are associated with accelerated bone loss and increased cardiovascular disease, long-term therapy with GnRH agonists is not advised. For this reason, this therapy can be combined with supplemental estrogen to minimize these risks. Since GnRH agonists have serious risks, are expensive therapy, and are usually administered by injections or implants, the combination of GnRH and estrogen is reserved for patients with severe symptoms who are not responsive to other forms of therapy.

Other medications
Tranquilizers, as well as antidepressants that are not specific serotonin reuptake inhibitors (SSRIs), may also relieve some PMS symptoms. The use of tranquilizers should be carefully weighed to ensure that the benefits outweigh the risks since drug dependence (addiction) is a possible risk.

For very bothersome breast swelling or pain, a doctor may suggest bromocriptine. Bromocriptine may relieve premenstrual breast tenderness by decreasing the release of hormones from the pituitary gland. Prolactin is one of many hormones that stimulate breast tissue. Bromocriptine does not relieve other symptoms of PMS. Serious side effects of the drug are rare, but bothersome side effects are common, such as nausea and lightheadedness.

Surgery
As a last resort, when no other therapies have worked and the PMS symptoms are very severe, a doctor and patient may consider surgery. Oophorectomy, or removal of the ovaries, eliminates PMS. This is radical therapy and should be considered only when nothing else has relieved the symptoms and PMS has had devastating affects on a woman’s personal and professional life. In addition, it is only an option when a woman has completed her child-bearing.

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New Studies Lead to a Better Understanding of PMS
By Dr. Philip Sarrel, M.D.

Even though PMS, or premenstrual syndrome, affects just about all women at some point in their lives, doctors have up until now understood very little about it. But new studies now point to a biological factor — hormones — as the principle cause for PMS.

The ovarian hormones estrogen and progesterone are produced during each menstrual cycle. These hormones circulate in the blood stream, enter cells throughout the body, and have effects on how these cells are able to carry out their daily functions. The brain is made up of millions of cells that are sensitive to the effects of ovarian hormones and the fluctuations in these hormones which occur during the menstrual cycle. For most women, ovarian hormones serve to support basic brain functions including sleep and temperature control, sexual feelings, ability to reason, and moods. For many women, however, brain cell reaction to ovarian hormones can be negative; millions of women experience the monthly occurrence of PMS (premenstrual syndrome) with irritability, anxiety, and sadness during the week to ten days preceding menstruation.

PMS has been the subject of many scientific studies that have helped us to understand how ovarian hormones influence the workings of the brain. Ovarian hormones affect blood flow to the brain; they help sustain and promote the growth of brain cells, and they help control the production and release of brain chemicals (neurotransmitters), which are responsible for many different actions in the brain.

A recent study carried out at the National Institute of Mental Health found that PMS symptoms represent an abnormal response to normal hormone production levels. Women with severe symptoms were compared to women who did not have the syndrome. When the women with severe symptoms were treated with a drug which inhibited their ovaries from producing hormones, the symptoms decreased significantly. These women were also given a placebo, that is, a preparation which had no effects on their ovaries and which did not contain any hormones. When they received the placebo, the symptoms were unaffected. The women with PMS whose symptoms decreased when their ovaries were inhibited were then given the hormone-blocking drug, but this time they had either estrogen or progesterone added. When either of these natural hormones was taken, the women had significant recurrence of their PMS symptoms. The women who did not suffer from PMS showed none of the reactions to the treatments that were seen in the PMS-affected women.

This study seems to clearly identify PMS as a disorder of abnormal sensitivity to normal levels of ovarian hormones. Symptoms such as sadness, anxiety, and irritability, which occur in cycles relating to the time of menstruation, should be regarded as a biological, and not a psychiatric disorder. Although the ovarian-blocking drug cannot be given indefinitely, it could be used for women with the most severe symptoms for at least a short time. Over a longer period, women would suffer from the effects of inadequate levels of ovarian hormones, such as from bone loss and osteoporosis. However, the hormone-blocking drug helps define PMS as a condition caused by hypersensitivity to ovarian hormones.

Hopefully, this new understanding of PMS may lead to new and better treatments.

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The inside of your vagina, like the inside of your mouth and nose, is covered with a mucus membrane — a type of body tissue that produces moisture. So it’s normal to feel a little dampness in your underpants during the course of a day. In fact, if the vaginal lining stayed dry you would be susceptible to vaginal infections, and sexual intercourse would be painful!

Most women produce more mucus around the middle of their menstrual cycle — usually a couple of weeks after a period. This increase coincides with ovulation — the release of the egg (or ovum) from the ovary. During pregnancy there is often an increase in vaginal discharge, and sometimes it becomes quite thick. There are also certain types of birth control pills which tend to make some women feel damp, too.

Sexual excitement stimulates the membranes to produce fluid to lubricate the vagina in preparation for intercourse, and after sexual intercourse there may be quite a large amount of discharge.

Normal discharge that is clear and smooth or creamy has a very slight smell that can be described as sweet or soapy. What is not normal is any discharge that is smelly, itchy, discolored, or irritating.

Anything like that should be discussed with a doctor, along with any bleeding between periods. The most likely cause of abnormal vaginal discharge is an infection.

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Yeast infection is a very common vaginal infection. It is caused by a form of yeast known as candida. Candida occurs naturally in the vagina and bowel, and usually it is no trouble because it is kept in check by other, harmless bacteria which inhabit the same places. However, if these bacteria are reduced — by antibiotics, for example — the yeast can grow and cause problems. Pregnant women and those with diabetes often get yeast infections, and it is most likely to appear just before a period. Ask your doctor about a one dose medication that treats yeast infections.

Symptoms include a thick, white vaginal discharge that looks like cottage cheese, irritation and itchiness around the vagina, and discomfort when urinating and during sexual intercourse.

Other common problems
Trichomonas is a tiny parasite that may be transmitted during sex or picked up by contaminated washcloths or towels. Men can get it, too, but rarely show any symptoms. Because their symptoms may be hidden, it is necessary for men to be treated for trichomonas at the same time as their partners, so the disease is not passed back and forth.

Symptoms: Itching, soreness, and a burning sensation in the vagina. Foul-smelling, discolored vaginal discharge.

Chlamydia is a sexually transmitted disease that may cause symptoms in both men and women. It can lead to urinary infection or fertility problems if not treated.

Symptoms: Watery, sometimes odorous vaginal discharge. Pain during urination.

Gonorrhea is a bacterial sexually transmitted disease. It is very infectious.

Symptoms: Possible slight white, green, or brown discharge. Men have a discharge, swelling, and pain when urinating.

What to do
If you think you may have an infection, go and see your doctor or visit a specialized clinic. Vaginal infections are very common and there is absolutely nothing to be worried or embarrassed about. They can be treated with antibiotics or anti-fungal remedies that your doctor can prescribe. Your doctor may decide to test the discharge first to help diagnose the exact infection. Many vaginal infections can be passed back and forth between a couple--and sometimes only one of you will show symptoms even though you are both infectious. So it is important for both partners to be treated. If infections are not treated immediately, they may cause more serious problems later on — so it’s best to deal with them at the first sign of symptoms.

Ways to help yourself
Keep air circulating around your crotch by wearing cotton (not synthetic) underpants and loose clothing. Wipe from front to back after using the bathroom to avoid moving bacteria from your rectum to your vagina. Avoid scented soaps or bath salts — they might irritate the sensitive vaginal tissue. Never use a tampon to absorb non-menstrual vaginal discharge — if you need to protect your clothes use a pantiliner.

Non-infectious causes of vaginal discharge
Cervical erosion: Sometimes a small area on the neck of the uterus (cervix) becomes raw and oozes. It may cause a heavy, clear, no odor discharge. Sometimes there is a little blood. The discharge tends to be worse just before a period. Bleeding after sexual intercourse is also common in this condition. Cervical erosion is treated by minor surgery.

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