Heed the Call

I've been thinking for a few years about writing a book for women about Joseph Campbell's Journey of the Hero, but hip & irreverent and aimed at helping us transform our lives, find deeper meaning, sustain us through the depletion of motherhood, etc.

A new book comes close: Jim Gordon, MD's Unstuck: Your Guide to the Seven-Stage Journey Out of Depression. But many women won't read it because it's about depression, so I still need to write my book.

In the meantime, let's talk about that seven-stage trip of the heroine. Here it is, paraphrased from Joe Campbell (who discerned these steps from scriptures and myths) and Jim Gordon, MD.

1. The Call: Awareness that we need to change, not in a small way but a huge way. We realize we're 20-50 pounds overweight. We get diagnosed with pre-cancer of the breast. We tired of being chronically overwhelmed and overbusy. We can't take another day of PMS. Some kind of journey is ahead.
   
2. Guides: Finding and selecting those who can help, can augment our recovery; those people that provide synergy to the development of our own intuition and inner wisdom.
3. Surrender to Change: Figuring out what we need to let go more fully, how to take off the shoes that are too tight and get a pair that actually serve you....
4. Demon Facing: How do we identify the challenges - the reasons we overeat, the reasons we don't nurture ourselves, the reasons we overschedule. Perfectionism, being ruled by the inner authoritarian, the erosive effects of resentment. Identifying through this process "the unique daimon, the source of our own meaning, purpose and direction," according to Jim Gordon, MD.
5. The Dark Night of the Soul: the only way to heal the pain is to go straight through it - as Jim writes, "Allowing and inviting the deepest life-giving freedom to emerge  as we move through the despair that may come to any of us."
6. Spirituality: The Blessing - this is the realization that a power greater than ourselves can restore us to sanity and transform our lives. Does not require belief in God, can be a belief in Unity, Peace, Higher Self, or whatever your conception of a higher power is.
7. The Return: Re-learning how to live abundantly, joyously, drunkenly alive once again, consciously connected to ourselves and others.

Jim Gordon then provides a chapter on each of these steps in a path toward healing from depression. I'm using this 7-Step Healing Journey to perform a full-body cleanse. What is your Call to Action?

PMS: Natural Approaches

PMS always worsens this time of year - so I thought I'd post the latest data from a favorite database: Natural Medicines Comprehensive Database. Short version of what is proven to be helpful:

• calcium 1200 mg/day
• Chasteberry
• Ginkgo
• Magnesium
• Pyridoxine
• Vitamin E

While I agree with what they say about the glories of calcium, magnesium and chastetree, I disagree with their comments on natural progesterone. Here's what they say....


The cluster of symptoms called "premenstrual syndrome" got its official name in 1931, but it has been recognized since antiquity. Up to 85% of women are affected by PMS to varying degrees. It often starts with development of menstruation in young women and tends to follow a consistent pattern until menopause.


Over 150 symptoms associated with PMS have been catalogued. The most common are irritability, agitation, headache, depression, breast tenderness, fluid retention, and weight gain. These symptoms typically show up in the second half of the menstrual cycle, about 7-10 days before the start of the next period.

Minerals / Vitamins

ACOG guidelines suggest that several nutrition supplements are worth trying as a first step in treating PMS.

Calcium is one of the more interesting minerals used for PMS. Researchers began to suspect a calcium-PMS connection when they noticed that calcium deficiency and PMS share similar symptoms. In addition, women who have PMS tend to have abnormally low levels of calcium at the time of ovulation, compared to women without PMS.13776 Low calcium levels stimulate overproduction of parathyroid hormone. Too much parathyroid hormone can affect mood, possibly by interacting with serotonin.13777,13778

Some evidence suggests that women who consume an average of 1283 mg/day of calcium from the diet have about a 30% lower risk of developing PMS, compared to women who consume 529 mg/day.13094

What really makes the case for calcium is that clinical trials show giving 1000-1200 mg of elemental calcium daily for a few months to women with PMS significantly improves mood and decreases bloating, food cravings, and pain.1822,1823,1824

Calcium makes sense for most women with PMS...especially if they don't already get enough calcium in their diet.

Magnesium deficiency might be another factor that contributes to symptoms of PMS. Women with PMS tend to have lower magnesium levels than other women.6847 Women with PMS who take 360 mg/day of magnesium supplements seem to have improved mood and less fluid retention.1187,1188,6847 Taking magnesium might also reduce premenstrual migraine.1186,6847

Magnesium might be beneficial because it is involved in the activity of serotonin and other neurotransmitters. Magnesium also has a role in vascular contraction and cell membrane stability.

There is less evidence for magnesium than calcium. It's too soon to recommend magnesium for most women, but it might be worth considering for women with premenstrual migraine, fluid retention, and poor mood, despite other treatments.
Vitamin E is sometimes suggested for PMS. There is some evidence that women with PMS who take vitamin E 400 IU/day for three cycles have improved mood, reduced PMS-related anxiety and food cravings.4719,4720 Women with PMS do NOT seem to have reduced vitamin E levels. It is not known how vitamin E might work to improve symptoms of PMS. The evidence isn't strong enough to recommend vitamin E for most patients just yet.

Practice Pearl - Advise women with diabetes or heart disease NOT to use vitamin E supplements in doses of 400 IU/day or more. There is some concern that these doses of vitamin E could increase the risk of heart failure in patients with diabetes or heart disease. More evidence is needed to verify this potential risk. In the meantime, explain to these patients that the potential benefit of using vitamin E doesn't outweigh the potential risks.
Vitamin D is now being studied for prevention of PMS. There is some evidence that increasing total or dietary intake of vitamin D is associated with a decreased risk of developing PMS. Women with an average vitamin D intake of 706 mg/day seem to have about a 40% lower risk of developing PMS compared to women with an average vitamin D intake of 112 mg/day;13094 however, taking vitamin D supplements does not appear to reduce the risk of developing PMS. And there is no evidence that vitamin D can decrease symptoms in women with existing PMS. Advise patients to make sure they get adequate amounts of vitamin D in their diet.

Pyridoxine (vitamin B6) is another vitamin that is recommended for PMS. One theory is that PMS might be related to low dopamine levels. Pyridoxine is a co-factor needed for dopamine production. Another theory is that pyridoxine and other B vitamins might prevent fat accumulation in the liver. This could improve estrogen metabolism and potentially affect PMS symptoms.
There is not much scientific support for these theories. But there is some evidence from clinical studies that pyridoxine might help. Taking 100 mg/day of pyridoxine supplements seems to decrease overall symptoms of PMS as well as depression.3093

Practice Pearl: Advise patients to be careful with pyridoxine. High doses can cause peripheral neuropathy. Recommend not using doses over 100 mg/day. This is generally safe...plus there's no evidence that doses over 100 mg/day are any more effective.
Manganese is a lesser known mineral. It's in most multivitamins, but in very small amounts. Low intake of dietary manganese has been linked with increased symptoms of PMS.7135 There is some evidence that taking manganese in combination with calcium might improve symptoms of PMS...irritability, depression, anxiety, tension, restlessness, etc.2004 But its not known if this benefit is due to the calcium or the manganese. For now, don't recommend manganese for PMS. Instead, let patients know that if they take a multivitamin, they're probably getting enough manganese.

Supportive Treatment: Analgesics, NSAIDs, Diuretics


Supportive treatment is also recommended as a first step in treating PMS. These treatments generally target specific symptoms.

For relief of headache, backache, or cramping, acetaminophen (Tylenol) or NSAIDs (ibuprofen, naproxen, etc) are typically used. For bloating and fluid retention, spironolactone (Aldactone) is often used. It works as a diuretic to decrease fluid retention, and it has the added benefit of having an antiandrogen effect. This might further contribute to symptom relief in women with PMS.

Women with PMS also often turn to natural products for supportive treatment.
Ginkgo (Ginkgo biloba) is sometimes tried. We don't usually think of it as a traditional "woman's herb," but there is some evidence ginkgo leaf extract can relieve PMS fluid retention and its consequences...breast swelling and tenderness, pelvic pain and swelling, and swollen hands and feet.6229 Investigators started looking into ginkgo because women who were taking it for memory reported relief from fluid retention associated with PMS. No one is quite sure why ginkgo seems to work for this indication, but one theory is that it INHIBITS platelet activating factor (PAF).5719,9760 PAF normally triggers inflammation, leading to vascular congestion, edema, and breast swelling. Therefore, it is thought that ginkgo might have an anti-inflammatory effect.
Evening primrose oil (Oenothera biennis) is often recommended for PMS. Evening primrose oil contains the omega-6 fatty acid, gamma-linolenic acid (GLA). It is thought that some women with PMS are deficient in gamma-linolenic acid, possibly due to a defect in their ability to convert linoleic acid to gamma-linolenic acid.6034 This could be important because GLA and its metabolites are precursors to the anti-inflammatory prostaglandin E1.6036,12470

In theory, by taking evening primrose oil, women could boost GLA levels, decrease inflammation, and possibly relieve some symptoms of PMS. But the clinical evidence says otherwise. Several small-scale studies suggest that evening primrose does NOT relieve symptoms of PMS.1105,1106,6847,8219 Don't recommend it.
Antidepressants


Selective serotonin reuptake inhibitors (SSRIs) are now being used more for PMS. In fact, fluoxetine, under a different brand name Sarafem (to distinguish it from Prozac), and sertraline (Zoloft) are approved for the more severe symptoms of premenstrual dysphoric disorder (PMDD). Fluoxetine and sertraline primarily help severe mood changes, including depression and anxiety, but can also improve breast tenderness, bloating, irritability, and headache.12337,13779,13780

The ACOG guidelines suggest considering antidepressants in Step 2, for women who don't respond to supportive treatment and lifestyle changes. Fluoxetine or sertraline are considered the first line antidepressants for PMS or PMDD.12337,12349

Some women are reluctant to use conventional antidepressants. Many turn to "natural" alternatives.

St. John's wort (Hypericum perforatum) is the most popular herbal antidepressant...and the best studied. Numerous studies show that it can be beneficial for mild to moderate depression. But there is only very preliminary evidence that it can help for PMS symptoms.6429
Before patients try St. John's wort, remind them of its downside...St. John's wort causes LOTS of drug interactions. It is a potent INDUCER of cytochrome P450 3A4. It can decrease levels and the effectiveness of lots of drugs. Some of these include the HIV protease inhibitors, non-nucleoside reverse transcriptase inhibitors, oral contraceptives, cyclosporin, some statins, and many others.

Practice Pearl - Tell women who take St. John's wort that if they use oral contraceptives for birth control they should use a back up method of contraception. St. John's wort can decrease the effectiveness of oral contraceptives, which could result in unexpected pregnancy.11886,11887

SAMe (S-adenosyl-L-methionine) is another well-known natural antidepressant. SAMe works by donating methyl groups to various physiological processes, including synthesis of neurotransmitters. SAMe increases levels of serotonin, norepinephrine, and dopamine.5196,5231,5232,9110 It does seem to help for depression and seems to be safe. But there is no reliable evidence that it works for symptoms of PMS. Don't recommend it.

Advise patients to avoid supplements containing L-tryptophan or 5-HTP. These products are precursors to serotonin. They are often marketed for depression, anxiety, and sometimes for PMS. There's actually some evidence that L-tryptophan might improve some symptoms of PMS.6246 But there are lots of questions about the safety of these products. Years ago these products were linked to several cases of eosinophilia myalgia syndrome (EMS).902,919,7067,8053,10084,10085,11474,11478 Until more is known about the safety of 5-HTP and L-tryptophan, tell patients not to use them.

Practice Pearl - Tell women who take St. John's wort that if they use oral contraceptives for birth control they should use a back up method of contraception. St. John's wort can decrease the effectiveness of oral contraceptives, which could result in unexpected pregnancy.11886,11887
SAMe (S-adenosyl-L-methionine) is another well-known natural antidepressant. SAMe works by donating methyl groups to various physiological processes, including synthesis of neurotransmitters. SAMe increases levels of serotonin, norepinephrine, and dopamine.5196,5231,5232,9110 It does seem to help for depression and seems to be safe. But there is no reliable evidence that it works for symptoms of PMS. Don't recommend it.

Advise patients to avoid supplements containing L-tryptophan or 5-HTP. These products are precursors to serotonin. They are often marketed for depression, anxiety, and sometimes for PMS. There's actually some evidence that L-tryptophan might improve some symptoms of PMS.6246 But there are lots of questions about the safety of these products. Years ago these products were linked to several cases of eosinophilia myalgia syndrome (EMS).902,919,7067,8053,10084,10085,11474,11478 Until more is known about the safety of 5-HTP and L-tryptophan, tell patients not to use them.

Hormonal Agents


Lots of theories about PMS are based on hormone imbalances. Some investigators attribute PMS anxiety and depression to high estrogen and low progesterone. They think food cravings, headache, fatigue, and palpitations might be related to increased insulin resistance, low anti-inflammatory prostaglandin E1, and high levels of pro-inflammatory prostaglandin 2. And they attribute PMS fluid retention to high aldosterone levels.
Some clinicians try to adjust a woman's hormonal balance in an effort to address this potential underlying cause. Hormone therapy is usually directed toward suppressing ovulation. Oral contraceptives or gonadotropin-releasing hormones (leuprolide, goserelin) are tried. Oral contraceptives are most popular and make sense if the symptoms are mainly physical...breast tenderness, headache, etc. But when they are initiated, they can sometimes make these symptoms worse. And they're usually not helpful for mood changes. Many clinicians are reluctant to use gonadotropin-releasing hormone because they produce a "chemical menopause" that can lead to bone loss.

ACOG guidelines consider these hormonal options as the third step in treating PMS symptoms.

Lots of natural products are promoted for their hormone-like effects. Many women turn to these products with the hope of symptom relief, without the downside of conventional drugs.

Chasteberry (Vitex agnus-castus) is a very popular "woman's herb" evaluated in several studies for PMS. Chasteberry seems to be best for physical symptoms such as breast tenderness, edema, and constipation. It also seems to improve irritability, mood, anger, and headache.7055,7076,7078,7079 In some women, chasteberry improves symptoms by as much as 50%.7055 But chasteberry does not appear to be very helpful for symptoms of bloating.7055

There is also some evidence that chasteberry might help for the more severe symptoms of PMDD. One study found chasteberry to be comparable to fluoxetine 20-40 mg/day; however, chasteberry tended to be more effective for physical symptoms, while fluoxetine was more effective for psychological symptoms.12207

Exactly how chasteberry works for PMS is not known. But chasteberry has a variety of pharmacological effects that might be beneficial. Chasteberry might affect dopamine, acetylcholine and opioid receptors.7014,7015,10122 Chasteberry might also have estrogen and progestin activity.10979,11456

Chasteberry is very promising based on the evidence so far. But the evidence is somewhat limited due small sample sizes or inadequate study designs. Due to these limitations, chasteberry shouldn't be recommended just yet to most patients.

Natural progesterone is another product that is promoted for PMS...often over the Internet. But it doesn't work any better than placebo.1220,10332 Urge your patients to save their money and steer clear.

Black cohosh (Actaea racemosa), red clover (Trifolium pratense), and soy (Glycine max) are widely known as "women's herbs." They may be helpful for menopausal symptoms, but there isn't much evidence they work for PMS symptoms. Don't recommend them.
Also, steer patients away from dong quai (Angelica sinensis) for PMS. There is no reliable evidence that it is effective...and not enough is known about its safety.

The Bottom Line


If your patient wants to take a natural approach to relieving PMS symptoms, suggest 1200 mg of calcium daily. Be sure she understands that benefits would not appear for at least a few months. Even if she doesn't see an improvement in PMS symptoms, she will at least be getting some protection against osteoporosis.
Other minerals and vitamins might be helpful...magnesium, vitamin E, and pyridoxine. But there is not as much evidence for these as there is for calcium. If patients want to try pyridoxine, remind them not to exceed 100 mg/day due to risk of neuropathy.

Chasteberry is the herb with the most evidence in support of efficacy for PMS. But it is still not enough to recommend to most women.

A few other natural products have some preliminary evidence, but more research is needed before these can be recommended...ginkgo, St. John's wort, and manganese.

Tell women that using evening primrose oil, progesterone, black cohosh, red clover, soy, or dong quai is unlikely to improve PMS symptoms.

References
902 Michelson D, Page SW, Casey R, et al. An eosinophilia-myalgia syndrome related disorder associated with exposure to L-5-hydroxytryptophan. J Rheumatol 1994;21:2261-5.

919 FDA Talk Paper. Impurities confirmed in dietary supplement 5-hydroxy-L-tryptophan. August 31, 1998. Available at: http://vm.cfsan.fda.gov/~lrd/tp5htp.html

1105 Budeiri D, Li Wan Po A, Dornan JC. Is evening primrose oil of value in the treatment of premenstrual syndrome? Control Clin Trials 1996;17:60-8.

1106 Khoo SK, Munro C, Battistutta D. Evening primrose oil and treatment of premenstrual syndrome. Med J Aust 1990;153:189-92.

1186 Facchinetti F, Sances G, Borella P, et al. Magnesium prophylaxis of menstrual migraine: effects on intracellular magnesium. Headache 1991;31:298-301.

1187 Facchinetti F, Borella P, Sances G, et al. Oral magnesium successfully relieves premenstrual mood changes. Obstet Gynecol 1991;78:177-81.

1188 Walker AF, De Souza MC, Vickers MF, et al. Magnesium supplementation alleviates premenstrual symptoms of fluid retention. J Womens Health 1998;7:1157-65.

1220 Freeman EW, Rickels K, Sondheimer SJ, et al. A double-blind trial of oral progesterone, alprazolam, and placebo in treatment of severe premenstrual syndrome. JAMA 1995;274:51-7.

1822 Thys-Jacobs S, Starkey P, Bernstein D, Tian J. Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Premenstrual Syndrome Study Group. Am J Obstet Gynecol 1998;179:444-52.

1823 Alvir JM, Thys-Jacobs S. Premenstrual and menstrual symptom clusters and response to calcium treatment. Psychopharmacol Bull 1991;27:145-8.

1824 Thys-Jacobs S, Ceccarelli S, Bierman A, et al. Calcium supplementation in premenstrual syndrome: a randomized crossover trial. J Gen Intern Med 1989;4:183-9.

2004 Penland JG, Johnson PE. Dietary calcium and manganese effects on menstrual cycle symptoms. Am J Obstet Gynecol 1993;168:1417-23.

3093 Wyatt KM, Dimmock PW, Jones PW, O'Brien PM. Efficacy of vitamin B6 in the treatment of premenstrual syndrome. BMJ 1999;318:1375-81.

4719 London RS, Murphy L, Kitlowski KE, Reynolds MA. Efficacy of alpha-tocopherol in the treatment of the premenstrual syndrome. J Reprod Med 1987;32:400-4.

4720 London RS, Sundaram GS, Murphy L, Goldstein PJ. The effect of alpha-tocopherol on premenstrual symptomatology: a double-blind study. J Am Coll Nutr 1983;2:115-22.

5196 Rosenbaum JF, Fava M, Falk WE, et al. The antidepressant potential of oral S-adenosyl-l-methionine. Acta Psychiatr Scand 1990;81:432-6.

5231 Friedel HA, Goa KL, Benfield P. S-adenosyl-L-methionine. A review of its pharmacological properties and therapeutic potential in liver dysfunction and affective disorders in relation to its physiological role in cell metabolism. Drugs 1989;38:389-416.

5232 Bottiglieri T, Hyland K, Reynolds EH. The clinical potential of ademetionine (S-adenosylmethionine) in neurological disorders. Drugs 1994;48:137-52.

5719 Kudolo GB. The effect of 3-month ingestion of Ginkgo biloba extract on pancreatic beta-cell function in response to glucose loading in normal glucose tolerant individuals. J Clin Pharmacol 2000;40:647-54.

6034 Hardy ML. Herbs of special interest to women. J Am Pharm Assoc 200;40:234-42.

6036 Belch J, Hill A. Evening primrose oil and borage oil in rheumatologic conditions. Am J Clin Nutr 2000;71:352S-6S.

6229 Tamborini A, Taurelle R. [Value of standardized Ginkgo biloba extract (EGb 761) in the management of congestive symptoms of premenstrual syndrome]. [Article in French]. Rev Fr Gynecol Obstet 1993;88:447-57.

6246 Steinberg S, Annable L, Young SN, Liyanage N. A placebo-controlled study of the effects of L-tryptophan in patients with premenstrual dysphoria. Adv Exp Med Biol 1999;467:85-8.

6429 Stevinson C, Ernst E. A pilot study of Hypericum perforatum for the treatment of premenstrual syndrome. BJOG 2000;107:870-6.

6847 Bendich A. The potential for dietary supplements to reduce premenstrual syndrome (PMS) symptoms. J Am Coll Nutrition 2000;19:3-12.

7014 Wuttke W. Dopaminergic action of extracts of Agnus Castus. Forschende Komplementarmedizen 1996;3:329-30.

7015 Jarry H, Leonhardt S., Gorkow C, Wuttke W. In vitro prolactin but not LH and FSH release is inhibited by compounds in extracts of Agnus Castus: direct evidence for a dopaminergic principle by the dopamine receptor assay. Exp Clin Endocrinol 1994;102:448-54.

7055 Schellenberg R. Treatment for the premenstrual syndrome with agnus castus fruit extract: prospective, randomized, placebo-controlled study. Br Med J 2001;322:134-7.

7067 FDA. Information paper on L-tryptophan and 5-hydroxy-L-tryptophan. Office of Nutritional Products, Labeling, Dietary Supplements. Center for Food Safety and Applied Nutrition. February 2001.

7076 Lauritzen CH, Reuter HD, Repges R, et al. Treatment of premenstrual tension syndrome with Vitex agnus castus: Controlled-double blind versus pyridoxine. Phytomedicine 1997;4:183-9.

7078 Berger D. Schaffner W, Schrader E, et al. Efficacy of Vitex agnus castus L. extract Ze 440 in patients with premenstrual syndrome (PMS). Arch Gynecol Obstet 2000;264:150-3.

7079 Loch EG, Selle H, Boblitz N. Treatment of premenstrual syndrome with a phytopharmaceutical formulation containing Vitex agnus castus. J Womens Health Gend Based Med 2000;9:315-20.

7135 Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academy Press, 2002. Available at: www.nap.edu/books/0309072794/html/.

8053 Sullivan EA, Kamb ML, Jones JL, et al. The natural history of eosinophilia-myalgia syndrome in a tryptophan-exposed cohort in South Carolina. Arch Intern Med 1996;156:973-9.

8219 Paasonen MK, Penttila O, Himberg JJ, et al. Platelet taurine in patients with arterial hypertension, myocardial failure or infarction. Acta Med Scand Suppl 1980;642:79-84.

9110 Bottiglieri T. S-Adenosyl-L-methionine (SAMe): from the bench to the bedside--molecular basis of a pleiotrophic molecule. Am J Clin Nutr 2002;76:1151S-7S.

9760 Kudolo GB, Dorsey S, Blodgett J. Effect of the ingestion of Ginkgo biloba extract on platelet aggregation and urinary prostanoid excretion in healthy and Type 2 diabetic subjects. Thromb Res 2002;108:151-60.

10084 Johnson KL, Klarskov K, Benson LM, et al. Presence of peak X and related compounds: the reported contaminant in case related 5-hydroxy-L-tryptophan associated with eosinophilia-myalgia syndrome. J Rheumatol 1999;26:2714-7.

10085 Greenberg AS, Takagi H, Hill RH, et al. Delayed onset of skin fibrosis after the ingestion of eosinophilia-myalgia syndrome-associated L-tryptophan. J Am Acad Dermatol 1996;35:264-6.

10122 Meier B, Berger D, Hoberg E, et al. Pharmacological activities of Vitex agnuscastus extracts in vitro. Phytomedicine 2000;7:373-81.

10332 Wyatt K, Dimmock P, Jones P, et al. Efficacy of progesterone and progestogens in management of premenstrual syndrome: systematic review. BMJ 2001;323:776-80.

10979 Liu J, Burdette JE, Xu H, et al. Evaluation of estrogenic activity of plant extracts for the potential treatment of menopausal symptoms. J Agric Food Chem 2001;49:2472-9.

11456 Wuttke W, Jarry H, Christoffel V, et al. Chaste tree (Vitex agnus-castus)--pharmacology and clinical indications. Phytomedicine 2003;10:348-57.

11474 Kilbourne EM, Philen RM, Kamb ML, Falk H. Tryptophan produced by Showa Denko and epidemic eosinophilia-myalgia syndrome. J Rheumatol Suppl 1996;46:81-8.

11478 Carr L, Ruther E, Berg PA, Lehnert H. Eosinophilia-myalgia syndrome in Germany: an epidemiologic review. Mayo Clin Proc 1994;69:620-5.

11886 Pfrunder A, Schiesser M, Gerber S, et al. Interaction of St John's wort with low-dose oral contraceptive therapy: a randomized controlled trial. Br J Clin Pharmacol 2003;56:683-90.

11887 Hall SD, Wang Z, Huang SM, et al. The interaction between St John's wort and an oral contraceptive. Clin Pharmacol Ther 2003;74:525-35.

12207 Atmaca M, Kumru S, Tezcan E. Fluoxetine versus Vitex agnus castus extract in the treatment of premenstrual dysphoric disorder. Hum Psychopharmacol Clin Exp 2003;18:191–195.

12337 PMS Guidelines. Pharmacist's Letter/Prescriber's Letter 2000;16(8):160803.

12349 The American College of Obstetricians and Gynecologists. Clinical management guidelines for premenstrual syndrome. ACOG Practice Bulletin. No. 15. April 2000.

12350 Patel S, Popovich NG. Premenstrual dysphoric disorder. US Pharmacist CE. September 2004.

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13094 Bertone-Johnson ER, Hankinson SE, Bendich A, et al. Calcium and vitamin D intake and risk of incident premenstrual syndrome. Arch Intern Med 2005;165:1246-52.

13776 Thys-Jacobs S, Alvir MJ. Calcium regulating hormones across the menstrual cycle-evidence of secondary hyperparathyroidism with PMS. J Clin Endocrinol Metab 1995;80:2227-32.

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13778 Rojansky N, Halbreich U, Zander K, et al. Imipramine receptor binding and serotonin uptake in platelets of women with premenstrual changes. Gynecol Obstet Invest 1991;31:146-52.

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F L O U R + S U G A R = E V I L

Some of us are as addicted to food as an alcoholic is to alcohol. Kay Sheppard wrote a great book about this, entitled Food Addiction: The Body Knows. I am especially interested in how addiction to flour and sugar leads to depression, anxiety, over-exercise, distorted body image, lethargy, irritability, PMS, weight obsession, and strained relationships, and by extension, how recovery can heal these conditions.

Here is her questionnaire for self-diagnosis:

1. Has anyone ever told you that you have a problem with food?

2. Do you think food is a problem for you?

3. Do you eat large amounts of high calorie food in a short period of time?

4. Do you eat to overcome shyness?

5. Do you eat when you are disappointed, tense or anxious?

6. Can you stop eating without struggle after one or two sweets?

7. Has your eating ever interfered with any part of your life?

8. Has being overweight ever affected any part of your life?

9. Do you weigh yourself once or more per day?

10. Do you eat more than you planned to eat?

11. Have you hidden food so that you would have it for yourself?

12. Have you felt angry when someone ate food you saved for yourself?

13. Do you worry that you can't control how much you eat?

14. Have you ever felt frantic about your size, shape or weight?

15. How many of these methods of weight loss have you tried in the past?

• self-induced vomiting
  
• laxatives
• diuretics
• fasting
• compulsive exercise
• amphetamines
• cocaine
• OTC diet pills
• sorbitol
• chewing and spitting food
• acupuncture, acupressure
• hypnosis
• urine shots
• special foods, drinks & supplements
• weight loss programs: how many? how often?

16. Have you ever felt so ashamed of the amount you eat that you hide your eating?

17. Have you ever been so upset about the way you eat that you wished you would die?

18. Do you overeat more than twice/week?

19. Do you invent plans in order to be alone to eat?

20. Do you seek out companions who eat the way you do?

Next time... stages of food addiction and how to recover, with the latest thinking from Dr. Mark Hyman, MD, and data on the role of dopamine in the food addict's brain.

PMS: Why, Why, Why?

I see a lot of women in our practice who suffer the 3 to 10 days before menstruation with irritability, rage and crazy mood swings. Many of these women have needlessly been started on an anti-depressant such as Prozac or Zoloft or Paxil. We have myriad natural ways of easing Premenstrual Syndrome (PMS), from raising serotonin more naturally (without derailing libido) to nutritional changes to supplements that re-balance the underlying hormonal causes.

Eckhart Tolle, the luminous spiritual guide of Oprah and millions of others, has a great take on PMS. I am excerpting his text from A New Earth, p 154.  See if it resonates with you.

The Collective Female Pain-Body

The collective dimension of the pain-body has different strands in it. Tribes, nations, races, all have their own collective pain-body, some heavier than others, and most members of that tribe, nation or race have a share in it to a greater or lesser degree.

Almost every woman has her share in the collective female pain body, which tends to become activated particularly just prior to the time of menstruation. At that time many women become overwhelmed by intense negative emotion.

The suppression of the feminine principle especially over the past two thousand years has enabled the ego to gain absolute supremacy in the collective human psyche. Although women have egos, of course, the ego can take root and grow more easily in the male form than in the female. This is because women are less mind-identified than men. They are more in touch with the inner body and the intelligence of the organism where the intuitive faculties originate. The female form is less rigidly encapsulated than the males, has greater openness and sensitivity toward other life-forms, and is more attuned to the natural world.

If the balance between male and female energies had not been destroyed on our planet, the ego's growth would have been greatly curtailed. We would not have declared war on nature, and we would not be so completely alienated from our Being.

Nobody knows the exact figure because records were not kept, but it seems certain that during a three-hundred year period between three and five million women were tortured and killed by the "Holy Inquisition,"an institution founded by the Roman Catholic Church to suppress heresy. This surely ranks together with the Holocaust as one of the darkest chapters in human history. It was enough for a woman to show a love for animals, walk alone in the fields or woods, or gather medicinal plants to be branded a witch, then tortured and burned at the stake. The sacred feminine was declared demonic, and an entire dimension largely disappeared from human experience. Other cultures and religions, such as Judaism, Islam, and even Buddhism, also suppressed the female dimension, although in a less violent way. Women's status was reduced to being child bearers and men's property. Males who denied the feminine even within themselves were now running the world, a world that was totally out of balance. The rest is history or rather a case history of insanity.

Who was responsible for this fear of the feminine that could only be described as acute collective paranoia? We could say: Of course, men were responsible. But then why in many ancient pre-Christian civilizations such as the Sumerian, Egyptian, and Celtic were women respected and the feminine principle not feared but revered? What is it that suddenly made men feel threatened by the female? The evolving ego in them. It knew it could gain full control of our planet only through the male form, and to do so, it had to render the female powerless.

In time, the ego also took over most women, although it could never become as deeply entrenched in them as its men.

We now have a situation in which the suppression of the feminine has become internalized, even in most women. The sacred feminine, because it is suppressed, is felt by many women as emotional pain. In fact, it has become part of their pain-body, together with the accumulated pain suffered by women over millennia, through childbirth, rape, slavery, torture, and violent death.

But things are changing rapidly now. With many people becoming more conscious, the ego is losing its hold on the human mind. Because the ego was never as deeply rooted in woman, it is losing its hold on women more quickly than on men.

Pre-Conception Counseling: Role of Mercury

Suddenly I am seeing lots of women who want to conceive or are pregnant already.  I am also seeing scary numbers of women with high mercury levels.  When I was getting pregnent, the brilliant advice of the CDC was "limit how much fish you eat to once per week or less."  I don't find that satisfying.

If you have metal fillings in your mouth or you eat seafood regularly, there's a good chance you might be mercury toxic.  I was and didn't know it.  You see - I have a great love for sashimi.  I ate it once/week for about a year when my office was near a glorious sushi restaurant, and since I have no metal fillings, I wasn't too concerned. Then I tested and found I was toxic.

Symptoms? Fun things such as:

emotional rage

depression

mood swings

irritability

anxiety

brain fog 

dementia

Alzheimer's disease

senior moments

memory loss

heart irregularity

shortness of breath

blood pressure problems

dizziness

numbness tremors

vision/hearing problems

MS or ALS

recurring infections autoimmune conditions

chronic fatigue

allergies/asthma

gum problems

low thyroid function

cold extremitities

unexplained weight gain

low libido (for men - poor erections)

infertility

birth defects

headaches

insomnia

lack of energy

metallic taste

As my thinking about pre-conception counseling evolves, I am integrating the importance of assessment and detoxification from heavy metals such as mercury and toxins such as xenoestrogens, chemicals in the environment that act like estrogen in your body.

I tried a lot of different mercury detox programs over the past two years since I was first diagnosed and have a few favorites.  More on that later....

I am teaming up with two other extraordinary physicians to try to raise awareness among women especially of reproductive age -- Drs. Marsha Nunley, MD and Bruce Dooley, MD.  We are planning some educational programming in San Francisco for the fall.  Stay tuned!