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wherever you. Got your podcast? very

2:00

very lost. Oh, that's interesting. Okay.

2:02

I'm sure we're gonna get into that later But before we begin

2:04

can you give us a hi my name is tell us what

2:06

you do and where you do it just to ad lib Hi,

2:10

my name is Dr. Allison Shea I am

2:13

an assistant professor at McMaster

2:15

University in the Department of Obstetrics and Gynecology

2:18

with a cross appointment in the Department

2:20

of Psychiatry and Behavioral Neuroscience. I work

2:23

as a general OBGYN at St. Joe's

2:25

in health healthcare in Hamilton And I

2:27

also see patients with reproductive mood and

2:29

anxiety disorders that the women's health concerns

2:31

clinic there together with other

2:33

psychiatrists Okay, we're

2:36

ready to go and you are well qualified

2:38

Let's start with periods one-on-one give us a

2:40

brief tour of the different phases of the

2:42

menstrual cycle. Okay, great That's an

2:44

important first step. So the

2:46

menstrual cycle start date is the first

2:48

full day of bleeding So it's the

2:51

first day of full flow Some

2:53

may have some spotting for a few days before

2:56

but by convention, we don't count this as

2:59

the official start The

3:01

first half leading up to ovulation

3:03

is called the follicular phase Meaning

3:05

that the ovaries are preparing a follicle to

3:08

mature and potentially to be

3:10

released or to ovulate in

3:12

a typical 28 day cycle You

3:15

would ovulate mid cycle and your luteal phase

3:17

would start after day 14 after

3:21

Regulation and many will

3:23

notice some emotional symptoms

3:26

at the beginning of the luteal phase This is

3:28

because we get a significant drop in estrogen at

3:30

this time What's important

3:32

to know about estrogen and mood

3:34

changes is we know that estrogen

3:37

is involved in the regulation

3:39

of serotonin Synthesis, so

3:41

that's a neurotransmitter which is

3:43

involved in mood sleep and

3:45

many other important aspects of

3:47

regulating mood and physiology in your body

3:51

You also get an increase in estrogen

3:54

halfway through the luteal phase and another drop

3:56

off in the last five to seven days

3:58

and so You may be

4:00

feeling a bit better from that rise in estrogen, but

4:02

then it drops off again. So you

4:05

have two peaks and troughs that really occur

4:07

in the luteal phase in the second half

4:09

of the cycle. We also

4:11

get a rise in our progesterone and

4:13

then drop off as well. It's

4:16

important to know because

4:18

progesterone is calming for

4:21

many people who menstruate. What

4:23

progesterone does is it breaks down to

4:26

allopregnanolone. Allopregnanolone binds

4:28

the GABA A receptor in

4:30

your brain, so the same

4:32

place that something like Ativan

4:34

or clonazepam or Valium might

4:36

bind to. So

4:38

it binds there, it has a calming effect.

4:40

And then in the five to seven days

4:42

before your menstrual cycle, that drops off again

4:44

rapidly. So for those who

4:46

are experiencing the calming effect from the

4:49

progesterone, the loss of that can certainly

4:51

have profound impacts on mood as well.

4:54

Even following menstruation, your estrogen levels begin

4:56

to climb and they peak around day

4:58

12 and then soon

5:00

after they decline rapidly. And

5:03

a typical menstrual cycle is anywhere from 21 to 35

5:05

days and that's from day one of

5:08

full flow to day one of full flow for

5:10

the next cycle. And this includes about

5:12

two to seven days of bleeding

5:14

on average. 21

5:17

to 35 days. And

5:19

so would you say that on either side of

5:21

that, that would be considered abnormal? Definitely.

5:25

So there may be abnormal changes in

5:27

the menstrual cycle length for many reasons.

5:30

When menstrual cycles start to change

5:32

in your 30s or 40s

5:34

for some women or people who

5:36

menstruate, they become shorter

5:38

or longer. When menstrual

5:41

cycles are longer than this, it

5:43

may be associated with something called

5:45

polycystic ovarian syndrome. May

5:47

also be associated with stress in the body,

5:49

whether that be a physical stress or emotional

5:52

stress. And those who have

5:54

a very low body mass index often can

5:56

have changes in their menstrual cycle as well.

5:59

There are many other things. But those would be the most common. If

6:02

spawning all or most of the time

6:04

considered, is it always abnormal or

6:07

can it be normal? So it can be

6:09

normal, such as the spotting that I occur right

6:11

before the period for a few days

6:13

or maybe a few days after. But it's

6:15

really important to know there are many reasons that spotting

6:17

may not be normal. And if there's been a change,

6:19

it really is important to get checked out by a

6:21

healthcare provider. So things that might

6:23

cause spotting or things like sexually transmitted infections

6:25

like chlamydia or gonorrhea, they can cause the

6:28

cervix to be inflamed. And then this can cause bleeding.

6:31

There's some benign changes of the service as well

6:34

that can cause bleeding. But

6:36

it's important to know that cervical cancer can also cause

6:38

spotting. So it's important to stay up to date

6:40

on your path and see your doctor

6:42

or nurse practitioner if you have ongoing

6:44

spotting, which is new and different. So

6:47

we can close the loop on this part of the

6:49

discussion. When do you recommend

6:51

that women who

6:53

think they're having menstrual irregularities

6:56

or abnormalities see their healthcare

6:58

provider? If it seems like

7:00

things are different, it's a good idea to start

7:02

tracking your cycles. We don't

7:05

typically recommend tracking your cycles for every

7:07

person that menstruates. But if it notices

7:10

that things are different, there's been

7:12

a lengthening or shortening of the cycle

7:14

or the bleeding becomes prolonged or

7:16

heavy or bleeding at

7:18

different times that is new or different,

7:20

then that would be a reason to track it

7:22

for a few cycles. If there's

7:24

a persistent change, then that would be a good

7:27

idea to go talk to your healthcare provider. Do

7:30

you recommend any apps or devices that can

7:32

be used to track cycles? There

7:34

are many great apps out there. There

7:36

are a number of them. If you're thinking about

7:38

your mood, what I would recommend

7:40

is one which is specifically designed for

7:43

tracking mood. And I would like

7:45

to recommend, put a plug in for the McMaster

7:47

premenstrual and mood symptom scale. So

7:49

that's the Mac PMSS.

7:52

And this is available free on the app store.

7:56

What this does is it goes through physical and

7:59

emotional symptoms. associated with changes

8:01

in the menstrual cycle. You can also

8:03

track your bleeding in this time and

8:05

see what other things in your life,

8:07

such as sleep or life stress, may

8:09

be involved. And then you can have

8:11

objective data to bring that to your health

8:13

care provider if you are concerned with either

8:15

the physical or emotional symptoms that may be

8:18

going along with your menstrual cycle. You've

8:20

anticipated where I was going to go next. There's

8:23

a condition called premenstrual dysphoric

8:25

disorder, or PMDD. Tell

8:28

us about that. What's great

8:30

about social media right now is that people

8:33

who menstruate are getting the word

8:35

out about PMS and premenstrual dysphoric

8:37

disorder. And this is something that

8:39

was largely ignored for many, many years. And

8:42

it's great that we now have the tools

8:44

and the social media out there to help us

8:47

open the door to remove the stigma so that

8:49

people who menstruate can start to learn

8:51

about this. First, we have to differentiate

8:54

what is premenstrual syndrome and premenstrual dysphoric

8:56

disorder, which is PMDD. I

8:58

see a lot of these patients in my practice.

9:01

So PMS is defined as a

9:03

collection of symptoms, both physical and

9:05

emotional, that alert one to the

9:07

upcoming menstruation. PMS is experienced by

9:10

about 90% of those

9:12

who menstruate. And that includes emotional

9:14

symptoms such as angry outbursts, irritability,

9:16

crying spells, poor concentration,

9:19

and the physical symptoms, insomnia,

9:21

food cravings, floating weight

9:23

gain, some swelling in the hands

9:25

and feet. Some may

9:28

get some gastrointestinal symptoms, certainly headaches

9:30

and cramping. So those are

9:32

pretty typical symptoms that the large majority

9:34

of people who menstruate may experience. However,

9:37

the more severe form, which is

9:40

premenstrual dysphoric disorder or PMDD, is

9:43

a much more severe form of PMS that

9:45

impairs school, work or social

9:47

activities or relationship with others. It

9:50

was added to the DSM-5, which

9:52

is the Diagnostic Statistics Manual, the

9:54

fifth version in 2013. Prior

9:57

to this, it was not recognized as its

9:59

own disorder. and since then we've

10:02

been able to do a lot more work

10:04

and spread the word and reduce stigma. So

10:07

what it means is with everything

10:09

in the DSM-5 is you have

10:11

to meet a certain amount of criteria

10:13

to meet the disorder. So

10:16

what you need to have is at least five

10:18

symptoms in the final week before the onset of

10:20

men's disease that start to improve within a few

10:23

days after. Many will describe

10:25

a switch that goes off either halfway through

10:27

their cycle or about a week before their

10:29

period where they just feel like a completely

10:32

different person. The most common

10:34

symptoms are a marked affective

10:36

lability, so mood swings,

10:38

feeling sad or tearful, sensitivity

10:40

to rejection, as well as

10:43

marked irritability or anger. People

10:45

come in saying that they are fighting with

10:47

their partner or yelling at their children a

10:49

lot more and they've noticed that

10:52

there's a cyclical pattern to this. Many

10:55

will describe marked depression, hopelessness,

10:57

marked anxiety. We certainly

11:00

see an increase in suicidal

11:02

ideation as well as suicide attempts.

11:05

Many also complain

11:07

of physical symptoms as well. We

11:09

know that it's

11:11

related to sensitivity in hormone changes

11:14

during the menstrual cycle. It's important

11:17

to note that we don't see a difference in

11:19

the total hormone levels. So many

11:22

people will come in asking to

11:24

get their hormones tested, but there's no

11:27

evidence for that. We actually test absolute

11:29

hormone levels. There's no difference, but

11:31

we do see a difference in

11:34

the vulnerability to the changes throughout

11:36

the cycle, so when either the

11:38

estrogen increases or decreases or when

11:40

the progesterone increases or then drops off

11:42

in the week before the cycle. There

11:45

are a number of neurobiological mechanisms

11:47

which have been proposed that are

11:49

related to these mood changes. biggest

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your podcasts. So

12:19

you've laid out a continuum

12:22

between PMS and PMDD.

12:25

How do you manage each of them? Important

12:28

questions. So first things

12:31

first. We want to see what's actually

12:33

going on. So I want to ask patients

12:35

to prospectively track their symptoms to see if

12:37

it's actually PMS or PMDD. We

12:39

want to rule out any underlying abnormalities that may

12:41

be contributing to symptoms. So certainly making

12:44

sure that they're not anemic. Checking

12:46

their thyroid. Those are low hanging

12:48

fruit to start with. Then we

12:50

want to start with lifestyle interventions. Both

12:52

for PMS and PMDD. Certainly

12:55

during the luteal phase or the second half of the

12:57

cycle. So limiting caffeine,

12:59

limiting alcohol, having

13:01

a low-site salt diet if there

13:04

is difficulties with bloating or breast

13:06

tenderness. Increasing

13:08

exercise. And then there

13:10

are a number of dietary supplements that can

13:12

help with both PMS and PMDD. May

13:15

not help for more severe cases but

13:17

it's an easy first step in a

13:19

more natural approach for those who don't

13:21

want to take prescribed therapies. We

13:23

do have evidence for vitamin D6 which

13:26

is a cofactor in many important neurotransmitters

13:28

involved in mood. It's been

13:30

studied at a dose of 100 milligrams. People

13:34

can take it either all the time or in the luteal

13:36

phase. There is evidence for

13:38

optimizing both calcium and vitamin D which

13:40

really all female people should be doing

13:43

anyways for protection of bones. There's

13:45

some evidence for magnesium supplementation

13:47

in the luteal phase which

13:50

can also help with sleep. And

13:52

then there is also a natural

13:54

supplement called Vitex which is derived

13:57

from the chase tree or

13:59

chaseberry. actually have been a few

14:01

randomized control trials showing a reduction in

14:04

premenstrual irritability and anxiety

14:07

for those with less severe symptoms. So these

14:09

are nice first steps for those that have

14:11

PMS or who don't want to

14:13

take prescription therapies. In

14:15

terms of the prescription therapies, once

14:18

we've tackled those first

14:20

approaches, really the treatment

14:22

approaches are either to modulate the serotonin

14:24

or to modulate the

14:27

hormone, so the estrogen and

14:29

progesterone. There is evidence

14:31

for selective serotonin reuptake inhibitors or

14:34

SSRIs either to be

14:36

used all of the time or just in

14:38

the luteal phase in the second half of the

14:40

cycle. There's a Cochrane review that was

14:42

put out a few years ago that shows that both

14:45

approaches are equally

14:47

efficient and effective for

14:50

people who are suffering from PMDD. In

14:53

terms of the hormonal approaches, it's important to tell

14:55

patients that if the first thing doesn't work,

14:57

we have many options and please just be

14:59

patient because what works for one

15:01

person doesn't work for the next person. The

15:04

easiest first step is to use a birth control

15:06

pill which has been studied for PMS or PMDD

15:08

to suppress ovulation. So you

15:10

don't get that fluctuation throughout the month.

15:12

If you're not ovulating, you're not getting

15:14

those fluctuations in hormones. I

15:17

see lots of women with migraine headaches in

15:19

my role as an emergency physician whose headaches

15:21

are tied to their menstrual cycle. In

15:24

med school, I was taught that migraines are

15:26

connected to estrogen and progesterone. Is

15:28

that the case? And if so, how are they connected?

15:31

So certainly there is a connection. Many

15:34

will describe them as menstrual

15:36

migraines. The main culprit

15:38

we think for the migraine type headache

15:40

is the drop off of estrogen. So some

15:44

may get some migraines mid-cycle when

15:46

you have a drop after ovulation,

15:49

but many more will get in the

15:51

five to seven days and the first one to

15:53

two days of their menstrual cycle, menstrual

15:55

migraines due to the drop of estrogen as

15:57

well. that

16:00

migraines get worse often in the

16:03

perimenopause or the years leading up

16:05

to the final menstrual period and

16:07

that's because the estrogen fluctuations become

16:09

more severe. Progesterone

16:11

is tied to some headaches as well

16:14

but not as exclusively

16:17

to migraines per

16:19

se. The

16:21

question is how do we treat this

16:23

if it's a hormonal problem? You

16:26

know we're taught in medical school that if you have

16:28

migraines you can't take the birth control pill. You

16:30

think the birth control pill is what's going

16:32

to regulate those hormones. Right.

16:35

So this is

16:37

a difficult question to answer about how

16:40

to treat the menstrual migraines. We do

16:42

know that transdermal estrogen, so either a

16:44

patch or a gel, in

16:47

doses around what we give

16:49

for menopause hormone therapy and

16:51

sometimes higher, can help

16:53

menstrual migraines. So it's

16:55

important to know that transdermal estrogen is

16:57

not the same as oral estrogen. When

17:00

you give transdermal estrogen it bypasses

17:02

the liver. So it doesn't

17:04

go through the liver. We don't worry about increasing

17:07

clotting factors which is what

17:09

we worry about oral estrogen

17:12

and migraines. We think about the risk for

17:14

stroke. So we don't increase the

17:16

risk of stroke when we give estrogen through the

17:18

skin. So this has

17:20

become a more popular treatment for menstrual

17:22

migraines. It's giving a background level of

17:25

estrogen so then when you get those

17:27

drops off in the estrogen you don't

17:29

tank as much. It's kind of

17:31

like wearing a life vest or a life

17:33

jacket life preserver. So even though you get

17:35

that drop in estrogen you still have that

17:38

life jacket keeping you afloat so it's not

17:40

so severe. It will buffer that drop in

17:42

the estrogen. Now that said

17:44

there are some providers who still will

17:46

give a birth control pill to those

17:48

who suffer from migraines but again this

17:50

should be done with somebody who is

17:52

comfortable in this. Most of

17:55

the studies looking at stroke and migraine

17:57

were in studies that were

17:59

done many many years ago with higher

18:01

dose hormones, typically with pills

18:03

that had a 50 microgram

18:05

dose of ethanol estradiol. The

18:09

pills that we have now are typically 20 to

18:11

30 or even 10 micrograms of

18:13

ethanol estradiol, so much lower dose.

18:16

Newer studies show that there does not seem

18:18

to be a significant increase in stroke at

18:20

the lower dose pills. But

18:22

again, this may be an option, but

18:25

done with a closely supervised

18:27

healthcare provider who is comfortable watching

18:30

this and making sure that the migraines don't

18:32

get worse. Thinking

18:35

about the stigma that I mentioned off the top, what

18:37

are the societal factors that

18:39

can influence how someone experiences their

18:42

menstrual cycle? For

18:44

those who identify as female, who

18:46

were assigned female at

18:48

birth, this may not be distressing.

18:51

However, for those who don't identify

18:53

as being female or

18:56

those who are not

18:58

comfortable with the female characteristics,

19:00

then having a menstrual cycle can be

19:02

quite distressing and quite bothersome.

19:05

And so it's important for us to

19:08

understand that and

19:10

not assume that all

19:12

people who have a menstrual cycle are

19:14

considered themselves women or girls. So that's

19:17

the first thing, and that we can

19:19

identify them as people who menstruate, people

19:21

who have a uterus, people who have

19:23

ovaries. In

19:25

terms of cultural differences, there

19:29

are many different cultural differences that

19:31

come into play. There are some

19:33

cultures that females

19:35

are not meant to interact with

19:38

males in their cultures. There

19:41

are some that it makes no difference

19:43

at all, and that can

19:45

differ from culture to culture. And

19:47

so it's important to approach it with a cultural sensitivity

19:49

and understanding that your experience may

19:52

not be the same as somebody

19:54

else from a different culture. For

19:58

some women, periods are

20:01

something they can cope with easily and

20:03

for others they need more accommodations. And

20:05

I guess the question I'm asking is,

20:07

does society provide adequate accommodations considering the

20:09

range of symptoms and the

20:12

severity of symptoms that some women experience

20:14

with their periods?

20:16

So certainly not.

20:18

We are actually seeing,

20:20

you know, the UK

20:23

is well ahead of us in dealing

20:25

with things related to female and

20:28

health of those who have ovaries and

20:31

uterus. We are hearing

20:33

more that in the UK they

20:36

are bringing in sick leave for

20:38

those who suffer with severe cramps,

20:40

for those who may suffer from a

20:42

more painful period such as those who

20:44

suffer from endometriosis and allowing

20:46

a more flexible approach for

20:49

those who are more debilitated by their

20:51

period. I don't think we're there yet

20:53

here. Those who suffer

20:55

from more heavy periods or may

20:58

not be prepared and may not actually be carrying the

21:00

products that they need. And this is another

21:02

big problem we have in

21:04

North America is that products available for

21:06

bleeding periods are not readily available and

21:08

that can be cost prohibitive as well.

21:11

We are seeing some public spaces that

21:13

are providing free products such

21:16

as sanitary napkins or

21:18

tampons for those that menstruate,

21:20

which is a step in the right direction, but

21:22

we're not seeing that everywhere. And

21:24

certainly some may need accommodations to work at

21:26

home and they're having

21:29

more severe bleeding, more severe

21:31

cramps or more severe emotional

21:33

changes. But I don't think that

21:35

we're there yet. Maybe

21:37

in a number of years from now, but I think

21:39

we have a lot of work to do to understand

21:41

that those who menstruate are

21:43

not the same as those who don't menstruate. And

21:47

to understand that those

21:49

who menstruate are not the same as those

21:51

who don't menstruate and there are certainly many

21:53

physical and emotional changes that may affect your

21:55

day-to-day function and we need to have some

21:57

sensitivity around that. lack

22:00

of accommodation have an adverse effect on

22:02

women who are more affected by their

22:04

symptoms? Certainly.

22:08

Many women are ashamed. Many women don't want

22:10

to talk about it. For those

22:12

who have more severe pre-mental dysphoric

22:14

disorder, they are often missing

22:17

work days and they're ashamed

22:19

to talk to their employer

22:21

about it despite the fact that

22:23

they have a diagnosed medical condition

22:27

and having

22:29

a conversation may or may not be helpful with

22:31

your employer. But women don't want

22:33

to talk about something that is involving having a

22:35

psychiatric disorder. So we have a lot of work

22:38

to do in terms of reducing

22:40

stigma in terms of all psychiatric disorders.

22:43

But I know that you know that. I

22:45

do. And wow, there's a lot to unpack and

22:47

I'm just so

22:51

glad that we're opening up the conversation. I bet we're

22:53

going to get a huge response to

22:55

this episode of the dose. Dr.

22:58

Allison Shea, thank you

23:00

so much for sharing your knowledge with us. Thanks

23:02

for having me. Dr.

23:04

Allison Shea is an obstetrician

23:06

gynecologist at St. Joseph's Healthcare

23:09

in Hamilton. She's also a menopause

23:11

and reproductive mental health specialist. Here's

23:14

your dose of smart advice. The menstrual cycle

23:16

is the time from the first day of

23:18

a woman's period the day before her next

23:20

period. A normal menstrual cycle usually

23:22

ranges between 21 and 35

23:25

days. The menstrual cycle has

23:27

two phases. The first or

23:29

ovulatory phase happens when the ovary

23:31

releases an egg or ovum and

23:33

travels down the fallopian tubes. On

23:36

average it happens on day 14 of a

23:38

28 day menstrual cycle. That's

23:40

the phase when estrogen levels are at their highest.

23:43

The second or luteal phase begins around

23:45

day 15 of a 28 day

23:47

cycle and ends when you get your period. During

23:50

the luteal phase estrogen

23:52

levels fall off and progesterone levels

23:55

increase before decreasing right before the

23:57

period. The average menstruation

23:59

or bleeding Bleeding time is about 5

24:01

days and ranges between 3 to 7 days.

24:05

Given the variation in what's considered normal,

24:07

it's important to keep track of what's normal for

24:10

you. One way to do that

24:12

is to use an app that helps you track your periods.

24:15

While bleeding during a period is obviously

24:17

normal, it can also be due to

24:19

conditions such as cancer of the cervix

24:22

or uterus, sexually transmitted diseases and pregnancy.

24:25

See your health care provider if you notice

24:27

a persistent change in the amount, duration or

24:29

frequency of bleeding. Premenstrual

24:32

syndrome or PMS is a group of symptoms

24:34

linked to the menstrual cycle. Symptoms

24:37

may include cramps, bloating, pelvic

24:39

pain, headaches, fatigue, trouble sleeping

24:41

and mood changes. The

24:44

symptoms usually begin before menstrual bleeding

24:46

starts and may continue for several

24:48

days afterwards. PMS can

24:50

often be managed through diet and

24:53

exercise. Supplements that

24:55

may help relieve symptoms include vitamin B6

24:57

and magnesium. Vitex

24:59

Agnes Castus or Chasteberry may

25:01

reduce symptoms of PMS. Anti-inflammatories

25:04

relieve period cramps. Premenstrual

25:08

dysphoric disorder or PMDD is a much

25:10

more severe form of PMS. The

25:13

symptoms include mood swings, rage, severe

25:15

depression or anxiety during the luteal

25:17

phase of the cycle. PMDD

25:19

is considered a severe and chronic medical

25:21

condition that often needs attention and treatment

25:24

by your health care provider. A

25:27

menstrual migraine or hormone headache usually

25:29

begins before or during periods and can

25:32

happen every month. Effective

25:34

treatments include medications such as

25:36

anti-inflammatories, triptans, as well as

25:38

estrogen gels and patches. If

25:41

you have topics you'd like discussed or

25:43

questions answered, our email address is thedoseatcbc.ca.

25:46

If you liked this episode, please give us a

25:48

rating and review wherever you listen. This

25:51

edition of The Dose was produced by Isabel Gallant. Our

25:53

senior producer is Colleen Ross. The

25:56

Dose wants you to be better informed about your health if

25:59

you're looking for medical advice. See your health care provider.

26:01

I'm Dr. Brian Goldman. Until your next dose. For

26:10

more CBC podcasts

26:12

go to cbc.ca/podcasts.

26:16

If you like this episode please give us a

26:18

rating and review wherever you listen. This

26:21

edition of The Dose was produced by Isabel

26:23

Gallant. Our senior producer is Colleen Ross. The

26:26

Dose wants you to be better informed about

26:28

your health. If you're looking for medical advice

26:30

see your health care provider. I'm Dr. Brian

26:32

Goldman. Until your next dose.