Women's Bodies, Women's Wisdom (36 page)

It has been a number of years since Gwendolyn first began to listen to and understand her menstrual wisdom through learning to trust and transform her rage. When I last spoke with her, she was doing better than ever. She said that if she had to describe her life in one word, it would be
empowerment
. She’s taking care of old business, making amends to those she’s hurt, and telling the truth to those who have hurt her. She is thrilled that “the talents I was born with are flourishing: my voice, music, and art. I believe that we all have these talents. But we aren’t made to feel that we have anything worthwhile.” She wrote me a note that said, “When I become angry at all, I give myself quiet space, go within, and ask myself, ‘What is it that you’re afraid of or what pain are you trying to escape?’ I simply stay present with the feeling in my body until something shifts. Then I almost always get an answer that I can then work with.”

PMS and Codependence

There is a strong correlation between PMS and growing up in an alcoholic family system, in which the parents or grandparents were alcoholic. The correlation between PMS and giving your life away to meet other people’s needs—relationship addiction—is very high. In many families in which the men have a tendency to become alcoholics, the females tend to develop PMS. Children of alcoholics have a 40 percent chance of becoming alcoholic, not only because they have a genetic predisposition toward it but because they’ve learned that alcohol is the way to deaden their emotions. This behavior is frequently passed on to them, along with genes that predispose them to drinking. Women in alcoholic families or with alcoholic partners develop PMS as a result of cutting off their feelings. I’ve worked with countless women who have decided to break the chain of PMS experience by generations of women in their families. (Hypoglycemia [low blood sugar] and a resulting ten dency toward sugar craving are also very common in women from alcoholic families who have PMS. This condition tends to be much worse premenstrually and can be easily treated with the dietary recommenda tions I’ve already covered.)

Leslie, a forty-nine-year-old homemaker and former teacher with PMS, came to see me with severe premenstrual mood swings, sugar cravings, and fatigue. As I read through her history, I noted that her husband was an alcoholic and that she was in a teaching position that she hated. She had had an alcoholic mother and sister and had never addressed any of these family issues. During the initial visit, I counseled her about supporting her body during the menstrual cycle through nutrition and exercise, and stressed that she wouldn’t “cure” her premenstrual discomfort until she was willing to look at the messages it was sending her about her own family situation. I could tell that she wasn’t ready to hear this information, and she did not return for a follow-up.

Seven years later, however, Leslie made an appointment. She told me, “When I was in to see you the first time, you told me that I needed to check out my codependence and that my PMS and decreased energy were related to that. I left thinking, ‘Dr. Northrup’s a nice woman, but she doesn’t know what she’s talking about, and in fact I think she’s crazy. How could codependence and PMS be related?’ But now I real ize the connection between what was happening in my life and my PMS. I finally realized that my husband has been verbally abusive for years. I am in the middle of a divorce, and I see now that I had totally ‘de-selfed’ myself.”

Leslie told me that she had joined a twelve-step group and was picking up the pieces of her life and learning about the effects of living with verbal abuse and alcoholism for so many years. Leslie’s feelings are no longer deadened. She’s becoming her own person and determining what she will and will not tolerate in her family’s behavior. She no longer has PMS most months, but when she does, she pays attention to it, slows down, and makes the necessary adjustments in her life, so that she gets her needs met.

IRREGULAR PERIODS

After nearly thirty years as a physician, I continue to be amazed by how clearly menstrual cycles and bleeding are connected to the contexts of our lives. Abnormal uterine bleeding is nearly always connected to family issues in some way. As Caroline Myss says, blood is family—always. One woman told me that she and her two sisters, who were living in different parts of the country, skipped periods in the same month when a fourth sister had a miscarriage, although they didn’t realize it until they talked at their next get-together. One of my patients, age fifty-five, who had her last menstrual period at the age of fifty-two and went through a classic menopause with hot flashes and lab tests confirming “change of life,” nevertheless got a completely normal period right after her mother died. When a menopausal woman develops postmenopausal bleeding, I always ask her what is going on with her and her family. She will often tell me that an emo tionally significant family event preceded the bleeding. I had my final menstrual period on the day my youngest child left home for college. I hadn’t had any bleeding for eleven months prior to this.

Menstrual blood, especially when it comes at an unscheduled time, is a message. It carries wisdom of some kind. Myss points out that most bleeding problems originate from an imbalance in our system: too much emotion and not enough mental, intellectual energy to balance it. She notes that bleeding abnormalities are exacerbated when a woman internalizes confusing signals from her family or society about her own sexual pleasure and sexual needs. A woman may, for example, desire sexual pleasure but feel guilty about it or be unable to ask directly for what she desires. She may not be consciously aware of this inner conflict.

Most practicing physicians have seen the profound effect that the psyche can have on the menstrual cycle. Way back in 1949, S. Zuckerman recognized that emotional disturbances could disorganize menstrual rhythm, accelerate uterine bleeding, and also influence the time of ovulation. Diffuse networks of nerves connecting the brain with the ovaries (called pregan-glionic autonomic pathways) are one of the ways the connection between emotions and uterine and ovarian function is mediated.
⁷⁴
It is also well documented that the thoughts arising in the prefrontal cortex of our brains result in feelings associated with neurotransmitters that directly influence the hypothalamus and pituitary—the parts of the brain that are intimately connected with all the organs and functions of the body.

What Are Regular Periods?

Before I examine the subject of menstrual period irregularity, it’s necessary to explain what is normal. Women are sometimes taught that their periods are irregular if they do not occur every twenty-eight days. I consider periods regular when they occur roughly every twenty-four to thirty-five days. Having a period every twenty-eight days like clockwork happens for some women but not all. Thousands of women who don’t fit the every-twenty-eight-day pattern are under the impression that their periods are irregular, when in fact they are completely normal.

Period regularity is determined by a complex interaction between the brain (hypothalamus, pituitary gland, and temporal lobes), the ovaries, and the uterus. Period patterns can change with changes in seasons, lighting conditions, diet, or travel, or during times of family stress. Irregular and anovulatory menstrual cycles are associated with premature bone loss. Often women can tell when they have ovulated because they have a clear discharge twelve to sixteen days from the first day of their last menstrual period. (This is discussed in more detail in chapter 11.) Cycles in which a woman has ovulated are also characterized by what is called premenstrual
molimina
.

Molimina is a group of “symptoms” resulting from normal cyclic hormonal changes in the body. These include a slight premenstrual redistribution of body fluid, often experienced as “bloating” or slightly tender breasts, slight abdominal cramping, and mood changes associated with being in a more reflective, less active state. Women who don’t ovulate usually don’t have these changes and will often get a period out of the blue, without having any idea that one is due. Periods in which there is no ovulation tend to be more irregular.

EXCESSIVE BUILDUP OF THE UTERINE LINING (ENDOMETRIAL
HYPERPLASIA, CYSTIC AND ADENOMATOUS HYPERPLASIA)

In some women with irregular periods, a biopsy of the inside of the uterus (endometrial biopsy) reveals a condition in which the normal lining of the uterus has been replaced by an overgrowth of glan dular tissue. Under the microscope, the endometrial glands look as if they are piled on top of each other and packed too closely. This overgrowth results from overstimulation of the uterine lining by es trogen without the balance of progesterone. It is known as cystic and adenomatous hyperplasia (meaning too many glands) of the endometrium.
⁷⁵
(It is not to be confused with endometriosis, which will be discussed at length in chapter 6.) Hyperplasia results when a woman’s ovaries haven’t produced eggs regularly. Instead of a uniform thickening and then sloughing off of the uterine lining (the endometrium), caused by the hormones associated with regular ovulation, the endometrium gets out of sync. Some parts of the lining “think” it’s day seven, while others “think” it’s day twenty-eight. This results in irregular and intermittent bleeding.

Cystic and adenomatous hyperplasia or simple endometrial hy perplasia is not considered dangerous unless abnormal cells are present in the biopsy of the uterine lining. Finding some simple endometrial hyperplasia on the biopsy is fairly normal and is not a case for alarm if it happens only once or twice. Many women in their forties and fifties skip an ovulation every now and then as their ovaries undergo the changes leading up to menopause. When a woman’s periods become irregular, she does not necessarily require a uterine biopsy, though this decision must be made on a case-by-case basis depending on her history and examination findings.

Treatment

Please note that for this and other conditions, I will be discussing the treatments that are most commonly prescribed in the United States. These treatments do not address the issues underlying symptoms. The underlying issues and what a woman can learn from them are covered in the individual stories throughout this chapter.

Many cases of simple endometrial hyperplasia go away on their own. However, a very small percentage of women with this condition have atypical cells on their biopsies. Endometrial hyperplasia needs to be monitored and followed to be sure it is going away rather than progressing. Women with chronic anovulation over many years do have a statistically higher incidence of uterine cancer, especially if they are also obese or have been diagnosed with polycystic ovary syndrome (see below as well as chapter 7). Gynecologists are trained to treat everybody as though there were a potential cancer risk. Therefore initial conventional treatment of endometrial hyperplasia consists of giving a synthetic progestin such as Provera or Aygestin for one to three months and then repeating the endometrial biopsy to make sure that the condition has cleared. I often recommend natural progesterone for this purpose, especially in those women who have adverse side effects from synthetic progestin. (See page 132 for the difference between synthetic and natural progesterone.) Physicians vary widely on how much of the drug they give and for how long they give it. Prescribing a progestin drug is sometimes called a “medical D&C” (dilation and curettage of the uterine lining), because it causes the endometrial lining to slough off in a uniform manner all at once and helps the uterus get rid of the tissue buildup. Natural progesterone, on the other hand, has the ability to down-regulate estrogen receptors, meaning that it reduces the cells’ sensitivity to estrogen; this often clears up benign endometrial hyperplasia.

Some women with persistent endometrial hyperplasia do not respond to treatment with progestin or progesterone and may require a surgical D&C in the operating room. In extremely rare instances, they may need a hysterectomy if this condition does not go away or if it pro gresses to the stage of producing abnormal cells.

DYSFUNCTIONAL UTERINE BLEEDING (DUB)

Skipping periods more than just occasionally, frequent bleeding between periods, or spotting between periods is known as dysfunctional uterine bleeding, or DUB. (See also the section on polycystic ovaries and anovulation in chapter 7.) Women who have had cesarean sections may occasionally have abnormal bleeding patterns because of disruptions of the uterine lining caused by the scar on the uterus. Many abnormal patterns are hypothalamic in origin, meaning that they are related to the complex interaction between the brain, ovaries, and uterus. Severe anxiety and depression change neurotransmitter levels in the brain and can affect hypothalamic function. Dysfunctional uterine bleeding is often associated with anovulatory cycles and too much es trogen relative to progesterone. It is also related to the hormonal imbalance that results from elevated cortisol and insulin levels, which change the way estrogen is metabolized. Though doctors are trained to look for endocrine abnormalities—such as thyroid problems or pitu itary problems— that can cause menstrual abnormalities, these tests almost always come back normal. Because DUB is sometimes (though rarely) related to high prolactin levels caused by small pituitary tumors known as pituitary microadenomas, a blood test for this hormone is also indicated. However, prolactin hormone levels that are too high, a condition known as hyperprolactinemia, is not common. Moreover, the tiny pituitary tumors that cause it have often been found to go away on their own.

A diagnosis of DUB is made on the basis of history, blood tests that check pituitary and thyroid hormone levels, and sometimes a biopsy from inside the uterus to see if the uterine lining shows signs of anovu lation or abnormal cells.

Conventional Treatment

The conventional treatment of DUB consists of giving hormones such as birth control pills to regulate the periods. This common treat ment is now given even up until menopause in women who don’t smoke. Birth control pills do result in reliable periods every month, and taking them may be the first choice for women whose lives are too busy to change their diets, take supplements, or exercise. But pills don’t heal anything—they simply mask the underlying issues in the body or put an imbalance to sleep for a while. Taking birth control pills to regulate a woman’s period is like shooting out the indicator light on the dashboard of your car that tells you the engine needs attention. Nevertheless, like most gynecologists, I have prescribed birth control pills for many women, both for contra ception and for DUB, because taking the pill is the easiest way for a woman to eliminate her symptoms without doing the work of changing aspects of her life that are contributing to the problem. Sometimes this is appropriate, but a woman should be very clear that this is what she’s doing when she takes period-regulating hormones.