The symptoms of PMS are numerous and involve almost every system in the body. More than 150 symptoms have been docu-mented: emotionally based symptoms such as anxiety, irritability, mood swings, depression, and fatigue, and physical symptoms such as headaches, bloating, breast tenderness, weight gain, sugar craving, and acne. For many women, the emotional symptoms and fatigue are the most severe, adversely affecting their family relationships and their ability to work.

A woman may have as many as 10 or 12 of these symptoms. Many PMS patients describe severe personality changes-much like Dr. Jekyll and Mr. Hyde. They say they are irritable, witchy, and mean-that they yell at their children, pick fights with their spouses, and snap at friends and co-workers. They often spend the rest of the month repairing the emotional damage done to their relationships during this time.

Many factors increase the risk of PMS in susceptible women. It occurs most frequently in women over 30. (The most severe symptoms occur in women in their thirties and forties.) Women are at high risk when they are under significant emotional stress or if they have poor nutritional habits and don't exercise. Women who are unable to tolerate birth control pills seem to be more likely to suffer PMS, as are women who have had a pregnancy complicated by toxemia. Also, the more children a woman has, the more severe her PMS symptoms.

PMS rarely goes away spontaneously without treatment. My experience is that it gets worse with age. Some of my most uncom-fortable patients are women in their middle to late forties, who are also approaching menopause. These women often feel they have the worst of both life phases as they pass from their active repro-ductive years into menopause. Often, PMS symptoms coexist with bleeding irregularities and hot flashes. Once the PMSis treated, the accompanying fatigue and mood symptoms clear up. Ther-apies for PMS are discussed in the self help section of this book.

No single hormonal or chemical imbalance has been linked to PMS. Instead, nearly two dozen hormonal, chemical, and nutritional imbalances may contribute to causing the symptoms. Even more confusing for patients and physicians alike is that the underlying causes may differ from one woman to another. As a result, no single wonder drug cures PMS, although many drugs have been tested, including hormones, tranquilizers, antidepres-sants, and diuretics. Luckily, PMS seems to respond very well to healthful lifestyle changes. In my practice, I have found PMS to be a very treatable problem. It does require, however, that women participate actively in their own program, adopt better nutritional habits, and deal with stress more effectively.

Menopause
Menopause, the end of all menstrual bleeding, occurs for most women between the ages of 48 and 52. However, some women cease menstruating as young as their late thirties or early forties, while others continue to menstruate into their mid-fifties. Fatigue often accompanies this process as women go through the hor-monal changes that lead to the cessation of menstruation.

For most women, the transition to menopause occurs gradually, triggered by a slowdown in the function of their ovaries. The pro-cess begins four to six years before the last menstrual period and continues for several years after. During this period of transition, estrogen production from the ovaries decreases, finally dropping to such low levels that menstruation becomes irregular and finally ceases entirely. For some women this transition to a new, lower level of hormonal equilibrium is easy and uneventful. For many women, however, the transition is difficult and fraught with many uncomfortable symptoms, such as irregular bleeding, hot flashes, mood swings, and fatigue. As many as 80 percent of all women going through menopause experience some of these symptoms.

Many women approaching menopause experience heavy, irreg-ular bleeding. The increased blood loss in these women can trig-ger a loss of energy as well as decreased stamina and endurance. Though most cases of heavy, irregular bleeding in transitional women are due to fluctuating hormonal levels, other medical problems can cause bleeding, too. These include fibroid tumors (an overgrowth in the muscular tissue of the uterus), polyps, uter-ine cancer, and cervical cancer.

The hormonal deficiency that develops during this period may also trigger other physical and emotional symptoms. One of the most uncomfortable symptoms is hot flashes-sudden and intense sensations of heat that occur unexpectedly. A woman suddenly notices that she feels warm, and often experiences heavy sweat-ing. As the sweating cools her skin temperature, she begins to shiver. In response to this uncomfortable fluctuation in tempera-ture, many women alternately shed and add clothes. Hot flashes frequently begin on the chest, neck, or face, and radiate to other parts of the body.

Eighty percent of women in menopause experience hot flashes, with 40 percent of these women having symptoms severe enough to seek medical care. Hot flashes may occur during both day and night. When they occur at night, they can interrupt a woman's sleep pattern, leaving her exhausted and fatigued during the day from sleep deprivation. Though most flashes appear to occur without any specific environmental trigger, coffee and alcohol intake may spark a flash. The frequency, intensity, and duration of hot flashes vary greatly. For most women they last two or three minutes, but they can last longer, even up to an hour in some cases. In most women, the symptoms begin to subside within four to six years after the last menstrual period.

The tissues of the vagina and urethra undergo a number of changes as the hormonal levels diminish. The vaginal and urethral linings become thinner, drier, and inelastic. Blood supply to the vaginal and urethral area decreases. The cervix secretes much less mucous than in a woman's fertile years. The vagina actually shrinks, becoming much shorter and narrower at the opening.

As a result, sexual intercourse often becomes painful or uncom-fortable. Sexual arousal no longer produces the same level of lubrication, and the capacity for vaginal expansion in response to sexual arousal may decrease. Vaginal infections may become more frequent because the tissues are easily traumatized. The changes that occur in the urethral tissues may increase the frequency of urination. Women find that they have to get up at night to void, which-like hot flashes-can interrupt sleep and worsen fatigue. Even more frustrating for some women is the tendency to leak urine when they laugh, sneeze, or cough.

Besides the physical changes, many women may note mild to marked changes in their moods during menopause. These symptoms include insomnia (often associated with hot flashes), irritability, anxiety, depression, and fatigue. Both estrogen and progesterone have been studied for their effects on mood: If estro-gen predominates, women tend to feel anxious; if progesterone predominates, women may feel depressed and tired. With a decrease in both hormones, symptoms can run the gamut from irritability to fatigue and depression. The severity of the symp-toms probably depends on the woman's individual biochemistry, as well as social factors. Women have worse symptoms if they are under severe emotional stress or have aggravating dietary habits, such as excessive caffeine, sugar, or alcohol intake.

Many effective treatments, such as hormonal replacement ther-apy and the use of vitamin, herbal, and mineral supplements, help support menopausal women's reproductive and glandular systems. Stress management techniques and regular exercise may also help to restore energy and vitality and stabilize mood. These are discussed in the self help section of this book.

Hypothyroidism
Hypothyroidism-an underactive thyroid-is far more common in females than in males. In fact, 90 percent of diagnosed cases are women. Low thyroid condition is a common cause of chronic fatigue and tends to worsen with age. The thyroid affects our energy level because it controls our metabolism (the rate at which our cells burn fuel and oxygen). Women with a slow metabolism caused by an underactive thyroid can suffer from a variety of symptoms. Besides fatigue, hypothyroid women often complain of a hoarse voice, constipation, intolerance to cold, thickening and scaling of skin, facial puffiness, delay of deep tendon reflexes, and slowness of speech, thought, and movement. They also tend to gain weight easily and find it hard to lose weight on a conven-tional diet. They may suffer from low blood pressure as well as low blood sugar and may crave carbohydrates. Clinical diagnosis of hypothyroidism in older women may be difficult because many women do not have the typical symptoms mentioned above. In many older women, debilitation and apathy may be the only signs of low thyroid function. Medical studies suggest that thyroid screening by simple blood tests of thyroid hormones should be a routine part of the physical examination for older patients.

Hypothyroidism is generally treated by thyroid replacement therapy. Older patients may require a much lower maintenance dose of thyroxine than younger women. Self help aspects of treatment and prevention include taking iodine either in the diet or in supplementary form. According to some evidence, adequate intake of vitamin A, vitamin E, and iodine may be necessary to maintain thyroid health and integrity. Once the underlying thy-roid deficiency is treated, many fatigued women notice a rapid improvement in their energy level and vitality.

Women with low thyroid function often have exhaustion in other endocrine glands. The adrenal glands are particularly affected by poor thyroid function, as well as any other physical and emotional stress. The adrenals are two almond-sized glands that secrete several dozen hormones. Cortisol is an important hormone produced by the adrenal glands that helps regulate our response to stress. Stress can be a response to strong emotional feelings, such as anxiety or depression, or to physical triggers, such as an allergic reaction, infectious disease, burns, surgery, or an accident. Whatever the source of stress, cortisol lessens its injurious effects on the body, reducing pain, swelling, and fever.

When stress has been recurrent and of long duration, the adrenal glands can become exhausted, mustering less and less ability to buffer the negative effects of physical and emotional stress. As a result of adrenal exhaustion, the individual may experience an increase in fatigue and tiredness. Much rest, stress management, and nutritional support are required to restore the adrenals and rebuild the physiological "cushion" to deal with stress. Many helpful techniques listed in the self help section of this book help to restore the glandular system.

Hematological (Blood-Forming) System

Anemia
Anemia is one of the most common health problems affecting women of all ages. As many as 20 percent of all American women suffer from anemia. Women who are anemic have a reduced num-ber of red cells circulating in their blood or a reduced amount of hemoglobin (the oxygen-carrying protein in the red blood cells).

Anemia reduces the amount of oxygen available to all the cells of the body, so the cells for the body's normal chemical functioning have less available energy. Important processes, such as muscular activity and cell building and repair, slow down and become less efficient. Greater than 95 percent of the body's chemical reactions depend on optimal oxygen levels in the cells and tissues. As a result, the symptoms of anemia can be very debilitating.

Because the lack of oxygen impairs the body's ability to carry out its numerous chemical reactions, many women with anemia feel extremely tired and fatigued. Because muscular activity is inhibited, they lack endurance and physical stamina. I have had many physically active patients who had to stop pursuing vigor-ous aerobic exercise programs when they developed anemia, because they lacked the physical energy to continue an active exercise regimen.

When the brain cells lack oxygen, dizziness may result and mental faculties are less sharp. Women who are anemic tend to be pale with poor skin color and tone. They often appear "washed out" and seem listless. They lack the glowing skin color that we tend to associate with good health and vitality. Women with ane-mia may also suffer from hair loss and brittle, ridged fingernails.