Sandra Ishkanes is a Functional Medicine specialist. She takes a whole-body approach to healthcare, combining nutrition, lifestyle and cutting-edge medical testing.
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TG was 43 when she came to see me about what she described as severe premenstrual syndrome (PMS):
“Two weeks before my period starts and usually around the new moon, I go what can only be described as loony! I lose the plot and shout for no reason, get angry very easily and have absolutely no control over it. This goes on until I get my period 2 weeks later and then I’m totally fine. It’s affecting myself and my family enormously now, so I desperately need some help. GP just wants to put me on either the mini-pill, antidepressants or fit the coil - neither of which I am keen on, due to a bad experience with hormones when I did my IVF treatments.”
TG’s husband had difficulties with conception and they went through several rounds of IVF. They now have 3 happy and healthy children, but with one cycle of IVF she had an extreme reaction to Cyclogest, a synthetic progesterone. She described her reaction as being 1000 times worse than PMS.
Prior to having children her PMS only occurred 1 day before her period, where she was ‘scatty and snippy’. Since having the twins 3 years ago it had got much worse and over that last 2 years it had become severe.
Her periods were regular and the extreme PMS came on very suddenly.
She was lactose intolerant.
She found it difficult to fall asleep and was a light sleeper.
She experienced ‘winter blues’ and hated the winter months feeling very miserable in January and February.
She experienced obsessive compulsive disorder and says she is “extra controlling, and gets panicky if someone else is in charge’.
TG’s diet was high in sugar and carbohydrates: toast with jam or cereal with fruit for breakfast, sandwiches for lunch, and frequent rice dishes for dinner.
She ate 6 times a day, snacking on fruits, chocolate and brownies.
She didn’t drink enough water and frequently had juice.
She had minimal amounts of vegetables and a low intake of fish.
I requested standard blood tests from GP, and a 21 day progesterone test from a private lab. Her most significant results showed that she was deficient in vitamin D and severely deficient in vitamin B12. Her luteal progesterone level was normal.
TG described her symptoms as severe PMS, but I suspected that she was suffering from premenstrual dysphoric disorder (PMDD). Both PMS and PMDD are associated with disturbing, predictable, recurring, cyclic symptoms that start towards the end of the cycle and stop shortly after the onset of menstruation. Common symptoms include headaches, breast tenderness, bloating, irritability, depression, angry outbursts, and anxiety. The difference between PMDD and PMS is the severity and predominance of mental/emotional symptoms in PMDD and the marked impairment of personal/social relationships, including increased conflicts. PMDD is at the most severe and disabling end of the spectrum of premenstrual disorders.
The diagnostic criteria for PMDD are detailed below and TG experienced at least 5 of the symptoms including 3 of the specific symptoms, which seriously interfered with her social activities and personal relationships.
Diagnostic Criteria for PMDD
Presence of 5 of 11 depressive, anxiety, cognitive, or physical symptoms, with at least 1 of the first 4 specific symptoms* experienced in most of the menstrual cycles for the past year. The symptoms may begin a week before menses and must completely remit within a few days after the onset of menses.
Depressive, anxiety, cognitive, and physical symptoms:
Depressed mood, feelings of hopelessness, self-deprecation
Sudden feeling of sadness or tearfulness, with increased sensitivity to rejection
Anxiety, tension, feeling of being "keyed up" or "on edge”
Persistent irritability, anger, increased interpersonal conflicts
Decreased interest in usual activities
Lethargy, fatigue, lack of energy
Changes in appetite and cravings for certain foods
Insomnia or hypersomnia
Feeling overwhelmed or out of control
Breast tenderness or swelling
Joint or muscle pain
2. Symptoms interfere with social, occupational, sexual, or school functioning.
3. Symptoms are discretely related to menstrual cycle and are not merely worsening of preexisting depression, anxiety, or personality disorder.
4. Criteria 1, 2, and 3 must be confirmed prospectively by daily ratings for at least 2 consecutive symptomatic menstrual cycles.
The exact cause of PMDD is unknown, but it appears to be related to an abnormal response of neurotransmitters including serotonin and GABA to normal ovarian function. In PMDD there is no demonstrable hormonal imbalance, rather PMDD is the result of the way that oestrogen and progesterone affect serotonin and GABA metabolism.
PMDD usually starts within 1-2 weeks before the onset of menstruation, when progesterone is climbing and oestrogen is decreasing. Progesterone is converted to alloprogesterone which normally interacts with GABA receptors in the brain to produce feelings of calmness and relaxation. In PMDD however, it is thought that the GABA receptor is malformed which means that the alloprogesterone does not lead to calmness, and instead results in high anxiety, anger and other mental/emotional symptoms. This is probably why TG had such an extreme reaction to the synthetic progesterone she received during IVF treatment - the very high level of progesterone induced extreme PMS symptoms. The malformation of the GABA receptor is associated with various nutritional deficiencies, including vitamin K, magnesium and vitamin B6.
At the same time, the decreasing oestrogen level in the luteal phase is associated with a decrease in the level of serotonin. In PMDD this can be hightened, leading to a serotonin imbalance which can cause depression, anxiety, sugar cravings, insomnia, headaches, obsessions and compulsions.
Serotonin is not found in food, but it is synthesised from l-tryptophan, which is found in protein as an amino acid. Synthesis of serotonin requires vitamin B6 and vitamin D. TG had vitamin D deficiency as evidenced by her blood test, which likely contributed to her ‘winter blues’ and may have impacted her serotonin level and led to insomnia. Melatonin, the sleep hormone, is synthesised from serotonin, and hence sleep is worsened when vitamin D is low.
TG’s diet, which was high in sugars and starch, and low in vegetables, fibre, omega 3 fats and water was also a likely contributor to her symptoms. A high carbohydrate intake depletes the body of essential vitamins and minerals, while a lack of omega 3 fats and vegetables can lead to deficiencies in essential anti-oxidants and micronutrients.
I recommended a low carbohydrate, moderate protein, high fat nutrition plan which was rich in fish and eggs, with a high level of vegetables and beneficial fats, and personalised to TGs requirements.
I recommended that TG buy a SAD lamp and expose her eyes the bright light every morning. Bright light therapy has shown to help with winter blues, regulating energy in the daytime and the sleep cycle at night.
Vitamin D: calibrated dose of emulsified vitamin D drops
Vitamin B complex: calibrated doses of all 9 B vitamins
Minerals: sufficient minerals including zinc, selenium, molybdenum, copper, manganese, chromium and boron
L-tryptophan: purified tryptophan increases brain serotonin, but foods containing tryptophan do not. TG took l-tryptophan at specific times in her cycle.
Lithium orotate: to modulate brain health
Wheatgerm oil: to provide sufficient vitamin E
Electrolife: a supplement that I make for my clients as required, and which contains electrolytes (magnesium, potassium, sodium, and bicarbonate), as well as sulphur, vitamin C and soluble fibre.
I track each symptom on a scale of 0 to 6, with 0 representing the best that it can be and 6 representing the worst that it can be.
Shouting and pent-up anger: 6
Falling asleep: 4
Eating well: 4
TG had followed my recommendations very well and was feeling better in general. Her sugar cravings had diminished significantly and in fact she found many foods too sweet to eat. She was eating 3 nutritious meals a day and had completely eliminated snacking. She was falling asleep easier and her sleep was deeper and more restful. Her emotional and mental symptoms in the 2 weeks before her period had much improved as her reactions to what would usually be stressful situations had calmed down and she felt better able to cope. She was now able to take herself away from potentially explosive situations and spend a little time on her own aiming to calm down and relax. I recommended a breathing exercise that could help to activate the relaxation response. I also tweaked her nutrition plan and supplements.
Shouting and pent-up anger: 4
Falling asleep: 3
Eating well: 0
TG reported that she had felt very calm over the last month and including during her period. She stopped shouting and feeling irritable, and took all the stresses and strains of life in her stride. She had stopped having added sugar completely as she couldn’t eat sweets or chocolate anymore, and had lost 3kg in the process. She had been encouraging her family to reduce sugar as well, and found that her son had ‘completely mellowed from being hyperactive’. She was surprised and delighted with the outcome of following my recommendations and was looking forward to spending time with her family over the coming holidays.
Shouting and pent-up anger: 2
Falling asleep: 3
Eating well: 0
I was so pleased for TG and the quick turnaround she made in her health that benefited not just her, but her family as well. In 8 weeks her emotions had completely calmed down and she was able to take on all of life’s ups and downs without dreading her period or feeling desperate. We agreed that TG will have brief check-in in 3 months time to monitor her health and determine her dosage of vitamin D for the winter months.
“Since having had my children, my hormones were all over the place and my mood swings were out of control. I did not recognise myself or my actions throughout certain times of the month and after a while I finally plugged up the courage to go and see my GP to talk about the symptoms I was experiencing.
The help which I was offered was one of three options:
1) To take the mini pill
2) Go onto anti-depressants
3) Have the coil fitted
Neither of which I wanted to do, as I figured that these would mess even more with my hormones, give me side-effects and not solve the underlying issues. After some research I found Sandra and we ended up having a telephone consultation to see, if she could help and if we would “click”.
I am so very glad I made this phone call, as we ended up meeting and having a total of three face-to-face consultations.
Quite frankly it changed me; my outlook on life; my hormone imbalance. It also gave me an immense insight into nutrition and how important it is to eat healthily and keep a balanced life-style.
I was the constantly tired and grumpy mum, who was constantly snacking and having frequent energy crashes throughout the day, which resulted in me being snappy and quite frankly unpleasant to be around.
I didn’t realise how my food choices affected my energy levels and hunger. Sandra helped me put a nutritional plan together, which allowed me to have stable, steady blood sugars and well-regulated insulin levels throughout the day.
From a sugary diet, I changed to a more protein based, healthy fats and low carbohydrates diet. Combined with the right supplements, this changed me within just three to four weeks. The impact was huge.
Knowing what triggered the hormone imbalance and what I needed to do to balance it out again, was the biggest part of the jigsaw. Finally, I was able to take back control.
I cannot thank Sandra enough for all of her help and input and would recommend her to any woman going through difficulties with a hormone imbalance.”