Fixes for heavy bleeding, cramps, PMS

Katherine Sutherland, an OB-GYN in Mountain View, California, knows something about terrible periods -- and not just from her patients. She used to go through tampons every hour, excusing herself to go to the bathroom between appointments. Heavy bleeding made doing what she really loved --hiking -- especially difficult. Truth is, she wanted her period to go away altogether. In 2003 Sutherland, then age 51, got her wish. She had a minor surgical procedure called endometrial ablation, or by its brand name, NovaSure, to remove her uterine lining and stop heavy bleeding. And she hasn't had a period since. "I was delighted," she says. "Up until that time I'd never missed one period." Sutherland recently hiked 8,000 feet to the ancient Incan city of Machu Picchu in Peru.

Many women, perhaps 95 percent, have period issues -- bleeding like Sutherland's, debilitating pain, out-of-control PMS, or annoyances such as constipation or diarrhea. Thanks to a variety of new remedies that can make over (or eliminate!) periods, you don't have to suffer. We've collected the best fixes for five of your most common problems.

Killer cramps

Virtually all women in their childbearing years have period pain (or dysmenorrhea). In fact, it's a leading reason for calling in sick to work or school. "Your uterus is a muscle, and it squeezes really hard," says Susan Haas, M.D., an associate professor of obstetrics and gynecology at Boston University. "Sometimes it can squeeze so hard it blocks the arteries coming into it. Just like in a heart attack, when the arteries are blocked, it causes pain." Health.com: Pelvic pain -- solve the mystery

The fixes

Naproxen, aspirin, and ibuprofen help by short-circuiting the production of pain-causing chemicals called prostaglandins that are involved in muscle contractions. They work best if you start an hour before your cramps hit. "Load up with a double dose and keep the blood level up," Haas says. (The maximum safe daily dose of ibuprofen is 2,400 milligrams, or 12 200-mg pills. Take the minimum dosage that works for you.) Right when you get your period, start with 800 mg and then go to 600 mg every six hours. But talk to your doctor if you have elevated heart disease risks; the Food and Drug Administration recently reported that all NSAIDs, except aspirin, may heighten cardiovascular risks. And remember that extended use of high dosages of aspirin or NSAIDs may cause gastrointestinal troubles.

Omega-3 fats from fish oil seem to block prostaglandin production, too. And research shows that women with low intakes of omega-3s have more painful periods. While mainstream docs are mostly neutral on the idea of increasing omega-3s to fight period pain, some think it makes sense.

Heat is an old-fashioned, but useful remedy for relaxing crampy muscles. Get out your heating pad, or try new nonprescription heat wraps, which last for eight hours and can be worn under clothes. Health.com: Your guide to fibroid fixes

Severe bleeding

Ten million American women have heavy bleeding, also called menorrhagia. (The average woman loses about three to four tablespoons per cycle; more than five tablespoons is considered heavy.)

The fixes

NovaSure, in which a wand is inserted into the uterus through the cervix, emits energy that, in most cases, permanently removes the uterine lining. It's best for women who, like Katherine Sutherland, no longer want to have children. (Getting pregnant after having the uterine lining removed could be risky.) The five-minute procedure is done in a gynecologist's office. Many women report lighter bleeding right away. And a recent study found that after seven years, more than 95 percent stopped having periods.

The 365-day birth-control pill, called Lybrel, is another way to skip monthly menstruation. Approved by the FDA in May, Lybrel has no placebo pills, so you just keep taking an active pill each day. (Breakthrough bleeding can be an issue for about 20 percent of users. And, since Lybrel contains estrogen, it's not for women who are prone to blood clots, such as smokers, who get migraines with an aura or who are over age 35 with elevated heart disease risks.) Health.com: Is it safe to ditch your period?

If you'd prefer having a period, just with less bleeding, the traditional pill is also useful for curbing heavy flow. Its constant level of progesterone causes the endometrium to develop a much thinner lining. During your week of placebo pills, you get a lighter period because you shed a thinner lining over time. Another option is to have a period just four times a year: With Seasonale and Seasonique you take 84 active pills in a row.

Mirena may be for you if pill-taking isn't your thing. This intrauterine device secretes progestin on a daily basis, thinning the uterine lining so there's virtually nothing to shed. "One-third of women get no period, one-third get a much lighter period, and the other third have only irregular spotting," says Dan I. Lebovic, M.D., a reproductive endocrinology and fertility specialist at the University of Michigan Health System. Drawbacks? Pain during insertion, and possible cramps and bleeding for about three weeks afterward.

Punishing PMS

About two-thirds of regularly menstruating women have premenstrual symptoms, says Jean Endicott, Ph.D., director of the Premenstrual Evaluation Unit at Columbia University's College of Physicians and Surgeons. It could be headaches, breast tenderness, or big, unpleasant mood swings. Up to 8 percent of women who have PMS suffer mood changes severe enough to cause problems in their personal lives and daily routines; this more serious version of PMS is called premenstrual dysphoric disorder, or PMDD. The fixes Calcium supplements are a good first thing to try, Endicott says, because research shows they ease symptoms. (Calcium may help even out hormone levels, although no one knows for sure why it works.) Besides, most women don't get enough calcium in their diets anyway. She suggests 1,200 mg daily, and not just on the day you're PMS-ing. "It should help take the edge off" over time, Endicott says.

Daily exercise -- like fast walking, lifting weights, or even dancing -- may be the last thing you want to do when in the throes of PMS, but it has proven antidepressant and antianxiety effects.

Antidepressants (Paxil, Prozac and Sarafem) can relieve severe symptoms. The new twist is that you don't have to take one daily -- but instead as soon as you feel anxious. "We tell (women who choose this option) to put a red flag on the calendar noting when they're likely to have symptoms so they remember to take the medication beforehand, when it can be most effective," Endicott says. Another choice: Yaz, a birth-control pill that's FDA-approved to treat PMDD. Clinical trials show it can cut symptoms by at least half, though the reasons are unclear.

Gastro upsets

Many women have diarrhea, gas, or constipation during their periods. Prostaglandins, the chemicals that cause cramping in your uterus, do the same in your bowels. "For lots of women, it's common to have a loose stool or diarrhea on the day they have a lot of bleeding," says Leslie Miller, M.D., University of Washington-Seattle clinical associate professor of obstetrics and gynecology.

Fiber can help keep GI issues under control. Aim for 30 grams a day from cereal, fruit with the skin, and vegetables. But don't add fiber to your diet too fast when you get your period; that could worsen diarrhea. For constipation, check your habits. Miller says women often hold in bowel movements because they're in public places. Before you know it, you are bloated and constipated. "When you get the urge, go," Miller advises.

Ibuprofen and other similar anti-inflammatory medicines may reduce gastro cramping. To avoid tummy irritation, take it with food.

All of the above

Some women experience a combo of excessive bleeding, cramping, breast tenderness, headaches, PMS, and other troubles. What to do?

The fix

Stop treating the individual symptoms. Miller recommends continuous birth control pills -- you just skip the placebo week and move on to your next pack. If your insurer won't pay for that, ask about Lybrel and the other pill options. Also, consider NovaSure if childbearing isn't in your future.

4 Self-Help Strategies for PMS

Perhaps some 90% of women have symptoms that indicate that their menstrual period is due to arrive. About 60% of those women will indicate that their premenstrual symptoms are troublesome. Nearly all cultures have a set of physical or mood symptoms which are attributed to being "premenstrual". Interestingly, this set of common symptoms varies from culture to culture. Studies done with the US subjects suggest that the "American Top Ten" of bothersome premenstrual symptoms include:

1. Irritability
2. Mood swings
3. Swelling of abdomen/breasts
4. Restlessness
5. Tension
6. Depression
7. Anxiety
8. painful breasts
9. Decreased concentration
10. Forgetfulness
    

The first approach to improving premenstrual symptoms is a trial of "lifestyle" and non-prescription treatments. Which of these is most likely to benefit you?

EXERCISE

Stanley (1989), in a study of exercise and PMS symptom relief, found that women should start to obtain some symptom improvement from as little as: 110 minutes/week of swimming, 70 minutes/week of aerobic dance, or 50 minutes/week of jogging. You will note that aerobic exercise seems to dominate the list. The effectiveness of aerobic exercise was confirmed in a study of women with documented PMS (Steege, 1993). The women were randomly assigned into either aerobic or weight training groups. The aerobic exercise group showed the best symptom relief.

SUPPLEMENTS

Several well designed studies have suggested that an increased daily intake of vitamin D to 800 IU/day, accompanied by an increased intake of dietary calcium to 1200 mg/day may prevent PMS symptoms (Bertone-Johnson, 2005). ThysJacobs (1998) treated women with documented PMS using 1200 mg of calcium carbonate daily to gain significant reductions in mood symptoms, pain, fluid retention, and food cravings.

Magnesium supplementation has also been studied (Facchineti, 1997). Taking up to 360 mg of magnesium daily from cycle day 15 until flow has been found to decrease negative moods when compared to a placebo/sugar pill (Facchineti, 1991).

Vitamin B6 is a cofactor in the formation of serotonin, a neurotransmitter that figures prominently in studies of severe mood swings and depression. Without adequate Vitamin B6 less serotonin can be converted from the essential amino acid tryptophan. The RDA for vitamin B6 is 2mg/day, yet PMS studies have used doses ranging from 50-800 mg/day. For treatment of premenstrual mood swings, irritability and depression doses should be no more than 300 mg/day. Reversible nerve injury has been reported at higher doses.

DIET

Studies have shown that women with PMS crave carbohydrates. In animal models increased carbohydrate intake causes increased release of serotonin, that neurotransmitter in the brain which prompts feelings of improved mood. It has been theorized that women with PMS may be attempting to self medicate for their down moods by increased cravings for starches and sweets. Yet simple sugars can cause the body to release additional insulin, so it is recommended that "complex carbohydrates" be consumed instead. The use of whole grain bread and cereal products can be part of a morning or lunch meal. Legumes in the form of lentils, split peas, or beans can help buffer blood sugar. Think bean burritos on a whole grain tortilla...or lentil soup with a whole wheat bagel plus low fat cheese.

The recommendations to decrease intake of caffeine, alcohol, and salt are based upon much less rigorous science. Early studies in the US (1985) and China (1989) found that increased PMS symptoms were linked to as little as one cup of caffeine beverage per day. Women given an intravenous dose of alcohol were noted to have decreased tolerance for alcohol effects in the premenstrual week, as opposed to their postmenstrual week. The average American diet can contain as many as 8,000-9,000 mg of sodium per day. For women with salt sensitive fluid retention, restricting salt intake to less than 2,000 mg per day may be helpful. Take a look at you favorite snack foods, even among the low fat variety there can be considerable sodium content.

COMPLEMENTARY & ALTERNATIVE TREATMENTS

With an increased interest in "alternative therapies" some researchers have chosen to study herbal, or body work therapies for common premenstrual symptoms.

• Soy isoflavones (68 mg/day) may be helpful for breast tenderness, abdominal bloating, cramps and headaches (Bryant, 2005).
  
• Chasteberry (in the form of Vitex agnus castus extract, 20 mg daily) was found to be more effective than placebo for the relief of mood swings, headache, breast tenderness, and bloating (Schellenberg, 2001).
  
• Ginko biloba (80 mg twice a day from cycle day 15) was most successful in treating breast pain. (Tamborini, 1993).
  
• The only study utilizing St. Johns Wort (900 mg/day in divided doses) for anxiety and depression showed benefit. However, it was evaluated in only 19 women—all of whom knew they were getting the real herb treatment.

Ear, hand, and foot reflexology demonstrated improvement in premenstrual symptoms (Oleson & Flocco, 1993), as did one which utilized nine sessions of Qi therapy (Jang, 2004). Acupuncture on the outer part of the ear decreased cramps, nervousness, food cravings and other premenstrual problems (Gerhard, 1992).

WHEN TO SEEK PROFESSIONAL INPUT

If your symptoms have not responded to self help measures then it is time to see your GYN, or clinic, for some additional evaluations. There may be an underlying medical disorder (e.g., thyroid disease, depression, anemia, atypical migraines, etc) which is responsible for low grade symptoms which are worsened during the premenstrual week.

When symptoms are determined to be PMDD (Premenstrual Dysphoric Disorder) there are numerous prescriptive medication options. While PMDD has a greater emphasis on the mood symptoms of "PMS", if a woman is having marked physical symptoms she might be tried on drugs to target her specific physical concerns such as bloating or severe headache.

The most important take home message: If premenstrual symptoms are bad enough to impair your relationships or quality of life then it is time to take action. Try the self help strategies first. If those do not provide enough relief then your GYN provider may be able to help.

Ovary Removal Before Menopause Increases Risk for Dementia

Women who have their ovaries removed before menopause run a heightened risk of developing dementia or other mental problems later in life — unless they take estrogen until age 50, a new study suggests.

Experts said the research needs to be confirmed by further study, but the findings suggest another issue for premenopausal women and their doctors to discuss as they consider ovary removal.

And if they decide to go ahead with surgery, they need to consider the risks and benefits of taking estrogen to age 50, said Dr. Walter Rocca, a Mayo Clinic neurologist and lead study author.

Hormone therapy has been linked to a greater risk of dementia and heart attacks when given to women after age 65. But recent research indicates that when given before menopause or just afterward, it does not raise heart attack risk and may protect against dementia.

The study did not include women who had ovaries removed as part of cancer treatment, and Rocca said the results do not apply to such women. The work was published Wednesday in the online edition of the journal Neurology.

Ovaries produce estrogen. Rocca said the likeliest explanation of the study results is that removing ovaries causes a sudden deficiency of that hormone, which in turn affects the brain.

Hundreds of thousands of women have their ovaries removed each year in the United States. In women around age 45, approaching menopause, ovaries are often removed during hysterectomies as a precaution against developing ovarian cancer. In addition, some women at unusually high risk of developing ovarian cancer have ovaries removed without hysterectomies, as do others who have ovarian problems like endometriosis.

Women younger than 45 often take estrogen after ovary removal because of symptoms like hot flashes and concerns about developing osteoporosis, noted Dr. Nancy Chescheir of Vanderbilt University. But older women who have the surgery are less likely to start estrogen therapy, said Chescheir, who did not participate in the new research.

The new study found the risk of later mental impairment was higher when the surgery was done at younger ages.

The research examined the fates of about 1,500 women who had one or both ovaries removed from 1950-87, and compared them to about 1,500 other women. Interviewers spoke with either the women themselves or somebody who knew them, asking about signs of memory impairment and any diagnosis of dementia or Alzheimer’s disease.

Overall, the study found that women who had had one or both ovaries removed showed about a 50 percent increase in risk of the later mental problems.

A second study, which included about 2,300 women who had had the surgery and about 2,400 who had not, found about a 70 percent increased risk for a diagnosis of Parkinson’s disease or Parkinson’s symptoms like tremors.

Still, that outcome was far less common than mental impairment, and experts said the evidence behind it was weaker than that provided in the mental-impairment paper. The Parkinson paper finding is “not quite ready for prime time” in terms of affecting patient care, said Dr. JoAnn Manson, chief of preventive medicine at Harvard’s Brigham and Women’s Hospital. She was not involved with either study.

The mental-impairment paper suggests that a premenopausal woman without a family history of ovarian cancer who has to decide on whether to have her ovaries removed should ask her doctor whether that step is really necessary, she said.

“It’s very reasonable and important to have that conversation with her doctor,” Manson said.

Chescheir noted that estrogen therapy carries its own risks, such as a higher rate of blood clots and breast cancer, but that ovary-removal patients younger than 50 may want to have a serious discussion of that option after surgery.