Women’s health

The diagnosis of PMS is made by excluding other causes for the symptoms (e.g. depression, low thyroid function or other gynaecological conditions such as endometriosis) and the suspect symptoms need to fit the following criteria:

• symptoms start at or after ovulation, ie during the luteal phase of the menstrual cycle
• symptoms are relieved by the end of menstruation (relief can start as soon as the period starts)
• there is a symptom-free period of at least one week (this is during the follicular phase of the menstrual cycle)
• symptoms occur in at least 4 of the previous 6 cycles and be severe enough to affect the woman’s daily functioning
• and that the woman has at least one emotional symptom (see below).

To determine if you have PMS the first step then is to increase your awareness of your cycle and symptoms; using a diary or a period tracker app where you can note your symptoms will enable you to see a pattern over time.  This one strategy can tell us so much about your health and hormones, including whether it might be PMS, and I recommend doing this to young girls through to menopausal women.

Note: If you feel anxious or depressed or have any of the symptoms all month, with no respite, it is not PMS.  Nonetheless you still need to work out what is happening and get support to manage what you are experiencing.

Other investigations or assessments will vary depending on your symptoms and medical history.  Possible areas to consider include thyroid disease, early menopause, iron deficiency, depression, generalised anxiety disorder, headache or migraines unrelated to the cycle.

Symptoms

Yes, it involves chocolate.

There is more to it however, with over 150 symptoms recorded, including:

Emotional and cognitive

• anxiety
• depression
• tearfulness
• irritability
• anger and aggressiveness
• lower threshold for reacting
• mood swings
• poor concentration and focus
• forgetfulness
• feeling out of control of emotions
• changes to sleep; insomnia or excessive sleep

Physical

• breast swelling and tenderness
• abdominal bloating
• constipation and/or diarrhea
• lower back pain
• fluid retention
• weight gain
• fatigue and weakness
• palpitations
• headaches
• clumsiness
• feeling lightheaded
• food cravings

You may have seen PMS categorised into 5 types, depending on the dominant symptom (briefly, PMS A for anxiety, C for craving, D for depression, H for hydration/bloating and P for pain) however I don’t find these helpful or accurate and to be honest, I had to just look them up again to remind me what they were!

The majority of women will notice some changes during the month, and some changes may even be positive, such as increased energy and libido mid-cycle or following a period.  For the majority of women with PMS symptoms they can manage it with nutrition, exercise, relaxation and self-awareness and care, but for some women it requires more support and herbal medicine and key nutrients can help.  Whilst it is easy to make jokes about PMS, it can be completely debilitating, making life miserable and leaving you feeling like you have no control of your body or moods and no-one deserves to feel that way.

• 95% of women experience at least one premenstrual symptom
• 30% describe their symptom(s) as moderate
• 5-10% describe their symptoms as severe

Because only 5% of women are completely free of premenstrual symptoms, and the majority of women have at least some symptoms, those symptoms are often then seen as normal.  An awareness of natural, cyclic changes with mild signals is healthy and normal; having symptoms that change how and if you do your usual exercise; how you function at work or study, how you interact with others (especially loved ones), your feelings of anxiety and depression, and change how you feel about yourself are not normal. And you do not have to keep trying to ride it out.

The causes of PMS are not fully understood, and it is likely that a number of factors are involved.

PMS occurs in the luteal phase and women who are not ovulating (because they’re pregnant, taking the pill or some other drug that stops ovulation, or have been through menopause) do not get PMS, so clearly hormonal fluctuations play a role.   However, it is not as simple as one hormone always being too high or too low, and research has found that the reproductive hormone levels in women with and without PMS are pretty much the same.  That suggests it is not so much the level of hormones but how our bodies respond to those hormones, and this may be influenced by the function of cell receptors to hormones (that act as gatekeepers to hormones entering the cells) or the way in which the cells respond once the hormones enter them.

Hormones and neurotransmitters that appear to be involved in PMS, by being too high, too low, or the responses to these agents is not typical include: serotonin, dopamine, GABA (gamma-amino butyric acid), endorphins, prolactin, melatonin, oestrogen, progesterone, lutenising hormone, cortisol, and adrenaline.  That covers the brain, ovaries, adrenal glands, and the gut, just from the point of view of where these agents are made.  More important to realise is that these hormones and neurotransmitters act on every body system.

You might be thinking I wrote the gut in the above sentence by accident because it seems a bit out of place in that list, but it is relevant.  To metabolise and excrete hormones normally you need a gut and liver that are working well.  For example, chronic constipation can increase the unwanted re-absoprtion of hormones from the bowel.  Serotonin, which helps muscle contraction as well as feelings of well-being and happiness, is manufactured in the brain as well as in the intestines and up to 90% of the body’s serotonin, can be found in the gastrointestinal tract.  A dysfunctional gut may affect serotonin levels and function. Nutritional status is important as key nutrients provide the ingredients for the body to make neurotransmitters, and this is influenced by what you eat as well as how well your gut is working.

Inflammation is another issue to consider. Inflammation affects brain and neurotransmitter expression and function and is associated with mood disorders, including low mood and depression and anxiety.  Poor digestive function and an imbalance of the microbiota in the bowel is a key source of low level simmering inflammation and an area always to review and address.

Women with a history of, or current anxiety and depression may experience more severe emotional symptoms and this implies that brain neurotransmitters are involved.  Women with PMS tend to have lower levels of endorphins, the ‘feel-good’ neurotransmitters, as well as having lower levels of and/or different responses to GABA, which effects anxiety.

To summarise, causes include:

• reproductive hormones
• neurotransmitters
• stress hormones
• gut function and microbiota (gut bugs)
• nutritional status
• history of depression and/or anxiety
• stress
• other factors that are not known

• As above, both the causes and symptoms of PMS vary from woman to woman, so the treatment will differ.  That said, there are some common approaches, including:
  • Eating whole foods, to help stabilise blood sugar (even without PMS fluctuations in blood sugar level can cause moods swings, clumsiness, palpitations etc) and provide loads of essential nutrients
  • Reduce exposure to environmental toxins and endocrine disruptors
  • Avoid excess alcohol and very salty/sugary processed foods and caffeine
  • Do some exercise
  • Get some sunshine if it is possible, especially first thing in the morning (helps to regulate melatonin)
  • Have a couple of early nights in the week before your period if possible
  • Relaxation and meditation or yoga
  • And don’t forget to keep a PMS/period diary – just knowing what is happening, when and why can help enormously!

Premenstrual dysphoric disorder is a severe form of PMS and is included in the Diagnostic and Statistical Manual of Mental Disorders (DSM), a key text defining and describing mental health illnesses.  The most recent edition, DSM-5, identifies 4 criteria for the diagnosis of PMDD as follows. 

Criterion A: in most menstrual cycles during the past year at least 5 of the following 11 symptoms were present (including at least 1 of the first 4 listed):

• Significantly depressed mood, feelings of hopelessness, or strong self-critical thoughts
• Marked anxiety, tension, feelings of being wired
• Major mood swings (eg, feeling suddenly sad or experiencing increased sensitivity to rejection)
• Persistent and marked anger or irritability or increased interpersonal conflicts
• Decreased interest in usual activities (eg, work, school, friends, and hobbies)
• Difficulty in concentrating
• Fatigue, marked lack of energy and tiring easily
• Considerable change in appetite, overeating, or specific food cravings
• Insomnia or excessive sleeping
• Feeling overwhelmed or out of control
• Physical symptoms as for PMS, such as breast tenderness or swelling, headaches and bloating.

As with PMS, the symptoms are in the luteal phase, and especially during the last week before the period. Symptoms start to reduce once the period starts, and they are absent in at least the week following the period.

Criterion B:  the symptoms are severe enough to significantly impact on relationships, work and study. Examples include withdrawing for people or lowered performance at work.

Criterion C:  the symptoms are connected to the menstrual cycle and not due to another cause, such as depression (note, both can be present).

Criterion D: that A, B, and C above are confirmed with diarising for at least 2 months before a diagnosis can be made.

It used to be thought that endometriosis was pieces of normal endometrial tissue (the inner lining of the uterus) that were in an abnormal location, for example, on the ovaries or bowel.  We now know that this is incorrect.

In simple terms, the endometrium is made up of two layers: the functional layer and the basal layer.  The functional layer is the layer that proliferates and thickens under the influence of hormones in order to support the implantation of the fertilised egg.  Hormone levels drop when there is no pregnancy and the proliferative layer sheds, known as menstruation.  The basal layer is the support layer in between the muscle (myometrium) of the uterus and the functional layer of the endometrium.  The basal layer doesn’t change under the influence of hormones and is not shed, and it so remains the same throughout the cycle.  The basal layer provides the foundation for developing a new functional layer next cycle.

This is important because endometriosis deposits do not have a basal layer like normal endometrial tissue does.  Further, endometriosis deposits resemble the functional layer of endometrial tissue but they are not the same.

Endometriosis then is endometrial-like tissue growing outside the uterus.  Some of the differences in the tissue structure of endometriosis and the hormones and chemicals associated with it are responsible for the pain, inflammation and other issues endometriosis causes.

Adenomyosis is endometrial-like tissue growing in the myometrium (muscle layer) of the uterus.

 The cause of endometriosis is not clear and it is likely to be a combination of factors, including the following.

• Genetics is part of the story (from your mother or father) and so far 12 regions on the human genome have been identified that are associated with endometriosis.
• Environmental factors, including chemicals, toxins, or viruses. It is not fully understood how these effect the development of endometriosis but they may act as a trigger for the development of endometriosis, similar to viruses triggering auto-immune conditions such as Type 1 diabetes mellitus.  Dioxins have been found to be associated with endometriosis, including if exposed as a foetus in utero.
• Women with endometriosis having altered immune function and may have increased antibody production and immune cytokines (chemicals that influence inflammation and how your immune cells work) in pelvic fluid and in the blood supply.  Endometriosis is not just a condition of the uterus or even of the pelvis, but it is a systemic condition as seen with raised inflammation markers and antibodies in the blood.
• Having abnormal or altered endometrial tissue, and changes to normal menstrual flow are other factors that likely contribute to endometriosis. A commonly held theory for many years was that endometriosis was simply caused by retrograde menstruation, where the shed endometrium flows out the Fallopian tubes instead of through the cervix and out the vagina.  This theory cannot cover situations where endometriosis is found outside the pelvis and doesn’t account for the fact that some degree of retrograde menstruation is normal, with about 70% of women experiencing it (and those 70% don’t all have endometriosis).  When retrograde menstruation occurs our immune cells recognise that tissue as being in the wrong place and it cleans it up; perhaps the altered pelvic immune function in women with endometriosis prevents this.
• Oestrogen plays a role, influencing but not causing endometriosis. When testing oestrogen levels they vary widely and so are not useful in diagnosing or even monitoring the condition.   In fact, endometriosis has been found in the developing foetus but it is inactive, and exposure to oestrogen at puberty appears to trigger the condition for some teens.  Endometrial tissue may be more responsive to oestrogen, may have more receptor sites for oestrogen, there may be altered oestrogen production in the ovaries as well as conversion of androgens into oestrogen, or there may be an altered/abnormal responses to oestrogen.  Oestrogen both influences and is influenced by inflammation and it can have varied interactions with the immune system, some of which may be altered in endometriosis.
• Abnormal bowel microbiota – the gut had to be involved somehow! In addition to its role in gastrointestinal functions, the microbiota regulates a variety of inflammatory and proliferative conditions and it plays an important role in regulating circulating oestrogen levels through the enzyme β-glucuronidase.  In addition, endotoxins (such as lipopolysaccharides) from the gut may act as triggers for endometriosis growth and exacerbate inflammation.

Associated factors include:

• No pregnancies or later full-term pregnancies.
• Possible connection between alcohol (which is oestrogenic), caffeine and no exercise.
• Having other immune conditions, eg auto-immune diseases.
• Women with endometriosis have been found to have lower levels of zinc and selenium than women without endometriosis; interestingly both these minerals are important for immune function, reproductive function and inflammation.
• A history of pelvic or gynaecological infection, and alterd microbiota in the vagina, cervix and uterus.

Endometriosis may be superficial (e.g. shallow deposits on the lining of the peritoneum or bowel) or it may be deep infiltrating lesions, where the endometriosis grows into the tissue or organ (e.g. the bowel, bladder or ovary).

The most common sites for endometriosis are:

• surface of the ovary
• inside the ovary (endometriomas, or chocolate cysts)
• the peritoneal surface of the uterus
• the fallopian tubes
• the Pouch of Douglas (also called the Posterior cul-de-sac), between the back of the uterus and the bowel
• uterovesical pouch (between the front of the uterus and the bladder)
• uterosacral and broad ligaments
• the bowel
• bladder
• side of the pelvic wall
• outside of the pelvic (far less common): vulva, vagina, cervix, lungs, diaphragm, liver skin, caesarean-section scars, laparoscopy/laparotomy scars
• and in the uterus, which is adenomyosis.

 Source: http://endometriosis.org/endometriosis/ 

Endometriosis is an unusual condition in that the degree of disease does not necessarily correspond to the severity of symptoms.  Further, symptoms will vary depending on where the endometriosis is, how deep it is and what other conditions the woman may have.

The two most common symptoms are pain and fertility problems.  Not all women have pain, but at least 50% do, and it can be severe and debilitating.  Likewise, not all women will have fertility issues and those that do will have issues specific to them and where their endometriosis is; for example, she may have scarring on her Fallopian tubes so the fertilised egg cannot travel to the uterus.

• Pain: during ovulation, before and during your period, deep pelvic dyspareunia (pain during sex) which persists after sex, abdominal and back pain, pain that radiates (e.g. down your leg), pain urinating or having your bowels open, spasm pain in the vagina.
• Bleeding: heavy periods, irregular bleeding, long periods. Bleeding from the bladder or bowel.
• Bladder and bowel: changed bowel habits (constipation, diarrhoea), needing to urinate more frequently, bloating.
• Fatigue
• PMS
• Emotional distress, low mood, anxiety and depression due to pain and impact on life.
• Quality of life: time off work and study, inability to play some sports or do vigorous exercise, limiting holidays due to symptoms.
• Subfertility/infertility

The pain may be caused by cramping of the uterus, inflammation and ischaemia, as well as from pelvic and hip nerve and muscle involvement and this may be best managed by a physiotherapist who specialises in this treatment.

In Australia, the average time it takes to be diagnosed with endometriosis is 7 years.  One of the reasons for this is the incorrect belief that young women cannot have endometriosis or that they may be exaggerating their symptoms (bit patronising), when it is entirely possible to experience symptoms from endometriosis from your first period.  Unfair.  In that time, women often feel unheard and frustrated.  It is hoped that recent efforts to increase awareness will reduce that time and new diagnostic tests are being developed which will also help.

The current gold standard for diagnosis is biopsy of the deposits via a laparoscopy (or laparotomy).  Specialist gynaecology ultrasound services now provide a specific pelvic ultrasound that requires taking a full bowel prep beforehand, and whilst they are unable to detect every endometriosis deposit they can detect many and are a valuable tool.  An experienced gynaecologist, especially one who specialises in endometriosis, may be able to feel the deposits on a vaginal examination as well as detecting muscle spasm or other issues.

As with all conditions, a thorough history is indispensable, with the duration and pattern of symptoms giving a good indication of whether endometriosis might be present as well as understanding the impact the condition has had on the quality of life for the woman.

• Surgical excision of the endometriosis deposits by a gynaecologist who specialises in endometriosis; for this to be fully effective you need to address the trigger(s) for endometriosis and work to enhance gut health, normalise immune function and reduce inflammation.
• Hormonal therapy (the pill or Mirena IUD)
• Physiotherapy can be invaluable for symptoms control

Nutrition, herbal medicine and lifestyle

• Key approaches are aimed at:
  • supporting normal immune function
  • optimising gut function and microbiota
  • reducing inflammation
  • aiding normal ovarian function
  • reducing pain
  • managing the experience of pain
  • help address stress, anxiety and depression
  • improving energy and sleep
  • helping prepare for and recover from surgery
  • optimising fertility

In 2013 an expert panel brought together by the US National Institute of Health agreed that the name PCOS was unhelpful, as per a panel member Dr Rizza:

“[The name PCOS] is a distraction, an impediment to progress … It causes confusion and is a barrier to effective education and communication. It focuses on … polycystic ovarian morphology, which is neither necessary nor sufficient to diagnose the condition.”

That means that by focusing on what the ovary looks like, we have overlooked what happened before the ovary changed, what caused the ovary to look like that and to explore other metabolic factors.

The new name will be Metabolic Reproductive Syndrome (MRS) and the process of having this changed commenced in 2016 and will take some time to be fully implemented.  Metabolic Reproductive Syndrome more accurately reflects that this syndrome affects more than just the ovaries and reproductive system, and indeed, it may be more accurate to say that the ovaries show the effect of this syndrome, rather than are the cause of the syndrome.

The diagnosis of PCOS is most commonly based on the Rotterdam Criteria, which is a consensus statement of experts in the area, and it requires two of the following:

1. Oligo-ovulation or anovulation
2. Clinical or biochemical hyperandrogenism
3. Pattern of polycystic ovaries on ultrasound that is not due to other causes

Let’s break that down a bit.

1. Oligo-ovulation or anovulation

This is when the woman has abnormal periods.  Oligo-ovulation is infrequent or irregular ovulation which is indicated by cycles of ≥36 days or <8 cycles a year.  Anovulation is no ovulation which eventually leads to no periods.

2. Clinical or biochemical hyperandrogenism

Hyperandrogensim means there are elevated levels of androgens, such as testosterone.

Biochemical hyperandrogenism is where those elevated androgens are detected on blood tests.  Blood tests performed in diagnosing PCOS include testosterone and sex-hormone binding globulin (SHBG), which influences how much of our sex hormones are free to act in our bodies.  Other tests help exclude other causes of irregular periods such as prolactin, follicle-stimulating hormone (FSH) and thyroid stimulating hormone (TSH).  Yet further tests may be performed to assess insulin and blood glucose, cholesterol or iron.

Clinical hyperandrogenism is the signs and symptoms, such as facial hair and acne.

3. Pattern of polycystic ovaries on ultrasound that is not due to other causes

First off, if a woman or girl is positive for the first two criteria then an ultrasound is not required for diagnosis.  This is important as a vaginal ultrasound is not recommended for non-sexually active adolescents and women and is considered unreliable in adolescent girls as large, multicystic ovaries are a common finding (around 70%).  Abdominal ultrasounds can be used but they are not as accurate.

The Rotterdam criterion for ultrasounds indicating PCOS would be 12 or more small follicles (2-9mm) on one ovary or one/both ovaries are enlarged (>10ml volume).

An updated approach

Whilst the Rotterdam Criteria is still the basis of most diagnoses, it is imperfect in diagnosing PCOS as it is such a varied syndrome. More recently, research findings suggest that the criteria be changed to reduce the number of women and in particular adolescents, being over-diagnosed with PCOS, especially when that diagnosis is being based on ultrasound results.  This more recent approach includes the following:

• Increasing the number of small follicles required from 12 to >19 per ovary (some suggest it should be 25 or more) and that the follicles are on the perimeter of the ovary (not in the middle).
• Anti-Mullerian hormone (AMH) is tested as it may be more accurate than counting follicles. A reading of serum AMH >35 pmol/l is indicative of PCOS.

Another test that is performed is blood levels of luteinising hormone (LH) and follicle stimulating hormone (FSH). LH is usually increased and FSH can be normal or decreased. The ratio of LH to FSH is usually 1:1 in women without PCOS where in women with PCOS of may be >2:  This test alone is not enough to diagnose PCOS  as it is possible to meet the other criteria  and yet have normal LH and FSH.  Finally, an adrenal hormone dehydroepiandosterone (DHEA) may also be elevated.

Confused yet?

To summarise, if you have PCOS you have at least two of the below: 

• your periods are infrequent or absent
• you have excess male hormones on blood tests and you have symptoms of excess male hormones (eg excess hair)
• your AMH is elevated and
• ultrasound may show there are too many small follicles

Remember, the ultrasound alone is not enough to diagnose or exclude a diagnosis of PCOS

The main symptoms are due to elevated androgens and insulin resistance.  Women from different ethnic backgrounds may respond to elevated androgens differently which risks affecting accurate diagnosis.  Remember, for any of the following, there may be other causes that are not PCOS.  Different studies report quite different findings on how common symptoms are and this may reflect differences across ethnic groups as well as methods to assess symptoms.

• irregular periods
• irregular ovulation
• excess hair – hirsutism, unwanted, male-pattern hair growth in women with  excessive amounts of dark, course hair on the face, chest and back
• hair loss – alopecia, especially male-pattern hair loss of receding hairline and thinning on the top of the scalp
• acne
• insulin resistance and type 2 diabetes mellitus
• weight gain and difficulty losing weight
• sub-fertility and infertility, largely due to not ovulating; weight loss (if overweight or obese) and treatments to initiate ovulation reduces fertility problems

PCOS also affects emotional and mental health with around 29% of women experiencing depression compared to 7% for women without PCOS and as many as 57% of women with PCOS having anxiety compared to 18% of women without PCOS.  Women may experience poor self-esteem, have a negative body image, concerns about fertility and overall reduced quality of life.

If PCOS is not effectively treated, it does increase the risk of other health conditions, including endometriosis, abnormal endometrial lining of the uterus, pregnancy complications and miscarriage, cardiovascular disease, sleep apnoea as well as increased gynaecological surgery such as curettes, laparoscopy and hysterectomy.

The precise cause is not known and it likely involves a combination of genetic and environmental factors as well as insulin resistance and lifestyle factors.

Daughters or sisters of a woman with PCOS have a 50% chance of having PCOS and this makes it likely that PCOS is at least partially due to a change, or mutation, in one or more genes, although which genes is not yet known. Some research on animals suggests that in some cases PCOS may be caused by genetic or chemical changes that occur in utero.

A study in 2013 by Australian researchers found that women with PCOS were more likely to have insulin resistance (IR) than women without PCOS.  They reported that 62% of overweight women without PCOS had IR compared to 75% of lean women PCOS and 95% of overweight women with PCOS. IR is typically seen in overweight people and this shows that not only is IR more common, but it also seen in healthy weight lean women with PCOS.  This abnormality in insulin is thought to be an important step in developing PCOS.

Insulin is a hormone produced by the pancreas and it enables to cells of the body to take up glucose to use as energy or stored as fat.  When insulin is produced and is working normally it means the blood glucose levels are kept in a healthy range.  Insulin resistance is when the cells cannot take up or use insulin normally.  This leads to higher blood glucose levels which in turn prompts the pancreas to make even more insulin to try to lower the glucose levels, ending up with high blood glucose and blood insulin levels.

Elevated insulin stimulates the production of excess androgens in the ovaries and adrenal glands, causing the main symptoms of PCOS such as irregular ovulation and periods, acne, excess hair growth and weight gain that is difficult to shift.  The elevated androgens and the elevated insulin alters communication between the pituitary gland in the brain (which makes LH and FSH) and the ovaries and reduces the amount of sex-hormone binding globulin (SHBG) being made by the liver.  SHBG normally binds some of the hormones so less is active in the body, so lower levels of SHBG means there is an excessive amount of androgen hormones and a greater ratio of them is freely available and acting on the cells.  The causes of IR include lifestyle factors such as being overweight because of a diet or physical inactivity as well as genetic factors.

Body areas involved in the development of PCOS

• pancreas (produces insulin)
• liver (produces SHBG and metabolises hormones for excretion)
• hypothalamus (in the brain, produces gonadotropin releasing hormone, which tells the pituitary what to do)
• pituitary (in the brain, produces LH, FSH and prolactin)
• adrenal glands (sit on top of your kidneys and produce DHEA, oestrogen, androgens as well as cortisol which also affects stress and blood sugar)
• digestive tract (used hormones are excreted by the gut constipation can cause re-absorption of hormones)
• oh, and the ovaries!

It is obvious why the name PCOS doesn’t really over it!

The first step is getting an accurate diagnosis.

Medically the main treatment is to use an oral contraceptive pill that specifically lowers androgens, such as Diane/Brenda.  Spironolactone may be suggested to help reduce hair growth and drugs such as Metformin are used to reduce insulin resistance.  PCOS is treated by a GP, an endocrinologist, a gynaecologist or even a gynae-endocrinologist (just not as many of these specialists) and it is usual that lifestyle strategies are recommended in addition to medication.

The naturopathic approach also looks at more than just the ovaries, although instead of ‘turning off’ the ovaries with the pill, we aim to normalise ovarian function and sex hormone levels.  Insulin resistance and symptoms are addressed and the strategies for all include lifestyle, diet, nutrients and herbal medicine.

Herbal medicine and nutrient supplements for PCOS

Which herbs and nutrients are appropriate will vary for everyone, depending on their blood tests, symptoms and priorities and you would not use all of the following listed!  Some that may be helpful include:

• insulin resistance: magnesium, chromium, zinc, cinnamon, lipoic acid, inositol, Barberry, Globe artichoke
• anxiety: magnesium, B vitamins, Skullcap, Magnolia, Kava, Chamomile
• depression: B vitamins, Omega 3 fatty acids, St John’s wort, Lavender, Saffron
• ovulation problems: Licorice and Peony (work best combined), Tribulus, Wild yam, Black cohosh, inositol
• stress and adrenal issues: magnesium, Vitamin B5 and 6, Licorice, Rehmannia, Withania, Rhodiola, Oats, St John’s Wort

Some simple things to try yourself:

• a low glycaemic index (Low GI) diet. This includes wholefoods, protein and little processed foods and avoiding added sugar
• eat regularly as it helps maintain your blood glucose level and reduce insulin resistance
• adequate water
• making sure you enough fibre, at least 30gm. This can be done by enjoying plenty of fruit, veges, wholegrains, legumes, nuts and seeds
• eating oily fish (sardines, mackerel, salmon, trout), flaxseed, walnuts, pumpkin seeds, avocado and their oils to get enough omega 3 fatty acids
• green tea, can after meals can reduce sweet cravings and is anti-inflammatory and antioxidant
• avoid plastics and chemicals that may interfere with hormone production and function, e.g don’t re-heat food in plastic containers, avoid BPA containers and sodium laurel sulphate (SLS) in toiletries
• exercise regularly; current guidelines are for 150minutes of exercise a week. Start slowly and build up – a 20-30 minute walk is an excellent place to start. Exercise helps improve insulin sensitivity and reduces androgens (male hormones)

Peri-menopause

Peri-menopause is the transition phase leading up to the last period when ovarian function declines & menopausal symptoms appear. This stage lasts 4-7 years for most women.  During this time, ovulation becomes less and less regular and hormone levels fluctuate.  Common symptoms include:

• initially the menstrual cycle may be shorter, so your periods are more frequent
• later, your periods become less regular and you may miss a month or more
• periods change in the flow as well and while they may be lighter, more commonly they are heavier
• periods can be shorter or longer
• you may have menopausal symptoms such as hot flushes or mood swings

Menopause

Menopause is the last menstrual period, and you are considered to be in post-menopause 12 months after your last period.

Post-menopause then is 12 months after your last period onwards.

There is another term sometimes used for peri-menopause and menopause and that is climacteric.  Climacteric is not used much anymore as it is less specific and refers to a period of reproductive capacity in men and women.

The average age at menopause for Australian women is 51-52 years old, with most women going through menopause between 45 and 55 years of age. Some women transition through menopause earlier:

• Early menopause is when menopause occurs before 45 years of age.
• Primary ovarian insufficiency (previously known as premature ovarian failure) is when menopause occurs before 40 years of age.

Early menopause and primary ovarian insufficiency may occur spontaneously or it may be induced.

• Surgically or medically induced menopause is when menopause is caused by the removal of the ovaries, radiotherapy or medications such as chemotherapy.

Note: Oopherectomy is removal of the ovaries,  which means you will have no ovarian hormones and will go through menopause at the time of surgery.  Hysterectomy is removal of the uterus, which will mean you have no periods. If you have a hysterectomy but still have your ovaries, you will still experience menopause, just without the period changes.

Menopause is a reasonably recent phenomenon; up until the twentieth century the majority of women would have died before they reached their 50s.  In the 1850s the average life expectancy for a women was 52 years where it is now closer to 88 years, with women spending one-third of their lives in post-menopause.

A number of factors, the strongest of which is genetics, influences how old you are at menopause.  Whilst there are always exceptions, the age your mother, maternal aunts and grandmother, and sisters went through menopause usually gives you an idea of how old you will be.  The research on other influences for the age at menopause is inconsistent, but likely influences include weight as a young child, your nutritional status, smoking (smoking damages your ovaries), year of birth cohort, socio-economic status and race.

The clinical features of menopause that are common for all women are the end of periods and the loss of fertility.  Over time, due to the reduction in oestrogen and progesterone, women will be more prone to reduced bone density and cardiovascular disease.

The symptoms of menopause are different for each woman and 20% of women have no sign or symptom other than her period stopping.  The majority of women (60%) have mild to moderate symptoms while 20% of women have symptoms significant enough to interfere with life.  Women who have medically or surgically induced menopause don’t have the long transition time of peri-menopause that other women have, instead going from having functioning ovaries to full menopause sometimes in a matter of hours and they may experience more intense symptoms.

Physical symptoms

• hot flushes: a sudden wave of heat flowing through your upper chest, neck, and face, your skin may appear flushed or blotchy. You may perspire and then after the flush you feel cold.  Some women feel their heart racing during hot flushes.
• sleep disturbances, including from night sweats
• fatigue
• vaginal and vulval dryness and pain during sex
• generalised aches and pains
• bladder problems and increased risk of incontinence (urine leakage)
• metabolism changes, losing muscle and gaining a bit of weight
• bloating
• headaches and migraines
• breast pain
• formication, which is itchy crawling skin, like ants under your skin
• hair loss, brittle nails

Mental and emotional symptoms

• loss of libido
• mood changes
• depression
• irritability
• cognitive changes
• difficulty concentrating
• feelings of anxiety
• feeling overwhelmed and not able to cope like you used to
• forgetfulness
• PMS worsening in the peri-menopause
• lack of concentration
• flat mood or feeling depressed
• mood swings

Sometimes it may be hard to work out what is causing what: do you feel overwhelmed and depressed because of menopause or because of things happening in your life? Are you only forgetful and have trouble concentrating because you haven’t slept?  It I important to address all the possible causes if able.

After such a long list of symptoms it is worth repeating that the majority of women have mild or moderate symptoms, and often these can be readily managed.

The diagnosis of menopause is having no period for 12 months.

It is possible to check hormone levels and after menopause they will be low.  However because the levels fluctuate in the peri-menopause testing becomes hard to interpret and is not always performed.  The two main hormones tested are:

• Follicle stimulating hormone (FSH), which rises significantly (it is your brain trying to prompt the ageing ovaries to mature the follicles and ovulate)
• Oestradiol (a form of oestrogen) which is significantly lower at menopause

Anti-mullerian hormone (AMH) is sometimes tested especially in younger women, and low levels are indicative of peri-menopause.

For all women a healthy wholefood diet with good fats, protein and carbohydrate is important, as is exercise in managing symptoms.

For specific symptoms then specific lifestyle, nutritional and herbal treatments can make all the difference, such as sage for hot flushes, or omega 3 fatty acids for depression.

Fibroadenomas: These are a common cause of breast lumps, especially in young women. The lump is made up of fibrous tissue and glandular tissue, feels firm and rubbery and you can move it, and they don’t hurt.

Breast cysts: cysts are sacs filled with fluid and breast cysts may enlarge and feel tender right before your period, and then it may be hard to feel them after your period. They are common between 35 and 50 years of age but can occur at any age.

Fibrocystic breasts: this is a combination of cysts and thickened breast tissue (fibrosis). The breasts may feel lumpy and if they are sensitive to hormones the lump(s) may increase in size and be tender pre-menstrually.

Mastitis: this is an infection in the breast and usually occurs during lactation.  The area is red, hot and painful and it is usual to have a fever.

Cyclical breast pain: this is pain associated with changing hormone levels during the menstrual cycle.  It usually starts in the second half of the menstrual cycle, increases until the period starts, then it settles once the period starts.  The pain usually involves upper outer breast area radiating to underarm and it can be spread over both breasts, but may be more severe in one breast. The pain can even spread down the arm and to the shoulder blade.  The pain is described as dull, heavy and achy and the breasts are tender to touch. Cyclical breast pain usually settles during pregnancy and stops after menopause.

Non-cyclical breast pain: this isn’t associated with your menstrual cycle and it can be either constant or intermittent, in one or both breasts and can affect a localised area or the whole breast. The pain is described as burning, prickling or stabbing pain, drawing, achy or a feeling of tightness. The cause of non-cyclical breast pain maybe unknown, previous breast surgery or radiation, medications or possibly iodine deficiency.

Nipple discharge: Nipple discharge when breastfeeding is normal but may occur at other times.  It may be clear, milky or blood-stained.  Nipple discharge is usually hormonal but should be checked to rule out anything serious.

As always, the first thing to do is to get an accurate diagnosis of what is causing the symptoms, and specifically to exclude cancer.  Management of your breast condition is then determined by the cause and the symptoms.  Simple strategies that may help include:

• either going without a bra, or wearing a better-fitting and supportive bra
• apply warmth (hot bath or hot water bottle) or cold (with an ice pack)
• reduce caffeine, especially from coffee, cola and tea (and if you eat a lot of chocolate you may need to cut that back a bit too)
• reduce your intake of salt and sugar
• make sure you get good levels of omega 3 fatty acids (oily fish, linseed, walnuts) and olive oil
• vitamins that may help include B1 (thiamin), B6 (pyridoxine) and vitamin E