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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 20 of 20. This is the beginning of the thread.
Posted by Cady on January 16, 2009, at 5:49:58
I have bipolar disorder and either PMDD (severe PMS) or PME (premenstrual exacerbation of bipolar disorder). Not sure which, but either would be the result of ovulation followed by other hormone changes in the 2nd half of the cycle.
I have found that birth control pills stop the PMS by stopping ovulation, but cause equally bad mood problems, especially as the blood levels of progestin increase over the course of the month. This is true of all pills. I switched to NuvaRing which is a lower dose than any pill and blood levels are steady throughout the day and month. Much better.
The problem is that all of the above interact with a lot of psych meds, limiting my treatment options for bipolar disorder. If you have heard that NuvaRing does not interact, that's not true. It is metabolized the same way -- full prescribing information confirms this. Another problem I have with taking hormones is the serious health risks (blood clots, stroke, etc.)
Anyway, if there were another alternative, I would try it. I can't take antidepressants because they make me manic (trust me, it doesn't matter which type of AD).
Has anything else worked for anyone on severe PMS?
Posted by seldomseen on January 16, 2009, at 7:30:46
In reply to Ideas on female hormonal dilemma?, posted by Cady on January 16, 2009, at 5:49:58
I may have a radical proposal, but first what bipolar meds are you on/tried?
Seldom
Posted by Larry Hoover on January 16, 2009, at 7:38:35
In reply to Ideas on female hormonal dilemma?, posted by Cady on January 16, 2009, at 5:49:58
> Has anything else worked for anyone on severe PMS?
I can't speak from experience, but I hope you haven't overlooked nutritional aspects.
There is solid evidence that calcium supplementation improves PMS symptoms. Participants in a double-blind study took 300 mg calcium carbonate 4 times a day.
There is weaker evidence for the efficacy of magnesium supps, but most people are deficient anyway. 300 mg/day would be a good target.
To ensure uptake, you need to have sufficient vitamin D, so 1000 IU/day would be sensible.
There is lesser evidence for the efficacy of vitamin B6 (pyridoxine), perhaps because some people don't utilize the most common supplemental form very well. Therefore, a trial of activated B6, P-5-P (pyridoxal-5-phosphate) makes more sense. 100 mg/day in the week preceding symptom onset would be a good trial. Because increased intake of one B-vitamin increases demand for others, it's a good idea to combine the P-5-P with a B-complex supplement.
And finally, gamma-linolenic acid has a folk reputation for alleviating PMS, particularly that found in evening primrose oil. It may even be another fat in EPO other than the GLA that has some effects. Hard to say. Doses as high as 4000 mg/day are in the literature, but I'd go with perhaps 1200. Also, it's more effective with e.g. fish oil (long-chain omega-3 fatty acids).
I've listed them in the order of proven efficacy, but in any case, don't try all of them at once, or you'll have no idea which substance, or which dose, has any benefits.
Regards,
Lar
Posted by SLS on January 16, 2009, at 8:54:56
In reply to Ideas on female hormonal dilemma?, posted by Cady on January 16, 2009, at 5:49:58
Hi.
What do you experience during your PMDD episodes that you do not experience during the rest of the month?
Rage?
Anger?
Impulse control?
- Scott
Posted by SLS on January 16, 2009, at 9:29:54
In reply to Ideas on female hormonal dilemma?, posted by Cady on January 16, 2009, at 5:49:58
Hi Cady.
Hi Larry.
For what it is worth, I performed a quick review of PMDD literature and "alternative" treatment approaches. I just wanted to say that I found that Larry's list of alternative is accurate and very well presented.
Larry, what is chaste-tree berry extract? I saw this mentioned.
I also saw suggested a low fat diet and exercise.
- Scott
Posted by Phillipa on January 16, 2009, at 10:48:54
In reply to Re: Ideas on female hormonal dilemma?, posted by SLS on January 16, 2009, at 9:29:54
I feel very lucky as didn't have PMS when of the age just one day of increased anxiety and then a three day headache and some weight gain. Long time ago but found the B6 per my ob-gyn did work. Figured if I retained fluids in other body parts headaches could be from swelling also. And it worked. Phillipa ps wierdly even now post menopausal once a month get headaches for three days stange. Phillipa
Posted by B2chica on January 16, 2009, at 11:56:53
In reply to Ideas on female hormonal dilemma?, posted by Cady on January 16, 2009, at 5:49:58
have you tried any mood stabilizers like lamictal?
what about AP's such as abilify or zyprexa?
Posted by Cady on January 16, 2009, at 17:25:05
In reply to Re: Ideas on female hormonal dilemma?, posted by seldomseen on January 16, 2009, at 7:30:46
> I may have a radical proposal, but first what bipolar meds are you on/tried?
>
> SeldomI take Lamictal, Abilify, and a benzo (as needed). Estrogen decreases Lamictal, so I take extra Lamictal. I have also tried Gabapentin and Topamax. I stopped Topamax after one or two months because it reduced the estrogen to the point where my cycle was not regulated at all. I wanted to try Trileptal instead of Abilify, but it interacts like Topamax. I asked my ob/gyn if I could take extra hormones to offset the Trileptal, and she would not entertain the idea. I know some women do take extra to offset interactions like this, so I might ask another ob/gyn.
Posted by seldomseen on January 16, 2009, at 17:48:50
In reply to Re: Ideas on female hormonal dilemma?, posted by Cady on January 16, 2009, at 17:25:05
Here is my radical proposal. I would come off the hormones altogether and let the abilify and lamictal work to see if they control the PMDD.
If this is simply not an option, then I would see if there is a women's psychiatric clinic in your area - they are usually at large medical centers. I just don't think an OB/GYN has the specialized training to manage bipolar disorder in the context of PMDD. Likewise, a psychiatrist might not either, but the two combined might give you a better shot.
Seldom
Posted by SLS on January 16, 2009, at 18:04:31
In reply to Re: Ideas on female hormonal dilemma? » Cady, posted by seldomseen on January 16, 2009, at 17:48:50
> Here is my radical proposal. I would come off the hormones altogether and let the abilify and lamictal work to see if they control the PMDD.
>
> If this is simply not an option, then I would see if there is a women's psychiatric clinic in your area - they are usually at large medical centers. I just don't think an OB/GYN has the specialized training to manage bipolar disorder in the context of PMDD. Likewise, a psychiatrist might not either, but the two combined might give you a better shot.
>
> SeldomSounds good to me.
Cady, you didn't answer my questions.
Anyway, I was driving at the possibility that Trileptal would be a good drug to try.
Lamictal might be good for the bipolar, but has not shown efficacy in PMDD. In fact, I have seen some women with PMDD report that it made them feel worse - anxiety and agitation and aggression.
- Scott
Posted by Larry Hoover on January 16, 2009, at 19:27:03
In reply to Re: Ideas on female hormonal dilemma?, posted by SLS on January 16, 2009, at 9:29:54
> Hi Cady.
>
> Hi Larry.
>
> For what it is worth, I performed a quick review of PMDD literature and "alternative" treatment approaches. I just wanted to say that I found that Larry's list of alternative is accurate and very well presented.Thanks, Scott.
> Larry, what is chaste-tree berry extract? I saw this mentioned.
It's a progesterone-receptor agonist, I believe. Rather than re-invent the wheel, here's a link:
http://health.howstuffworks.com/chaste-tree-herbal-remedies.htm
Regards,
Lar
Posted by Cady on January 16, 2009, at 20:24:22
In reply to Re: Ideas on female hormonal dilemma? » Cady, posted by SLS on January 16, 2009, at 8:54:56
> Hi.
>
> What do you experience during your PMDD episodes that you do not experience during the rest of the month?
>
> Rage?
> Anger?
> Impulse control?
>
>
> - ScottThe mood symptoms are irritability progressing to rage. I also have other symptoms like food cravings, clumsiness, muscle tension, headaches.
Posted by Cady on January 16, 2009, at 20:44:11
In reply to Re: Ideas on female hormonal dilemma?, posted by SLS on January 16, 2009, at 18:04:31
> > Here is my radical proposal. I would come off the hormones altogether and let the abilify and lamictal work to see if they control the PMDD.
> >
> > If this is simply not an option, then I would see if there is a women's psychiatric clinic in your area - they are usually at large medical centers. I just don't think an OB/GYN has the specialized training to manage bipolar disorder in the context of PMDD. Likewise, a psychiatrist might not either, but the two combined might give you a better shot.
> >
> > Seldom
>
>
>
> Sounds good to me.
>
>
>
> Cady, you didn't answer my questions.
>
> Anyway, I was driving at the possibility that Trileptal would be a good drug to try.
>
> Lamictal might be good for the bipolar, but has not shown efficacy in PMDD. In fact, I have seen some women with PMDD report that it made them feel worse - anxiety and agitation and aggression.
>
>
> - ScottScott, I hope I have answered your question now (separate sub-thread, but basically the answer was irritability to rage). I started answering questions then got called away.
I like both ideas. Could try no hormones and current meds first. Then no hormones and Trileptal if that didn't work. Then back to hormones if needed. (Scott, do you happen to know how long Trileptal can take to work?)
No women's psych clinic here, unfortunately. Wish there were.
Posted by Larry Hoover on January 16, 2009, at 21:00:21
In reply to Re: Ideas on female hormonal dilemma?, posted by Cady on January 16, 2009, at 20:44:11
Cady, I hope you'll consider the calcium/vitamin D angle seriously, too. One of many medical references.....
J Am Coll Nutr. 2000 Apr;19(2):220-7.
Micronutrients and the premenstrual syndrome: the case for calcium.
Thys-Jacobs S.
Metabolic Bone Center, St. Luke's-Roosevelt Hospital Center, College of Physicians and Surgeons, Columbia University, New York, New York 10019, USA.Premenstrual syndrome afflicts millions of premenopausal women and has been described as one of the most common disorders in women. Research over the past few years suggests that a variety of nutrients may have an important role in the phase related mood and behavioral disturbances of the premenstrual syndrome. There is scientific evidence, at least for a few of these micronutrients, specifically calcium and vitamin D, supporting cyclic fluctuations during the menstrual cycle that may help explain some features of PMS. Ovarian hormones influence calcium, magnesium and vitamin D metabolism. Estrogen regulates calcium metabolism, intestinal calcium absorption and parathyroid gene expression and secretion, triggering fluctuations across the menstrual cycle. Alterations in calcium homeostasis (hypocalcemia and hypercalcemia) have long been associated with many affective disturbances. PMS shares many features of depression, anxiety and the dysphoric states. The similarity between the symptoms of PMS and hypocalcemia is remarkable. Clinical trials in women with PMS have found that calcium supplementation effectively alleviates the majority of mood and somatic symptoms. Evidence to date indicates that women with luteal phase symptomatology have an underlying calcium dysregulation with a secondary hyperparathyroidism and vitamin D deficiency. This strongly suggests that PMS represents the clinical manifestation of a calcium deficiency state that is unmasked following the rise of ovarian steroid hormone concentrations during the menstrual cycle.
Posted by Cady on January 16, 2009, at 21:36:53
In reply to Re: Ideas on female hormonal dilemma? » Cady, posted by Larry Hoover on January 16, 2009, at 7:38:35
> > Has anything else worked for anyone on severe PMS?
>
> I can't speak from experience, but I hope you haven't overlooked nutritional aspects.
>
> There is solid evidence that calcium supplementation improves PMS symptoms. Participants in a double-blind study took 300 mg calcium carbonate 4 times a day.
>
> There is weaker evidence for the efficacy of magnesium supps, but most people are deficient anyway. 300 mg/day would be a good target.
>
> To ensure uptake, you need to have sufficient vitamin D, so 1000 IU/day would be sensible.
>
> There is lesser evidence for the efficacy of vitamin B6 (pyridoxine), perhaps because some people don't utilize the most common supplemental form very well. Therefore, a trial of activated B6, P-5-P (pyridoxal-5-phosphate) makes more sense. 100 mg/day in the week preceding symptom onset would be a good trial. Because increased intake of one B-vitamin increases demand for others, it's a good idea to combine the P-5-P with a B-complex supplement.
>
> And finally, gamma-linolenic acid has a folk reputation for alleviating PMS, particularly that found in evening primrose oil. It may even be another fat in EPO other than the GLA that has some effects. Hard to say. Doses as high as 4000 mg/day are in the literature, but I'd go with perhaps 1200. Also, it's more effective with e.g. fish oil (long-chain omega-3 fatty acids).
>
> I've listed them in the order of proven efficacy, but in any case, don't try all of them at once, or you'll have no idea which substance, or which dose, has any benefits.
>
> Regards,
> Lar
>Thanks for all the info. I take a basic multivitamin, plus calcium, magnesium, zinc and copper. Also EPA/DPA about 2.5mg/1.5mg from fish oil. Although calcium and fish oil have not seemed to help with PMS or mood in general, I continue to take them just in case they are helping, and for their other health benefits. I haven't tried B6 yet or EPO.
Posted by SLS on January 17, 2009, at 7:46:18
In reply to Re: Ideas on female hormonal dilemma?, posted by Cady on January 16, 2009, at 20:44:11
Hi Cady.
> (Scott, do you happen to know how long Trileptal can take to work?)
I am going to take the easy way out and say that it is variable depending on the person and the degree of non-menstrual, classic rapid cyclicity. Without rapid-cyclicity, you might feel some amelioration of rage as soon as your first menstrual cycle. I can't imagine that it would take anything longer than 3 months, however, I am only guessing. I was on Trileptal for a few months. I did feel slightly better within 2 weeks. For non-menstrual rapid-cyclicity, it often takes 2 or more mood stabilizers and 6 or more months before the treatment penetrates the cycle.
I know I am not being terribly helpful here. You are in relatively uncharted territory when it comes to making treatment choices with confidence. For instance, I have seen Trileptal and Lamictal help penetrate a rapid cycle in bipolar disorder, yet the Lamictal might be counterproductive in PMDD if the few reports I read reflect a majority. I don't know that they do. You still might want to give it a trial for yourself if you haven't already.
If you take Trileptal, and it doesn't seem to be helping or hurting, I would leave it in place and then perhaps add Topamax. If 2 is better than 1, you will never discover this by taking 1 at a time. With Topamax, if you begin low and titrate very gradually, you can often avoid the cognitive side effects it is notorious for producing. I had no problem with it. I have seen Topamax monotherapy treat very effectively mixed-mania with rage. Topamax is underestimated, I think.
I think using an AP is a good idea. Have you tried Seroquel?
- Scott
Posted by Cady on January 17, 2009, at 9:00:18
In reply to Re: Ideas on female hormonal dilemma? » Cady, posted by SLS on January 17, 2009, at 7:46:18
Thanks, that is helpful.
I have non-menstrual ultra-rapid cycling, too. Lamictal has never stabilized me, but my doctors have kept me on it while trying various additions (Gabapentin, Topamax, Abilify). Gabapentin did not work. Topamax was ok but incompatible with the hormone therapy. Abilify is currently helping, so I would be reluctant to stop it. I have never tried Seroquel. Would I take it in addition to Abilify, or rather as a substitute? Do you know if Seroquel has more of an antidepressant effect than Abilify? If I switch from Lamictal to Trileptal, I am thinking I might need another med that is more on the antidepressant side. My understanding is that Trileptal is more antimanic.
Posted by SLS on January 17, 2009, at 9:56:18
In reply to Re: Ideas on female hormonal dilemma?, posted by Cady on January 17, 2009, at 9:00:18
> Thanks, that is helpful.
>
> I have non-menstrual ultra-rapid cycling, too. Lamictal has never stabilized me, but my doctors have kept me on it while trying various additions (Gabapentin, Topamax, Abilify). Gabapentin did not work. Topamax was ok but incompatible with the hormone therapy. Abilify is currently helping, so I would be reluctant to stop it. I have never tried Seroquel. Would I take it in addition to Abilify, or rather as a substitute? Do you know if Seroquel has more of an antidepressant effect than Abilify? If I switch from Lamictal to Trileptal, I am thinking I might need another med that is more on the antidepressant side. My understanding is that Trileptal is more antimanic.Generally, but it had a slight antidepressant effect on me.
> > If you take Trileptal, and it doesn't seem to be helping or hurting, I would leave it in place and then perhaps add Topamax. If 2 is better than 1, you will never discover this by taking 1 at a time.
The point I was trying to make, is that I would add stuff instead of swapping out stuff. If the Lamictal isn't exacerbating your PMDD, then I would leave it in place and try adding Trileptal or possibly lithium. Lithium + Lamictal is supposed to be able to penetrate the rapid cycle. As I may have mentioned, a friend of mine with a dramatic ultra-rapid-cycle has had success with Lamictal + Trileptal along with Keppra and Nardil. You have a plethora of options yet to explore.
Again, you must allow for at least 6 months for a mood-stabilizer regime to penetrate and abolish rapid cycling. The NIMH (NIH) has done much work in this area. They support the Lamictal + lithium strategy. They use retrospective life charting and contemporaneous mood charting to help elucidate patterns of illness and responses to medication. I think you might profit from charting your mood. I have a chart on my website that you can use:
http://www.slschofield.com/medicine/mood_chart_beam.pdf
You'll need a PDF file reader to view and print out the chart:
You can use the free official Adobe Reader, which is a large program:
Instead, you might prefer to use a lightweight, but excellent free program, Foxit Reader:
Additionally, this is an example of life chart:
http://www.slschofield.com/medicine/mood_chart_nimh_r.pdf
- Scott
Posted by Cady on January 17, 2009, at 10:42:39
In reply to Re: Ideas on female hormonal dilemma? » Cady, posted by SLS on January 17, 2009, at 9:56:18
> > Thanks, that is helpful.
> >
> > I have non-menstrual ultra-rapid cycling, too. Lamictal has never stabilized me, but my doctors have kept me on it while trying various additions (Gabapentin, Topamax, Abilify). Gabapentin did not work. Topamax was ok but incompatible with the hormone therapy. Abilify is currently helping, so I would be reluctant to stop it. I have never tried Seroquel. Would I take it in addition to Abilify, or rather as a substitute? Do you know if Seroquel has more of an antidepressant effect than Abilify? If I switch from Lamictal to Trileptal, I am thinking I might need another med that is more on the antidepressant side. My understanding is that Trileptal is more antimanic.
>
> Generally, but it had a slight antidepressant effect on me.
>
> > > If you take Trileptal, and it doesn't seem to be helping or hurting, I would leave it in place and then perhaps add Topamax. If 2 is better than 1, you will never discover this by taking 1 at a time.
>
> The point I was trying to make, is that I would add stuff instead of swapping out stuff. If the Lamictal isn't exacerbating your PMDD, then I would leave it in place and try adding Trileptal or possibly lithium. Lithium + Lamictal is supposed to be able to penetrate the rapid cycle. As I may have mentioned, a friend of mine with a dramatic ultra-rapid-cycle has had success with Lamictal + Trileptal along with Keppra and Nardil. You have a plethora of options yet to explore.
>
> Again, you must allow for at least 6 months for a mood-stabilizer regime to penetrate and abolish rapid cycling. The NIMH (NIH) has done much work in this area. They support the Lamictal + lithium strategy. They use retrospective life charting and contemporaneous mood charting to help elucidate patterns of illness and responses to medication. I think you might profit from charting your mood. I have a chart on my website that you can use:
>
> http://www.slschofield.com/medicine/mood_chart_beam.pdf
>
> You'll need a PDF file reader to view and print out the chart:
>
> You can use the free official Adobe Reader, which is a large program:
>
> http://get.adobe.com/reader/
>
> Instead, you might prefer to use a lightweight, but excellent free program, Foxit Reader:
>
> http://mirrors.foxitsoftware.com/pub/foxit/reader/desktop/win/3.x/3.0/enu/FoxitReader30_enu_Setup.exe
>
> Additionally, this is an example of life chart:
>
> http://www.slschofield.com/medicine/mood_chart_nimh_r.pdf
>
>
> - Scott
>I like the above charts -- they are well organized. Last spring I started with an Excel chart by Dr. Jim Phelps, available at:
http://www.psycheducation.org/FAQ/MoodCharts.htm
I changed the line graph to a bar graph, and added more info such as mixed mood, anxiety, irritability, and number of mood switches, so it has coincidentally become more like yours. It still only takes me a minute each night.
Posted by rskontos on January 25, 2009, at 18:44:31
In reply to Ideas on female hormonal dilemma?, posted by Cady on January 16, 2009, at 5:49:58
Cady,
Have you had your levels of hormones check to see exactly where each are?I did. I thought my estrogen was low it was not, actually progestrone was low. Along with a few others. Now that I have been taking the right supplements I feel much better. It takes a little time to get the hormones balanced but once you get the lab results and get the right supplements it gets better faster.
Also Larry is right. My vitamin was so low and I was tested in the summer when you'd expect it to be higher. So I am on 2000 mg. of vitamin d, along with calcium. I have taken evening primrose oil for a while now along with a bio-identical progestrone and feel so much better.
Also look into bioidenticals versus synthetics. Look at
www.womenlivingnaturally.com website for great information.good luck.
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