National Prize of Applied Sciences nominee Dr. Jorge Lolas Talhami and his research on “cyclical hysterotoxemia”. Featuring: Dr. Enrique Vazquez-Vera - MD, FACOG; Dr. Jorge Lolas Talhami; Amanda Parodi; and Yusnaiberth Rivero De Detraux. Content presented by Dr. Enrique Vazquez-Vera - MD, FACOG at the 2015 NAPMDD National Conference 8/9/2015. View the session video at: http://napmdd.org/denver2015nc/session-03.html Become a member of NAPMDD at: http://napmdd.org/join

1. ConfessionsConfessions of a Gynecologist
Enrique Vazquez Vera MD
F.A.C.O.G.

2. Video

5. Diisclosure
• The purpose is to share information that still needs
solid Scientific Research.
• Unbiased Research is the ONLY way to make solid
steps towards better medical care.
• We are in need of evidence-based treatments

6. Current Accepted Definition
• Women of reproductive agereproductive age have one or more emotional or physical
symptom in the premenstrual phase of the menstrual cycle.
• Symptoms are associated with substantial distress or functional
impairment.
• Precise diagnostic criteria outlined in the Diagnostic and Statistical
Manual of Mental Disorders:
– The presence of at least five luteal-phase symptoms
• At least one of which must be a mood symptom (ie, depressed mood, anxiety or tension, affect
labiality, or persistent anger and irritability)
– Two cycles of daily charting to confirm the timing of symptoms.
– Evidence of functional impairment.
– Symptoms must not be the exacerbation of anotherSymptoms must not be the exacerbation of another
psychiatric conditionpsychiatric condition

7. PMS // PMDD
• Serious premenstrual
distress with associated
deterioration in functioning.
• Prevalence is not well
understood
• Correlation of symptoms
with menstrual cycle is
critical

8. PMDDPMDD and the Fate of History ???

9. Current Scenario
• Lack of solid Research
• Poor Statistical Information
• Poor Scientific Evidence
• Economical Interests
• Weak Diagnostic Criteria
• Social overuse of the Terminology
• The Cause is UNKNOWNUNKNOWN

11. What is then PMDD ??
“InflammatoryInflammatory state that predisposes
end organs to an altered hormonalaltered hormonal
responseresponse and translates in to a
infinite cluster of cyclicalcyclical
symptomssymptoms”

12. OrganOrgan
InflammationInflammation
D I S E A S ED I S E A S E

13. Reproductive
Female
Reproductive
Female
InflammationInflammation
PMDDPMDD

15. Inflammmmation
• What is It ?
• Why do we Care ?
• What is the Connection with PMS/PMDD ?
• What can we Do about it ?

16. Depression andand Inflammation
• Inflammation can be measured
• The markers have been shown to alter
neurotransmitters
• The main inflammatory markers are NFKB, IL-6
• The end result (imbalance) of
– Serotonin
– Dopamine
– Norepinephrine

17. Depressssive Inflammmmation
• Inflammation and clinical response to
treatment in depression: A meta-
analysis.
European Neuropsychopharmacology Journal,
20152015
• The patients that respond to Antidepressant
Therapies have lower levels of inflammatory
markers (CRP,IL-6,TNFα).

18. Premenstrual Inflammmmation
• Association of inflammation markers with
menstrual symptom severity and
premenstrual syndrome in young women.
Hum Reprod. Epub 2014
• Chronic Inflammation markers and PMS
• 277 women from 18-30 yr
• TNFα, IL-6,CRP
• Correlation of severity found

19. Serotonin
• Epigenetic: Genetic defect on receptor 1A 3
times more common in patients with PMDD
• SSRI decrease symptoms by 40%
• Serotonin levels are markedly lower in
patients with PMS

20. What do we know??
• The Ovarian Hormonal pattern are = to Normal Patients= to Normal Patients.
• Decreased serotoninserotonin activity in PMS on the luteal phaseluteal phase.
• Evidence that emotion processing variesemotion processing varies among the stage of
the menstrual cycle.
• The brain is modulated by hormonalbrain is modulated by hormonal changes.
• Emotional Memory increases in the luteal phase
• Plasma testosterone is lowerPlasma testosterone is lower in the luteal phase of patients
with PMDD
• There is High levels of inflammatory substancesHigh levels of inflammatory substances in patients
with PMDDPMDD

21. What can we do ??

22. Current Management

24. Suggested Management Principles
• Tackle inflammation from all directions
• Stress,Gut,Diet,Exercise,Meditation,Infections,
Hormonal Imbalance.
• Follow Evidence Based Recommendations

25. What can we Do ??
Decrease inflammation in all fronts !!

26. Management
Step 1 Supportive TherapyStep 1 Supportive Therapy
– Diet
• Food Sensitivity testing or Elimination Diet
• Favor a diet high in Complex Carbohydrates
• Carbs 30%, Protein 20%, GOODGOOD Fats 50%
• Favor sources of TryptophanTryptophan (serotonin precursor)
– Seaweed (SPIRULINA), Spinach,Eggs.
• Favor prebiotic foods ( Onion, Asparagus)
• PROBIOTICS PROBIOTICS AND MORE PROBIOTICS !!!!
– Minerals and Vitamins
• Increase Dietary Calcium (500 mg) Warning
• Magnesium 360 mg day
• Vitamin E 400 mg Day Warning
• Vitamin D3 1000 IU daily
– NSAIDs

27. • Increase availability of serotonin
• Fluoxetine (Prozac, Sarafem)
• Sertraline (Zoloft)
Management
Step 2 Selective Serotonin Reuptake Inhibitors (SSRI)Step 2 Selective Serotonin Reuptake Inhibitors (SSRI)

28. • Hormonal Contraceptives
• GnRH Inhibitors
Management
Step 3 Hormonal Ovulation SuppressionStep 3 Hormonal Ovulation Suppression

29. Management
Step 4 Dr Lolas TreatmentStep 4 Dr Lolas Treatment

31. Dr Lolas Treatment
• Altered production of inflammatory substances.
• Caused by Direct or Indirect insult to the female reproductive
organs
– Traumatic deliveries,Sexual trauma,pelvic infections
• The treatment
– Intracervical administration
• NSAIDs
• Antibiotics
• Antfungals
• Cryotherapy
• 4 Months of therapy plus maintenance

33. Regulation of ImmunityImmunity in the Female
Reproductive TractReproductive Tract
• FRT deploys more than a
dozen antimicrobials
substances.
• Hormones REGULATE the
immune response and the
INFLAMMATORY response
• Menstrual Cycle regulate
the intensity and type of
immune response deployed
• NFKBNFKB is released

34. The Miami Experience

35. Pre-treatment
Week 1 Week 2 Week 3
Week 4 Week 5 Week 6

36. RResults
• 3 Patients have been treated (No Cryotherapy)
• All three patients have proven inflammation of the cervix by
conventional criteria with cultures and biopsy.
• Their Symptom scores have been recorded and show a
gradual reduction of symptoms with exacerbations
• In ALL three patients there is clinical findings of change at
least

38. Future Plans
• Far from being able to tell that the regimen
works a 100%.
• Urgent need for standardization of protocol
and randomized control study to validate
results.
• Current knowledge and experience points
towards treating the inflammatory cascade
along with the TRADITIONAL conventional
therapy

39. Thank You !
Enrique Vazquez Vera MD FACOG
Miami Obstetrics and Gynecology
enva_2004@hotmail.com
305-270-2331

40. Resources
• Dr Mercola.
• Dr Scott Russo, PhD. One Mind Institute
– Inflammation and depression
• Institute for Functional Medicine (IFM)

41. PMDDPMDD