The following blog post is an academic article I wrote for my Masters of Health Science (Traditional Chinese Medicine) degree. It explains the TCM approach to treating premenstrual dysphoric disorder.
Can Traditional Chinese Medicine Provide Primary Treatment for Premenstrual Dysphoric Disorder?
Premenstrual dysphoric disorder (PDD) is a condition which often lies under the radar in society, although it can affect up to 13% of women (Ussher, 2014). PDD symptoms can have a considerable impact on life quality and impair day to day functionality (Pearlstein, 2016). Pharmacologic treatment options for PDD include: antidepressants, hormonal therapy or the contraceptive pill and GnRH agonists. Such treatments will often be necessary until menopause and are not without side effects (Rapkin & Lewis, 2013). PDD was only included in the full diagnostic category in the American Psychiatric Manual of Mental disorders in 2013, previously only appearing in the appendix in 1994 (Rapkin & Lewis, 2013). Given PDD is a relatively recently recognised disorder, it does not regularly appear in historical or modern Traditional Chinese Medicine (TCM) texts. PDD is often perceived as a severe form of premenstrual syndrome (PMS) (Maharaj & Trevino, 2015), which is commonly treated by TCM and included in recent TCM literature. Given this and considering recent research of TCM PDD treatment, it is worth investigating whether there is scope for TCM to provide not only supportive care, but a viable alternative treatment for PDD.
Etiology, Biomedical Diagnosis & Treatment
The diagnosis of PDD, as set out in the American Psychiatric Association, involves a number of symptoms that must be experienced in combination. These include changes in mood such as depression or anxiety, coupled with physical symptoms such as breast swelling, headaches, joint pain and lack of concentration. Such symptoms must be severe enough to impact life quality, be present during a minimum of two luteal phases of a menstrual cycle and be relieved by the onset of the menses (Hantsoo & Epperson, 2015; Maharaj & Trevino, 2015).
It is beyond the scope of this paper to provide a detailed description of the etiology of PDD. Current medical reviews do suggest the etiology is not fully understood and warrants further investigation (Hantsoo & Epperson, 2015; Maharaj & Trevino, 2015). It has been suggested some causation involves the metabolites of progesterone, allopregnanolone (ALLO) and pregnanolone which influence the GABA neurotransmitters. Such transmitters are responsible for the regulation of stress, alertness and anxiety. Research for PDD has indicated that during the luteal phase, Allo and pregnanolone are at a decreased level, thereby affecting the mood during this time (Maharaj & Trevino, 2015; Rapkin & Lewis, 2013). The other key potential causation of PDD involves serotonin and estrogen. Symptoms of PDD, such as depression and cravings, appear to involve the neurotransmitter serotonin. Serotonin levels are influenced by estrogen, which decreases during the luteal phase. Hence it has been suggested PDD sufferers are sensitive to such hormone and neurotransmitter fluctuations (Hantsoo & Epperson, 2015).
Regardless of these two key causative features, the first line strategy to treat PMDD is with antidepressants, chiefly selective serotonin reuptake inhibitors (SSRIs). The treatment effect is particularly rapid for this disorder. SSRIs are associated with side effects such as nausea and fatigue, but usually such effects do not cause a high attrition rate during research (Hantsoo & Epperson, 2015; Maharaj & Trevino, 2015). This treatment is usually required until menopause as many women experience a recurrence of symptoms if treatment is discontinued (Pearlstein, 2016). Other treatments for PMDD include GnRH agonists, due to the down regulation of the hypothalamic-pituitary-ovarian axis, which in turn reduce luteal hormones and the oral contraceptive. Due to the anovulatory effect of these treatments, improvements in PMS and PMDD have been noted (Hantsoo & Epperson, 2015; Maharaj & Trevino, 2015). However these treatments are usually not recommended for the long term, involve side effects and present obvious limitations concerning fertility (Pearlstein, 2016).
Although the etiology of PDD stipulates there is evidence of hormonal fluctuations and the potential flow on effect on the central nervous system, the reasons why someone may have such sensitivities is unclear. One common thread present in PDD research is heightened and prolonged levels of stress (Ussher, 2014). Stress has been potentially linked to the fluctuations in the progesterone metabolites listed above, though this is yet to be substantiated by research (Hantsoo & Epperson, 2015). Ussher argues in her article ‘Premenstrual Dysphoric Disorder’ against over medicalising PDD and emphasizing biomedical treatment. The etiology of PDD may not be purely physical but influenced by emotional experiences concerning relationships and family satisfaction (Ussher, 2014). Evidence has not suggested cognitive therapy as an effective stand-alone treatment for PDD (Maharaj & Trevino, 2015). However, circumstances may advocate supportive care from medical practitioners and recognition from partners and family members may play an important role in reducing PDD symptoms.
Current Evidence of TCM Treatment Efficacy of PDD
A systematic review by Hsing-Tu et al. (2014) involving both Chinese herbs and acupuncture for the treatment of PDD and PMS did find a reduction of symptoms. However, only eighteen trials were reviewed and a majority had a relatively small participation rate. This review concluded that a stricter diagnostic criteria and a refined treatment intervention would have provided a better quality of evidence, though this would have excluded all of the studies within the review. It is interesting to note that no adverse side effects were suffered by any of the participants (Hsing-Yu et al., 2014). A review in 2013, which was not specific to PDD but focussed on acupuncture treatment for women with depression and anxiety, again due to such a small number of relevant trials, did not provide substantial evidence (Sniezek & Siddiqui, 2013). A Cochrane review for the use of Chinese herbal medicine for PMT found that of 32 randomly controlled trials only two studies met the criteria standards. However both of these still appeared to be of low methodological quality. Issues regarding their independence, placebo controls and diagnostic standards were raised in the review (Jing, Yang, Ismail, Chen, & Wu, 2009). These reviews clearly stipulate the need for improved quality research concerning TCM treatment of PDD and PMS. Since their publication, two studies of interest reflect a potential advancement. One of these involved applying the common Chinese herbal formula Xiao Yao San to rats. Biomarkers indentified rats with PMS depression and then measured changes within the ratio of glutamate to y-aminobutyric acid of the central nervous system. It was found Xiao Yao San improved symptoms of PMS depression (Gao et al., 2014). Although animal studies sit low on the evidence hierarchy scale, it does provide justification for further trials with human participants. A single blind randomised control trial using acupuncture versus sham acupuncture did provide evidence of the efficacy of acupuncture to treat PDD (Carvalho et al., 2013). Due to the low participation rate it represents more of a pilot study, though it could be considered justifiable evidence to support further research trials with similar methodology and greater participation numbers.
A Clinical Perspective
Although there is currently insufficient evidence to purport TCM for treatment of PDD, it is a condition commonly treated in a clinical environment. Speaking as a practitioner and on behalf of peers, women’s health issues such as PMS and PDD are commonly seen and successfully treated in the clinic. Interestingly in Taiwan, a survey was conducted between 1998 and 2011 as part of their National Health Insurance Research Database using a sample size of 2 million people. Jia Wei Xiao Yao San was identified as the most commonly used Chinese herbal medicine formula. The condition most associated with this formula is PMS (Hsing-Yu et al., 2014). Due to its popularity, it stands to reason such a highly accessed formula would have some efficacy regarding PMS. According to the TCM diagnosis framework, the post ovulatory or luteal phase in a cycle represents the need to smooth the flow of Qi and Blood, particularly of the Liver. Here it can be seen if PMS or PDD is present it will involve some form of Qi or Blood stagnation.
Another common component for a PDD pattern is the presence of an underlying deficiency, which can exacerbate stagnancy and PDD symptoms. Therefore applying a Qi and Blood regulating and potentially nourishing formula or acupuncture protocol should elicit a positive result (Lyttleton, 2013). Such a treatment should also involve an empathetic dialog between the practitioner and client. TCM advocates the importance of the duality between the spirit or Shen and the physical body, and where PDD is concerned, there is particular relevance of the Liver and its influence on emotions (Maciocia, 2009). Often an explanation of this to the patient can improve their understanding as to why they suffer such symptoms and how they can be better managed. As Ussher (2014) argues, recognition and acceptance can positively contribute to PDD treatment. Here TCM can provide a two-tiered strategy in treating PDD, both providing supportive care and a physiological treatment in attempt to create sustainable change.
Opportunity versus limitations of TCM treatment of PDD
A lack of substantial statistical evidence does represent an obvious hurdle for the treatment of PDD with TCM. Without the approval or awareness of biomedical practitioners, it is far less likely women will seek out TCM treatment for PDD. Whether it is acupuncture, Chinese herbal medicine or a combination of both, treatment usually occurs over a prolonged period. As the condition is usually of a chronic nature, sustainable relief will not be achieved quickly. In addition to this, the factor of cost must also be considered. Affordability and time commitment in a clinical setting are the key limitations to successful treatment. Due to such limitations, relationship satisfaction and home support is imperative for not only TCM but also biomedical treatment. Without this support PDD symptoms can often become worse and successful ongoing treatment less likely.
Although TCM faces significant limitations treating PDD, it also provides opportunities for successful treatment. It is important to note that TCM can be utilised alongside existing biomedical treatment. This is particularly relevant in a clinical setting, as many women seeking assistance with PDD or PMS will likely already be receiving some form of biomedical treatment. Recently an acupuncture trial treating depression, whilst applying a TCM Liver regulating and Heart nourishing protocol, reported acupuncture actually accelerated the onset of SSRI medication effects. This study demonstrates the potential integration of TCM with biomedicine whilst still applying a TCM diagnostic framework (Yi et al., 2015). In addition to this, there is some evidence to demonstrate the safety of taking Chinese herbal medicine and SSRI medication consecutively, although this concept needs to be more thoroughly developed to ensure safety and reassure the biomedical fraternity (Liu et al., 2015; Wu et al., 2015).
A considerable benefit of the TCM approach for PDD is the tailored nature of treatment. Although it is common for this disorder to fall under a common TCM pattern as mentioned above, a thorough diagnosis will ensure any individual traits or subtle disharmonies are identified and then a treatment can be designed accordingly. This is most relevant when considering fertility issues. The treatments of the contraceptive pill or GnRH Agonists are not appropriate when pregnancy is a priority. Acupuncture and/or Chinese herbs, on the other hand, are able to treat PDD whilst engendering potential conception. Although SSRI medication is deemed relatively safe for pregnancy, side effects are often experienced (Barth et al., 2016). Nausea, sleep disturbance and fatigue, all common side effect of SSRI medication, may not be considered as life affecting as depression, though they do represent further obstacles to life fulfilment. As suggested previously, TCM and in particular acupuncture is usually well tolerated with minimal side effects. Chinese herbal medicine may elicit some form digestive disturbance but can also be easily altered to assist with any adverse reaction. Although not substantiated by specific research, it is worth mentioning TCM treatment may also be able to assist side effects that may occur because of SSRI medication.
Finally, as previously mentioned, biomedical treatment will likely need to continue until menopause and SSRI medication will often continue thereafter. From a TCM perspective, though not properly explored in this paper, antidepressant or anovulatory medication will always impact the body pattern and if used long term, could exacerbate internal disharmony or imbalance. It is the role of TCM to attempt to correct such imbalance. Once achieved, the symptom, such as premenstrual depression, should improve or diminish. There may not be need for ongoing treatment. Naturally this is dependant on the treatment response and personal circumstances of each patient.
Currently, further randomised control trials with sound methodology are needed to substantiate the efficacy of TCM treatment of PDD. Due to limitations of common biomedical strategies, there is significant opportunity for TCM to provide treatment either in conjunction with biomedicine or as a primary treatment of PDD. It is the intention of TCM to provide sustainable relief by creating the physiological changes necessary for symptomatic reprieve, and by providing supportive care, a necessary component of treatment, to improve the life quality of a patient.
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