Clinical:Case Study: Out of Context

Original materials created in August 2002 by Sunitha Sukurasen, M.D. and Justina Trott, M.D.

History

TJR is a 34y/o woman who comes into your office stating her “hormones are out of whack.” She complains of premenstrual moodiness, interrupted sleep, bloating, and irritability. She describes a major impact on her family relations. She finds herself yelling at her children, and her husband suggested she “get help.” She wants to know what she can do. TJR works as a nurse and shares the night shift with her coworkers once a week. She eats erratically, and does not exercise.

Exam

Normal Studies: Routine screening labs, including thyroid function are normal.

Discussion

TJR exhibits what has been termed in contemporary medicine as premenstrual syndrome or “PMS.” The exact cause of PMS is unknown. The emotional and physical symptoms that occur premenstrually are related to hormonal and physiologic changes that occur during the luteal phase of the menstrual cycle. While symptoms are usually attributed to hormonal changes in a causal and linear fashion, the true picture is more complicated. Many instances of PMS are the result of the incongruency between our normal cycles and our external environment. An external life and schedule that is consistent with our internal biorhythms and cycles is important for health.

Human existence is characterized by biorhythms. The menstrual cycle is a biorhythm (infradian1 ) that enables pregnancy. Ultradian2 and circadian3 and other rhythms4 vary throughout the menstrual cycle. Circadian rhythmicity and sleep-wake homeostasis, for example, interact to regulate hormone secretion. Circadian rhythms and sleep modulate not only the hypothalamic- pituitary axis, but also other endocrine systems such as glucose regulation and in the renin-angiotensin system. Circadian rhythms have been observed in blood constituents, amino acids, phosphorus, body temperature, heart rate, blood pressure, and urine volume as well as behavioral parameters such as mood, vigilance, and cognitive performance.

External forces can modify internal biorhythms. Although circadian rhythmicity is maintained when subjects are sleep deprived, when they are starved, or when they are given equal amounts of food at short intervals over the day, various other external challenges such as chemicals (i.e. melatonin) and stress, can cause phase shifts. The timing of single meals and exercise can have effects on the pattern of at least some variables, including hormones, and the effects of sleep-wake homeostasis, and can alter the expression of many rhythms, especially those of the endocrine system.

Biorhythms are sex-specific, differing between men and women. Women’s intrinsic biorhythms, for example, vary throughout the menstrual cycle. These rhythms interact with each other in synergistic ways. The interaction is regulated at the suprachiasmic, hypothalamic, pituitary and peripheral levels and is expressed through prolactin, growth hormone, thyroid stimulating hormone, ACTH, LH and FSH, insulin and other hormones and their feedback loops. These rhythms have emotional and physical manifestations.

All cultures have intrinsic rhythms of daily activities that support the dominant culture (including ethnicity, gender, age, etc.). Dominant groups may support schedules and lifestyles consistent with their own intrinsic rhythms, which may be asynchronous for other groups. When our external schedules are inconsistent with our biorhythms there is asynchrony which may cause phase delays or advances. Such disruptions can lead to a variety emotional and physical symptoms such as fluid retention, irritability, fatigue, body aches and changes in cognition. The final common mediator of these asynchronous effects seems to be activation of the norepinepherine/locus ceruleus (NE/LC) system resulting in complex interactions affecting ILG (insulin like growth factor, leading to elevations in blood glucose ), cortisol, the immune response (infection and autoimmune disorders), coagulation, vascular smooth muscle reactivity (migraine and angina), and neurotransmitters (depression).

Although TJR may experience premenstrual moodiness as a result of changes in neurotransmitters, it is as likely that luteal phase hormonal changes permit ease of access to feelings and lower tolerance for dominant societal constraints with which she is able to cope at other times in her menstrual cycle. It therefore appears that one day she tolerates her home and work environment and the next day is angry about it. For TJR, societal and institutional schedules are largely fixed by the dominant culture, rather than being conducive to her intrinsic biorhythms, and the biorhythms of most women. Most schedules are not flexible enough to accommodate variations in an individual woman’s biology and physiology. As a result, potential for adverse consequences exists.

Plan

In the complex world we live in we often hope for clear, straightforward, easy and quick solutions to common problems. TJR tried many prescriptions, hormones, antidepressants, diuretics and sleep aids. None of them were particularly effective. Her new provider shared some of her thoughts about “PMS” and its causes. TJR decided to make some lifestyle and schedule changes, and view her “irritability” in the context of societal expectations. She changed her schedule and stopped working the night shift, began exercising, and ate on a more regular basis. She avoided stimulants like caffeine, and foods with high sugar content. Her sleep and her ability to cope with stressors in her life improved. She felt better and was able to make better decisions for herself and her family.

References

Physiology, Robert M. Berne, Matthew N. Levy, Mosby 1998 chapter 45, pp 779-799

Endocrinology, 4th edition, Leslie J. DeGroot, J. Larry Jameson, W. B. Saunders

Company, chapter 17, pp 235- 25

Int J Clin Pharmacol Res 1997; 17(4): 155-64

Arch Gen Psychiatry 1990 Dec; 47(12):1139-46

Biol Psychiatry 2000 Nov 1;48(9):920-31

Psychoneuroendocrinology 1995;20(4):395-403

Psychiatry Res 1996 May 17;62(2):147-60

Annals of Internal Medicine 1998; 129: 229-240

JCE & M 1998 VOL 83 No. 6: pp 1842-45

• Infradian: longer than circadian
• Ultradian: every one to two hours
• Circadian: approximately 26 hours
• 4Higher and lower frequency ranges, with some in the range of 5-15 minutes