Healthy Eating for Women

PMS is a common problem which deserves sympathetic attention and appropriate management. Many women find that with support and encouragement they can work out solutions for themselves; and if problems persist, then various medical treatments can be tried. Now that many practices have well woman and family planning clinics, the ‘best person’ to deal with PMS may be any member of the team. It is probably helpful to have someone able and willing to deal with the complex interaction between psychological and physical symptoms, relationship and social difficulties. A purely medical approach will fail to engage the woman in examining her situation on a broad front and may encourage her to pin too much hope on pharmacological solutions for problems that may benefit from adjustments to lifestyle and stress.

Health visitors, counsellors, and nurses as well as GPs should be aware of PMS and how it may be affecting their patients. Primary care team members, because of their knowledge of an individual woman and her circumstances, are ideally placed to help her work out whether PMS is the main cause of her distress or whether other factors in her life are actually to blame.
PMS is a problem that is best dealt with by empowering the woman to do as much as she can to help herself and collaborate positively in evaluating any medical treatments prescribed.

Women coming to the surgery with PMS need time to work out what the problems and solutions are and so a number of appointments may be necessary. The initial consultation should seek to establish a therapeutic relationship, identify the woman’s complaints and begin to prioritize the difficulties.

History

Assessment starts with the history of the main troublesome symptoms, the timing in the menstrual cycle, the severity, and the impact on the woman and those around her. Ask her why she is seeking help now. There may have been a crisis, an unmanageable extra stressor, or she may have heard about a new treatment that she would like to try. She will not have the definitions of PMS to hand and so may rely on magazine articles, a friend’s suggestion, or a scan of the Internet to prompt her presentation. As many as half of women who present complaining of PMS do not have cyclical symptoms after diary keeping so another label needs to be found, and guidance towards a more useful focus. Unfortunately, many women come already certain of their diagnosis and do not want to contemplate an alternative. This may be because they fear the stigma of depression or relationship difficulties and are not confident about solutions to such issues.

Social and relationship context

Women often feel responsible for the emotional well-being of those around them. They blame themselves when things go wrong and look for internal reasons for social and relationship problems. It may be easier to blame the hormones than confront the misery of an absent partner or wayward children. Some social problems are intractable but can be borne except when further strained by premenstrual symptoms.

Cultural norms, expectations and fears

Many women cannot deal with their own anger and are very upset about irritable outbursts, especially when directed at ‘innocent victims’ such as their small children. A typical example of this might be as follows: a woman is overwhelmed with guilt and depression because of an irritable outburst with partner or children. She is appalled at her behaviour and seeks an explanation that allows her to retain her image of herself as self-controlled and loving and reject the side of herself that becomes angry or demanding because it is not how women should behave, even if the anger is justified. She may describe herself as ‘Jekyll and Hyde’ and does not accept her different reactions as part of normality but instead feels out of control and therefore ill. The most frequent fear is that this represents ‘madness’ and PMS offers a hormonal explanation that avoids this conclusion. Reassurance about her sanity and the role of stress may allow exploration of psychological factors.
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There appears to be no distinctive type of woman likely to experience PMS, although in general it appears to be more common in women in their thirties and forties and in women who have children. Certain events may be linked to the onset of PMS, such as stopping the oral contraceptive, the birth of a child, or sterilization, which suggests a hormonal connection. PMS can still be experienced following hysterectomy if the ovaries remain. PMS seems to be common across all social classes although it seems that women who seek medical help specifically for PMS are more likely to be in social classes I and II. Therefore, the primary health care team should be alert to the possibility of PMS in women consulting for other problems, such as anxiety or depression. There also appears to be a general link between adverse life events and PMS. Women tend to experience PMS as more of a problem during times of stress, such as when there are problems at home or at work, or during examination times or when moving house.

Despite some views that PMS is a complaint of â neurotic women, there is no consistent relationship between women’s personalities and PMS. There do, however, appear to be links between PMS and general psychological health. Women who are psychiatrically ill may experience more, and more severe, premenstrual psychological symptoms than psychologically healthy women. Women with PMS are more likely to have had a depressive illness in the past and more likely to have had postnatal depression (Halbreight 1996). Recently, interest has focused on PMS in perimenopausal women. During the time leading up to the menopause, PMS can become more severe and blur into the menopause. It is possible that some women are more vulnerable than others to hormonal fluctuations and are therefore at risk of problems with PMS, the menopause, and a mild form of postnatal depression and so require extra support at these times.

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From earliest times men have written about women’s changing moods and behaviour and attributed them to their female anatomy and their menstrual cycle. In the twentieth century, Frank (1931) coined the term premenstrual tension (PMT). He perceived a link between symptoms in the latter half of the menstrual cycle and the fluctuations of the reproductive hormones. From the 1950s, Dalton has campaigned for the better recognition and treatment of such symptoms and widened the concept, calling it premenstrual syndrome (PMS). Since then, PMS has received much publicity, in both the lay and medical press. There is still much debate about the syndrome’s definition, aetiology and treatment, but following considerable research and debate, there is now a better understanding of PMS and a range of ways of managing the problem. It is a complex and fascinating topic that raises many questions about the interactions between hormones and physiological changes and life events and stress. Women today are taking an active and positive role in acquiring knowledge and information about health issues and many women hear about PMS and identify similar symptoms in themselves.

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Endocrine changes

The sequence of hormone events occurring in the menstrual cycle during which ovulation takes place is shown in Fig 1.1. At menstruation, plasma levels of the anterior pituitary hormone, follicle-stimulating hormone (FSH), are already rising, stimulating the growth of several Graafian follicles within the ovary. In general, the end result of this follicular development is (usually) one mature follicle and ovum. The developing follicle produces increasing amounts of oestrogens, notably oestradiol. As levels of oestradiol begin to rise early in the follicular phase of the cycle, production of FSH is suppressed  by negative feedback but oestradiol levels continue to increase over the next few days until a critical level is reached. Here, by positive feedback it triggers the anterior pituitary to release about 24 hours later a surge of luteinizing hormone (LH) with levels up to 50 IU/l and to a lesser extent FSH with levels up to 15 IU/l; such levels only occur for one day. Ovulation follows the onset of the LH surge within about 34—36 hours and the ruptured ovarian follicle develops into the corpus luteum which secretes both oestradiol and progesterone in the second half or luteal phase of the cycle. Levels of both oestradiol and progesterone therefore rise after ovulation, reaching peak levels between days 18 and 22 of a 28-day cycle. In the last few days of the cycle, if pregnancy has not occurred, the corpus luteum degenerates and oestradiol and progesterone levels fall before menstruation ensues. Plasma levels of progesterone can be measured to assess ovulation and levels greater than 16 nmol/l on days 18—22 are indicatory. The time period from the LH surge to menses is consistently close to 14 days but may vary normally from 12 to 17 days. However, variability in cycle length among women is principally due to varying number of days required for follicular growth and development in the follicular phase. Menstrual bleeding can occur both in ovulatory and anovulatory cycles. In the latter the ovary produces enough oestrogen to stimulate endometrial growth and bleeding occurs when oestrogen levels fall. Bleeding in anovulatory cycles tends to be irregular, painless and heavy. In the past decade it has been found that ovarian follicles also produce peptide hormones such as inhibin and activin, which inhibit and stimulate FSH production, respectively. While these peptides are not measured routinely, they may be in specialized centres.

Endometrial events

The process of menstruation is poorly understood and it is not really known why women should bleed at all since it does not seem to fulfil any biological function. It only occurs in a restricted number of species: humans and most subhuman primates. Consequently, scientific understanding of the physiological mechanisms involved in the process of menstruation is based on animal as well as human data. Endometrium undergoes growth, degeneration and regression prior to menstruation and bleeding occurs from endometrial blood vessels, especially spiral arterioles. In most species that menstruate, endometrial arterioles are unusual in that they are profusely coiled as they run through the endometrium and also change throughout the menstrual cycle. Endometrial vessels have the unique property of undergoing benign angiogenesis (growth) during each menstrual cycle; otherwise this process is restricted to neoplasia and tissue injury. While this process is clearly  under the control of ovarian steroids, endometrial endothelium lacks steroid receptors. These are present on endometrial epithelium and stromal cells, which produce angiogenic polypeptides, which then act on the endothelium. These arterioles undergo profound vasoconstriction which starts 4—24 hours before menstruation and lasts until the end of menstrual bleeding. Bleeding results from relaxation of individual blood vessels and then ceases as they constrict. If constriction did not occur, it could not unreasonably be expected that women would bleed to death at the menarche. Another phenomenon that occurs during menstruation is myometrial contraction. The myometrium contracts throughout the menstrual cycle and there is increased activity during menstruation especially in women with primary dysmenorrhoea.

Of the pathways thought to play a major role in abnormal menstruation, the evidence for altered eicosanoid biosynthesis is compelling. Prostaglandins have the capacity to affect both haemostasis and myometrial contractility. Very high levels of prostaglandins are found in uterine tissues and menstrual blood. Prostaglandin levels are further increased in women with menorrhagia and dysmenorrhoea and clinically inhibitors of prostaglandin biosynthesis are effective in these disorders. In menorrhagia there is also additional evidence of an altered responsiveness to the vasodilator prostaglandin E2. Increased concentrations of prostaglandin E2 receptors are present in myometrium collected from women with excessive bleeding. In dysmenorrhoea the leukotriene pathway allied to prostaglandins has also been implicated in that higher levels of leukotrienes are present in endometrium of dysmenorrhoeic women. Finally, increased endometrial fibrinolysis has been implicated in menorrhagia leading to the use of antifibrinolytic agents.

Variation in menstrual blood loss The amount of blood loss at each menstruation has been measured in several population studies. In several hundred women not complaining of any menstrual problems, objective measurement of menstrual blood loss (MBL) shows a skewed distribution with the mean of about 35 ml and the 90th percentile of 80 ml. MBL is considered excessive if greater than 80 ml: without treatment, such a loss leads to iron deficiency anaemia and constitutes objective menorrhagia (Fig 1.2). Blood losses up to 1600 ml have been measured in some women. Despite variation in the total amount of blood lost, 90% is lost within the first 3 days, fitting in with patientsâ€^TM description of a tap being turned on and off.

Variation in cycle length and duration of menstruation

Cyclical vaginal bleeding is known to occur at well defined intervals from the menarche to the menopause. Since ancient times it was shown that the length of the menstrual cycle, i.e. from day 1 of one period to day 1 of the next, approximated to the phases of the moon. The Greek ‘menâ€^TM means month. Women in many cultures refer to their periods as the moon and some women believe they are actually caused by the moon! Not surprisingly, the 28-day cycle has become the symbol of health and normality in relation to reproductive function and women begin to worry that something is wrong if their menstrual cycle deviates from this 28-day ‘normâ€^TM. Furthermore, medications to induce artificial cycles, such as the oral contraceptive and hormone replacement, are also generally geared to producing 28-day ‘idealâ€^TM cycles. It therefore leads to women seeking medical treatment to regulate periods if cycles become either short or long.

It is important that women should be informed that there is a large degree of variability in cycle length that is compatible with good health.Variability in cycle length was best evaluated in the classical study of Vollman (1977). The famous 28-day cycle happens to be the commonest cycle length recorded (Fig 1.3), but only just, and then in only 12.4% of cycles documented. Cycle length changes with age, forming a U-shaped curve from the menarche to the menopause. Mean cycle length drops from 35 days at age 12 to a minimum of 27 days at age 43, rising to 52 days at age 55 years with an enormous range of cycle length.

Clearly, there is a wide variation in normal cycle length, especially in the first few years after the menarche and in the years preceding the menopause. It is important that normal biological variation be recognized by both women and their doctors so that they do not become obsessed by the 28-day ‘idealâ€^TM
Similarly, there are also misconceptions about duration of menstruation. In a series of 321 women in Oxford, average duration of menstruation was found to be 5—6 days (Fig 1.4, from Rees, unpublished observations). Furthermore, there was no difference in duration of menstruation between women with normal blood loss and objective menorrhagia.

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At any one time women might complain that their periods are: too short; too long; too frequent; too infrequent; too light; too heavy; too painful; too irregular; too early (menarche); too late (menarche); too early (menopause); too late (menopause); or too awful! This is excluding the complaint that it is unfair that they should have them at all and men are remarkably lucky.

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Disorders of menstruation form a significant part of the general practitioner’s work. This is not surprising since women will each experience about 400 menstruations between the menarche and the menopause. In a national community survey undertaken by MORI in 1990, 31% of women reported heavy periods. Of these, one-third had consulted a doctor within the past 4 months. The Fourth National Morbidity Survey in General Practice (1991—1992) (the latest figures since this survey is undertaken every 10 years) showed that for women aged 25—44 the consultation rates for menorrhagia were 65 per 1000 person-years at risk: and 5% women aged 30—49 consult their general practitioner for menorrhagia in one year. Menorrhagia is the main presenting complaint in women referred to gynaecologists and accounts for two-thirds of all hysterectomies, and nearly all endoscopic endometrial destructive surgery. When it comes to hospital referral, menstrual disorders are the second most common cause of all referrals for all ages and both sexes. Menorrhagia is the main presenting complaint in women referred to gynaecologists and is a common indication for surgery. Management has changed with the use of new therapeutic options. In the mid-1980s therapeutic endoscopic endometrial destructive operations and in 1995 the levonorgestrel-releasing intrauterine device were introduced in the UK. In 1988 in NHS hospitals in England 78 043 hysterectomies and 649 endometrial destructive operations were performed. In 2000/01 there was a reduction in the number of hysterectomies (47 052) and an increase in endometrial destructive techniques (17 298). An inverse social gradient in hysterectomy has been observed in several studies. Hysterectomies for menstrual bleeding have been shown to be inversely related to social class and education and have become more common at younger ages. It has recently been shown that the social differentials in hysterectomy are greater at younger rather than older ages, which may reflect different indications for surgery (Marshall et al. 2000). P.2
The importance of menorrhagia led the Royal College of Obstetricians and Gynaecologists to publish two guidelines in 1998 and 1999 on its management in both primary and secondary care. However, uptake of the recommendations in primary care has not been uniform throughout the UK and substantial differences in management still exist between practices when investigating and prescribing for menorrhagia (Grant et al. 2000; Turner et al. 2000).

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