the premenstrual problem: cyclical hysterotoxemia
TRANSCRIPT
ConfessionsConfessions of a GynecologistEnrique Vazquez Vera MD
F.A.C.O.G.
Diisclosure
• The purpose is to share information that still needs solid Scientific Research.
• Unbiased Research is the ONLY way to make solid steps towards better medical care.
• We are in need of evidence-based treatments
Current Accepted Definition• Women of reproductive age reproductive age have one or more emotional or physical
symptom in the premenstrual phase of the menstrual cycle.
• Symptoms are associated with substantial distress or functional impairment.
• Precise diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders:– The presence of at least five luteal-phase symptoms
• At least one of which must be a mood symptom (ie, depressed mood, anxiety or tension, affect labiality, or persistent anger and irritability)
– Two cycles of daily charting to confirm the timing of symptoms.
– Evidence of functional impairment.
– Symptoms must not be the exacerbation of another Symptoms must not be the exacerbation of another psychiatric conditionpsychiatric condition
PMS // PMDD• Serious premenstrual
distress with associated deterioration in functioning.
• Prevalence is not well understood
• Correlation of symptoms with menstrual cycle is critical
PMDDPMDD and the Fate of History ???
Current Scenario
• Lack of solid Research• Poor Statistical Information • Poor Scientific Evidence • Economical Interests• Weak Diagnostic Criteria• Social overuse of the Terminology• The Cause is UNKNOWNUNKNOWN
What is then PMDD ??
“InflammatoryInflammatory state that predisposes end organs to an altered hormonal altered hormonal
responseresponse and translates in to a infinite cluster of cyclical cyclical
symptomssymptoms”
Organ
Inflammation
D I S E A S E
Reproductive Female
Inflammation
PMDD
Inflammmmation
• What is It ?
• Why do we Care ?
• What is the Connection with PMS/PMDD ?
• What can we Do about it ?
Depression andand Inflammation
• Inflammation can be measured• The markers have been shown to alter
neurotransmitters• The main inflammatory markers are NFKB, IL-6• The end result (imbalance) of
– Serotonin– Dopamine– Norepinephrine
Depressssive Inflammmmation
• Inflammation and clinical response to treatment in depression: A meta-analysis. European Neuropsychopharmacology Journal, 20152015
• The patients that respond to Antidepressant Therapies have lower levels of inflammatory markers (CRP,IL-6,TNFα).
Premenstrual Inflammmmation
• Association of inflammation markers with menstrual symptom severity and premenstrual syndrome in young women. Hum Reprod. Epub 2014
• Chronic Inflammation markers and PMS• 277 women from 18-30 yr• TNFα, IL-6,CRP• Correlation of severity found
Serotonin
• Epigenetic: Genetic defect on receptor 1A 3 times more common in patients with PMDD
• SSRI decrease symptoms by 40%
• Serotonin levels are markedly lower in patients with PMS
What do we know??• The Ovarian Hormonal pattern are = to Normal Patients= to Normal Patients.• Decreased serotoninserotonin activity in PMS on the luteal phaseluteal phase. • Evidence that emotion processing varies emotion processing varies among the stage of
the menstrual cycle. • The brain is modulated by hormonal brain is modulated by hormonal changes.• Emotional Memory increases in the luteal phase• Plasma testosterone is lower Plasma testosterone is lower in the luteal phase of patients
with PMDD• There is High levels of inflammatory substances High levels of inflammatory substances in patients
with PMDDPMDD
What can we do ??
Current Management
Suggested Management Principles
• Tackle inflammation from all directions
• Stress,Gut,Diet,Exercise,Meditation,Infections,Hormonal Imbalance.
• Follow Evidence Based Recommendations
What can we Do ??
Decrease inflammation in all fronts !!
ManagementStep 1 Supportive TherapyStep 1 Supportive Therapy
– Diet• Food Sensitivity testing or Elimination Diet• Favor a diet high in Complex Carbohydrates• Carbs 30%, Protein 20%, GOODGOOD Fats 50%• Favor sources of TryptophanTryptophan (serotonin precursor)
– Seaweed (SPIRULINA), Spinach,Eggs.
• Favor prebiotic foods ( Onion, Asparagus)• PROBIOTICS PROBIOTICS AND MORE PROBIOTICS !!!!
– Minerals and Vitamins• Increase Dietary Calcium (500 mg) Warning• Magnesium 360 mg day• Vitamin E 400 mg Day Warning• Vitamin D3 1000 IU daily
– NSAIDs– Spironolactone
• Increase availability of serotonin • Fluoxetine (Prozac, Sarafem) • Sertraline (Zoloft)
ManagementStep 2 Selective Serotonin Reuptake Inhibitors (SSRI)Step 2 Selective Serotonin Reuptake Inhibitors (SSRI)
• Hormonal Contraceptives• GnRH Inhibitors
ManagementStep 3 Hormonal Ovulation SuppressionStep 3 Hormonal Ovulation Suppression
ManagementStep 4 Dr Lolas TreatmentStep 4 Dr Lolas Treatment
Dr Lolas Treatment• Altered production of inflammatory substances.
• Caused by Direct or Indirect insult to the female reproductive organs – Traumatic deliveries,Sexual trauma,pelvic infections
• The treatment– Intracervical administration
• NSAIDs
• Antibiotics
• Antfungals
• Cryotherapy
• 4 Months of therapy plus maintenance
Regulation of ImmunityImmunity in the Female Reproductive TractReproductive Tract
• FRT deploys more than a dozen antimicrobials substances.
• Hormones REGULATE the immune response and the INFLAMMATORY response
• Menstrual Cycle regulate the intensity and type of immune response deployed
• NFKBNFKB is released
The Miami Experience
Pre-treatment Week 1 Week 2 Week 3
Week 4 Week 5 Week 6
RResults• 3 Patients have been treated (No Cryotherapy)
• All three patients have proven inflammation of the cervix by conventional criteria with cultures and biopsy.
• Their Symptom scores have been recorded and show a gradual reduction of symptoms with exacerbations
• In ALL three patients there is clinical findings of change at least
Future Plans
• Far from being able to tell that the regimen works a 100%.
• Urgent need for standardization of protocol and randomized control study to validate results.
• Current knowledge and experience points towards treating the inflammatory cascade along with the TRADITIONAL conventional therapy
Resources
• Dr Mercola.
• Dr Scott Russo, PhD. One Mind Institute
– Inflammation and depression
• Institute for Functional Medicine (IFM)
PMDD