Key
words; Premestrual syndrome, stress, drugs, antistress therapy.
In 1998, during the 2° World Congress on
Stress, in Melbourne, I read a free communication on the pre-menstrual syndrome
as paradigm of an internal metabolic stress.
Some time later I
inserted this communication in my Internet site, putting it into the field
named Speculations, since I did not had got yet any satisfying clinical case
history about what I sustained and I am
sustaining it.
So
I wrote there:
Now, I am
convinced that neither the last three
are specific symptoms. Only recently, however, it occurred I could verify in my clinical practice what I had
realized.
I
treated a PMS, till now rebellious to the usual therapies (Douglas, 2002), with
antistress drugs, since the symptoms of stress were evident.
The
case history.
07.09.2002:
She is nearly 32 years at the first consultation and complains for a PMS with
depression, anxiety, retchs, colic pain and of the kidney areas, weeping,
desperation sense, irritability towards the objects and the persons, not more
mammary tension after stopping of the oestrogenic-progestinic pill, some sleep troubles, abdominal swelling, headache,
foods' refusal (Cross et al, 2001), a lump in the throat, unwillingness, faint feelings, not
stomachache, tiredness, bad thoughts, not intrusive thinking, light early-morning
fatigue.
Starting therapy
(daily doses): Glutamine 125mg; pyridoxine 150mg; carbamazepine 200mg;
amitriptylina 6mg; diazepam 5mg.
11.01.2003: She
shows a more relaxed face and looks more beautiful, as many persons told
her. Fourth menses after therapy, her
PMS nearly disappeared. Her husband says that she changed very much, in a better way. They are left some hot flashes,
some armpit oversweating, a light migraine and initial feeling sick, some
furuncles. She did not feel mammary
tension as well as feelings of whole swelling anymore.
With
the SAMe she has improved decidedly her sexual satisfaction, and at work she is
going well. She has still fat hairs, and
is always sensitive to the odours in the premenstrual period, even if some
lesser. Some colic pain remained, and she is feeling tired, even out of the
premenstrual period, but she admits that she had a great deal to do. The liver
enzymes are increased, for which the carbamazepine stopped.
This
is the report this woman wrote on 04.11,2002, of which I reproduced only
meaningful parts, while the whole text is in the Italian version.
My
name is M. L:, ... I had fallen into the abyss of the depression, because
pathology..., called "the premenstrual syndrome."
When
this compound stopped to work, I assumed other commonly used antipain dugs.
The
assumption of this drug went along for about two years. Initially the pain
disappeared, however when the time went on it came out again, not limited to
the abdomen only but even the pelvic zone, the anus, the vagina, with so
violent contractions such to jeopardize even the urination.
So
I was forced, on suggestion of the gynaecologist, to assume the
oestrogenic-progestinal pill.
In
facts I began to live in a bit of terror for the arriving menses. I cried and I was irritated
till the starting of the menstruation and for the following 3-4 days.
The
panic attacks became always stronger and now they could begin even 15 days
before the menses. I was always more unsociable and without any interest.
The
PMS did not appear even in the following menses. I began so my second therapy month, and my body has
overcome side-effects of the preceding month, even for the fact that my regimen
had a drug changed. There are however
blue days, where I warn the desire of crying, but then it passes. During my
duties, my colleagues said me they find me different, in comparison with some
months ago, more serene, more open towards persons and the talk."
03.05.2003: After stopping
of the pill she has deflated. The control of the liver enzymes showed
parameters in the normal range. At work her colleagues find her well, she
speaks more, has more ideas, is better in the group. All, from the husband,
find her changed in better. She had premenstrual periods without colic ache and
without panic attacks, even if she suffered the springtime seasonal stress. In
particular:
February
2003: In his premenstrual period she was unwilling for two days, with weeping,
anxiety perceived mainly at the door of the stomach, irritable, unsociable,
with pimples and hot flashes. No panic attacks, but great tiredness, which
lasted even several days after the premenstrual period. The general health
physician found her with low blood tension (ABT: 110-70 Hg), as usually she
does in springtime, with tiredness, dizziness, blurred vision, tachycardia. She
was given midodrine hydrochloride 2.5mg daily by the oral via. She thinks that
the severity of this premenstrual syndrome was about 70% as compared of which
experienced before the antistress drug therapy.
March, 2003: The premenstrual period (about seven days) featured nervousness,
weeping, exaggerated worries as for the work of the husband, hot flashes, lack
of appetite that then went on. She did intake little amounts of food, and the
weigh did not change, but she had the feeling of her stomach door closed. She
did not worry about her coming menses. She thinks that the severity of this
premenstrual syndrome was about 70% as compared of which experienced before the
antistress drug therapy.
At the March end she had flu with vomit and stomachache.
April 2003: She suffered from nervousness and irritability in her premenstrual
period, with a crying fit, during which she warned a suffocation feeling, but
weeping stopped after some minutes. She has eaten without any problem. She
thinks that the severity of this premenstrual syndrome was about 80% as
compared of which experienced before the antistress drug therapy.
3 May 2003: Her premenstrual period is now running, and it seems less severe,
in comparison with the preceding month.
Therapy prescribed, daily doses, by oral via: Amitriptyline 8mg, diazepam
5.6mg, creatine 1 g, SAMe 200mg, pyridoxine 150mg, oxcarbamazepine 150mg.
08.11.2003:
Altogether she is doing well, but she had several blood losses from the uterus
and she was given a curettage. The premenstrual syndrome is decidedly reduced,
even when other reasons of stress added. On October, she felt the seasonal
stress, with working problems, for which she had impatience versus nursed
patients. In premenstrual days she has pimples in her face.
Unchanged
therapy.
This
is the written note by the patient I got on 11.08.2003 with the time course of
the six last months of drug therapy.
"
In May I had an other consultation with Dr Cocchi, very expected by myself
because, since the spring becoming, my psychosomatic balance [or, better: My
somatopsychic balance?] inclined to deteriorate. The anxiety was increasing and
with it, mainly in stressing moments tied to my work turn, first the
tachycardia, then fit of crying and air hunger.
Physical
tiredness occurred also, and I perceived it particularly to hips and to the
inferior limbs muscles, so that I laboured in going up down the stair and in after
short walking. On advice of my family practitioner, I left my work for seven
days, looking for restoring so what I had previously reached. Only adding
diazepam even to the mornings and creatine, my balance recovered.
As
for the following May and June, they were two particular and complicated
months. Since March-April between two menses I had blood losses to which I did
not mind and I did not want to consult a gynaecologist.
Subsequently,
the blood losses transformed in a continuous menses that covered entirely the
May month and June. In facts the menses came regularly, but at the end of it,
after four or five days, it began a second blood loss, which fully lasted
between a cycle and the following.
I
started to have agitation, and often to bother me, with the always fixed
thought on that happening, and I came to cry because I feared that could be a
cancer. My family practitioner convinced me to consult a gynaecologist, who
proposed me an operation of curettage to solve the problem. The US scan
diagnosed the presence of microcystes into the left ovary, in addition of the
fibroma, of which I was already informed. In those two months I was much
anxious, with strong stomach pain and retchings (not in the premenstrual
period).
July:
The hospital that had to do my curettage communicated me the date of the
intervention with only three days in advance. I was forced to stop all the
therapy in course, because the curettage should be acted in general anaesthesia
[a prudential attitude, but not an essential one]. The family practitioner then
prescribed me 15 rest days, with absence from the work, a period I lived as a
nightmare. I feel me without any energy, with a strong back pain at the level
of the kidney areas, and my mood worsened in noticeable way.
I
was in a blue mood, with long crying moments, oversweating, some air hunger. I
did not succeed to feed me, even for the hot weather, I was always home
stretched out on the bed or on the couch because my lumbar pain. When I walked
in the street or in the courtyard the pain increased.
When
I was home alone, it seemed that the whole world was gaudy against me, and I
slept much either by day and by night. The haemorrhage after surgery did not
elicit any problem, but according to Dr Cocchi, the amitriptyline grew to 16mg,
daily.
August:
A calm month both at home and at work, and the general being improved in
notable measure. The histological report resulted negatively. During the first
two days of the menses I was successful to feed me only a few following the
nausea and the hypersensitivity to the odours. I had strong hot flashes, which
let me uneasiness on the job. For the remaining things, not menstrual pain, in
spite of the curettage and not panic attacks occurred.
September:
An exceptional month, even because in summer holidays during the first two
weeks. In holiday I was relaxed, taking part in the proposed activities, I went
out for some excursion or I rested. Before the departure, in accord with Dr
Cocchi, I reduced the amitriptyline to 12mg. The climate was warm but well
airy. I came back at home in the 4-5 days preceding the menses. This time
however the appetite was excellent, to such a point that I had to halve every
ration, because the hunger I felt was excessive, and however I increased two
kg. The psychophysical state was well, without anxiety, but light irritability,
many bursts of heat, which unfortunately continued, and I found me in a boring
bath of the sweat.
October:
In premenstrual period I did not have any nausea, and so I successfully ate
without any problem. I had annoying hot flashes, lumbar pain and, desultorily,
light tachycardia. I felt me as sensitive, with vulnerability to some events,
as the memory of what I lived, with related psychological changes.
To
conclude, I am doing well, different, even if sometimes I fear to come back as
I was. I think that me even the psychotherapist helped me a lot to correct my
attitudes or behaviour related to wrong entangled ideas on me the same. Because
the depression I felt me as different, not normal, and I accused me of what was
happening and I made me guilty. This guilt sense overpowered me, giving me a
kind of suffocation, and limited me not only in the couple's life, but even in
the work.
Now, thanks the
drug therapy and to the psychotherapy I can control better what happens me. So,
because I feel myself more sure, and I succeed to express in a better way what
I think or I feel in a particular circumstance.
About
two weeks ago, during a working time, a colleague with whom I am rarely in a
couple, said me "L, I do not know what you have had, and has done, but you
are much changed." I perceived this observation much favourably, even if I
did not answer, for the delicacy of the problem, but I only smiled.
The
depression is a terrible illness, and anyone who did not experience it, does
not understand it.
June
2004: She is doing well. Now, her face is much different, more relaxed and more
oval. Her premenstrual phases are much bearable. Not all the months she had
headaches. Sometimes she had nausea and lack of appetite. The pain is nearly
missing. She has some metrorrhagias and she assumes a progestinal drug for it.
Groundless tachycardia happened and she had some low blood tension. Between
February and April she had a depressive moment, primarily of the asthenic type.
Her job is going well. Now, she attends a professional course to improve her
situation in her work.
Therapeutic
variation (daily doses, by the oral via): Diazepam stopped; Bromazepam 2mg;
SAMe 100mg; pyridoxine 37.5mg.
This
is the written note she bought to me on 05.06.2004.
"Since
November, when I did the last checkup with Dr Cocchi, till now my health
situation improved. The menses did never create any anxiety problems, phobias,
want to die. By now I do not have any fear of them.
However,
during these months some episodes of nausea, lack of appetite, headaches
occurred but not to every cycle. What now worries me as a few are the uterine
blood losses that are relapsing, in spite of the curettage I underwent the last
year. This doesn't happen every month, a fact that causes me some emotional
stress, even if I am under control of an endocrinologist.
In
spring, or better since February, I started to have tachycardia at rest, mainly
when I was going to fall asleep, or in home, in company of persons during relaxing
moments, without any specific cause for their onset.
This
troubles did not encompass the premenstrual week only, but it had a random
onset. I felt a sense of oppression to the chest, my temples pulsated strongly,
as even the carotids, and I had air hunger. When I was in bed, I had to lead
myself in sitting position because the suffocation feelings and the need to
breathe deeply.
By
minding the season change, as previously Dr Cocchi advised me, I added eight
drops of diazepam [ 1.6mg] in the mornings. This year did not succeed in
bearing it. I was not able to face the day. I was sleepy, although busy in the
study [she is attending a professional course] and in the work, and I felt much
asthenic. I had to stop this morning's diazepam. With the usual therapy I felt
me better, even if however the tachycardia did not disappear, and I had it
throughout all April, disappearing slowly. On May low blood tension occurred,
and I did face it with midodrine drops, the general practitioner prescribed me.
The
premenstrual syndrome disappeared, or at least not there are not more those
dreadful days that came back every month. Sometimes I have some nervousness,
some sudden mood change of depressive type, but sometimes I laughing till the
tears. I am attending a course of specialization for nursing, and in spite of
my initial perplexity, at the end I find me well there. However, it was, at
least in the first times, a reason of further stress.
To
guess, I perceive myself as changed, and the persons with whom I am in touch every
day go on to observe it, either work colleagues and family members. They
reported me that I have my face features more serene and relaxed.
As
for me, I am ready to reduce the drugs if Dr Cocchi thinks it suitable [????
And so, even if we are dealing with a substituting therapy?]. I think still now
to what happened to me and to the fact of not being aware that I needed a
different help, by leaving to spend so many years and by living with horrible
mood and desire to die. The depression is an awful state, and some weeping in
my premenstrual days is neither distantly comparable to what I suffered before
I started this drug therapy.
June
2004, after two weeks from the latest checkup, by phone: She says that she did
not face the lightening of drug therapy. Now, she is depressed, crying, much
irritable. Even the patients elicit to her much nervousness, but she controls
herself and does not show it.
The
premenstrual period that occurred meanwhile, was nearly a return to the past,
as ugly as it was.
I
advised her to return to the preceding drug therapy, by stopping bromazepam,
and taking diazepam and doubled doses of SAMe and pyridoxine.
First
10 days of the January 2005: This is sixth checkup after 27 months of
antidepressant-antistress drug therapy. At the actual doses of drugs the
premenstrual period is much bearable, if not nonexistent.
She
has ended brightly the course of health specialization and this has reduced the
causes of stress. In the change of the season she has been a little dysphoric,
moreover shows traces of fatiguing the greater working load. Her mood is
currently normal.
She
goes on with the current therapy.
First
ten days of June 2005: The premenstrual period is much tolerable. Not all the
months she had the headache. Some time she has nausea and lack of appetite.
Pain did not come out. She had metrorrhagia, and she is under treatment by the
low dosing luteal hormone. It appeared some casual tachycardia, with pallor
episodes and low blood tension. The job is going well.
Therapeutic
variation (daily doses, by the oral via): Bromazepan 2mg.
First
10 days of December 2005. Altogether she is well off. Now, the menstrual cycle
is regular. She did not suffer anymore from metrorrhagia. Lately she had some
attacks of frontal and centre skull headaches. The job is always going well.
She attends a gym. The face is more serene, more relaxed. She thinks she sleeps
still too much [Is it a compensation symptom?].
Therapeutic
variation (daily doses, by the oral via): Bromazepam 1.6mg; amitriptyline 6mg;
oxcarbamazepine 300mg; pyridoxine 75mg.
Discussion.
The
presumed action of the female steroid hormones on the release of some brain
neurotransmitters involved in the mood control, does not enough explain many
symptoms of that woman. Not specific symptoms of the PMS were found even in other stress reactions in
males male (Cocchi, 1998).
Though
about the 90% of the women are suffering from PMS, the fact that about 10% of
them is free of it, needs further explanations.
For
an acquired good threshold of response to the stress, I mean a threshold that did not have stable
alterations of the hippocampus-cortico-suprarenal double feedback, otherwise
induced by burden risk factors that mostly acted in pre- peri- neonatal time
(Sapolsky et al., 1990).
But when these women are fighting other
stresses, without any relationship with the menses' cycle, the SPM can emerge,
since the sum of the stresses surpasses even the resistance of the high
threshold they own.
- the PMS was
particularly imposing;
- an
estrogenic-progestinal therapy of 15 years, with five different combinations of
the two hormones, had given
disappointing results, mainly on psychic symptoms;
- the
psychotherapy, after an initial improvement, could not maintain it.
Therefore
the hypothesis of an antistress therapy by drugs should were justified from the
ineffectiveness of both the hormonal and the psychological treatment,
beyond the presence of stress symptoms,
mainly psychic ones, other than those of the PMS.
The
demonstration that the drug therapy should be individually tailored, to act on
stress reactions that are in its turn individualized, may be found in the fact that I had to stop
the glutamine, a physiological compound of primary importance in the balance of
brain neurotransmitters, where it is the precursor of the glutamic acid and of
the GABA.
Twenty-six
menstrual cycles with very reduced PMS can always be debatable for this different therapeutic approach, in a form of
PMS no longer responder to traditional
treatments. However, the thing has worked since the first cycle, following the
drug therapy I theoretically foretold.
With
the last updating on December 2005, the report of this case history ends, after
39 months of antistress drug therapy.
References.
Cocchi
R.: Pre-menstrual syndrome
as the paradigm of an internal biochemical stress. The 2nd
World Congress on Stress, Melbourne, 1998.
Cross
GB; Marley J; Miles H; Willson K.: Changes in nutrient intake during the
menstrual cycle of overweight women with premenstrual syndrome. Br J Nutr 2001,
85: 475-482.
Douglas S.: Premenstrual syndrome. Evidence-based treatment in family practice.
Can Fam Physician 2002, 48: 1789-1797.
Mortola
J.F.: The premenstrual syndrome. Curr. Ther. Endocrinol. Metabolism. 1997, 6:
251-256.
First on Internet
on January 2003. Copyright by Renato Cocchi, 2003
Author's
address: Dr Renato COCCHI, via Rabbeno, 3,
renatococchi@libero.it