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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP 4. - PMS
RADIO 4
THURSDAY 17/03/05 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
SHAUGHN O'BRIEN
PRODUCER:
HELENA SELBY
NOT CHECKED AS BROADCAST
MYERS
Hello. Cool, calm and collected in the first half of the month, only to lose it in the run up to your period. Most women are aware of mood swings and other signs that their period is due, like bloating and tender breasts, but some women really suffer and so do their partners, in fact it's often the man in your life who's most likely to point out that you've got PMT. Premenstrual tension or premenstrual syndrome, as it's now called, isn't terribly well understood, though in the last few years it has been recognised as a distinct medical condition and there are new and effective treatments, especially for the more severe psychological symptoms. Research now shows that women who experience PMS have normal levels of hormones but have a low level of the brain chemical serotonin, this can be boosted by drugs such as prozac and seroxat.
Well my guest today is one of the doctors who's carried out research into the use of these drugs for PMS, he's Professor Shaughn O'Brien, consultant obstetrician and gynaecologist at University Hospital North Staffordshire. So if you'd like to speak to him about this or any other treatment for PMS call us now 08700 100 444 or you can e-mail checkup@bbc.co.uk.
Professor O'Brien, I know this is a women's condition but men really shouldn't switch off at this point, should they, because it does affect them too.
O'BRIEN
Not at all. It can have a major impact on not just the woman herself but it can have a major impact on the functioning of the family, the interrelationships and it can have a major impact on people in work - female colleagues and male colleagues alike. So yes it does have an impact there.
MYERS
Well Liz Row in Dartmouth know all about it, had PMS for years. Past the point now, I think, the symptoms have gone but your question then for our professor.
ROW
Hello.
MYERS
Hello Liz yes.
ROW
Hello. My question really is, I'm 71, I taught all my life, I didn't ever have a day off for what was never known as premenstrual syndrome, tension or whatever it was. We got on with it, we had a job to do, we had a family to bring up, my mother was the same and so was my husband's mother. I just don't understand why suddenly in the last few years this has become such an important point in women's lives.
MYERS
So you're saying we've gone soft a bit about this, we should just struggle through as indeed you and your generation had to - do we have to do that anymore I wonder Professor?
O'BRIEN
Well I don't think that has to be suffered anymore but what you have to realise is that maybe your experience was different from the experience of lots of other women. There's only about somewhere between 2-5% of women who get it really very badly. The other 90-95% actually do have symptoms but they're not so bad. So you might have been one of the patients more in the middle group or in fact you had it very badly and suffered in silence. There are lots of drugs available now and you wouldn't have to suffer in silence, so I'm not really sure whether you were suffering in silence or there were other women who had much more severe symptoms than you, who perhaps had been wrongly diagnosed as having some other psychological problem.
MYERS
But the good point is Liz having gone through the menopause at least you're free of these symptoms nowadays, is that the case?
ROW
Well obviously yes, I'm free of all symptoms but I do think that if - if there are only 3-5% of women who suffer from these things is there not a chance that this is something which is being put into women's minds and therefore even more drugs are being pumped into people?
MYERS
Well I hear your point, thank you very much for saying that, and we'll hear from others though as to whether it's something in their minds or whether it's something extremely serious for them and certainly they're not imagining it. But picking up the point you made there, which because you're postmenopausal you're obviously free of symptoms, that's not the case, I think, for everyone. Alice Kerr joins us now from Glasgow. Your point being that you still get PM - PMS, PMT?
KERR
Indeed and I actually have to laugh about it because I thought that once you were postmenopausal that you became a sort of androgynous figure and that you didn't have a cycle. And I have. I've had PMT for 45 years and I really was looking forward to the menopause to some extent.
MYERS
Have you not even got a little better?
KERR
I haven't. What happened was the HRT muted the symptoms for me. I'm now off HRT and back there it is again. And I can tell you to the day and the hour when it begins because I'm so used to it - I mean I've had 45 years of it.
MYERS
Is this unusual? Let me ask the professor and see whether he's got some advice for you.
O'BRIEN
Yes, it's very unusual to continue with the symptoms. It's not the first time I've heard it. It doesn't get - it can't really be the same premenstrual syndrome as we normally understand because we know that when you stop the menstrual cycle they disappear and when you, with the HRT, get the cycle back then you can restimulate symptoms. I actually missed whether you said your symptoms - what happened to your symptoms when you were on HRT.
KERR
They were muted.
O'BRIEN
They were muted?
KERR
They were muted.
O'BRIEN
And you were on week on, week off - three weeks on and then a bleed type of HRT were you?
KERR
No I wasn't, it was on a non-bleed.
O'BRIEN
So you were on the non-bleed continuous type and it muted it?
KERR
Yes.
O'BRIEN
Well there's an argument ...
KERR
And I always knew but it was definitely muted as compared to now. That's why I find it so strange, I just find it so interesting that I'm back on a cycle again but I don't have a breakthrough bleed.
O'BRIEN
That really doesn't fit in with all the science that's been stated. It may be that you have - maybe you've always had a cyclical problem with your moods and so forth which coincided with the menstrual cycle, that would be the only scientific explanation for it.
KERR
Ah, I don't understand - I know - I just find it quite fascinating.
O'BRIEN
Well it does sound as if you would benefit from perhaps going back on to that continuous non-cyclical HRT to keep away the symptoms if you felt your symptoms were bad enough to warrant it.
MYERS
And can you just help us with a little bit more of understanding how this whole syndrome connects with the menstrual cycle?
O'BRIEN
Right, now in a normal menstrual cycle you bleed about once every 28 days for about five days. Halfway through the cycle you ovulate. And then at the time of ovulation you produce a hormone called progesterone and that happens in all normally menstruating regularly ovulating women. So you have two weeks of progesterone and that's the precise time at which PMS occurs. Now nobody has ever demonstrated different levels of the progesterone, so what we've concluded - and there's a fair amount of scientific evidence to show it - is that some women are more sensitive to their own levels of progesterone than are women without symptoms. And a lot of the theory points towards this being the serotonin deficiency - that's the brain hormone which somehow - and it's still not fully understood - somehow allows women to be more sensitive to their own normal levels of progesterone in that second half of the cycle.
MYERS
So there's a complex link then, you're suggesting, between the hormones and if you like a woman's sensitivity to it and these brain chemicals - serotonin - and you know about that because when you treat women using serotonin then you get a good response, people feel a lot better, not just emotionally, psychologically, but in some cases physically too, so some of the range of symptoms can be relieved.
O'BRIEN
Yes absolutely correct. In fact you can approach treating PMS, severe PMS, either by suppressing the menstrual cycle in various ways, which we'll probably come back to, or you can actually boost the serotonin levels, making patients less sensitive to their own hormones. You can do that with the drugs like prozac and seroxat, they're called the SSRI drugs.
MYERS
Would this be relevant in this case for Alice?
O'BRIEN
I think from what Alice has said her best bet would be to use a non-cyclical HRT in a lowish dose which she could take for quite a few years with very little risk.
MYERS
So take that up again even at the age of 71, risks and benefits, there is of course quite a big debate about using HRT?
O'BRIEN
You'd have to weight it up against the severity of your symptoms, if the symptoms are very, very bad you could justify it, if the symptoms were mild then I think you'd be better off just putting up with the symptoms. If it was very bad you could also consider taking one of the SSRIs but I'm not so sure, it just depends how bad the symptoms are, like with most things that you treat in medicine and in life the worse the symptoms the more you can justify the treatments you're giving for it.
MYERS
Thanks for that answer and thanks for the question.
We've got an e-mail from Katie in Plymouth who says she suffers from PMS, has done all her life, and it plays a big part in how she lives her life. She says she's very unsettled, as are her relationships: For one week of the month I am a completely different person, she says, do you think a consultation with a doctor would be useful? I would have thought it would be essential.
O'BRIEN
Oh yes I think so, if it's causing that terrible distress which you do find in this proportion of patients, as I said 2-5%, if it's so bad then the first thing you should do I think is not just go straight to the doctor but suffer it for two months and actually keep a record of your symptoms - all of the different symptoms that worry you - keep those on a chart and also keep them in relation to when your menstruation occurs because...
MYERS
Why is that so important?
O'BRIEN
Well the whole key to this diagnosis is seeing that the symptoms occur before the period and then when the period comes, by the end of that period the symptoms actually disappear completely if it's the pure form of PMS.
MYERS
So if your symptoms, your difficulties, your relationship difficulties, don't really go adrift exactly in synchronicity with your menstrual cycle then you've got other problems, it's nothing to do with PMS?
O'BRIEN
Well I think so, usually and not 100% so, but usually if you've still got the mood swings and the depression and the bloatedness on the fifth and sixth and seventh day up to ovulation we're really talking about something different there because that's something that's there all the time. And if you start looking for a hormonal cause for that and start treating it with hormonal treatments then you're going to be - you're going to run into trouble because it's not going to work.
MYERS
Do you think Katie's likely to get a sympathetic hearing from her GP?
O'BRIEN
It depends on the GP.
MYERS
Really.
O'BRIEN
I think it does very much depend on the GP, there are some who are fully aware of what's going on, will be sympathetic to it and they may talk it through with you, offer you hormonal treatment or if appropriate one of these SSRI drugs. I'll tell you one important thing and there's a study that's being done - several studies that are being done now where the use of drugs like prozac and seroxat have only been used in the second half of the cycle - so you take them from day 14 to 28 and then you have two weeks on and two weeks off. And even given like that they're very effective in some patients.
MYERS
Another e-mail from Sheila and she has found, I think, a sympathetic doctor because she's visited him for uncontrollable crying, feelings of depression, she says, and irrational behaviour for five days before her period every month. She's on the pill and he is suggesting that she should take the pill for three months without a break. Is it safe, would this be sensible, she's asking?
O'BRIEN
Yes, that's quite a good plan. No one's really ever shown that the pill works, that's the first thing and sometimes PMS comes for the first time on the pill. If we're saying that the problem is due to ovulation, the pill stops ovulation and so you think well the PMS should go away. But when you give the pill of course you're giving the same sorts of hormones and you're giving them in a cyclical manner, so you may still well get PMS symptoms. So what you can try and works in certain patients is not to have a break - you take the pill continuously, you don't have a break, you don't ovulate, you don't have a period - and that can be very effective. And what most patients do is to actually have a break because they like to feel they're still functioning - have a break every three to six months and then have a period and then of course you'll have one episode of PMS every four months, three months or whatever it is. There's one key message there of course and that is a lot of patients think that if the period's not happening the blood in the womb is building up and one day some huge period's going to come along. But that doesn't happen, no, it doesn't happen, it actually stops the lining of the womb from forming, so there's no bleeding, just a little bleed when they come of it.
MYERS
Now I know a lot people like to try and deal with their symptoms, particularly if they're not too severe, by doing something for themselves, rather than having any sort of medical intervention. Charlotte in North London, who joins us now, thinks that avoiding alcohol is important, that's been your experience has it?
CHARLOTTE
Oh gosh it's not just that, I mean I do have - I've lost things, I walk into walls, I have mood swings, terrible sweats and not necessarily all the same symptoms at the same time, breast swelling - all these things that you've been discussing. But I think that through monitoring your sugar levels to a degree does help and alcohol obviously uses up sugar and I'm quite - I'm concerned about taking drugs that would alter your mood because I think that would be giving you artificial highs and lows, it seems to me that it's bad enough already without adding the hormones in - antidepressants into the equation.
MYERS
Are you sympathetic with Liz then who talked earlier about kind of soldiering on or would you actually like some help?
CHARLOTTE
No I know what she means, I mean - is that the elderly lady who called first of all?
MYERS
Yes.
CHARLOTTE
I'm not sympathetic with that because I think it is like the doctor said in a way - in a much subtle way than I'm probably going to say, the kind of thing well I don't get it so nobody else does, kind of mentality in a way and I found that with most things - if you don't ever have a symptom like PMS or period pains or arthritis, anything, if you don't have those things then maybe you're not - you don't understand why it would be a problem to struggle on. I do struggle on. The people that I work with said that you should talk to them because apparently I've been a right pain the last few days.
MYERS
Well you raise a good point there, do you tell people and the trouble is if you do - particularly if it's an employer for example - might you be stigmatised in some way, perhaps you lose chances of promotion, I mean professor what would you advise women to do, make a big point of it?
O'BRIEN
Can I just make sure you've got the diagnosis and I think you have but when you've had your period do the symptoms just disappear or do you still have them after your period?
CHARLOTTE
They do - they do fade yes, they do. My breast swelling seems to go down, I don't seem to be in such a - well no my brain doesn't feel like - I mean I'm having it at the moment ...
MYERS
You're doing very well.
CHARLOTTE
I've got a spongy brain and I - oh god.
O'BRIEN
You're leading up to your period now are you?
CHARLOTTE
Yes I am, I should get in the next couple of days, so I've had these symptoms for about seven days and for the last 25 years.
O'BRIEN
One good thing is, you see, you know that the period is going to come and your symptoms are going to go away for a period of time, so that makes it a little bit easier to cope with, so that's one thing. The other thing you should perhaps do - I think if you do let your employers know then they can be understanding - you tell them you're going to be good for two weeks at least in the cycle. With regard to the very first part of question I think you can do a lot of non-medical things and the NAPS - National Association for PMS have a website and a helpline and they can give you lots and lots of good advice on what approaches you can use that are non-medical and I think everybody should try non-medical approaches before going to their doctor, as well as filling in a two month chart to plot them, as I said earlier. So what I would do, if I were you, I would try reducing the alcohol and other things that don't seem quite right, see if that actually gets rid of your symptoms, if it does you've found part of the cure and you continue with that, if it doesn't work then you can go back to it I suppose. But contact NAPS because they're very, very good at talking you through non-chemical, non-hormonal and non-surgical ways of treating PMS.
MYERS
And last thought on that line, a question from Sarah Tyzack in Oxfordshire, which has come on the e-mail, which is about diet. She finds that eating lots of fruit and veg, cutting out almost all sugar and refined carbohydrates, eating whole grains, for example, seems to make her feel a bit better. Is there any evidence, I mean it's her evidence, is there any scientific evidence that that is a way forward for people?
O'BRIEN
It is a big problem with PMS because some people will respond to anything, so there's a placebo effect, and it is almost impossible to do a research study which compares these sort of interventions with a placebo. So I think you should try it and again if it works, that's the same for all patients really, if you try something and it's yoga or acupuncture and so long as they're not too expensive, and if it works then that's right for you. And patients respond individually to different things.
MYERS
Peggy Billett joins us from Bath and is finding some things quite useful - evening primrose oil for example?
BILLETT
Yes that's right. I couldn't go on HRT or anything like that because I come from a very high risk cancer family, so my doctor, after I went in desperation that I was feeling like I wanted to murder people for one week every month, he gave me a video which explained what was going on and also recommended evening primrose oil and B6, which I still take now because I tend to be hormonal still. But I had a lot of the symptoms that the ladies have already said - the sweating and the swelling - and I also had, nobody's mentioned it, dreadful craving for chocolate and I could eat boxes of it and pounds of it but I was extremely hyperactive while I was in PMT, but I used to just warn everyone to stay away from me basically.
MYERS
I take it now you're postmenopausal, you're saying ...
BILLETT
I am - I am now.
MYERS
... so it's pretty well resolved now.
BILLETT
Yes. Now the only thing I was thinking that I still take - I get SAD, which is a serotonin lack of in the winter, so I still take evening primrose oil and B6 and try and do it homoeopathically. But I'm not a terribly stable person, I don't know whether that's anything to do with - or whether it's purely physical.
MYERS
Well let's get a comment from Professor O'Brien.
O'BRIEN
You probably had a mixture of things before - bit of - maybe a little bit of underlying moodiness, seasonal affected disorder I think you mentioned and a combination of PMS and all of those. So the PMS ones have gone, all the ones related to the hormone cycle, so you're probably still a little bit left some of the things that were there before but you're only left with those now. Evening primrose oil is completely harmless but expensive I think but is one of the good fatty acids that people are recommending for general diet. Vitamin B6, well that is involved in producing serotonin, it's one of the co-factors in the chemical pathways, so maybe - it's never been proven to work - but maybe that's a good reason for why this might be working. You certainly won't be doing any harm by taking either of those and so if you're finding - again if you're finding it's effective then you should continue it.
MYERS
Thanks for the question Peggy. We'll move to Devon, we talk to Babette Jackson, who's got a daughter with problems, tell us a little bit about her.
JACKSON
Hello, good afternoon. Yes our daughter has been suffering from premenstrual dysphoric disorder since she was 13, so just when she started menstruating we discovered she had a cyclical problem and was getting completely cut off for a whole week - not being able to go to school and function socially and even to the extent where she would not be able in the morning to get dressed and do sort of very basic getting dressed and needing our reassurance and not being able to make up choices whether she wanted tea or various other things. And this going on for eight days and this has been going on now since - well for the last nine months. And she started being given [indistinct drug names] for 14 days and there was not much change and then she was prescribed the combined pill - Yasmin - for three months and as I said - you mentioned previously - she was given it back to back but her periods were not suppressed.
MYERS
Okay, look I'm going to interrupt, not to be rude but just because that's quite a lot to take in, and let me ask the professor. I mean first it seems desperately young, just as soon as the daughter has started her periods she's already into this desperate cycle.
O'BRIEN
Well first of all, it's always been said that women have PMS later on in life and it follows having children and so forth but that's not true. The minute some young girls start to ovulate, rather than menstruate, when they first start to ovulate they can get quite severe PMS. And what used to happen in the past they were under-diagnosed because people would say oh that's puberty, that's being an adolescent, that's being a teenager and they would never - never identify this diagnosis. So young girls were wrongly accused when they actually had PMS, which can be very severe. You've obviously got a very good GP, because he's obviously up to date, he's tried the appropriate things. I don't know if he's tried Yasmin continuously because there's one research study showing that Yasmin, which is one of the oral contraceptive pills but has got a slightly different formulation, there's one good study showing that that's effective. But I would say that we should try it continuously without a break and see how that goes. If she is so badly affected and it's clear cut and she has a good three weeks out of the four then I know it's controversial in young people but it may just be worth trying a very low does of one of the SSRIs like prozac just in the luteal phase of the cycle, that's just in the second half of the cycle, that may be worth trying because I must be honest there aren't many other things that are going to be useful for someone so young.
MYERS
And just a quick comment on that - is it something that goes in families?
O'BRIEN
There seems to be a link in families, we've been doing some genetic studies which haven't shown that at the moment but we're looking at different angles of the genetic studies to see if there really is a family incidence.
MYERS
We've got another e-mail I'd like to throw in quickly, it's from Ian Payne, who says he heard about Check Up and wondered if men suffer a similar problem - he says call it PMT for argument's sake - within their own body cycle?
O'BRIEN
Men have a hormone cycle which is not like a menstrual cycle, it's a sort of three monthly cycle and it's not in any way as profound as the female hormone cycle, but people have shown a cycle of mood change that follows that.
MYERS
You don't think it's a reflection of their partner's mood changes?
O'BRIEN
If they've got a monthly cycle then that's going to possibly - and quite been well documented - that that is related to the partner's cycle.
MYERS
Okay, well interesting point to end on and there we must indeed end. Thank you very much indeed Professor Shaughn O'Brien for your expertise today and thanks as ever to everyone - and there have been lots of you phoning in or e-mailling. If you'd like to hear the whole programme again you can do that, go to our website bbc.co.uk follow the trail to Check Up. If you'd like to speak to someone then go to our helpline, call 0800 044 044. And I hope you'll join me again next Thursday afternoon at 3 o'clock when our topic will be obsessive compulsive disorder.
ENDS
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