Tired or Fatigued?
From Sleep Apnea to Chronic Fatigue Syndrome
What is Sleep Apnea
Chronic Fatigue Syndrome
Fatigue is associated with many problems and conditions, ranging from PMS, to Chronic Fatigue to ... simply needing a good night’s sleep.
Ruling out the obvious, (tired or exhausted from exertion and/or lack of sleep) women who experience persistant fatigue often suffer from a sleep disorder, such as Insomnia or Sleep Apnea.
Sleep Apnea: a disorder of breathing during sleep, usually accompanied by loud snoring. Apnea can disrupt and/or stop breathing during the night, interfering with adequate oxygen intake during sleep. Two types of apnea:
Obstructive Sleep Apnea: (OSA) the most common type: due to an obstruction in the throat during sleep, generally results in loud snores. A narrowing of the upper airway typically caused by physical changes of aging, weight gain, or alcohol consumption before sleep.
Central Sleep Apnea: has a neurological basis. Patients having both obstructive and central apnea must wake to breathe, sometimes hundreds of times during the night, usually without remembering.
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Symptoms of Sleep Apnea include
- Dry mouth upon waking
- Depression
- Difficulty concentrating
- Fluctuating weight
- Loud Snoring
- Frequent trips to the bathroom during night
- Insomnia (problem going to sleep)
- Prespiration (excessively) while asleep
- Waking during the night with the sensation of choking
- Waking and gasping for air
- Waking with headaches
- Waking unrefreshed and having trouble staying awake during the day
- Waking up sweating
Sleep Apnea can be a very dangerous condition and should be checked by a physician as soon as possible.
Chronic Fatigue Syndrome is characterized by a feeling of exhaustion, weakness, fatigue, and other symptoms that have persisted for over 6 months. It is often associated with another chronic syndrome: fibromyalgia. There is little understanding about the cause of CFS. Some believe it is primarily caused by immune system dysfunction, other s belive a virus is involved. Government (NIH) researchers are investigating the causes of CFS. In 1994 the Government redefined the disease along with a rather complex set of steps for its diagnosis. You can find this information at this Center for Disease Control web page.
Do you have CFS? Short questionnaire:
- Has your fatigue lasted for more than 6 months? (despite getting enough rest and are not overworking)
- Is your physician unable to explain your symptoms?
- Are you unable to accomplish even half your previous workload/output?
- Have you experienced 4 or more of the following symptoms, either recurring or lasting 6 months or more?
- Difficulty concentrating
- Joint pain without redness or swelling, may migrate
- Unexplained muscle soreness
- Unusual headaches or headaches that hurt all over head
- Prolonged fatigue (over 24hrs) from exercise or work - that formerly was not a problem.
- Short-term memory problems
- Sore throat
- Tender and/or painful lymph nodes (neck, armpits, groin, etc.)
- Sleeping problems
Alopecia in Women: New Condition, Same old Cracks
A complex, often perplexing condition, but help is available.
Alopecia in Women?
New Condition - Same old Cracks?
Androgenic Alopecia
Estrogen Deficiency and Alopecia
Alopecia and PCOS
Workup and Diagnosis
Treatments for Alopecia
Points to Remember
Related conditions
Alpecia in Women
Alopecia is simply Latin for “hair loss” - perhaps too simply, for such a complex and subtle condition. Sadly, Alopecia is one of those subjects that medical schools tend to breeze past. Since the condition imposes no threat to health or life, MDs often dismiss the problem as being “untreatable”, and even “insignificant.” If the patient seems “overly distressed”, she’s likely to receive a referral to a mental health provider. In our opinion, the importance of hair to a woman seems entirely natural - and the best course of action would be to treat the problem - not simply bring in a specialist to convince the woman that it’s “OK.”
New Condition - Same Old “Cracks” TOP
Alopecia is yet another example of problems that “fall between the cracks” of medical specializations. As a component of the skin - it falls in the domain of dermatology. As a female problem, your ObGyn might take an interest. However the real causes of Alopecia are internal, based on hormone activity, and therefore the domain of endocrinology. Unfortunately many MDs don’t understand alopecia - regardless of specialization - but there are some that do. As a patient, it’s your right (and responsibility) to keep looking until you find that special MD that cares enough about your disorder, then see it through together.
The most common form of alopecia in women is Androgenic Alopecia, (also called “AGA”) affecting about 20% of women before age 40 - and about twice as many thereafter. The two major culprits in androgenic alopecia are Androgen: a male hormone related to testosterone, and declining estrogens. Their mischief centers around the shrinking and deactivation of hair follicles in the scalp - resulting in “miniaturization” of the follicle,and eventual loss of the hair.
Ironically, androgens can also stimulate the hair follicles of the face and neck, which can result in unwanted facial hair (hirsutism) in some women. Note: hirsutism, acne, and significant weight gain are not symptoms of alopecia, but may indicate PCOS, with differing treatment options.
Estrogen Deficiency and Alopecia TOP
Estrogen arrests the onset of alopecia by countering testosterone - however it also exerts very positive effects on women’s hair-growth! These effects can be seen in the fast-growing, full head-of-hair women experience during pregnancy, which inevitably thins some time after child birth. Just how much thinning occurs depends on the rate of decreasing estrogen levels.
While the onset of alopecia during perimenopause is generally associated with increasing androgen levels; during and after menopause it is generally attributed to declining estrogen levels.
Androgenic alopecia can be compared with male pattern baldness, since both are caused by testosterones (androgen) and happen somewhat predictably in time, as well as spatially on the scalp. In women, the impact is generally less severe, with the front hairline being preserved. Most affected are the crown, vertex and temples, with the least effect around the perimeter - front, sides and back.
Both Alopecia and PCOS can result in hair loss or thinning, however it is important to make the distinction, because the indicated treatments differ.
In practice we have seen women diagnosed with PCOS when their problem was androgenic alopecia - as well as cases when PCOS mistakenly diagnosed as being alopecia. Hirsutism, (unwanted facial and other hair), adult acne, and significant weight gain are symptoms typically associated with PCOS.
- (Blood) testing for total and free testosterone and estrogens, dhea-s, blood counts and iron.
- Interview / questionnaire: If symptoms include increased hair growth (hirsutism), acne, oily skin, or irregular periods; additional testing is indicated, per discussions on hirsutism and on PCOS.
- Oral contraceptives are a good start. They can lower free testosterone levels by about half. However they care generally supplemented with additional treatment/medications, such as:
- Testosterone-blocking medications. The most frequently used is spironolactone (aldactone®). finasteride (propecia®, proscar®) also shows promise with androgenic alopecia—however pregnancy absolutely cannot occur with either this medication or spironolactone. (The action associated with them could interfere with male genitalia development in the fetus.)
- Minoxidil (rogaine®) has been officially approved for alopecia in women. Now available without prescription, rogaine is available in 2% and 5% strengths, however the 5% strength is rarely recommended for women because it works too well. If spilt on the forehead (for example) it could cause hair to grow there. Scalp flaking and irritation are also frequent problems at this strength. minoxidil must be applied twice per day to the entire scalp - a challenge for long haired women. Furthermore, it requires three to nine months to produce a noticeable effect, and doesn’t work for everyone. Finally, discontinuing the drug will cause any new minoxidil-hairs to fall out. Having said the above, Minoxidil has a definite place in treatment of alopecia - particularly when other treatment options are not available or have failed.
- Estrogen When alopecia results primarily from declining levels of estrogen, then estrogen replacement therapy makes sense. Pre-menopausal women with normal cycles or using OC would not likely be estrogen deficient. Again, irregular cycles in pre-menopausal women may be due to PCOS or other problems, and further evaluation is required. If the decision for estrogen replacement is made, we would estimate your more “youthful” pre-menopausal estrogen level as a baseline, then gradually increase the amount while monitoring your reactions. Women’s bodies not require estrogens uniformly, rather need it in varying amounts for different purposes. Experience has shown us that reducing hair follicle sensitivity usually requires a higher estrogen level than does resolving hot flashes or other PMS symptoms. However we have found that increasing the dose often stabilizes the follicle, and even promotes regrowth for alopecia patients.
- Alternative: Saw Palmetto is thought to inhibit the testosterone activating enzyme 5 alpha reductase. Used mainly by men to reduce prostate enlargement, it may also provide a degree of benefit to women with alopecia. However experience in women is too limited to recommend Saw Palmetto as a first-line treatment. A problem with herbal treatments in general is the lack of regulation means you have no assurances of potency. That said, Herbs and supplements have proven themselves to be quite useful for certain female conditions, including PMS and the relief of menopause symptoms.
- Avoid products that contain testosterone, such as the popular libdo enhancers such as Estratest® and Estratest HS®. They can result in hair loss, as can the popular supplement DHEA, since it is converted in testosterone in the body.
- Some women have hair folicles that over-react to normal levels of testosterone. This means you can have alopecia even though your hormones are “normal.”
- Perhaps because it is not a disabling or life-threatening disease Alopecia receives little formal research attention. However a growing number of women’s health specialists such as ourselves are citing successes in their own practices. While not every treatment listed above will be successful; we have a selection of treatment options. The key is identifying the treatment - or combination - best suited for the individual patient. Hence, we are able to achieve stabilization in most cases of androgenic or estrogen deficiency alopecia. Stabilization means decreasing the rate of shedding, so that the hair stops thinning. (note: some hair loss is normal, and new replacement hair is always growing) Continued treatment will improve both the quality and quantity of hair, usually increasing lustre and strength as well. (for easier combing, styling) We cannot (and don’t) promise to restore hair to it’s original condition. However we can usually make a genuine improvement - and that’s usually more than enough. When women, who have felt the sting of shame and embarassment, can venture out in public with confidence - they can begin to enjoy their lives once more.
- The most disturbing aspect of androgenic alopecia is the attitude of many “conventional” medical practitioners toward it. Why any physician would tell a patient “it can’t be helped” when effective treatment options exist, is beyond our comprehension. Furthermore, even if your hormones and other blood tests are “normal,” your alopecia can still be successfully treated. We urge you to ignore any doctor that tells you “you have to live with it.”
- If you suffer from alopecia, there is hope and help for you.
Related (but rare) conditions TOP
- Telogen effluvium - diffuse hair loss that results in decreased hair density but does not progress to complete baldness
- Anagen effluvium - diffuse shedding of hairs, including growing hairs, that may progress to complete baldness
- Alopecia areata - patchy, non-scarring hair loss
PMS 101 - Know Thyself
Imagine a disease as old as humanity ... acutely distressing to both body and mind ... afflicting half the population at least a dozen times per year ... its very existence reputed until recently - yet even today nobody understands exactly how it works!
What is PMS (PMDD)? Physical Symptoms of PMS Mental Symptoms of PMS What Causes PMS Defining characteristics of PMS Diagnosing PMS: How Do You Feel? Treating PMS - Chart Up! Multi-faceted Treatment Plan PMS Treatment - Lifestyle PMS Treatment - Exercise & Fitness PMS Treatment - Nutrition Vitamins, Minerals, and Supplements PMS Treatment - Herbs & Supplements A word about herbs and supplements PMS Treatment: Hormone Therapy Bio-Identical Hormone Therapy PMS Treatment - Alternative Medicine PMS Treatment: Anti-Depressants PMS Treatment: Other Medications The Last Word: Hope
PMS (Pre Menstrual Syndrome): The physical and psychological symptoms that occur in the week before a woman’s menstrual period. (health.webmd.aol.com)
Well, that’s a start, but we still haven’t answered the question: what is it? Ahem ... ah ... well, actually we don’t quite have 100% agreement on that point… While some folks think it’s hormonal, others say it’s nutritional. Some people believe it’s genetic, and still others are convinced that it’s all in your head! Most physicians generally agree that PMS can be defined as a set of conditions, cyclical in nature, producing both physical and mental symptoms, linked to the hormonal changes of the female reproductive cycle. That’s better; but I should add that there are approximately as many variations on PMS as there are women reporting them. Psychiatrists, naturally, felt compelled to devise the (more “psychiatric” sounding?) name “PMDD” (Premenstrual Dysphoric Disorder), however most physicians agree the two definitions refer to the same set of conditions.
Over 150 symptoms have now been associated with the disorder. However, to minimize confusion, we shall list only the most commonly reported.
Weight gain
Bloating, fullness
Edema (water retention)
oliguria (reduced urination)
Sensitive, painful breast
Joint and muscle pain
Cramps, diarrhea, constipation
Pelvic discomfort
Vaginal dryness, discomfort
Heart palpitations
Sweating
Skin problems (acne, oily skin)
Unwanted Hair (or) Hair loss
Greasy or dry hair
Headache
Anger, Irritability
Anxiety
Frustration
Sadness, Impulsive Crying
Mood swings (severe or frequent)
Insomnia (or) hypersomnia
Sluggishness, fatigue
Dizziness, light-headed, vertigo
Paresthesia (tingling sensations)
Decreased sexual desire
Decreased concentration, indecision
Food (and other) cravings
After a great deal of study (and millions of patients) PMS’s defining characteristics and patterns are well known. While disagreement exists regarding the best way to treat PMS, agreement is fairly universal that the group of conditions results from hormonal changes (i.e. declines) just prior to menstruation. However, the exact mechanism of this action - and why so many symptoms result - remains a mystery!
Defining characteristics of PMS TOP
Cyclic Pattern: The most obvious characteristic of PMS. Symptoms are usually most severe a few days after ovulation - and there should be a symptom free time period 1 week after menstruation ends. If symptoms occur during this time, other conditions should be considered.
Broad Spectrum of Effect: Why do PMS symptoms affect some patients profoundly and not others? At one end of this spectrum some women may reach the point of dysfunction - while others notice only mild discomfort.
Genetic Component: If a patient’s mother or sister has PMS symptoms, then her chances of having them are much greater.
Mind and Body: PMS affects both the body and mind, giving rise to a holistic treatment philosophy.
Neurotransmitters: Some physicians have linked PMS to reduced levels of gaba and Serotonin resulting in depression - which can be treated by supplements.
Turbulence: PMS often increases at times of hormonal turbulence, for example, puberty, childbirth, after miscarriage or pregnancy termination or changes in contraception.
Child birth: Women who experience postnatal illness are more prone to PMS.
Gradual worsening: Women aged 30-45 years often experience most severe PMS.
Pre-existing: PMS often makes pre-existing conditions worse.
Diagnosing PMS: How Do You Feel? TOP
Few conditions frustrate mainstream physicians more than PMS. It has no clear cause, a multitude of diverse symptoms all found in other disorders, no simple test, no drug or surgical cure ... and finally, it eventually cures itself! (after menopause) Even today some physicians actually doubt its existence. (Undoubtedly they are male physicians!)
PMS symptoms mimic other conditions, (PCOS, Perimenopause, pcd, etc.) and these need to be ruled out. Additionally, your history and physical information should rule out autoimmune disease, vascular disease, seizures, endometriosis and other problems. In addition checking your thyroid (tsh), blood work for diabetes and anemia may be required. In some cases a psychometric written test can be useful to determine whether depression, anxiety or panic disorder are creating or exacerbating your symptoms.
The key to the PMS diagnosis is the cyclical nature of the disorder. If we cannot identify a symptom-free period at some time during the patient’s cycle - usually about 1 week after menstruation ends - we must consider other problems. (Symptoms during pregnancy or after menopause also indicate other problems)
Since there is no “PMS Test” certain diagnosis is greatly aided by the patient’s ability to “listen” to her body and communicate her impressions and feelings to her physician.
Since there is no “PMS pill”, successful treatment will again require diligent patient self-examination and good communications between doctor and patient.
There are many treatments and strategies for treating PMS as a whole, and for zeroing-in on specific symptoms. The starting point for PMS treatment is determining what your body needs, and what it responds to best.
Chart Your Symptoms: the first step is to chart your symptoms throughout your entire cycle, noting the type, duration, intensity, and possible trigger of each symptom. This chart will become a powerful reference in your treatment plan for both you and your physician.
- Copy the list of symptoms (above) down the left margin of a sheet (leaving room for several columns to the right).
- Check or underline each of the symptoms you experience. (Add any not listed to the bottom)
- Next to each symptom, first, rank the severity: mild, moderate, or severe.
- Next note the time of occurrence relative to your cycle.
- Next to that, note any events that seemed to trigger that symptom. Do certain stresses have more impact? Do certain foods impact you differently at these times?
- Leave empty space at the end of each line, or underneath. (will be used to note treatment and result).
Multi-faceted Treatment Plan TOP
A Multifaceted or “holistic” approach is generally the best for dealing with the multiple and overlapping symptoms of PMS. Using your Symptom Chart, you can first identify the most severe symptoms, then select treatments from the options listed below that make sense for you. Be sure to try options from all the major categories, because some categories of treatment are more effective for certain symptom groups.
Its OK - in fact quite necessary - to experiment with the various options, being sure to fastidiously note the results in your next chart. In other words, you will create a new Symptom chart for each cycle going forward, noting the treatments used and resulting changes to the symptom(s).
Activity and Stress: When are you taking on your biggest stresses? Since you have “better” times and “worse” times throughout the day, try and adjust your schedule to take the pressures off during the times you are least able to cope. (i.e. when your symptoms are peaking) The object of time/stress management isn’t always easy given the demands of work and family, but you can probably make a few positive adjustments.
Stress Reduction: helpful practices range from prayer and meditation to simple breathing exercises and other relaxation techniques, to tai chi and yoga. The benefits of these techniques may not seem apparent at first - in fact, the perceived drop in energy makes some people feel anxious. This sensation passes however, and you will learn to use the relaxed moments to refresh and reinvigorate yourself. Imagine awakening from a good night’s sleep twice each day ... that’s the purpose of these “waking naps.”
PMS Treatment - Exercise and Fitness TOP
Studies show that women who exercise regularly tend to have milder PMS symptoms. Not surprising, since exercise is a proven mood elevator, besides being vital for long-term and overall health. We suggest you get started with a low impact aerobic exercise program, at least 3 30-minute sessions per week. If your PMS symptoms make the exercises unappealing or downright painful, try a lighter version, such as dancercise, or for that matter, swimming or a room full of treadmill machines.
The choice is your’s. The benefits are real - but you will have to work for them. (Remember: better late than never and a little is infinitely more than nothing.) Finally, you don’t have to do it all at one sitting. Consider dividing your workout into 2 or 3 10-minute periods throughout the day.
Reflection: Through the lens of PMS, many women say they gain a deeper understand of themselves, and their relationships with others. They can use the period of heightened sensitivities to put their feelings and responses in perspective. (Silver linings have turned up in stranger places!)
Sleep: get as much as possible.
Smaller, Frequent Meals: Smaller, more frequent meals are recommended particularly as you near menopause. Consider 6 small meals per day. Research indicates that rapid changes in blood sugar wreaks more PMS havoc than a more constant level. Skipping a meal can result in a blood sugar drop which releases adrenaline into the bloodstream, likely to send moods off the map. Overeating or binging on sweets and carbs will bounce the blood sugar, inviting bloating fatigue and irritability which PMS will probably magnify.
Carbohydrates and Serotonin: According to MIT researcher judith wurtman, during PMS the brain becomes deficient in the mood controlling neurotransmitter Serotonin. As any women who has experienced PMS knows, intense food cravings often result. Dr. Wurtman’s work contributed to the development of antidepressant drugs specifically designed for PMS (PMDD) patients, (discussed below). “Dr. judy” also suggests you can give your brain a boost by laying off proteins and fat. Her formula for brainy bliss is five parts carbohydrate for one part protein. (our protein suggestion: turkey or tuna) High in complex carbohydrates, this snack should do an good job stimulating the brain’s production of PMS-relieving serotonin!
Craving and Comfort: If your brain is screaming “chocolate chip cookies” what it really means is “serotonin, please!” You can grant that wish just as thoroughly by eating a complex carb, (e.g. a lovely bean-curd and tofu on rye crisp) and avoid the blood sugar havoc created by a sugar/fat delight. However, a small “comfort foods” treat on occasion isn’t out of the question. (After all, the object is to feel better!) Enjoy a hot cup of soup, fruit, or a sugar-free sherbert! (Well, maybe one medium choc-chip - but just one!)
Vegetarian diet: Minimizing fat in your diet should ease PMS symptoms, but if you decided to go “vegan”, make the change gradual or the plan could backfire. Your body needs time to adjust to the new menu.
Caffeine, alcohol: Substantially reduce or eliminate these to reduce bloating, fatigue, tension and depression.
Water: Since water retention is a problem with PMS, many patients avoid drinking it. The opposite is true. Drinking more water will flush the body and prevent retention.
Salt: Reducing salt the week before your period helps reduce bloating and fluid retention - however if you are thin and have low blood pressure, use caution. If you feel weak or dizzy the week prior to menses, take salt normally.
PMS Treatment - Vitamins, Minerals, and Supplements TOP
Start with an adult multi-vitamin that includes iron, then the following are optional.
Vitamin B-6: (Pyridoxine) no more than 100 mg per day - The most powerful of the B-vitamins for reducing PMS symptoms. B6 plays a vital role in the body’s utilization of carbohydrates, fats, and proteins and is also important to the proper function of the nervous system; has beneficial effect on brain chemistry; Reduces water retention
Vitamin B-complex: is also used in some PMS formulations, in combination with B-6.
Vitamin E: 600-800 units per day - Good for sore breasts. Improves oxygen utilization and limits free radical damage. Note: check the label - “mixed tocopherols” are preferable to “alpha tocopherol,” which is preferable to “D,L-” which is synthetic.
Calcium: 1000-1500mg/day - May be abnormally low during the luteal phase of the menstrual cycle in patients with PMS - can relieve cramping, backache, and nervousness. Suggest using one with Vitamin-D included, (600-800IU) calcium doesn’t work for everyone, but it’s good for your bones.
Magnesium: (Mg) 500-1000mg/day - Supports the action of both calcium and B-6. Also helps to normalize the metabolism of sugar and stabilize moods. (dose conservatively, has been known to cause diarrhea)
PMS Treatment - Herbs & Supplements TOP
Botanical remedies have been reported helpful for many symptoms of PMS. The trick is finding what works for your PMS, then fine tune the dose and master the preparation. A few problems with herbs and botanicals:
- Information can be sketchy and incomplete.
- Quality can be poor or inconsistent
- Low availability of quality research on most products
- Much usage information is exaggerated or inaccurate.
- Since they are not regulated, Caveat Emptor applies.
- The ideal source would be a degreed medical professional. Others (“herbalists”) may be useful, however check credentials and reputation.
American (Wisconsin) ginseng (Panax ginseng). This form is suitable for women. There are innumerable brands and not all are reliable. Some are adulterated with caffeine. Avoid the very expensive forms sold in Chinese stores unless you are a ginseng expert. Stick with an established brand with a good reputation.
Agnus castus: A very powerful hormone regulating herb, and hence it should be used with care. Those using oral contraceptive or HRT should ideally seek medical advice before use. Not recommended for persons with history of hormonal imbalance. If you suffer from pain around the time of ovulation or you have a family history of ovarian cysts - do not take this herb unless under the guidance of a medical herbalist or trained physician. Regular use is not suitable for women under 20 years of age. If you feel safe to take this herb it can be a fantastic remedy for the classic symptoms of PMS.
Black cohosh: Useful when PMS occurs around time of perimenopause. A Herb tonic to enhance any reduction in nervous tension and anxiety. Do not use if allergic to aspirin.
DLPA: As directed - Lifts depression, associated with PMS
Dong Quai: Used by millions of Chinese women as a tonic, said to relieve PMS symptoms including pain, bloating, vaginal dryness, and depression. Often taken in soups. Western studies have not proven benefit. Long term safety is unknown.
Siberian ginseng: (Eleutherococcus) May be useful for improving energy.
Evening primrose oil. Said to help reduce breast tenderness, requires 3 months to work, Omega 3 EFAs should be included in diet and meat consumption reduced. .
St John’s Wort: (Hypericum) This is widely used for mood problems. Onset is gradual and there are rumors of liver problems.
Liquorice tea: Taken in the second half of the cycle liquorice is said to reduce estrogen and increase progesterone levels. It also nourishes the adrenal glands. Do not take liquorice if you have high blood pressure or suffer from severe water retention. In mild cases of water retention it may be beneficial if taken in moderate amounts.
L-phenylalanine: This is converted in the brain to several important neurotransmitters. Not much published but experience suggests it can help.
L-tryptophan: has good reports, however safety is currently a concern due to contaminated shipments. The FDA has withdrawn - do not risk using until these problems are resolved.
Vitex: (chaste tree or chaste berry). Best supported by research. Test subjects reported help with breast tenderness, edema, inner tension, headache, constipation, and depression.
A word about herbs and supplements. TOP
Not all vitamins, minerals and herbs are absolutely safe. At high doses, some vitamins have produced unforseen and damaging effects. In an unregulated industry contamination can be a problem.
We recommend a conservative approach. Although some health food stores urge the purchase of many different products, we recommend limiting your use to one or two herbs plus two-three vitamins and/or minerals concurrently. Check with your doctor about potential conflicts with any prescription medications you may be taking. Give new products time to prove themselves.
PMS Treatment: Hormone Therapy TOP
Over the counter “natural hormone creams:” While these may provide minor, temporary relief from a few symptoms; they are not effective hormone therapy. The reason: they are not true bio-identical hormones. They can be called “natural” because they are derived from organic plants (e.g. yam and soy) however their hormone-like natural ingredients are not nearly as effective as the true bioidentical hormones available only by prescription. Their minimal, unpredictable effects tend to fade quickly resulting in escalating cost with diminishing returns - unregulated quality, and dosing difficult to control and maintain.
PMS Treatment: Bio-Identical Hormone Therapy TOP
Available only via prescription, FDA approved bio-identical Hormones consist of estradiol, micronized progesterone and micronized testosterone. The active hormones are extracted from soy and yam oils via purifying and concentrating pharmaceutical processes, graded and distributed in crystaline powder form to compounding pharmacies.
In our experience bio-identical hormones can be the most powerful PMS treatment, because the address the basis of the problem: shifting/declining hormones. The key to success, as always, is dosing. It is therefore imperative that you work with a physician or practitioner experienced in using bio-identical hormone therapy with a compounding pharmacist. Your physician should evaluate your history and physical, including a special blood workup on your reproductive and other hormones, and use the findings to determine the correct dosing protocol. You will begin a schedule of supplements taken at times during your cycle to compensate severe hormonal shifts. Some adjustment may be necessary before the ideal individualized protocol is reached. However, when that happens, you should be very pleased with the result.
Note: Bio-identical hormones are not, and should not be confused with synthetic hormones such as Premarin or Prempro, which are extremely powerful, not bio-identical, (they are made from conjugated horse urine and other chemicals) and should never be used to treat PMS.
PMS Treatment - Alternative Medicine TOP
Acupuncture: may be worth a try, however it is time consuming and expensive. Be sure your practitioner is reputable, licensed and uses disposable needles. Also, needles should not be inserted in chest wall.
Acupressure massage: another ancient Oriental healing method, applies finger pressure to specific points on the skin surface to help prevent and treat illness. Acupressure has been used to help relieve the cramps, bloating, fluid retention, weight gain, and low back pain relating to their menstrual cycle.
Massage: Massage has proven therapeutic benefit, but treatments must be repeated, adding to the expense. Shop around, bearing in mind the efficacy of treatment will depend entirely on the skill of your therapist.
Fasting and detoxification: Fasting an ancient healing practice from India and other eastern countries. However, fasting has risks including negative mood changes and a weakening of the bodies defenses over time. If you decide to try this, please proceed with common sense and caution. Slender women and those with hypoglycemic tendencies may not tolerate it well. We suggest working with an experienced, licensed practitioner who can (an integrative physician) help you design a safe fast that is well suited to your metabolism.
PMS Treatment: Anti-Depressants TOP
By “antidepressant” we actually refer to a class of drug called SSRIs (selective serotonin reuptake inhibitors), developed by MIT researchers about 25 years ago. Prosaic is probably the most recognizable name in this category - and is classified as an antidepressant. However SSRIs are also being used to treat PMS symptoms in women who are not otherwise clinically depressed - with good results. Drugs such as Sarafem (licensed in 2000) were designed specifically for treating severe PMDD (PMS), and can provide significant reduction in symptoms such as low energy, mood-swings, irritability, and concentration problems.
The decision to sue SSRIs is a serious one that we don’t believe necessary for everyone - especially as a first step in PMS treatment. We would suggest trying other methods first, while reserving the use of drugs like Serafem as a last resort. However, if you have been struggling with PMS for some time, and feel you are losing ground, then an SSRI may offer the relief you need.
On the other hand, if your PMS symptoms are mild enough to usually “take in stride” then supplements and other treatments will probably suffice. Antidepressants are not addictive. You can try them, and stop at will without experiencing “withdrawal symptoms” or other ill effects.
Note: do not take Sarafem if you’re currently taking another type of antidepressant called a “MAO inhibitor.” Examples include Isocarboxazid, Phenelzine, and Tranylcypromine.
PMS Treatment: Other Medications TOP
NSAIDs: including Advil (ibuprofen), Alleve (Naproxen), and Motrin can reduce cramps and other discomforts. Be sure to take these with food, and if you have pre-existing gastric or liver problems, consult your physician first. Alternatively, there are more powerful prescription versions of these available as well. Prescription pain-killers can also provide powerful relief, however due to their habit-forming nature, many physicians are reluctant to use these when many alternatives exist.
Diuretics: (aka “water pills”) rid your body of excess fluid by dehydrating you - which also stresses your body, then triggers another cycle of fluid retention. If fluid retention is a big problem, you might consider a mild diuretic. However we suggest avoiding powerful ones such as Lasix (furosemide) which may “put you through the wringer”.
Tranquilizers: (Benzodiazepines) trade names include Valium, Xanax, Serax, Ativan, Klonopin, Librium and Tranxene - these may alleviate depressive and anxiety symptoms in some patients. We do not recommend their use however, because they are addicting, and can produce severe withdrawal symptoms - in extreme cases: death.
GnRH agonist: shown to benefit a broad range of symptoms in most patients. However it increases the risk for osteoporosis and should used only for a short time. Hormonal add-back therapy can also be administered in a low dose to reduce this issue.
Spironalactone: A steroid with diuretic and antiandrogen properties, has been used for quite some time - however results have been mixed.
PMS can be a confusing, frustrating, sometimes disheartening condition ... but whatever you do - don’t give up. PMS almost always gets better when patients and physicians persist. Follow the instructions outlined above with a positive, creative attitude; keeping open to change and new ideas.
Don’t go it alone: Find help. Trained health care professionals who care about PMS are out there, and waiting to help you. This is one of the most important, positive steps you can take. Try to remember: you are not alone and help is available.
Help for Women with Polycyctic Ovarian Syndrome
What is PCOS
PCOS is is estimated to affect at least 10% of American women to some degree. It is also one of the most perplexing and fast-growing disorders challenging women and their doctors today. Many patients encounter conflicting diagnoses and 2nd opinions, leading to discouragement, and in worst cases: treatment dead ends. If this sounds like your story, we urge you to keep trying - even if you must find a new physician - because PCOS can usually be helped, with time, effort and understanding.
While the exact causes of PCOS are unknown, like PMS, we know a great deal about it’s symptoms and patterns of development. A genetic predisposition also appears to exist. We know that PCOS results in hormonal imbalances that wreak havoc with female wellness: particularly her reproductive system and psychological well-being. Due in part to this, PCOS has the potential to produce a great variety of symptom type and intensity in patients - varying by individual. In fact, no two cases of PCOS are identical. (Other than perhaps in identical twins)
PCOS-Related Conditions:
- Obesity
- Skin and hair disorders
- Menstrual irregularities
- Hypertension
- Infertility
- Increased risk of coronary disease
- Metabolic syndrome
- High Cholesterol
- Pre-diabetic
- Diabetes
- Endometrial cancer
Diagnosing PCOS
Unfortunately, since no definitive test for PCOS has existed; as many
as half the women having PCOS either ignore it, or mistake it for
obesity, PMS, or other “female troubles.” Since symptoms often mimic those
of many other conditions, PCOS is often mis-diagnosed, sub-optimally
treated, or simply ignored by patients and physicians alike. Worst of all,
physicians frequently label these patients as overweight or obese,
then direct them to “lose weight and exercise.” Others may consult a
gynecologist, who typically treats the most obvious symptoms
(irregular cycles) while leaving other metabolic changes such as the
metabolic syndrome, hypertension, abnormal lipids (cholesterol), insulin resistance, pre-diabetes and diabetes inadequately treated.
Ironically, androgens can also stimulate the hair follicles of the face and neck, which can result in unwanted facial hair (hirsutism) in some women. Note: hirsutism, acne, and significant weight gain are not symptoms of alopecia, but may indicate PCOS, with differing treatment options.
Endocrinologists are often consulted but their efforts are often focused on diabetic and insulin resistance issues, leaving much of the management of the PCO to the Gynecologist. Dermatologists may also be involved in the treatment of cosmetic skin abnormalities such as acne and increased body hair. However, the the central need for a comprehensive weight control and nutrition plan is often left unmet. Thus the woman with PCOS may “fall through the cracks” as the treatment of her condition is split among different specialists. The diagnosis of PCOS can be tricky and it is frequently missed because physicians have not kept abreast of the recent international consensus convention on diagnostic criteria for PCOS.
For example: a woman can have a normal sonogram without ovarian cysts and still meet the diagnostic criteria for PCOS. A woman can also have regular cycles and still have PCOS - and also be capable of having a baby. Many women are told that they could not have PCOS because they have had a baby, have regular cycles, or have normal ovarian sonograms. These statements are false, and commonly lead to an incorrect diagnosis. While most women with PCOS tend toward obesity - it can also be absent - again raising the possibility of mis-diagnosis.
The Symptoms of PCOS
Many PCOS patients will have experienced menstrual disruptions soon after the onset of puberty, often due to the lack of menses - or, cycles will begin normally, then lengthen and/or skip months. Complicating matters, the introduction of oral contraceptives during this time usually stabilizes the cycle, leading many to a false sense of well being. Nevertheless, during this time other symptoms of the disorder also begin to appear.
These may include a variety of hair and skin problems arising from elevated or imbalanced androgens (male hormones) inherent to the disorder. Acne, seborrhea, dandruff are common, and may wax and wane with menstrual cycles. Hirsutism - excessive hair growing in male patterns - frequently occurs, and less frequently, but equally distressing: male pattern baldness.
Finally, overweight and obesity frequently appear, and/or a tendency to gain weight easily, and shed it only with great difficulty. Fat distributes generally in the body’s midsection: an “apple” shape - versus the “pear” that is typically associated with hypertension, diabetes and lipid metabolic abnormalities. PCOS increasingly has been linked to abnormalities of insulin and glucose metabolism. While losing weight may improve some of the metabolic aberrations, it will not “cure” PCOS.
Overview of symptoms:
- Infrequent or no menstrual periods, and/or irregular bleeding
- Infertility or inability to get pregnant because of not ovulating
- Increased hair growth on face, chest, stomach, back, thumbs, or toes
- Acne, oily skin, or dandruff
- Pelvic pain
- Weight gain or obesity, usually carrying extra weight around the waist
- Type 2 diabetes
- High cholesterol
- High blood pressure
- Male-pattern baldness or thinning hair
- Patches of thickened and dark brown or black skin on the neck, arms, breasts, or thighs
- Skin tags, or tiny excess flaps of skin in the armpits or neck area
- Sleep apnea: excessive snoring and halting breathing while sleeping
As patients grow into adulthood, several metabolic conditions may emerge as a result of PCOS’s hormonal fluctuations, including: hyperinsulinemia (excess insulin production), insulin resistance (poor response to insulin), impaired glucose tolerance (pre-diabetic), and type 2 diabetes mellitus (non-insulin-dependent, characterized by elevated blood sugar).
Infertility is another concern that emerges in adulthood. Difficulty conceiving often provides the motivation to (finally) visit a physician.
The First Step: Diagnosis
The first step is to obtain a definitive diagnosis, beginning with a
comprehensive physical evaluation and detailed patient history. The positive diagnosis can be made through analysis of symptoms and physical findings, hormonal testing, and ultrasound. Most patients will have positive results in two or more of the above-mentioned categories, for example: abnormal menstrual
cycles and/or increased sexual hair growth and/or obesity. Also telling are the presence of ovarian cysts in strings of pearls patterns revealed by ultrasound. These cysts gave rise to the disorder’s name, however they are not diagnostically critical.
Revised diagnostic criteria for PCOS have been proposed based on a 2003 consensus meeting held in Rotterdam. (European Society of Human Reproduction and Embryology/American Society of Reproductive Medicine consensus workshop group) These criteria comprise a broader spectrum of variations of PCOS considered to
represent forms of the condition of PCOS.
Two out of the following three are required:
- Oligo (infrequent) - and/or anovulation
- Clinical AND/OR biochemical signs of hyperandrogenemia (high male hormone levels)
- Polycystic Ovaries (by ultrasound) And,
- other etiologies which mimic PCOS (congenital adrenal hyperplasia, androgen secreting tumors, Cushings disease) must be excluded.
What Can be Done About PCOS
Diagnosing PCOS is not enough - the physician must also
diagnose your PCOS.
It is essential to approach PCOS from the functional perspective to evaluate your unique response to the disorder, including possible hormonal imbalances and other metabolic disturbances. Since there is no final “cure” for PCOS; our treatment goals are to relieve your distress and manage your symptoms over the long term. Later in maturity, your PCOS will most likely fade away, as is the outcome with most cases.
The Individualized Assessment
Your PCOS treatment begins with your Individualized Assessment (PCOS-IA). This detailed investigation of your health includes a review of your health history, lifestyle, genetic heritage, behavioral and other factors. Of special importance are extensive one-on-one interviews, questionnaires, some special tests and lab analyses.
The IA’s primary function is describe your unique “flavor” of PCOS, including
its developmental history and symptomology, biological and physiological factors such as weight status androgen (male hormone) levels or effect, ovarian function, pituitary function and hypothalamic function, degree of insulin resistance, and other aspects.
Using the IA’s data, we are able to design a treatment program that is specific and effective for your PCOS, based on a mix of appropriate methods and therapies. Fortunately, the selection of useful therapies continues to grow.
Effective PCOS Treatments
Weight Loss: Weight loss often brings improvement of endocrine hormonal balance, including possible return of ovulation and fertility. We are medical weight loss experts; experienced in the resolution of complex, and challenging weight management cases. (see Nu-Living Weight Management Program)
Oral Contraceptives: Oral contraceptives can be a mainstay of PCOS treatment for women that do not wish to become pregnant. They begin the process of re-balancing hormone levels, preserving ovarian function and reducing excess androgens (male hormones). However, the correct OC must be used: one that is tolerable and does not aggravate other present metabolic abnormalities, such as insulin resistance and/or diabetes.
Anti-androgens: These may improve the skin problems and hirsutism that occur with PCOS and are commonly used, however they are not officially FDA approved. Examples include spironolactone, flutamide, cyproterone acetate, and Finasteride
Gnrh Analogs: gonadotropin releasing hormone: released from the hypothalamus, GnRH promotes production and release of the gonadotropins (LH and FSH) from the pituitary gland. Useful therapy for suppression of the ovary and its abnormal hormonal production of PCOS, however high cost and undesirable side-effects limit use.
Fertility Drugs: “Fertility drugs” are commonly used in an attempt to temporarily override PCOS disruptions (of follicle growth and ovulation) and thereby facilitate ovulation. In addition to Clomiphene (an oral fertility agent), there are several injectable gonadotropin preparations that can be used.
Surgical therapy: Surgery is available for the treatment of infertility in women with PCOS, yielding a 75-85% probability of becoming pregnant after laparoscopic surgery. However pelvic adhesive formation, often severe, occurs in a number of cases, rendering surgery as a “last resort” measure in most practices today.
Anti-diabetic agents: By treating the insulin resistance, PCOS may be also treated, possibly reversed. Overall effectiveness remains an open question that can only be answered context of the individual patient. With some PCOS patients these medications have successfully restored normal menstruation and fertility, even the absence of the insulin resistance, making them (at least) a useful alternative when other therapies have failed.
Metformin (Glucophage): This drug has received much media attention, and for some women with PCOS, it can be a reasonable alternative. It received a strong endorsement from the American Diabetes Association, has been prescribed to over one million U.S. patients, and used in over 80 other countries. In studies Metformin helped restore normal menstrual cycles in approximately 50 percent of women with PCOS. Blood androgen levels sometimes decrease, but there may not be much improvement in hirsutism or acne. In addition, metformin does not provide contraception. In fact, it might stimulate ovulation, so women must be careful in their use of this drug if they do not want to become pregnant.
Metformin may also help with weight loss. Although not considered a” weight-loss drug”, studies have shown that women with PCOS who are on a low-calorie diet lose more weight with metformin added along with diet and exercise in the recommended regimen. Weight lost in the early phase of metformin treatment is often regained in time. These studies also suggested that metformin might reduce risk of early pregnancy loss and development of diabetes during pregnancy in women with PCOS.
Metformin is not presently FDA approved for the treatment of PCOS despite widespread use and numerous reports of its effectiveness. Metformin appears to have an excellent safety profile and is generally well tolerated, with the most frequently reported side effects including gastrointestinal upset and a tendency toward looser stools, and/or more frequent bowel movements. These are common in the first month and can be reduced by starting at lower dose; also more commonly experienced after a fatty meal, or dessert. Note: The long-term safety of metformin and other experimental drugs is currently unknown.
Actos and Avandia: the so called “insulin sensitizers” are approved for the treatment of type 2 diabetes. Like Metformin, these drugs have been used in the treatment of PCOS. While there have been encouraging reports and there are now on going studies; like Meformin, these drugs are not FDA approved for the treatment of PCOS.
PCOS Comprehensive Treatment
The first step in our functional program will be a visit Dr. terlinsky’s office, for a complete History and Physical, including a referral to the WHD/PCOS Program. This initial visit may last up to 3 hours, and includes the comprehensive PCOS-IA, and lab tests. It includes time for a relaxed, detailed discussion about your history, symptoms, concerns, family, and other topics which may play a role in your disorder. These discussions, along with questionnaire, lab and other data will determine your unique PCOS profile; and provide the detailed information Dr. Terlinsky will consider in your treatment program and protocols.
Treatment usually includes some combination of
the following elements:
- Diet Therapy
- Nutrition and Supplements
- Comprehensive weight management program
- Drugs, (OC) and/or Natural Medicines
- Hormone Balancing (Bio-Identical Hormones)
- Bi-Monthly Monitoring and Counseling with Dr.Terlinsky
Proposed treatment options will be fully discussed with the doctor,
including any potential risks, alternative treatments and answers to any questions you may have.
PCOS Program Costs
The cost is $1000 for the basic PCOS-IA Assessment, Profile and Treatment Program, plus an additional $200 per month to cover the ongoing Weight Loss Program, Hormonal Balancing program, PCOS monitoring, feedback and adjustment sessions.
Note: our PCOS program actually requires extensive doctor’s time and involvement compared to most of our other programs, because it incorporates major elements of several programs. Specifically, Hormone Testing and Balancing, Nutritional Support, Metabolic Testing and Support and our Nu-Living Weight Management program. (hint: it’s a bargain!)
A note on Health Insurance
Unfortunately, Insurance companies do not reimburse the amounts necessary to treat this complex and severe condition. Patients choose to pay out-of-pocket for their visits when they understand their health to be the very best investment they can make. After all, without your health, how can you fully enjoy life’s other good things: spiritual purpose, family, friends, possessions, hopes and dreams? It helps to ask the question: what is my health worth to me?
Putting Cost in Perspective
- What would you pay to add 20 years to your life?
- What would you pay to have a slim figure?
- What would you pay to avoid a heart attack?
- What would you pay to be full of energy and joy?
Proper treatment of PCOS can achieve the above and more, when you and your doctor do the work required. Insurance companies avoid issues such as PCOS because there exists no simple, rote cure - no inoculation, surgery, or drug.
All of these syndromes can be treated, but success depends less on drugs
or surgeries, and more on your physician’s expertise and
commitment and your willingness to participate with you to change habits
and lifestyle.
These kinds of variables are difficult for insurance providers to
assess, and probably will continue to be excluded until the industry
is reformed. In the meantime, we recommend entrusting your health and wellness issues to dedicated medical professionals - not teams of CPAs.
Our comprehensive programs include many hours of physicians time - at reduced rates - in order to return your health to an optimal level. The completed programs average $2,000 total cost, and may vary somewhat, depending on individual needs.
Divided over a lifetime of enjoyable health, the cost is very small
indeed: just 18 cents per day. Many people spend thousands each year dining out; on vacations, auto payments and home improvements! Wouldn’t it make sense to invest 18 cents a day in yourself - and begin enjoying those other things - and living life - to the fullest?
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