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The Dose Transcript for December 14, 2023

Host: Brian Goldman

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BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to The Dose. Our show this week is about the menstrual cycle. As a physician, I've been taught to ask every woman of childbearing potential about her periods. But as a guy, menstruation is not part of my personal health experience. Now, recently, I screened a new feature documentary that I recommend called Periodical. Great title. It's a deep dive into the marble, the mystery, the science, and yes, sometimes the shame and stigma of menses. A perfect time for The Dose to pose the question, how do you manage your mental and physical well-being during the menstrual cycle? Hi, Alison. Welcome to The Dose.

ALISON SHEA: Hi, Brian. Thank you for the invite. I’m excited to be here.

BRIAN GOLDMAN: I'm excited to have you here too. And I want to ask you, what do you remember about being taught about menstrual cycles, say, as a pre-teen or a teen?

ALISON SHEA: You know, we do get a lot of information about this from school in health and also from our parents, for some people, and often from our peers. But we actually get… I just want to say we get not a lot of training on the other end when we're going, when our periods start to change on the other direction. So the start of menses, the start of menstrual cycle, we do learn a lot. But when things start to change on the other end is when many people who menstruate are feeling very, very lost.

BRIAN GOLDMAN: Oh, that's interesting. Okay. I'm sure we're going to get into that later. But before we begin, can you give us a hi, my name is? Tell us what you do and where you do it. Just adlib.

ALISON SHEA: Hi, my name is Dr. Allison Shea. I am an assistant professor at McMaster University in the Department of Obstetrics and Gynecology, with a cross appointment in the Department of Psychiatry and Behavioural Neuroscience. I work at the General at St. Jo's Healthcare in Hamilton, and I also see patients with reproductive mood and anxiety disorders at the Women's Health Concerns Clinic there together with other psychiatrists.

BRIAN GOLDMAN: Okay, we're ready to go, and you are well qualified. Let's start with periods one on one. Give us a brief tour of the different phases of the menstrual cycle.

ALISON SHEA: Okay, great. That's an important first step. So the menstrual cycle start date is the first full day of bleeding. So it’s the first day of full flow. Some may have some spotting for a few days before. But by convention, we don't count this as the official start. The first half leading up to ovulation is called the follicular phase, meaning that the ovaries are preparing a follicle to mature and potentially to be released or to ovulate. In a typical 28 day cycle, you would ovulate mid-cycle and your luteal phase would start after day 14, after ovulation. And many will notice some emotional symptoms at the beginning of the luteal phase. This is because we get a significant drop in oestrogen at this time. What's important to know about oestrogen and mood changes is we know that oestrogen is involved in the regulation of serotonin synthesis. So that's the neurotransmitter which is involved in mood, sleep and many other important aspects of regulating mood and physiology in your body. You also get an increase in oestrogen halfway through the luteal phase and another drop off in the last five to seven days. And so you may be feeling a bit better from that rise in oestrogen, but then it drops off again. And so you have two peaks and troughs that really occur in the luteal phase in the second half of the cycle. But you also get a rise in progesterone and then drop off as well. It's important to know because progesterone is calming for many people who menstruate. What progesterone does is it breaks down to allopregnanolone. Allopregnanolone binds the GABAA receptor in your brain. So the same place that something like Ativan or Clonazepam or Valium might want to bind to. So it binds there. It has a calming effect. And then in the five to seven days before your menstrual cycle, that drops off again rapidly. So for those who are experiencing the calming effect from the progesterone, the loss of that can certainly have profound impacts on mood as well. Then following menstruation, your oestrogen levels begin to climb and they peak around day 12. And then soon after, they decline rapidly. And a typical menstrual cycle is anywhere from 21 to 35 days. And that's from day one of full flow to day one of full flow for the next cycle. And this includes about two to seven days of bleeding, on average.

BRIAN GOLDMAN: 21 to 35 days. And so would you say that on either side of that, that would be considered abnormal?

ALISON SHEA: Definitely. So there may be abnormal changes in the menstrual cycle length for many reasons: When menstrual cycles start to change in your mid-30s or 40s for some women. While people who menstruate, they become shorter or longer. When menstrual cycles are longer than this, it may be associated with something called polycystic ovarian syndrome. It may also be associated with stress in the body, whether that be a physical stress or emotional stress. And those who have a very low body mass index often can have changes in their menstrual cycle as well. There are many other things, but those would be the most common.

BRIAN GOLDMAN: Is spotting all or most of the time considered… is it always abnormal or can it be normal?

ALISON SHEA: So it can be normal, such as the spotting that may occur right before the period for a few days or maybe a few days after. But it's really important to know there are many reasons that spotting may not be normal. And if there's been a change, it really is important to get checked out by a health care provider. So things that might cause spotting are things like sexually transmitted infections like chlamydia or gonorrhea. They can cause the cervix to be inflamed and then this can cause bleeding. There are some benign changes of the cervix as well that can cause bleeding, but it's important to know that cervical cancer can also cause spotting. So it's important to stay up to date on your PAP and to see your doctor or nurse practitioner if you have ongoing spotting which is new and different.

BRIAN GOLDMAN: So we can close the loop on this part of the discussion. When do you recommend that women who think they're having menstrual irregularities or abnormalities see their health care provider?

ALISON SHEA: If it seems like things are different, it's a good idea to start tracking your cycles. We don't typically recommend tracking your cycles for every person that menstruates. But if the notice is that things are different, there's been a lengthening or shortening of the cycle, or the bleeding becomes prolonged or heavy, or bleeding at different times that is new or different, then that would be a reason to track it for a few cycles. If there's a persistent change, then that would be a good idea to go talk to your health care provider.

BRIAN GOLDMAN: Do you recommend any apps or devices that can be used to track cycles?

ALISON SHEA: There are many great apps out there. There are a number of them. If you're thinking about your mood, what I would recommend is one which is specifically designed for tracking mood. And I would like to recommend, put a plug in for the McMaster Premenstrual and Mood Symptom Scale. So that's the MAC-PMSS. And this is available free on the App Store. What this does is it goes through physical and emotional symptoms associated with changes in the menstrual cycle. And you can also track your bleeding in this time and see what other things in your life such as sleep or life stress may be involved. And then you can have objective data to bring that to your health care provider if you are concerned with either the physical or emotional symptoms that may be going along with your menstrual cycle.

BRIAN GOLDMAN: You've anticipated where I was going to go next. There's a condition called premenstrual dysphoric disorder or PMDD. Tell us about that.

ALISON SHEA: What's great about social media right now is that people who menstruate are getting the word out about PMS and premenstrual dysphoric disorder. And this is something that was largely ignored for many, many years. And it's great that we now have the tools and the social media out there to help us open the door to remove the stigma so that people who menstruate can start to learn about this. First, we have to differentiate what is premenstrual syndrome and premenstrual dysphoric disorder, which is PMDD. I see a lot of these patients in my practice. So PMS is defined as a collection of symptoms, both physical and emotional, that alert one to the upcoming menstruation. PMS is experienced by about 90% of those who menstruate. And that includes emotional symptoms such as angry outbursts, irritability, crying spells, poor concentration, and the physical symptoms, insomnia, food cravings, bloating, weight gain, some swelling in the hands and feet. Some may get some gastrointestinal symptoms, certainly headaches and cramping. So those are pretty typical symptoms that the large majority of people who menstruate may experience. However, the more severe form, which is premenstrual dysphoric disorder or PMDD, is a much more severe form of PMS that impairs school, work or social activities or relationship with others. It was added to the DSM-5, which is the Diagnostic Statistics Manual, the fifth version in 2013. Prior to this, it was not recognized as its own disorder. And since then, we've been able to do a lot more work and spread the word and reduce stigma. So what it means, as with everything in the DSM-5, is you have to meet a certain amount of criteria to meet the disorder. So what you need to have is at least five symptoms in the final week before the onset of menses that start to improve within a few days after. Many will describe a switch that goes off either halfway through their cycle or about a week before their period where they just feel like a completely different person. The most common symptoms are a marked affective lability, so mood swings, feeling sad or tearful, sensitivity to rejection as well as marked irritability or anger. People come in saying that they are fighting with their partner or yelling at their children a lot more, and they've noticed that there's a cyclical pattern to this. Many will describe marked depression, hopelessness, marked anxiety. We certainly see an increase in suicidal ideation as well as suicide attempts. Many also complain of physical symptoms as well. We know that it's related to sensitivity and hormonal changes during the menstrual cycle. It's important to note that we don't see a difference in the total hormone levels. So many people will come in asking to get their hormones tested, but there's no evidence for that. And we actually test absolute hormone levels. There's no difference. But we do see a difference in the vulnerability to the changes throughout the cycle. So when either the oestrogen increases or decreases, or when the progesterone increases or then drops off in the week before the cycle. And there are a number of neurobiological mechanisms which have been proposed that are related to these mood changes.

BRIAN GOLDMAN: So you've laid out a continuum between PMS and PMDD. How do you manage each of them?

ALISON SHEA: Important question. So first things first, we want to see what's actually going on. So I want to ask patients prospectively track their symptoms to see if it's actually PMS or PMDD. We want to rule out any underlying abnormalities that may be contributing to symptoms. So certainly, making sure that they're not anemic, checking their thyroid. Those are low hanging fruit to start with. And then we want to start with lifestyle interventions both for PMS and PMDD certainly during the luteal phase or the second half of the cycle. So limiting caffeine, limiting alcohol, having a low salt diet if there is difficulties with bloating or breast tenderness, increasing exercise. And then there are a number of dietary supplements that can help with both PMS and PMDD. May not help for more severe cases, but it's an easy first step and a more natural approach for those who don't want to take prescribed therapies. We do have evidence for vitamin B6, which is a co-factor in many important neurotransmitters involved in mood. It's been studied at a dose of 100mg. People can take it either all the time or in the luteal phase. There is evidence for optimizing both calcium and vitamin D, which really all female people should be doing anyways for protection of bones. There's some evidence for magnesium supplementation in the luteal phase, which can also help with sleep. And then there is also a natural supplement called Vitex, which is derived from the chaste tree or chasteberry. And there actually have been a few randomized controlled trials showing a reduction in premenstrual irritability and anxiety for those with less severe symptoms. So these are nice first steps for those that have PMS or who don't want to take prescription therapies. In terms of the prescription therapies, once we've tackled those first approaches, really, the treatment approaches are either to modulate the serotonin or to modulate the hormones. So the oestrogen and progesterone. There is evidence for selective serotonin reuptake inhibitors or SSRIs, either to be used all of the time or just in the luteal phase in the second half of the cycle. And there’s a Cochrane review that was put out a few years ago that show that both approaches are equally efficient and effective for people who are suffering from PMDD. In terms of the hormonal approaches, it's important to tell patients that if the first thing doesn't work, we have many options. And please just be patient because what works for one person doesn't work for the next person. The easiest first step is to use a birth control pill which has been studied for PMS or PMDD to suppress ovulation so you don't get that fluctuation throughout the month. If you're not ovulating, you're not getting those fluctuations in hormones.

BRIAN GOLDMAN: I see lots of women with migraine headaches, you know, in my role as an emergency physician whose headaches are tied to their menstrual cycles. In med school, I was taught that migraines are connected to oestrogen and progesterone. Is that the case? And if so, how are they connected?

ALISON SHEA: So certainly, there is a connection. Many will describe them as menstrual migraines. The main culprit, we think, for the migraine type headache is the drop off of oestrogen. So some may get some migraines mid-cycle when you have a drop after ovulation, but many more will get in the five to seven days and the first one to two days of their menstrual cycle, menstrual migraines due to the drop of oestrogen as well. We do know that migraines get worse often in the perimenopause or the years leading up to the final menstrual period. And that's because the oestrogen fluctuations become more severe. Progesterone is tied to some headaches as well, but not as exclusively to migraines per se. The question is how do we treat this if it's a hormonal problem? You know, we're taught in medical school that if you have migraines, you can't take the birth control pill.

BRIAN GOLDMAN: Right.

ALISON SHEA: And you think the birth control pill is what's going to regulate those hormones.

BRIAN GOLDMAN: Right.

ALISON SHEA: So this is a difficult question to answer about how to treat the menstrual migraines. We do know that transdermal oestrogen, so either a patch or a gel in doses around what we give for menopause hormone therapy and sometimes higher, can help menstrual migraines. So it's important to know that transdermal oestrogen is not the same as oral oestrogen. When you give transdermal oestrogen, it bypasses the liver. So it doesn't go through the liver. We don't worry about increasing clotting factors, which is what we worry about oral oestrogen and migraines. We think about the risk for stroke. So we don't increase the risk of stroke when we give oestrogen through the skin. So this has become a more popular treatment for menstrual migraines, is giving a background level of oestrogen. So then when you get those drops off in the oestrogen, you don't tank as much. It's kind of like wearing a life vest or a life jacket, life preserver. So even though you get that drop in oestrogen, you still have that life jacket keeping you afloat so it's not so severe it will buffer that drop in the oestrogen. Now, that said, there are some providers who still will give a birth control pill to those who suffer from migraines. But again, this should be done with somebody who is comfortable in this. Most of the studies looking at stroke and migraine were in studies that were done many, many years ago with higher dose hormones, typically with pills that had a 50 microgram dose of ethinylestradiol. The pills that we have now are typically 20 to 30 or even 10 micrograms of Ethinylestradiol. So much lower dose. Newer studies show that there does not seem to be a significant increase in stroke at the lower dose pills. But again, this may be an option, but done with a closely supervised health care provider who is comfortable watching this and making sure that the migraines don't get worse.

BRIAN GOLDMAN: You know, thinking about the stigma that I mentioned off the top, what are the societal factors that can influence how someone experiences their menstrual cycle?

ALISON SHEA: For those who identify as female, who were assigned female at birth, this may not be distressing. However, for those who don't identify as being female or those who are not comfortable with the female characteristics, then having a menstrual cycle can be quite distressing and quite bothersome. And so it's important for us to understand that and not assume that all people who have a menstrual cycle consider themselves women or girls. So that's the first thing. And that we can identify them as people who menstruate, people who have a uterus, people who have an ovary, who have ovaries. In terms of cultural differences, there are many different cultural differences that come into play. You know, there are some cultures that females are not meant to interact with males in their cultures, and there are some that it makes no difference at all. And that can differ from culture to culture. And so it's important to approach it with a cultural sensitivity and understanding that your experience may not be the same as somebody else from a different culture.

BRIAN GOLDMAN: For some women, periods are something they can cope with easily. And for others, they need more accommodations. And I guess the question I'm asking is does society provide adequate accommodations considering the range of symptoms and the severity of symptoms that some women experience with their periods?

ALISON SHEA: So certainly not. We are actually seeing, you know, the U.K. is well ahead of us in dealing with things related to female and health of those who have ovaries and uterus. We are hearing more that in the U.K., they are bringing in sick leave for those who suffer with severe cramps or those who may suffer from a more painful period, such as those who suffer from endometriosis, and allowing a more flexible approach for those who are more debilitated by their period. I don't think we're there yet here. Those who suffer from more heavy periods may not be prepared and may not actually be carrying the products that they need. And this is another big problem we have in North America is that products available for bleeding and periods are not readily available, and this can be cost prohibitive as well. We are seeing some public spaces that are providing free products such as sanitary napkins or tampons for those that menstruate, which is a step in the right direction, but we're not seeing that everywhere. And certainly, some may need accommodations to work at home because they're having more severe bleeding, more severe cramps or more severe emotional changes. But I don't think that we're there yet. Maybe in a number of years from now, but I think we have a lot of work to do to understand that those who menstruate are not the same as those who don't menstruate. And there are certainly many physical and emotional changes that may affect your day to day function, and we need to have some sensitivity around that.

BRIAN GOLDMAN: Does the lack of accommodation have an adverse effect on women who are more affected by their symptoms?

ALISON SHEA: Certainly. Many women are ashamed. Many women don't want to talk about it. For those who have more severe premenstrual dysphoric disorder, they are often missing workdays and they're ashamed to talk to their employer about it, despite the fact that they have a diagnosed medical condition. And having a conversation, you know, may or may not be helpful with your employer, but some women don't want to talk about something that is involving having a psychiatric disorder. So we have a lot of work to do in terms of reducing stigma in terms of all psychiatric disorders. But I know that you know that.

BRIAN GOLDMAN: I do. And wow, you know, there's a lot to unpack, and I'm just so glad that we're opening up the conversation. I bet we're going to get a huge response to this episode of The Dose. Dr. Alison Shea, thank you so much for sharing your knowledge with us.

ALISON SHEA: Thanks for having me.

BRIAN GOLDMAN: Dr. Alison Shea is an obstetrician gynecologist at St. Joseph's Healthcare in Hamilton. She's also a menopause and reproductive mental health specialist. Here's your dose of smart advice. The menstrual cycle is the time from the first day of a woman's period to the day before her next period. A normal menstrual cycle usually ranges between 21 and 35 days. The menstrual cycle has two phases. The first or ovulatory phase happens when the ovary releases an egg or ovum and travels down the fallopian tubes. On average, it happens on day 14 of a 28 day menstrual cycle. That's the phase when oestrogen levels are at their highest. The second or luteal phase begins around day 15 of a 28 day cycle and ends when you get your period. During the luteal phase, oestrogen levels fall off and progesterone levels increase before decreasing right before the period. The average menstruation or bleeding time is about five days and ranges between three to seven days. Given the variation in what's considered normal, it's important to keep track of what's normal for you. One way to do that is to use an app that helps you track your periods. While bleeding during a period is obviously normal, it can also be due to conditions such as cancer of the cervix or uterus, sexually transmitted diseases and pregnancy. See your health care provider if you notice a persistent change in the amount, duration or frequency of bleeding. Premenstrual syndrome or PMS is a group of symptoms linked to the menstrual cycle. Symptoms may include cramps, bloating, pelvic pain, headaches, fatigue, trouble sleeping and mood changes. The symptoms usually begin before menstrual bleeding starts and may continue for several days afterwards. PMS can often be managed through diet and exercise. Supplements that may help relieve symptoms include vitamin B6 and magnesium. Vitex agnus-castus or chasteberry may reduce symptoms of PMS. Anti-inflammatories relieve period cramps. Premenstrual Dysphoric disorder or PMDD is a much more severe form of PMS. The symptoms include mood swings, rage, severe depression or anxiety during the luteal phase of the cycle. PMDD is considered a severe and chronic medical condition that often needs attention and treatment by your health care provider. A menstrual migraine or hormone headache usually begins before or during periods and can happen every month. Effective treatments include medications such as anti-inflammatories, triptans, as well as oestrogen gels and patches. If you have topics you'd like discussed or questions answered, our email address is thedose@cbc.ca. If you like this episode, please give us a rating and review wherever you listen. This edition of The Dose was produced by Isabelle Gallant. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose.

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How do I manage my mental and physical well-being during the menstrual cycle? - Transcript

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