Menopause symptoms and hormonal imbalance

First, take a look at the list of PMS, perimenopause and menopause symptoms at the left. Did you ever imagine hormonal imbalance could wreak such havoc on your body?

It’s all the more disturbing if you reported any of these common symptoms to a medical professional and were dismissed with a raised eyebrow or a wave of the hand.

Go ahead. Count how many of these symptoms are bothering you right now. The more you have, the more important it is to get your body into balance. (Use the links in the list to get more information about your individual symptoms.)

What are your symptoms telling you?

Perimenopause (and later, menopause itself) is not an illness, but a natural process in a woman’s body. Your symptoms, like night sweats, irregular periods, vaginal dryness, and menopause insomnia, are just indicators of underlying hormonal imbalances or metabolic damage from poor nutrition, stress and other factors.

You need to regain the natural hormone balance of your body. With proper support, your body is perfectly capable of achieving a proper hormonal balance. That means you can be free of the unpleasant signs and symptoms of menopause, PMS or perimenopause.

We use multiple forms of natural remedies and support, depending on the level of menopause symptoms you’re experiencing. And there’s a special program if you’re trying to get off hormone replacement therapy (HRT). These combinations have been developed and refined in over 20 years of clinical practice involving tens of thousands of women.

As you may have already read, more than 85% of all women on the Personal Program report real improvement within weeks.

FDA Panel Recommends Fluoxetine for PMDD

Surveys indicate that from 3 percent to 8 percent of North American women in their reproductive years suffer from premenstrual dysphoric disorder (PMDD).

The Food and Drug Administration’s (FDA’s) Psychopharmacologic Drugs Advisory Committee has recommended that the FDA approve an indication for fluoxetine (Prozac) in the treatment of PMDD.

On November 3 Prozac-manufacturer Eli Lilly and Company announced the advisory panel’s unanimous recommendation. The FDA rarely rejects the advisory panel’s recommendations, and if approved, Prozac will be the first drug specifically indicated for PMDD.

The disorder afflicts from 3 percent to 8 percent of North American women in their reproductive years, according to an article published in the New England Journal of Medicine in June 1995. PMDD is characterized by dysphoria, tension, and irritability linked to the menstrual cycle. PMDD is in an appendix of the DSM-IV reserved for criteria needing further study, observed Judith Gold, M.D., former chair of APA’s Work Group on Late Luteal Phase Dysphoric Disorder, the name by which PMDD was formerly known.

"PMDD is still in the appendix and so is still a candidate for further research," she noted. But Gold added that "there has been quite a bit of research since DSM-IV came out showing that the SSRIs are quite effective" in treating PMDD.

The research includes studies on fluoxetine and sertraline (Zoloft) showing that "they are effective in controlling the mood disorder symptoms of PMDD in about 60 percent of patients who meet the PMDD criteria," said Gold. "There is a fairly sizable group, however, that don’t improve." That finding suggests that there may be varying etiologies for PMDD, she said.

Several studies conducted within the last few years have found that intermittent dosing with the SSRIs is effective in relieving the symptoms of PMDD, observed Gold. This suggests that women with PMDD "don’t have to take the medication constantly, but just in the premenstrual period," she said.

Another interesting finding is that the mood symptoms of PMDD are alleviated by lower doses of SSRIs than those normally used in treating depression, said Gold.

Diana Dell, M.D., who chairs the Women’s Caucus of the APA Assembly, is trained in obstetrics-gynecology and psychiatry. "It is likely that this will be the first of the SSRIs to be approved for this use," said Dell. "All of us in clinical practice have been using these drugs off-label this way for 10 years."

The agents used have included Prozac and the other SSRIs with "good results, whether used intermittently or continuously" and at lower doses than those used to treat depression, said Dell. "All of those drugs were developed during a time when including women and ethnic minorities in clinical trials had not been mandated," Dell added. "It doesn’t surprise me that lower doses are often effective in treating women."

The advisory panel’s recommendation is hoped to "presage greater attention to the development of diagnostic criteria and clinical treatments focused on gender-specific disorders," Dell commented. The terminology surrounding premenstrual dysphoria has changed over the years, she noted, but "the notion that PMDD is a more severe subset of PMS is far more palatable than that it is an entirely separate disorder."

"We are pleased with the [FDA] committee’s [recommendation] and look forward to continuing an ongoing dialogue with the FDA to obtain approval to market fluoxetine to treat PMDD," said Rajinder Judge, M.D., Lilly Research Laboratories’ director and global physician for fluoxetine.

In a press release on the advisory committee’s recommendation, Lilly said that although the etiology of PMDD is not clearly established, it "could be caused by an abnormal biochemical response to normal hormonal changes." Routine changes in estrogen and progesterone associated with menses may, in vulnerable women, induce a serotonin deficiency that could trigger the symptoms of PMDD.

The Lilly statement further notes that the course of PMDD differs from both major depression and premenstrual syndrome (PMS). "Major depression is episodic, and its symptoms can persist for weeks, months, or years." It is not linked to the menstrual cycle, the statement notes. PMDD is associated with more severe symptomatology and greater functional impairment than PMS, the statement notes.

Women Behaving Badly?

In 1875, Mrs. Lydia E. Pinkham of Lynn, Mass., began selling her famous Vegetable Compound, which she advertised as "a positive cure for all these Painful Complaints and Weaknesses so common to our best female population. It will cure entirely all Ovarian troubles, Inflammation and Ulceration, Falling and Displacements, and any consequent Spinal Weakness, and is particularly adapted to the Change of Life."

In 2001, drugmaker Eli Lilly and Co. began selling a product called Sarafem, also intended to treat a condition specific to women. According to the manufacturer's package insert, Sarafem is indicated for the treatment of premenstrual dysphoric disorder (PMDD), a newly proposed mental disorder not yet officially accepted by the American Psychiatric Association but listed in the appendix of that group's diagnostic manual.

No doubt part of what made Lydia Pinkham's miracle cure so successful was that it consisted of a blend of herbs in a 20% mixture of alcohol, a common 19th-century approach to taking care of a variety of ills. Lilly's Sarafem, on the other hand, is completely new millennium in approach. For women struggling with PMDD, this repackaged, relabeled version of the antidepressant fluoxetine hydrochloride -- better known to millions by the brand name Prozac -- "helps you be more like the woman you are, every day of the month, even during your most difficult days," according to the company's web site.
'Disordered' Thinking

Although separated by more than a century, the tonics promoted by both Mrs. Pinkham and by Eli Lilly are emblematic of what is to many people an ancient but troubling tradition in medicine: The tendency to categorize the normal bodily functions of women as "diseases" or "disorders" that need to be treated.

"From the time you're a preteen, from your very first inklings of hormonal rhythms all the way to the end of life, you're given the message that your body doesn't work or that it's not OK," says Madeline Behrendt, DC, in an interview with WebMD.

Behrendt, a chiropractor in private practice in Boise, Idaho, is also vice chairwoman of the Council on Women's Health of the World Chiropractic Alliance. In that capacity, she recently spoke on the issue at the United Nations Women's Conference, where, she says, she found that people all over the world appear to share her concerns.

"Over the past year there have been so many shifts: Now girls are being given hormonal drugs because so many of them are starting puberty early. Another big topic is menstrual suppression, where they're saying that menstruation is not normal -- it's a nuisance, it's unnatural, it's unhealthy. When I was growing up, if you didn't have your cycle that was called amenorrhea and that was a problem. Then it goes into the reproductive years where there are birth control pills, or PMDD, or a new specialty created last year called female sexual dysfunction," she says.

A Disorder Is Born

Behrendt and others point to the marketing of PMDD as being just the latest example of this trend. The package insert for Sarafem cites a definition of PMDD from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the psychiatrist's bible. According to the manual, the essential features of PMDD are "symptoms such as markedly depressed mood, marked anxiety, marked affective lability [mood swings], and decreased interest in activities."

What the prescription information fails to mention, however, is that PMDD is mentioned briefly in the main body of the manual as a "depressive disorder." But the full entry on PMDD is included in an appendix that lists conditions for which "there was insufficient information to warrant inclusion of these proposals as official categories ... in DSM-IV."

In other words, some critics charge, Sarafem is indicated for a disorder that may or may not exist.

"I have concerns about [formalizing] a social tradition of blaming women's behavior and bad moods on women's reproductive function," says Nada Stotland, MD, MPH, professor of psychiatry and obstetrics and gynecology at Rush Medical College in Chicago, and a member of a task force that determined DMS-IV diagnostic criteria.

Stotland, who acknowledges that she has given talks in venues supported by Lilly, tells WebMD that she argued against including PMDD in the main text of the manual.

"I would prefer to see us approach this interesting and worthwhile issue from the point of view, for example, of the effect of male and female hormones on behavior and mood, rather than picking out one sort of traditional condition," she says.

But Robert L. Spitzer, MD, professor of psychiatry at Columbia University in New York City and chairman of the work group to revise DSM-III criteria, has a different point of view.

"Many women's groups objected to the inclusion of the disorder, fearing it would stigmatize normal women, a view that I don't share," Spitzer says in an interview with WebMD. "My own view -- and the view of the people who originally proposed the category -- is that there is a small subset of women who suffer from this disorder, and the best thing you can do for these women is to recognize and develop effective treatments for it."

Behrendt, Stotland, and other critics acknowledge that some women have distinct physical changes related to their menstrual cycles, and that some women have debilitating problems that could be alleviated significantly by medication.

Where they draw the line, however, is in the classification of menstruation-related phenomena as disorders.

Cash or Compassion?

In medicine, some old habits are hard to break: The very word "hysteria" comes from the Greek for uterus (hystera). And if you think we've come a long way since then, baby, consider the following excerpt from an article titled "Eleven Tips on Getting More Efficiency Out of Women Employees," published in the July 1943 issue of the trade journal Transportation:

"4. Retain a physician to give each woman you hire a special physical examination -- one covering female conditions. This step not only protects the property against the possibilities of lawsuit, but also reveals whether the employee-to-be has any female weaknesses, which would make her mentally or physically unfit for the job."

Allyne Rosenthal, DC, a Chicago-based chiropractor and practitioner of functional medicine, has studied and written about the creation of PMDD as a distinct medical entity. She tells WebMD that new attention being paid by the medical and pharmaceutical industries to PMDD, female sexual dysfunction, and menopause may be motivated as much by cash as by compassion.

"The hallmark of adolescence is hormonal imbalance. Therefore, the numbers of young girls who will deemed to be candidates for this medication are astronomical if they go ahead with this, and that is one of the major problems," she says.

Rosenthal also expresses concern that fluoxetine was not tested for long-term use prior to FDA approval, yet giving it to combat the hormonal effects of menstruation is, in effect, writing a reproductive-length prescription.

"The tests on it were 6-8 weeks, but PMS is not a short-term syndrome," she says. She points to evidence suggesting that long-term use of Prozac and similar drugs could cause serious side effects, such as those seen with the older generation of powerful antidepressants that were prescribed in the 1950s, '60s, and '70s.
Lilly Responds

Asked by WebMD to comment on the concerns of critics, Lilly spokeswoman Laura Miller drew attention to an FDA "talk paper" issued in July 2000 to coincide with the agency's approval of Sarafem for PMDD. The document states that "on November 3, 1999, FDA's Psychopharmacologic Advisory Committee unanimously recommended approval for fluoxetine to treat women with PMDD. The committee concluded that fluoxetine was effective for the condition and that PMDD has well defined, accepted diagnostic criteria."

The very next sentence, however, offers this caveat: "The committee also advised that the drug should be used only to treat women whose symptoms are severe enough to interfere with functioning at work or school, or with social activities and relationships."

Miller also forwarded a "roundtable discussion" published in the Journal of Women's Health and Gender-Based Medicine, in which panelists from highly respected research centers in the U.S. and Canada conclude that "PMDD is a distinct entity with clinical biologic profiles dissimilar to those seen in other disorders. Thus, the relative safety and efficacy of potential treatments for PMDD can be evaluated, and, indeed many of those present thought that sufficient evidence is now available to support the use of [Prozac and similar antidepressants] in this disorder."

Natural Alternatives Also Work

"The vision of millions of women being put on this drug for a condition that can be so effectively treated in other ways is just stunning," Rosenthal says. "PMS is something that bothers a lot of women. There's no question about that, but it responds incredibly well -- and quickly -- to a combination of things, like vitamin B-6, magnesium, zinc, and the correct balance of proteins and carbohydrates in the diet."

In its marketing materials, Lilly draws a sharp distinction between PMS and PMDD, but others say the line is blurry, and that PMDD -- if it exists at all -- is really at the extreme end of a continuum representing the normal range of women's physiologic responses to hormonal variations.

"We need to give more credit to women for knowing what's going on in their own mind and bodies, and here we have a situation in which we have data quite conclusively showing that in this case women often do not know -- because it's OK for women to be crabby and because women don't allow themselves room to be sad, even if there are sad circumstances," Stotland says.

"And because psychiatric disorders are stigmatized, people who have just plain depression may not want to deal with that, and they have a tremendous tendency to blame it on PMS," she tells WebMD. "The dangers are that because women's hormonal changes happen to be in cycles, we forget that hormones have impact on men, and one might even say that we're neglecting men in that sense."

She notes that teenage boys tend to be at highest risk for driving accidents -- a fact reflected in their high insurance rates -- and that the adolescent surge of testosterone is probably to blame. No one, yet, however, is suggesting that teenage boys take hormone-adjusting drugs to keep them -- and other drivers -- safe.

"So which is worse: being crabby or being run over?" she asks.

Nevertheless, Stotland agrees that for a small subset of women who meet the very strict and serious symptom criteria for having PMDD, Sarafem probably helps. She also acknowledges that drugmakers have a right to make a buck.

"I have nothing against that. We live in a capitalist society in which we leave it to the pharmaceutical companies to develop nearly all the drugs, and any time they have a drug that's good for something, especially if it is for something especially widespread like the flu, they're going to try and get people to use that medication," she says.

But in this case, Behrendt worries, the desire to wring the maximum profit out of a product may have led the pharmaceutical company to put the cart before the horse.

"In terms of PMDD, I think the evidence speaks for itself," she tells WebMD. "Prozac's patent was running out, and suddenly a new disorder appeared -- PMDD -- that changed the classification to mental disorders. So with that a new class was formed, a new market was formed, and a new patent was formed."

Premenstrual Dysphoric Disorder

What is PMDD

PMDD stands for Premenstrual Dysphoric Disorder. It's a severe form of PMS Premenstrual Syndrome). Like PMS, PMDD occurs the week before the onset of menstruation and disappears a few days after. PMDD is characterized by severe monthly mood swings and physical symptoms that interfere with everyday life, especially a woman's relationships with her family and friends. PMDD symptoms go far beyond what are considered manageable or normal premenstrual symptoms.

PMDD is a combination of symptoms that may include irritability, depressed mood, anxiety, sleep disturbance, difficulty concentrating, angry outbursts, breast tenderness and bloating. The diagnostic criteria emphasize symptoms of depressed mood, anxiety, mood swings or irritability. The condition affects up to one in 20 American women who have regular menstrual periods.

Among 500 women recently surveyed, eight out of ten did not know that severe premenstrual problems have been officially classified as PMDD, nor did they know that such problems can be diagnosed and treated. Even more disturbing is that the one in four respondents who described their premenstrual symptoms as strong or severe were among those unaware of PMDD.

Twenty to fifty percent of women between the ages of 30 to 40 with regular menstrual cycles experience premenstrual syndrome (PMS) as a regular physiological occurrence every month. In more severe cases, affecting three to five percent of menstruating women, this syndrome is labeled as premenstrual dysphoric disorder (PMDD) . Patients with severe PMDD may be at risk for developing postpartum depression. Furthermore, women successfully treated with antidepressants often show breakthrough symptoms of depression in the premenstrual phase of their menstrual cycle. All that is needed is a small increase in the dosage of the antidepressant premenstrually.

PMDD Symptoms

Women with PMDD complain of irritability, anger, tension, marked depressed mood, and mood liability (crying spells for no reason), verbal outbursts, to such a severity that quality of life is seriously compromised. In addition to these symptoms, some women complain of exhaustion, fatigue, sleep disturbance, limited concentration and a host of physical symptoms such as breast tenderness, headaches, joint and muscle pain, bloating and weight gain.

The primary symptoms that distinguish premenstrual dysphoric disorder from other mood disorders (i.e., major depression) or menstrual conditions is the onset and duration of PMDD symptoms -- with symptoms appearing during the week or so before and disappearing within a few days after the onset of menses -- and the level by which these symptoms disrupt daily living tasks. (This diminished level of functioning is generally in great contrast with the same woman's interactions and abilities at other times during the month.)

The symptoms of PMDD may resemble other conditions or medical problems, such as a thyroid condition, depression, or an anxiety disorder. Consult a physician for diagnosis.

What Causes PMDD?

Although the exact cause of PMDD is not known, several theories exist. No one knows for sure, but it may be related to the neurotransmitter in the brain called serotonin (sair – uh – toe – nin). The symptoms of PMDD may occur when serotonin and other neurotransmitters are out of balance. In PMDD, this imbalance may be related to your monthly changes in hormones.

One theory states that women who experience PMDD may have abnormal reactions to normal hormone changes that occur with each menstrual cycle. This may include the fluctuation of estrogen and progesterone levels that normally occur with menstruation causing a serotonin deficiency, in some women (Serotonin is a substance found naturally in the brain and intestines that acts as a vessel-narrowing substance, or vasoconstrictor). Additional research is necessary.

How is Premenstrual Dysphoric Disorder Diagnosed?

Aside from a complete medical history and physical and pelvic examination, diagnostic procedures for PMDD are currently very limited. Your physician may consider recommending a psychiatric evaluation to, more or less, provide a differential diagnosis (to rule out other possible conditions). In addition, he/she may ask that you keep a journal or diary of your symptoms for several months, to better assess the timing, severity, onset, and duration of symptoms. In general, in order for a PMDD diagnosis to be made, the following symptoms must be present:

Over the course of a year, during most menstrual cycles, five or more of the following symptoms must be present:
* depressed mood
* anger or irritability
* difficulty in concentrating
* lack of interest in activities once enjoyed
* moodiness
* increased appetite
* insomnia or hypersomnia
* feeling overwhelmed or out of control
* symptoms that disturb social, occupational, or physical functioning
* symptoms that are not related to, or exaggerated by, another medical condition.

What is the Difference Between PMS and PMDD?

The physical symptom list is identical for PMS and PMDD; while the emotional symptoms are similar, they are significantly more serious with PMDD. In PMDD, the criteria focus on the mood rather than the physical symptoms. With PMS, sadness or mild depression is not uncommon. With PMDD, however, significant depression and hopelessness may occur.

In extreme cases, women may feel like killing themselves or others. These feelings must be taken as seriously as they are in anyone else and should be brought promptly to the attention of a mental health professional.

Women who have a history of depression are at increased risk for PMDD. Similarly, women who have had PMDD are at increased risk for depression after menopause. In simplest terms, the difference between PMS and PMDD can be likened to the difference between a mild headache and a migraine.

PMDD Treatment

Treatment for PMS depends on the severity of the symptoms. For mild cases, treatment recommendations include diet modifications such as high carbohydrate meals and reducing salt, caffeine and alcohol, as well as a variety of methods for stress reduction and relaxation such as exercise, counseling and stress/behavior management strategies.

For severe PMDD, treatment is more aggressive, often requiring pharmacological intervention in addition to nonpharmacological treatments. The selective serotonin reuptake inhibitor class of antidepressants are effective in the treatment of PMDD. Fluoxetine (Prozac - Serafem) has been widely studied and found to be effective in reducing symptoms of tension, irritability and dysphoria. These results have been replicated with sertraline (Zoloft) and paroxetine (Paxil). Use of the SSRIs is positive as well in that side effects, such as nausea, diarrhea, headache, and insomnia, to name a few, are minimal and reportedly tolerable by the majority of women.

For some women, even more drastic measures must be taken to ameliorate the symptoms of PMDD. For these women, hormonal therapies are necessary that work by suppressing the menstrual cycle. For some women, the severity of symptoms increase over time and last until menopause (when menses ceases). For this reason, a woman may require treatment for an extended period of time, and may require several re-evaluations to adjust medication dosages throughout the course of treatment.

Women, however, do face barriers to diagnosis and treatment. There is often a stigma attached to any condition that is associated with the menstrual cycle. Many women who do not seek treatment for the mood and physical symptoms of PMDD accept their symptoms as an inevitable consequence of the menstrual cycle which cannot be addressed.

Some women view seeking treatment for PMDD as a sign of weakness. Additionally, physicians aren't traditionally trained to recognize the signs and symptoms of PMDD symptoms are often dismissed as just a "part of being a woman." This attitude often keeps women from getting the help they need.

If you think you have PMDD find a doctor is familiar with PMDD or get a second opinion from another OB/GYN or psychiatrist.

If Your Doctor Prescribes Medication For Your PMDD

Or if your doctor prescribe an antidepressant for PMDD, they should inform you that antidepressants increased the risk of suicidal thinking and behavior in children and teenagers with depression and other psychiatric disorders. Patients starting therapy should be observed closely for worsening depression symptoms, suicidal thoughts or behavior, or unusual changes in behavior.

People on antidepressants and their families should watch for worsening depression symptoms, unusual changes in behavior, and thoughts of suicide. Patients should call their doctor if they have thoughts of suicide or if any of these symptoms are severe or occur suddenly. Be especially observant at the beginning of treatment or whenever there is a change in dose.

Most medications will give you side effects. Some women may experience side effects such as headache, upset stomach, tiredness, insomnia, nervousness, dizziness and difficulty concentrating. Side effects are usually mild and tend to go away within a few weeks.

* If you develop a rash or hives while taking any medication, call your doctor right away because this can be a sign of a serious medical condition.

Be sure to tell your doctor about other prescription or nonprescription medications you may be taking, including antidepressants, nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, vitamins and herbal remedies.