Anemia .. different types & how to treat

What is Anemia?

Anemia is a condition where there is an abnormally low number of red blood cells circulating in the body. It is the most common disorder of the red blood cells, affecting about 3.5 million Americans.


Anemia is not a disease. It is a condition that results from below-normal levels of hemoglobin in the red blood cells. Hemoglobin is the iron-containing pigment of the red blood cells that carries oxygen from the lungs to the tissues.

There are many different kinds of anemia, each with its own cause. For example, a poor diet can cause anemia. The more severe types of this condition are often inherited.

Why Does Anemia Occur?
To understand why anemia occurs, it's important to understand the function of blood itself. Blood is a mixture of plasma (the fluid part of the blood) and cells. Its red color comes from the predominant cells found in the blood, called erythrocytes.

A healthy person has about 5 million red cells in every cubic millimeter of blood. Each cell contains a protein (hemoglobin) that carries oxygen through the body.
The process of creating and recycling red blood cells is exceptionally complex. Trouble can occur at any point in this process. If the red blood cells fail to effectively transport oxygen throughout the body, anemia can result.

Facts About Anemia

The word anemia is Greek for "without blood."
Anemia is a common problem for menstruating women because their iron supplies are depleted monthly.

In young children, marrow in all the bones produces red blood cells. As a person ages, red blood cells are eventually produced only in the marrow of the spine, ribs, and pelvis.
The life span of a red blood cell is between 90 and 120 days.
Old red blood cells are removed from the blood by the liver and spleen, and the iron is returned to the bone marrow to make new cells.

A person with anemia will feel tired and weak because the body's tissues are being starved of oxygen. In fact, fatigue is the main symptom of most types of anemia. The severity of symptoms is in part related to the severity of anemia. Mild anemia can occur without symptoms and may be detected only during a medical exam that includes a blood test.

What Are The Symptoms Of Anemia?

Symptoms of anemia include:
. Fatigue
. Weakness
. Fainting
. Breathlessness
. Heart palpitations (rapid or irregular beating)
. Dizziness
. Headache
. Ringing in the ears (tinnitus)
. Difficulty sleeping
. Difficulty concentrating

Common signs include:

. Pale complexion
. The normally red lining of the mouth and eyelids fades in color
Rapid heartbeat (tachycardia)
. Abnormal menstruation (either absence of periods or increased bleeding)

. Other signs depend on the cause of the anemia. These can include spoon-shaped finger nails and toenails in iron-deficiency anemia, mild jaundice in hemolytic anemias, and leg ulcers in sickle cell anemia .

What Causes Anemia?

There are three general causes of anemia:

. Decreased red cell production by the bone marrow
. Increased red cell destruction, or hemolysis
. Blood loss from heavy menstrual periods or internal bleeding

When you're anemic, your body either produces too few healthy red blood cells, or destroys them faster than they can be replaced or loses too many of them. If your diet lacks certain vitamins and minerals, the production of hemoglobin can slow down.

Types of anemia caused by decreases in red cell production include iron deficiency anemia and vitamin deficient anemia.

If something in the body destroys or attacks red blood cells, the bone marrow tries to produce more blood. If the destruction of red blood cells is rapid, the marrow can't catch up. This problem is often inherited. The resulting anemia is called hemolytic anemia.

Hemolytic Anemia

A severe bleeding episode can result in temporary anemia until the body has had time to make up the blood that was lost. But even small, persistent losses of blood may cause anemia if you have a poor diet. A healthy person whose diet contains plenty of iron and vitamins can produce large amounts of new blood, reducing the risk of anemia

The Different Kinds Of Anemia
There are different kinds of anemia. Some forms of this condition are inherited, while others are brought on by poor nutrition.

Iron Deficiency Anemia
The body needs iron to produce the hemoglobin necessary for red blood cell production. In general, most people need just 1 milligram of iron daily. Menstruating women need double that dose.

Vitamin Deficiency Anemias
Vitamin B-12 is also essential in hemoglobin production. Normally, a chemical secreted by the stomach helps the body absorbs this vitamin. However, some people can't readily absorb B-12. The result is B-12 deficiency (pernicious anemia). Because the symptoms develop gradually this condition may not be immediately recognized. Those with thyroid disease or diabetes mellitus are at increased risk for this type of anemia. The condition occurs most often in 40- to 80-year-old northern Europeans with fair skin.

A lack of folic acid, another one of the B vitamins, can also lead to anemia. Folic acid deficiency is a particular problem for alcoholics.

Food rich in iron and vitamins

Hemolytic Anemias
Anemia caused by the premature destruction of red blood cells is known as hemolytic anemia. In this type of anemia, antibodies produced by the immune system damage red blood cells. This condition is sometimes associated with disorders such as systemic lupus, or lymphoma.

Toxic materials such as lead, copper, and benzene can also cause the destruction of red blood cells.

Blood transfusions may be necessary for some people with this kind of anemia. Hemolytic anemia can be acquired or inherited. Sickle cell disease and thalassemia are both inherited types of hemolytic anemia.

Sickle Cell Anemia

Sickle cell anemia is also known as Hemoglobin S disease. This is a serious, life-threatening inherited form of anemia. Persons with this disease have sickle-shaped red blood cells that are stiff and unable to squeeze through blood vessels.
Persons with this disease often suffer from pain in the joints and bones. Infections and heart failure can also occur.
The disease occurs in just 0.6 percent of the population, usually in African Americans.

Thalassemia
This is a group of anemias due to the defects in the genes producing hemoglobin. It is most common in people of Mediterranean descent. There are two major forms: thalassemia minor and thalassemia major.

As its name implies, thalassemia minor is mild and those suffering from this condition go on to live a full life. Treatment is often unnecessary. Thalassemia major can be serious, but it is very rare. Transfusions or bone marrow transplants are usually required. Thalassemia major is also called Cooley's anemia, named after the doctor who first described it in 1925.

Aplastic Anemia
This is one of the deadliest and most rare forms of anemia. Only two to six people per million have this type of anemia. The condition results from an unexplained failure of the bone marrow to produce all types of blood cells. Instead, fat cells replace bone marrow.
Aplastic anemia is usually found in adolescents and young adults. Symptoms can include bleeding in the mucous membranes. Chemicals such as benzene and certain pesticides can also cause this type of anemia.

Favism, G6PD Deficiency, Fava Beans and Legumes

What is Favism?

Favism describes the susceptibility to, and clinical presentation of, acute haemolytic crises as a consequence of eating broad beans in a subgroup of patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. It can be potentially life-threatening. Broad beans are derived from the plant Vicia fava, hence the condition's name. Susceptible patients may also experience the syndrome when exposed to the plant's pollen.

Favism is associated with some severe variants of G6PD Deficiency. It is called favism because the consumption of broad beans, sometimes called fava beans, causes. oxidative stress and hemolytic anemia In some cases eating any legume causes some degree of hemolysis.
The exact relationship between Favism and G6PD Deficiency is not known. Broad Beans (Fava Beans) contain vicine, divicine, convicine and isouramil, all of which are oxidants.

The condition had been thought to occur only in the Mediterranean variety of G6PD deficiency. However, there have been reports of the condition affecting children in Hong Kong, Thailand and Iran. This reflects common ancestry among populations in different parts of the world due to migration as well as the large number of genetic polymorphisms that constitute the variable alleles causing G6PD deficiency.

G6PD is crucial in maintaining red cell homeostasis and its deficiency leads to increased susceptibility to haemolysis induced by drugs, infections and substances in food. There are a huge number of polymorphisms of the gene with variable effects on the activity of the enzyme and a wide range of phenotypic susceptibility to haemolysis.

The gene for G6PD is located on the X-chromosome hence it is an X-linked inherited disease that primarily affects men. It can have clinical effects in homozygous women and a proportion of female heterozygous carriers.It is thought that the susceptibility to favism is determined by a combination of the particular G6PD polymorphism (predominantly the Mediterranean form), and by variability in other enzymatic mechanisms, particularly in the metabolism of L-DOPA (found in abundance in broad beans), and vicine, convicine and isouramil (the so-called 'anti-nutritional factors' that are present in broad beans)

Epidemiology

· G6PD deficiency is the commonest enzymopathy of man of clinical significance. It is thought to affect more than 400 million people worldwide.
· The highest prevalence of G6PD deficiency is found in tropical Africa, the Middle East, tropical and subtropical Asia, Papua New Guinea and various Mediterranean locations.
· Only a proportion of G6PD sufferers are prone to favism, and this proportion is variable between populations. A study in Sardinia, where there is a high prevalence of G6PD deficiency (7.5% of all males) found 508 cases of favism over a 9-year period. In a Thai study, favism was found in 3.6% of G6PD-deficient children. It therefore appears to be a relatively rare manifestation of a common genetic polymorphism.

Presentation

· There may be a past history of episodes of neonatal or childhood jaundice.
· A dietary history may reveal recent ingestion of broad beans.
· Check for recent medication changes or history consistent with infection.

Favism leads to acute, massive intravascular haemolysis. Its main clinical features are:

· Acute back and/or abdominal pain
· Acute pallor due to anaemia
· Haemoglobinuria causing the passage of dark or orangey-yellow urine
· Jaundice
· Patients with G6PD deficiency are prone to gallstones and splenomegaly due to recurrent, often subclinical, episodes of haemolysis.

Differential diagnosis

· Acute haemolysis caused by an alternative precipitant in G6PD sufferer (e.g. drugs – particularly antimalarials' infection)
· Sickle cell anaemia and crisis
· Exacerbation of other haemolytic anaemias, e.g. hereditary spherocytosis, autoimmune haemolytic anaemia
· Disseminated intravascular coagulation
· Systemic lupus erythematosus

Investigations

· Dipstick urine to reveal evidence of haemoglobinuria.
· FBC will show acute haemolytic anaemia picture with low haemoglobin.
· Reticulocyte count may be elevated (although often normal in early acute phase).
· Raised indirect bilirubin (unconjugated) indicating haemolysis.
· LFTs usually normal.
· Serum lactate dehydrogenase may be elevated, indicating haemolysis.
· Serum haptoglobins may be low, indicating haemolysis.
· Abdominal ultrasound may be used to detect gallstones and/or splenomegaly.
· Coombs' test is negative.
· G6PD activity assay in undiagnosed cases – may be normal if there is significant reticulocytosis as reticulocytes are rich in the enzyme; assay may need to be repeated in convalescent phase.

Associated diseases

· Glucose-6-phosphate dehydrogenase deficiency
· Gallstones due to chronic haemolysis
· Splenomegaly due to chronic haemolysis.

Management

· Avoid further ingestion of broad beans
· Folic acid supplementation
· Iron supplementation if ongoing acute severe intravascular haemolysis
· Oxygen therapy
· Bed rest and transfer to a high care/intensive care setting
· Intravenous fluids to reduce chance of acute oliguric renal impairment
· Blood transfusion or exchange transfusion sometimes needed to treat severe anaemia

Complications
· Death due to acute severe haemolytic anaemia (relatively rare)
· Ophthalmological damage due to intra-ocular intravascular haemolysis
· Acute renal failure
· Susceptibility to infection

Prognosis

This is variable depending on the degree of susceptibility to favism, quantity of beans ingested and access to acute medical care. Most cases do well with supportive care but there is significant morbidity and some mortality associated with the disease.

Prevention

· Avoidance of ingestion of broad beans in patients known to be G6PD deficient, or who have suffered previous episodes of favism.
· Genetic counselling and screening may be useful where there is a family history of G6PD deficiency, to allow diagnosis before exposure to haemolytic precipitants.
· Population screening and health education programs in areas of high prevalence of G6PD deficiency have been shown to reduce the incidence of favism in the at-risk population.

Herbs to treat G6PD Deficiency anemia
Chinese herbal doctors have reported some successful applications of using herbal combinations. During observation on patients receiving treatment with herbal remedy, all patients were judged as healing (full recovery and symptom free).

The most powerful feature of Traditional Chinese Medicine is that it allows you to easily combine multiple ingredients to form a recipe to suit the specific need of individual. The list below are to give you an idea of why you can get the herbal remedy best for you.

When you choose a herbal remedy there are two important things among your concerns: a good recipe and a correct way to cook it. A good recipe is half the good results.

Some Herbs are good for G6PD Deficiency anemia

Rhizoma Ligustici Chuanxiong
Radix Salviae Miltiorrhizae
Radix Angelicae Sinensis
Radix Codonopsis Pilosulae

How Is Anemia Diagnosed?

Anemia can be detected by a simple blood test. Most causes can be diagnosed by analysis of blood samples and by examination of the blood cells under a microscope.
A complete blood count test is always performed. The red blood cells and their iron-bearing protein, hemoglobin, are measured. The percentage of red blood cells in the blood is called a hematocrit.

A blood smear will determine the size, shape, and color of the blood cells. The shape of the red blood cells can be distorted in many blood disorders, such as sickle cell anemia.

Normal red blood cells (1) and abnormal sickle shape red blood cells (2)

Iron deficiency anemia is suspected when the red cells are low in number and unusually small. Measuring the amount of iron and its associated proteins in the blood can confirm this diagnosis.
Those with vitamin deficiency anemias have larger-than-normal red blood cells.

In some cases, a bone marrow biopsy may be necessary to confirm a diagnosis. A sample of bone marrow is removed from the back of the pelvic bone or from the breastbone. This sample allows physicians to determine the overall activity of the marrow and whether abnormal cells, such as cancer cells, are interfering with its function.

Other tests that may be needed include chemical examination of the stool for traces of blood, x-rays of the bowel to detect the presence of internal bleeding and examination of the small bowel lining to access its ability to absorb food normally.

How Is Anemia Treated?
The treatment for anemia depends on the type and cause.Iron deficiency anemia is treated with iron (ferrous sulphate) supplements, initially taken three times a day. If nausea, stomach cramps, diarrhea or constipation occur, the medication may be taken with a little bit of food.

Treatment should be continued for three to six months in order for the body to fully replenish its iron supply. As long as excessive bleeding is not present and there are no other complicating factors, the anemia will be corrected within a few weeks. However, if the iron deficiency is caused by blood loss that is not due to menstruation, the source of bleeding must be found and stopped. This may require surgery

ferrous sulphate

Pernicious anemia, or vitamin B-12 deficiency, is treated by a life-long course of intramuscular injections of B-12. Persons with this type of anemia receive a shot of B-12 several times a week when first diagnosed. The treatment may continue for life, with one shot about four times a year.
Folic acid deficiency anemia can be corrected by taking folic acid supplements once a day.

Hereditary hemolytic anemias, such as thalassemia is treated by first eliminating any existing infections and avoiding medications that suppress the body's immune system. These medications may attack red blood cells. In addition, persons with these types of anemia may require regular blood transfusions.

Sickle cell anemia patients may be given oxygen, oral and intravenous fluids and pain-killing drugs to reduce pain and prevent complications. Antibiotics are commonly prescribed as well. Sufferers will need blood transfusions when the anemia becomes severe or if misshapen hemoglobin needs to be replaced. In some cases, a bone marrow transplant may be effective. Adult patients may be treated with the cancer drug hydroxyurea (brand names Droxia, Hydrea).

Sometimes rare aplastic anemias and autoimmune hemolytic anemias will respond to steroids. Failure to respond to steroids may require removal of the spleen which can become enlarged with defective red blood cells. Aplastic anemias may require blood transfusions and medications to fight infections.

Most common symptoms of anemia

Other treatment options may be appropriate based on the cause of the anemia.
For instance, if the bone marrow has failed because of leukemia, intensive chemotherapy may be required. Bone marrow transplantation may be contemplated if a suitable donor exists.
With proper treatment, many types of anemia can be eliminated, especially those caused by iron deficiency and vitamin deficiency.

Good food for anemia

Need To Know:
Most cases of anemia are mild. Without treatment, however, serious problems can occur, since the reduction in red blood cells decreases the ability to absorb oxygen from the lungs.
Certain inherited forms of anemia, including thalassemia major, pernicious anemia, and sickle cell anemia can be life threatening.
You should never self-diagnose yourself with anemia. The symptoms of fatigue and weakness can be the result of many other diseases. If you suspect you have anemia, contact your doctor.

Typical tongue in case of vitamin B12 deficiency anemia

Putting It All Together
Here is a summary of the important facts and information related to anemia.

. Anemia affects about 400 millions around the world and making it the most common blood disorder in the U.S. where 3.5 million American already affected
. Anemia is the result of below-normal levels of hemoglobin in the red blood cells.
. There are many different kinds of anemia ranging from mild and easily treatable iron and, vitamin deficiency anemias to serious, and sometimes life-threatening aplastic and sickle cell anemias.
. Fatigue is the main symptom of most anemias.
. Anemia can be usually be detected with a simple blood test.
. Treatment of anemia is based on the cause of the disorder. Treatments range from folic acid or vitamin supplements in mild cases to bone marrow transplants in severe cases.
. You should never self-diagnose anemia. Symptoms of fatigue and weakness can be the result of many other diseases. If you suspect you have anemia, consult your doctor.

Medical laboratory is the place you can diagnose the anemia

Night Enuresis in children … Wetting the bed at night

It's common for toddlers to wet the bed, as they have not yet learned to control the flow of urine effectively. However, bedwetting can be a problem for older children too.

A child may wet the bed one or more times per night, and may sometimes have problems staying dry during the day, too. Bed wetting occurs on most nights in 15% of five year olds and is still a problem for up to 3% of 15 year olds. It's not an illness, but a condition that can be treated effectively and permanently.

Types of nocturnal enuresis

There are two types of nocturnal enuresis.

Primary nocturnal enuresis is when a child has never developed complete night-time bladder control.

Secondary nocturnal enuresis is when a child has accidental wetting after having had bladder control for six or more months. It's often associated with a period of emotional stress such as the birth of a younger sibling, a bereavement or school worries.

The urinary system

Why does bedwetting happen?

Urine is stored in the bladder, which stretches like a balloon as it fills up. When it stretches to a certain point, the nerves in the bladder wall send a message to the brain saying that it needs to be emptied. Urine passes out through the urethra. If a child is asleep and the brain does not "hear" this message, the bladder empties anyway.

The cause of bedwetting is unknown, but some factors are linked to it.

. Bladder size - bedwetting may be related to a small bladder size.
. Inherited aspect - children whose parents used to wet the bed are more likely to do so themselves.
. Infection - an infection in the bladder or kidneys may trigger bedwetting.
. Constipation - this can lead to leakage of urine.
. Antidiuretic hormone - children who wet the bed may have a lower level of a hormone called antidiuretic hormone, which suppresses the rate of urine production. This means they may make more urine than most people do at night.
. Delayed growth and development - some children’s nervous system is not mature enough to be able to sense when the bladder is full.
. Heavy sleeping - most doctors don't believe this alone can cause bedwetting, but in some cases it may play a role.
. Diet - dairy products, citrus fruits, chocolate and foods containing high levels of artificial colour and sweetener have been connected with bedwetting.
. Psychological and social factors - most often the cause of bed-wetting is not related to emotional problems. However, some children who wet the bed tend to be less mature and self-reliant than those who do.

Diagnosis

Parents worried about bedwetting can consult their GP, health visitor or school nurse. Most children will only need a general physical examination, and will have their urine tested with dip sticks.
It is rare that a child who wets the bed has any underlying illness. However, other possible problems such as diabetes, infections, or abnormalities will need to be ruled out.

Treatments
Treatment is not usually needed for children under six, because in most children, it will resolve spontaneously.

Treatment options include:

Alarms

Moisture alarm: Moisture alarms are considered a useful and successful way to treat bed-wetting. Medical research has shown that moisture alarms have helped many children stay dry.

This treatment requires a supportive and helpful family and may take many weeks or even several months to work. Moisture alarms have good long-term success and fewer relapses than medications.An alarm consists of a clip-on sensor probe that attaches to the outside of bed-clothing. An alarm is set off when the child begins to wet the bed. The alarm wakes the child, who will then go to the bathroom to finish and then go back to sleep. This slowly conditions the brain to respond appropriately during sleep to messages from the bladder.

A child who wets the bed needs to develop a better response to a full bladder, and an enuresis alarm can be an effective way to do this. When the child starts to wet the bed, a moisture sensor sends a signal to a control panel, which sounds an alarm. Some alarms also vibrate, which is useful for children with hearing impairments or those who sleep in a room with others.

As well as waking the child, who gets up to go to the toilet, the alarm stimulates the child's pelvic floor muscles to contract and so control the flow of urine. Gradually the child is conditioned to wake before the alarm sounds - or to sleep through the night without needing to urinate - and should start to achieve dry nights.

It is not usually recommended that children start using alarms till they are six or seven. They need to be old enough to understand the problem and how they have a part to play in treating themselves.

Alarms are effective in about 70% of children, but in 10-15% bedwetting returns. Continuing to use the alarm for at least three weeks after the child's last wet night can reduce the chance of this happening. A child will usually need an alarm for between three and five months.

Behavioral treatment is often more effective and certainly is safer than medical treatment. While behavioral treatment may take somewhat longer to show results, the improvement usually continues indefinitely.

There are several methods that may be helpful:

Retention Control Training: The child is asked to control urinating during the day by postponing it, first by a few minutes and then by gradually increased amounts of time. This exercise can extend the capacity of the bladder and strengthen the muscle that holds back urination. Parents should always check with a doctor before asking their child to practice retention control.

Night-lifting: This procedure involves waking your child periodically throughout the night, walking your child to the bathroom to urinate, and then returning your child to bed. By teaching your child to awaken and to empty his or her bladder many times during the night, it is hoped that he or she will eventually stay dry.

Drugs
Medications can work more quickly than alarms to treat bedwetting, so may be useful to help a child to build up confidence, especially if he or she is going on a school trip or sleepover.

However, medication only manages the problem in the short term rather than curing it.
A desmopressin nasal spray is usually effective in the short term. It works by making the child produce less urine. It works quickly and produces few side-effects. One puff is given to each nostril before bed. Desmopressin tablets are also available.

A drug called imipramine, which is used as an antidepressant in adults, may help by improving the child's sleep patterns or affecting the way the bladder muscles of the bladder work. However, it should not be used for more than three months. There may be side-effects such as changes in behaviour. It can be fatal in overdose and must be stored out of children's reach.

Some children who have daytime wetting as well may be diagnosed as having an "overactive bladder". This results in the bladder contracting even though it’s not full. A drug called oxybutynin may be helpful for this particular type of enuresis.

OXYBUTYNIN 5 MG

Combination treatment
It is possible to use drugs and an alarm at the same time. Scientific evidence suggests that more children become dry after using the alarm with drugs, compared to the alarm alone.

Complementary therapy
There is some scientific evidence to suggest that ultrasound treatment and electro-acupuncture may help, but these need more investigation.

Advice for parents

It's best to talk openly to your child about the problem. Give reassurance that he or she is not ill and that this problem can be solved. Praise all signs of improvement and all your child's efforts to conquer the problem. Do not blame, criticize, or punish your child or call them dirty or babyish.

Tips for a dry night
Make sure your child visits the toilet just before going to bed. Parents sometimes lift a sleeping child to the toilet before they themselves go to bed. However, this may encourage a child to wet the bed because their bladder does not feel full before they pass urine.

Make sure your child doesn't have a drink within two to three hours of bedtime. However, limiting a child's fluid intake during the day will not help to develop bladder control. Children should be encouraged to drink seven to eight cups of fluid, spaced out throughout the day. It’s best to avoid drinks that contain caffeine because they have a diuretic (urine-producing) effect.

Make it easy for your child to reach the toilet - perhaps leave a light on.
Encourage your child to return to her own bed after it has been changed.
Record wet and dry nights. Reward dry nights

Mattress protection

There are a number of specialist products available to keep beds dry, such as plastic mattress covers and dry-pants (mini-nappies.

Using herbs to treat night bed-wetting
1 - Drink eight ounces of cranberry juice thirty minutes before going to bed. Cranberry juice is known for assisting the urinary tract, which is the main cause for bedwetting. Healthy urinary tracts are able to hold urine for longer periods of time.
2 - Eat a combination of walnuts and raisins an hour or so before going to bed every night. These ingredients are known for their support of the digestive tract. Consume these ingredients every night until bedwetting has subsided, and even for several months afterwards, to ensure that you stop wetting the bed.
3 - Boil a cup of water, add oak bark into the hot water, and then drink the mixture. Natural herbs will boost the immune system and will also treat many different types of hormonal issues. Oak bark, wormwood and horsetail will prevent bedwetting by its vitamins and minerals.
4 - Practice urine retention throughout the day. During the daytime hours, when you start to feel the need to urinate, hold the urine until you absolutely need to go to the bathroom.

Premenstrual Syndrome ...PMS

PMS has been seen since the times of ancient Greece. It has been reported in Eastern (Asian) cultures as well as throughout the Western World. Modern scientific study of PMS has been going on since the early 1930s.

A woman is considered to have PMS when her premenstrual symptoms:

. cause significant discomfort
. interfere with her daily life
. occur primarily during the last two weeks of her menstrual cycle
. cannot be attributed to other conditions

. At least 80% of menstruating women have some premenstrual symptoms:
. About 40% of menstruating women have PMS
. About 10% have severe symptoms, a condition called premenstrual dysphoric disorder (PMDD). Nine million women, or approximately five to seven percent of women of childbearing age, have PMDD.

For most women PMS symptoms are mild. In others, the symptoms may be severe and even incapacitating. The severity of a woman's symptoms has much more to do with her body chemistry than her personality.

PMS can occur at any time after puberty, but more women experience symptoms in their 30s and 40s than in their teenage years. Women who have had more children tend to have more severe symptoms, and women whose mother had PMS are at increased risk. PMS tends to get worse as women age and experience hormonal changes. Women with a history of depression have a greater risk of PMS.

Nice To Know:
Hormones are chemicals produced in the body that control the activity of specific cells or organs. Hormone levels in women with PMS are normal throughout the menstrual cycle. Women with

PMS do not have too little or too much of the female hormones estrogen and progesterone, or the male hormone testosterone. However, the effects of the hormones are different from one woman to another

What Are The Symptoms Of PMS?
The number, type, and severity of symptoms vary among women. They may also be different in the same woman from month to month.

PMS symptoms include:
Fatigue: This is the most common symptom of PMS. Women with PMS may feel so tired they can barely get through the day. Some women also may have trouble sleeping at night.
Tension and irritability: A woman with PMS may feel very on edge. Small annoyances seem huge. Often her response is out of proportion to the problem.

Difficulty concentrating: Many women with PMS find it hard to do things that require concentration, such as balancing a checkbook, following recipes, or making business decisions.
They may also be forgetful.

Anger: During PMS, normal feelings of anger are often exaggerated. A woman may be more argumentative and lash out at those around her.

Depression: Sadness and crying easily are common feelings related to PMS. At times the sadness may feel profound and inconsolable.

Food cravings: Some women crave particular foods, such as sweets or salt. Others find their appetite for almost any food increases.

Breast tenderness: Many woman experience swelling and soreness around their nipples or breasts.

Bloating in the abdomen, hands, and legs: Some women with PMS gain weight. Others have fluid shifts to the abdomen, hands, and legs that make them feel uncomfortably swollen or puffy.
Headaches: Duration and severity of headaches vary from woman to woman, but are common during PMS.

What Causes PMS?
Experts say that the definitive cause of PMS is not yet known. However, the most likely explanation for PMS is that many women are sensitive to the hormonal shifts that occur in the second half of the menstrual cycle.

What Hormones Cause PMS?
PMS most often occurs in women with normal menstrual cycles. During the normal menstrual cycle, the ovaries make two main hormones, called estrogen and progesterone. Estrogen is made by the ovaries throughout the entire menstrual cycle. It reaches its highest levels during the second and third weeks and declines during the last week. During the last two weeks of the cycle the ovaries also make progesterone. The last two weeks of the menstrual cycle is called the luteal (secretory) phase.

Both estrogen and progesterone prepare the uterus (womb) to accept a fertilized egg. Both estrogen and progesterone also affect women's moods.

How Do Hormonal Changes Cause PMS?
The exact cause of PMS is still not known, but researchers believe that PMS symptoms occur because progesterone and estrogen cause changes in brain chemicals called neurotransmitters.

The most likely neurotransmitters affected are:

Serotonin: Women with PMS have fluctuations in serotonin levels. These changes may cause depression and carbohydrate cravings. Serotonin is made by the body from the amino acid tryptophan.

GABA: GABA stands for gamma-aminobutyric acid. This neurotransmitter is important in feeling calm.

Endorphins: Endorphins are important in the experience of pain and pleasure. Estrogen and progesterone change endorphin levels.

Norepinephrine: Norepinephrine and epinephrine are also neurotransmitters that influence mood. In addition, these substances play a role in blood pressure and heart rate.

Could Calcium And Magnesium Imbalances Be Involved?
Some researchers think that certain imbalances in calcium and magnesium levels may trigger PMS symptoms. These two minerals affect nerve cell communication and blood vessel opening and closing. These functions may be involved in PMS symptoms.

Does Stress Cause PMS?
No. PMS is not caused by stress. Women may experience more stress prior to menstruation, and they may handle stress differently during this time, but it is not the cause of PMS. Excessive stress can, however, make PMS symptoms worse.

How Can I Tell If I Have PMS?
Hormone levels in women with PMS are normal. So, there are no laboratory tests that determine if you have PMS. However, your doctor may do blood tests to determine if you have another problem besides PMS, such as a thyroid condition or early menopause (when menstruation stops, usually associated with aging).

Keeping A Symptoms Calendar
PMS is often incorrectly diagnosed as another physical or emotional problem. The main characteristic that distinguishes PMS is the timing of the symptoms.

So, to diagnose PMS a record of symptoms needs to be kept on a calendar for two to three months. This calendar can help you see patterns in your symptoms. Your doctor will use the calendar along with a health history and physical exam to determine if you have PMS.

How-To Information:
You can use a calendar to record your symptoms. Rate each symptom on a scale of 0 to 3:
0: means the symptom is not present
1: means the symptom is mild
2: means the symptom is moderate
3: means the symptom is severe and interferes with normal daily activities

Start the calendar on the first day of your period (Day 1) and use it every evening for one cycle.

. At the start of your next period, count up the score as follows:
. Add up all the points for the seven days before your period starts.
. Add up all the points on days 3 through 9 of the cycle.

PMS is probably present if:

. The total score on days 3-9 is less than 40; and
. The total score on the last 7 days is more than 42; and
. The score on the last 7 days is twice the score on days 3-9.

If the score on days 3-9 is more than 40, or if you notice that symptoms are not cyclical, you may have another condition like depression, a thyroid condition, or anxiety.

Should I Get Treatment For PMS?

PMS is not your fault, and it does not indicate psychological weakness. It is not something to be embarrassed about. Studies have shown that women with PMS are psychologically healthy.You should consider treatment for PMS if you notice any of the following, especially during the one to two weeks before your period.

Poor work or school performance: Poor performance at school or at work is often the result of difficulty concentrating, irritability, or fatigue.

Disturbing physical symptoms: Breast tenderness, bloating, and headaches.

Problems in your social life: PMS may disturb social relationships. This can include relationships with spouses, friends, lovers, and colleagues.

Difficulty parenting: Many women with PMS notice their children react to their mood swings and find themselves inappropriately angry at their children's behavior.
Suicidal thoughts: Suicidal thoughts are common in women with severe PMS.

What Treatments Work?
Many types of treatment are used to relieve symptoms of PMS. Most of them have not been scientifically proven to be effective, although they seem to help many women.

Most researchers and clinicians suggest starting with lifestyle changes, such as diet, exercise, and stress management. Over-the-counter and prescription medicines as well as non-drug treatments like vitamins, minerals, and herbal remedies are also used.

Different treatments are effective for different women. Although you may need to try several before having success, more than 90 percent of women can get at least some relief from their PMS symptoms.

Primary treatment for PMS currently includes:

. Non-drug and lifestyle approaches
. Medications
. Non-drug And Lifestyle Approaches

Many women begin with non-drug treatments, as they tend to have fewer side effects. Non-drug treatments include:
• Changes in diet
• Physical activity
• Stress management
• Nutritional supplements

What changes in diet can help?
Eating a healthy diet is important for general health and may also help relieve PMS symptoms such as bloating, breast tenderness, weight gain, irritability, and headaches.
This includes eating foods high in complex carbohydrates like whole grains and fresh fruits and vegetables, and avoiding saturated fats. It may also help to avoid salt, sugar, caffeine, alcohol, and red meat, and sometimes dairy products. Eating more small meals each day instead of three large meals may reduce food cravings and mood swings.

How can physical activity help?
Most women report that exercise improves their PMS symptoms. It is especially helpful in relieving stress, improving mood, and preventing weight gain.

Try to be physically active for at least 30 minutes on most days of the week throughout your menstrual cycle. Walking or other moderate physical activity may be enough, but some women find they need more vigorous aerobic exercise, such as jogging, biking, swimming, or climbing stairs. If you have not been exercising regularly, talk with your doctor before starting any vigorous exercise program.

What about stress management?
Everyone has events, people, and circumstances in their lives that cause stress. But the way that we handle stressors makes a huge difference in our physical and emotional well-being.
Identifying sources of stress and your reactions to them is the first step in managing stress. Try not to plan stressful activities during the days when your symptoms are worst.

Relaxation techniques, such as meditation, deep breathing, and yoga, help decrease PMS symptoms in some women. Talking with friends or with a counselor may give you ideas on changing negative responses to stress to healthier ones.

Causes of stress

Our society is often not tolerant of the changes that occur during premenstruation. In some cultures, premenstruation and menstruation are considered special times for women to reconnect with each other, slow down, and honor their own lives and bodies. Menstruation is also considered a time of cleansing.

By taking time to rest, and comforting yourself while still following healthy habits, you may minimize your discomfort.

What other non-drug treatments can help?
The most common non-drug treatments that help some women with PMS include vitamins, minerals, and herbal remedies. Acupuncture or massage may also help.

Calcium and magnesium. Calcium and magnesium levels fluctuate during PMS. Some researchers have found that calcium can reduce PMS symptoms by almost half. They now recommend trying calcium before trying prescription medicines. Magnesium supplements seem to help some women with PMS, although this has not been confirmed in any studies.

Vitamins. Some women report relief of PMS symptoms from taking vitamins, especially vitamins B6 and E, although there is currently no scientific proof. If you try vitamins beyond a daily multivitamin, be careful about the amounts you take. Some vitamins can cause harm in large doses.

Other dietary supplements. There are a variety of products available that combine different vitamins and minerals for relief of PMS symptoms. PMS Escape is one product that has been shown in a scientific study to help reduce food craving, irritability, depression, and problems concentrating. It contains complex carbohydrates, vitamins, and minerals in a combination that raises levels of the neurotransmitter serotonin.

One of the easiest ways to control the symptoms of PMS is through diet, as no medication can completely overcome the effects of a poor diet. Foods that are known to worsen the symptoms of PMS (and which therefore should be avoided) are those that are high in refined sugars and fats, and those that are highly processed and full of chemicals.

Foods made from whole grains, legumes, seeds and nuts, vegetables, seasonal fruits, and unsaturated vegetable oils have all been found to reduce PMS symptoms.

It has also been observed that Japanese women who eat a traditional diet of grains, fermented bean products, and sea vegetables have much less tendency to experience diseases associated with hormonal imbalance, such as PMS; examples of these traditional foods that can be found in health food stores and oriental markets include miso (a high-nutrient fermented soy product), tamari soy sauce; kelp; go masio (sea salt combined with ground and toasted sesame seeds); and umeboshi plums (traditionally used to maintain the body's acid-alkaline balance).

Fermented soy product

Some women find relief with the use of vitamin and mineral supplements. Magnesium can reduce the fluid retention that causes bloating, while calcium may decrease both irritability and bloating. Magnesium and calcium also help relax smooth muscles and this may reduce cramping. Zinc displaces copper in the body, which is important because an overabundance of copper can increase moodiness and produce higher levels of estrogen.

Foods containing Zinc

Vitamin E may reduce breast tenderness, nervous tension, fatigue, and insomnia. Vitamin B6 can help to regulate mood swings, irritability, fluid retention, breast tenderness, bloating, sugar craving, and fatigue associated with PMS. Vitamin B5 supports the adrenal glands and may help reduce fatigue. Vitamin D aids in the absorption of calcium, and can, like Vitamin A, decrease skin oiliness that exacerbates premenstrual acne.

Among the Vitamin-B Complex factors are choline and inositol, which enhance the liver's ability to break down fatty foods and fat-soluble hormones such as estrogen. Inositol is also a central nervous system tranquilizer, and may help to calm premenstrual anxiety and irritability.
Some Herbs can work good to stop PMS symptoms.

One important way to alter hormone levels may be by eating more phytoestrogens. These plant-derived compounds have an effect similar to estrogen in the body. One of the richest sources of phytoestrogens is soy products, such as tofu.

Additionally, many supplements can be found that contain black cohosh (Cimicifugaracemosa) or dong quai (Angelica sinensis), which are herbs high in phytoestrogens. Red clover (Trifolium pratense), alfalfa (Medicago sativa), licorice (Glycyrrhiza glabra), hops (Humulus lupulus), and legumes are also high in phytoestrogens.

Increasing the consumption of phytoestrogens is also associated with decreased risks of osteoporosis, cancer, and heart disease.

Angelica sinensis herb

What Medicines Can Help?

There are a number of prescription medicines used to treat PMS, including:

Birth control pills. These may help relieve the physical symptoms of PMS in some women, but the results are variable. Because birth control pills contain high levels of an estrogen-like hormone and progesterone -like hormone, they actually may cause premenstrual symptoms in some women. Women who experience PMS while on the pill should consider using another method of birth control.

Progesterone. Many studies have been done using progesterone treatment for PMS. The majority of these studies have concluded that progesterone does not improve PMS symptoms.

Selective serotonin-reuptake inhibitors (SSRIs). This class of antidepressants affects the availability of the neurotransmitter serotonin. The SSRIs fluoxetine (Prozac) and sertraline (Zoloft) have been shown in scientific studies to help reduce depression, irritability, and anxiety in PMS. Physical symptoms are usually helped too.

Other SSRIs are also being studied for their effects on PMS. SSRIs can cause the side effects of drowsiness, nausea, and jitteriness in a small percentage of women. Women who begin SSRI therapy must decrease dosages very slowly to avoid possible side effects should they decide to stop the therapy. About 60 percent of women with severe PMS experience significant relief from SSRIs. Many take them throughout their menstrual cycle, but some have success using them just during the premenstrual phase.

Anti-anxiety medicines. If SSRIs are not helpful, anti-anxiety medicines can be used to relieve anxiety associated with PMS. The one most commonly used is alprazolam (Xanax). It is in the class of medicines called benzodiazepines and works on the neurotransmitter GABA. Because alprazolam can be addictive it must be used cautiously. It should only be used during the few days a month when symptoms are worst. Alprazolam may cause drowsiness and difficulty operating motor vehicles.

Another anti-anxiety medicine, buspirone (BuSpar), may also help reduce anxiety and depression in PMS. It is not addictive and has less severe side effects than the benzodiazepines.
GnRH Agonists. Gonadotropin-releasing hormones (GnRH) agonists suppress the hormones that cause ovulation, causing a temporary menopause -like state. They are highly effective in treating PMS, including breast tenderness, irritability, and fatigue.

However, GnRH agonists can also cause menopausal symptoms, such as hot flashes and vaginal dryness. In addition, long-term use (more than six months) is associated with bone loss (osteoporosis). Small doses of estrogen and progesterone can be given in addition to GnRH agonists to lessen these side effects and allow long-term use.

How Can I Treat Specific Symptoms?

Many women address their PMS by treating the symptoms that arise. Specific symptoms that are often addressed this way include:

. Headaches
. Cramps
. Mood Changes
. Appetite
. Bloating,
. Breast Tenderness and Weight Gain

Headaches
Headaches are a common symptom of PMS. Increased tension premenstrually may cause tension headaches. There is also a higher incidence of migraine headaches premenstrually. Specific treatments are available for each of these types of headaches. They include acetaminophen (such as Tylenol) and aspirin for milder headaches. More serious headaches may require stronger pain medicine or medicines used to decrease the frequency of headache attacks. These require a prescription.

Cramps
Menstrual cramps are disabling to some women. Dysmenorrhea (painful menstrual cramps) is a different condition than PMS but may occur at the same time. The most effective treatment is to begin nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, before getting your period. Birth control pills are also likely to help with cramps.

Mood Changes
Mood changes, including irritability, depression, and fatigue, may best be relieved by the simple treatment of increasing your physical activity. Scientific studies have shown moderate physical activity to be as effective as medications in improving mental outlook. If physical activity alone does not help enough, talk to your doctor about other treatments.

Appetite
Appetite tends to decrease with vigorous exercise. Finding small ways to indulge without going overboard, and developing non-food ways of comforting yourself, for example taking a warm bath or nap may help. Treatment with SSRIs may also help.

Bloating, Breast Tenderness, And Weight Gain
Being physically active may help to minimize discomfort related to fluid gain.
If your symptoms are very uncomfortable, talk to your doctor about taking a diuretic (medicine that gets rid of extra water in the body). Spironolactone is the prescription diuretic most commonly used for PMS-related bloating.

Where should I start?
. Record your symptoms on a PMS symptoms calendar for two to three months in a row.
. Learn all you can about PMS.
. Make an appointment with your doctor to discuss your calendar results and see what treatments may be helpful for you. If your doctor does not take PMS seriously, get a second opinion.
. If your case is severe, you may need to see a doctor with specialized training in PMS. This may be a reproductive endocrinologist or a psychiatrist.

Living With PMS

PMS is not a psychological problem. However, normal life difficulties, such as work or relationship problems may seem more intense premenstrually. Ask your family and friends for support. Consider joining a PMS support group so that you can share experiences with other women who have similar problems. If your symptoms are creating major problems for you, a counselor or psychotherapist may be able to help you to cope better.

PMS is no longer a mystery. Nor do you have to continue living with difficult symptoms. Treatments are available that can improve the quality of your life. So don't keep your PMS to yourself. Seek help.

Will PMS get worse?

Most studies show that PMS tends to get worse as women get older until she reaches menopause. The symptoms usually become more intense and last longer. Because of this, women who have PMS should take steps early on to improve their symptoms

Putting It All Together
Here is a summary of the important facts and information related to premenstrual syndrome.
. Premenstrual syndrome is a term that refers to the physical and emotional symptoms that occur during the one or two weeks before the beginning of menstruation.
. Most women who have menstrual periods experience some premenstrual symptoms. About 40 percent of menstruating women have premenstrual syndrome, and 10 percent have severe symptoms.
. PMS is diagnosed when a woman has symptoms, the symptoms coincide with her menstrual cycle, and symptoms impair her functioning in life, and cannot be attributed to other conditions.
. Charting a calendar of symptoms is one way for a woman to determine if her symptoms relate to her menstrual cycle.
. The older a woman is, the more likely she is to experience PMS. Family histories of PMS, more children, being physically inactive and smoking are all associated with increased severity of symptoms.
. The most likely explanation for PMS is that many women are sensitive to the hormonal shifts that occur in the second half of the menstrual cycle.
. The more a woman understands PMS, the more can be done.
. There are many treatments for PMS that work. A woman will most likely need to try several treatment options before she finds the combination that works for her.
. Lifestyle changes alone, such as diet, physical activity and stress management may help many women with PMS. Other women may also need to take medicine.