Interviewer: Gail Edgell
Gail Edgell: Can you tell us a little about PMS?
Dr. Cabeca: That’s a significant area for many women. I would say that over 80 percent of women at some point in their lives will experience premenstrual symptoms. The definition of PMS is a cyclic appearance of one or more of a large constellation of symptoms. There are over two hundred that have been described as symptoms for PMS. The most frequently encountered problems include abdominal bloating, anxiety, breast tenderness, crying spells, depression, fatigue, irritability, thirst and appetite changes, weight gain and ethereal degrees of edema. Many women will complain of a 5-pound weight gain during their periods. But primarily, there is some agitation and irritability. If a patient doesn’t notice it, more than likely her partner or a family member will.
Gail Edgell: How does this change as a woman ages?
Dr. Cabeca: Most symptoms occur during periods of great hormonal fluctuations during a woman’s life. The main times of those are menarche, when a woman first starts her period, and perimenopause. Perimenopause is the time around menopause. That can be anywhere from five to fifteen years. Typically, the average age of menopause is 52. But we are seeing symptoms of hormone imbalance in the 30s in more than half of our patients. Women have difficulty with periods or premenstrual symptoms in the early part of their lives. It may decrease after childbirth and increase again during the perimenopausal time period.
I also want to mention that in order to call symptoms PMS by definition, depression or irritability the patient is already experiencing needs to increase in severity. Approximately 30 percent of women experience that increase in severity during the week of or five days prior to the period compared to the five days following the period. PMS typically develops in the week to two weeks before the period starts and usually will resolve with the period. That is how we are able to classify symptoms as being due to PMS, or premenstrual syndrome.
Gail Edgell: How do we go about resolving these issues five to ten days before our period if we are in those perimenopausal years?
Dr. Cabeca: It’s important to first identify what the symptoms are. I give patients a menstrual calendar or PMS symptom record and have them keep track of their primary symptoms. Again, there are two hundred symptoms. But I want to know the top five that are most bothersome for them. I have them keep track of when their period is. And I actually have them keep track of what they are eating, how much they are drinking, how much they are exercising. Those are all areas that I want to change — I always want to encourage positive, therapeutic lifestyle changes.
I also have patients rate their symptoms. Say they are having bloating, irritability, depression. I have them rate those symptoms on a 1-to-5 scale for the entire month. Then I can see the symptoms that they are classically working on or are most bothersome. The class of symptoms will affect my treatment recommendation.
Gail Edgell: Is it a good idea for women just to do this on their own? If they are not living near your practice, could they take this to their own ob-gyn?
Dr. Cabeca: Absolutely. And often, once they see it on paper, they can start to address those symptoms themselves. Most commonly, the symptoms that we see are related to estrogen dominance, especially in our age range — women from their 30s, 40s and 50s. Estrogen dominance is the function of a lot of xenoestrogens in our environment, the hormones that we have in our food and dairy products, etc. Also, as a woman approaches her 40s, her levels of progesterone, the hormone of pregnancy or the luteal phase, starts to decline much more than estrogen declines. There becomes a gap. In order for us to bridge that gap, we have to balance out progesterone.
Symptoms of estrogen dominance are mood swings, irritability and depression. When a patient goes to the doctor, the first prescription of choice typically is Prozac. We are going to say, “No, there is something else going on here.” Other symptoms are irregular periods, heavy menstruation and menstrual cramps. Traditionally, she may be offered birth-control pills. If that doesn’t work, there’s the hysterectomy option. More symptoms include decreased libido, headaches and loss of focus during intercourse — if she wants to have sex, she can’t focus or concentrate during it. And what does that lead to? Divorce. These are classic symptoms of the estrogen dominance that we are seeing in the 30s, 40s and 50s.
To treat that, I recommend progesterone. We need it whether we do or do not have a uterus. Many women, again, will go to the doctor with these symptoms of estrogen dominance and PMS with heavy or irregular bleed and be offered a hysterectomy. Therefore, they do not have a uterus but will hopefully still have ovaries. Regardless, they still have the hormone imbalance that led them to having a hysterectomy in the first place. Treating them with progesterone helps to balance that out. We know that progesterone — bioidentical progesterone, not progestins that are in birth-control pills and some HRT, or hormone replacement therapy — can be very protective. We know that this induces apoptosis in breast cancer cells. It helps regulate the p53 enzyme. It induces the tumor gene bcl-2. So it’s very important that we, again, use what’s natural and balanced.
It’s important to also know what we are using and to use it safely. I often prescribe a progesterone cream to use just those two weeks before the period starts as a treatment regimen — typically, a nice low dose, 20 or 30 milligrams. I have patients use it on thin skin: the inner arm, behind the knees, the inner thigh, the labia, the vulva. They’re all very good, vascular areas that absorb the hormone very well. This treatment can also help with symptoms of incontinence or vaginal dryness and improve sensation during intercourse. Balancing estrogen dominance with some progesterone is the way to treat PMS.
Gail Edgell: I think the other way is focusing on food intake. Can you tell us a little bit about foods that contain estrogen and how we might be able to control estrogen dominance in that way?
Dr. Cabeca: Most of our dairy and meats are hormone-laden foods. You want to choose as much free-range and organic as possible when you are choosing your food sources, even more of a vegetarian diet. I have a saying in my practice: “No wheat, no sweet, very little red meat.” It’s easy for patients to remember. Basically, if you can pick it, peel it, fish it, hunt it, milk it or grow it, then you can eat it. If your plate satisfies those qualifications, you’re doing pretty well. You want to eat as many whole foods and organic foods as possible because you’re not sure what chemicals and pesticides are being used. I encourage that, especially with premenstrual syndrome, when your body is trying to tell you something. You need to address that, honor that, recognize that, and give yourself time to heal.
A lot is also about perception. In the United States, about 90 percent of us will experience PMS at some time. In Asia, it is reported that less than 10 to 20 percent of women will ever experience PMS. Cultural attitudes, personality, dietary issues all make a difference. Also, the United States is a stress-driven nation. Stress depletes our hormones. It’s not just in our heads — it’s in our bodies. It creates physiological problems. We can’t get rid of all the stress in our life. But if we can create controls for those stressors, it makes it more manageable.
Aerobic exercise is very important to recommend to patients with PMS — for instance, boxing, which I love. We’ve also mentioned triathlon training. But just getting out and walking is very therapeutic. So are dietary changes. It has been noted that about 25 percent of women with PMS are low in calcium. Over 25 to 50 percent are low in Vitamin D. We know how important Vitamin D — which is actually a hormone — is in helping with depression and mood disorders. Ninety percent of women are low in folate and Vitamin E. Fifty percent or more may have a deficiency in iron, manganese and zinc. Therefore, replacing those nutrients is very important.
Focus on eating a diet high in leafy green vegetables, good protein sources, balanced amino acids. I start each day with a purity cleanse. It’s a balanced amino-acid detox shake that supports Phase 1 and Phase 2 detoxification of the liver. So it helps clean out the hormone-processing organ — the liver — but also helps decrease inflammation. All the amino acids help with neurotransmitter development. Therefore, I feel better, think clearer and feel stronger. Starting out with a balanced, good protein meal for breakfast is so important. However you can get it, it’s the most important meal of the day. Another of my sayings is “Eat breakfast like a king, lunch like a nobleman and dinner like a pauper.”
Fiber is another very important dietary recommendation for improving PMS. I may recommend flaxseed — fresh-ground flaxseed, 1 to 2 tablespoons daily. Flaxseed actually helps your body detoxify estrogen. Fiber is also very important in preventing constipation. Constipation helps your body reabsorb toxins; we want them out. So flaxseed can very much help with that and healthy hormone detoxification. No matter where we are getting the hormone, we want to make sure our body is getting rid of it safely. Omega-3 fish oils, flaxseed, broccoli, cauliflower, brussels sprouts, miso and tempeh can all help the body’s detoxification of estrogen.
Other important supplements to take are Vitamin B6, preferably a pyridoxal 5-phosphate — you do a hundred milligrams a day — and calcium, about 600 milligrams twice a day. Women should be getting approximately 1,200 milligrams of calcium a day, whether it’s through their diet or supplements. The better calcium is the glycinated or chelated calcium. MCHC calcium and calcium citrate are poorly absorbed. The forms of nutrients make a difference.
Gail Edgell: Can you sum up this topic for our audience?
Dr. Cabeca: If you’re experiencing symptoms of PMS or hormone imbalance, it is important to identify what is causing the hormone imbalance and work toward correcting it. If you do need to use hormones, use bioidentical hormones at the lowest effective dose possible under the guidance of a physician knowledgeable in that area. Taking hormones should not be regarded lightly. The same goes for other important supplements.
Clean up your diet, and exercise. We say that you have to think well, eat well, sleep well and move well to be well. Following those principles, choosing good nutrients — omega-3 fish oils, krill oil, magnesium, Vitamin B6, Vitamin E, Vitamin D, zinc — all of these can improve your symptoms tremendously. Help your body produce the hormones it needs to function safely. Often, patients will notice the difference within the first cycle, but most definitely by the second cycle.
I will be available for any questions. My website is www.cabecahealth.com.
Note: This article is an edited transcript of an audio interview. Changes have been made.