Premenstrual Syndrome (PMS)

I will be asking you to tell me very specifically how much you are bleeding. An example of a "detailed flow" is: M, M, H, L, L, VL/B

TAMPON or PADS: 

• Very Heavy (VH): changing a full pad/tampon every 1-2 hours
• Heavy (H): changing a full pad/tampon every 3-4 hours 
• Moderate (M): changing a full pad/tampon every 5-7 hours
• Light (L): changing a full pad/tampon every  8-12 hours
• Very Light (VL): changing pad/tampon less than every 12 hours.

MENSTRUAL CUP MEASUREMENTS

• Very Heavy (VH): 60 cc in a 24 hours
• Heavy (H): 40 cc in 24 hours
• Moderate (M): 20 cc in 24 hours
• Light (L): 10 cc in 24 hours
• Very Light (VL):  5 cc in 24 hours

**The Diva Cup comes in 20, 30 and 32 ml cups 32 being the largest but other cups may vary. 1 ml = roughly 1 cc 

Other important information about your flow: 

• Tail End Brown Bleeding (TEBB): brown bleeding at tail end of period. 
• Premenstrual bleeding: pink spotting or brown spotting at the prior to a full period starting. 
• Intermenstrual bleeding: bleeding between periods. 

Mainstream ObGyn doctors will almost always recommend the birth control pill as first line treatment. The birth control pill will suppress your normal menstrual cycle and simply provides a band-aide for the underlying problem(s). 

Please know NaPro Providers to not prescribe the birth control pill (mentioned briefly towards the end of this video). 

To the contrary, we believe the birth control pill is harmful to women physically, emotionally, and spiritually. We pride ourselves on taking our patients OFF hormonal contraception, finding the root cause of their symptoms, making a proper diagnosis and providing superior treatments for all of the conditions we treat. 

For more information about the spiritual harm brought  into the relationship via contraception, visit my  CrMS page, scroll to the bottom and read about SPICE. 

***** Do not take unless under medical supervision *****

Micronized Progesterone which is a bioidentical hormones. Dr. Lara Briden has an excellent podast where she discusses indications for, safety and efficacy of these supplements. Micronized” progesterone is biochemically identical to the progesterone your ovaries naturally make; it is very different from the synthetic progesterone which is found in many types of contraception pills and devices. 

Your CrMS charting is of the utmost importance. If you are prescribed progesterone hormone replacement therapy, this must be timed accurately and specifically to your menstrual cycle. Taking this medication too early or too late can cause more bleeding problems and increase your risk infertility. Whereas, taking this medication timed correctly will resolve these two problems. I will offer you two options for dosing .   

• Oral capsules taken at bedtime once daily on P+3 through P+12  
• Oral capsules inserted per vagina twice daily on P+3 through P+12 

Again, only bioidentical hormones supplementation is offered. I commonly prescribe prometrium capsules, which are taken orally. The generic brand is just as good and ot costs much less. Prometrium (micronized progesterone) is truly a  bioidendical hormone formulation which can be purchased through a regular retail pharmacy. This medication is generally well-tolerated. Some common side effects are quite pleasant, eg: you may feel more relaxed or sleepy and your might find your mood may improves. Some more unpleasant side effects may be: next-day fatigue, nausea, headaches, or dizziness. Most often the unpleasant side effects can be easily managed by taking the medication right before you lay your head down on the pillow and/or changing to a compounded formulation. Please know prometrium and generic progesterone capsules contain peanut oil, so you CANNOT take this if you have a peanut allergy.

Sometimes the Prometrium or generic micronized progesterone that is  purchased will include a package insert which will "warn" of possible birth defects. However, this warning refers to progesterone substitutes that are often prescribed in oral contraception pills, not the bioidentical progesterone we are prescribing.  NaPro providers, who were trained at the St. Paul VI Institute, have been safely prescribing micronized progesterone to many, many women to support pregnancies for over 35 yrs and they have not encountered problems. 

If the oral medication is not strong enough or if the side effects are bothersome, we can try a vaginal suppository. This will be prescribed for you by a specialty pharmacy called a "compounding pharmacy". You can see a list of compounding pharmacies by viewing Handout #21 here.

Sometimes we will have to use progesterone injections. I will ask you to watch this instructional video and choose someone such as your spouse or a close relative who is willing to administer the injections to you. I would also recommend injections be administered in the upper-outer quadrant of the buttocks (shown in the video) and that you alternate sides. Common side effects of the injections are: soreness, itching and/or mild bruising at the injection site, especially if the injection is done too quickly.        

***** Do not take unless under medical supervision *****

Naltrexone (off-label use):  

• NaPro Protocols recommend full dose naltrexone (50 mg) for PMS. 
• Naltrexone is commonly used to help people with addictions avoid alcohol use and or opioid use.  
• This medication is an opioid-receptor antagonist (blocks opioid receptors).  
• Thus, we call this an "off-label" use of this medication, which is somewhat common to do in mainstream medicine. 
• Many NaPro patients report wonderful success using naltrexone to treat PMS. 

I do occasionally use the full 50 mg dose of naltrexone in very severe cases. Most often I will recommend "Low-Dose Naltrexone" (LDN) for you namely b/c  there has been some discussion among the medical community that if a patient has been on full dose naltrexone for many years, this may present a conundrum if the patient needs opioid medications to control severe pain, such as after a surgery or after a significant injury has been sustained. The concern is twofold: 

1. If the pt is left on the 50 mg of naltrexone, it may be very difficult to manage his/her pain, because the naltrexone is blocking the pain receptors. 
2. Whereas, if the patient is taken off the naltrexone and given an opioid medication to control his/her pain, a regular dose of the opioid (eg; Percocet) may be too much, and the patient may be at a higher risk of respiratory depression (breathing stops) due to a normal dose of an opioid medication now being too potent, because the patient's opioid receptors have undergone a process called down-regulation, which occurs after long term opioid use. 

My recommended treatment for most cases: 

We would start at a very low dose and slowly titrate up to 8 mg and see how you feel. The 8 mg dose may be enough for most women. Again, in rare cases, we may continue uptitration to the full 50 mg dose, but I would prefer to use this short term. 

There are some studies that have emerged indicating patients who have been on 50 mg of naltrexone, for long periods of time, may present a conundrum if they need short term opioids to control pain, such as in the setting of a serious injury or if an emergency surgery is needed. Acute care medical providers are faced with a dilemma, ie: stop the naltrexone (which is filing 'mu-opioid" receptors) or continue the naltrexone and try to control pain. If naltrexone is abruptly stopped, their is a risk that the opioid dose will be too high for the patient, which can cause respiratory depression (breathing slows or even stops), OR if the provider chooses to continue with the naltrexone, it may harder to achieve adequate pain control for the patient. 

I prefer to prescribe naltrexone capsules from a compounding pharmacy.  You can view a list of  compounding pharmacies that I frequently work with here. 

*** If we agree on using the full dose, I will document you have been educated to the risks as noted above, and you would like to take this risk. Also, we would plan to use the full dose for only 4-6 mos.