A: An anal fissure is an ulcer in the tissue which lines the anal canal, which runs from the rectum to the anal opening. The ulcers are thin, elongated tears. They are fairly common, especially among young – and otherwise healthy – people. In acute cases, the fissure develops quickly, and heals almost as fast. A chronic case lasts for longer than a month or so, and recurs. A chronic fissure often develops when a healed fissure tears every time the sufferer defecates.

Fissures affect both sexes equally, and are common in children, too. Some fissures, usually those that occur in the front wall of the anus, appear in women who have given birth, while children who have strained too hard to defecate can also develop them. It has been estimated that up to one-third of all women suffer either hemorrhoids or anal fissures after giving birth (Dis Colon Rectum, 2002; 45: 650-5).

Sometimes, a fissure can arise after anal surgery, such as for the removal of hemorrhoids, or as a result of ulcerative colitis, irritable bowel syndrome, Crohn’s disease or gonorhoea. An anal fissure may also be caused, or worsened, by anal intercourse. In the main, however, they are caused by the passing of large or hard feces, which tear off the tissue lining in the anal canal. The problem is often associated with persistent constipation.

The fissure usually begins as a scratch, which fails to heal because of repeated contractions and stretching of the orifice. The tear can cause severe pain during and after bowel movements, and may become infected. Some sufferers may delay going to the toilet because of the pain. This, in turn, can cause further drying and compacting of the feces, thus worsening the condition.

The main symptom is pain during or after bowel movements, sometimes persisting for several hours. Pain can also occur when any pressure is placed on the anal area, such as when sitting on a chair. Sometimes the pain stops for days or weeks at a time.

Bleeding can occur during or after bowel movements. Often, the sufferer believes they have hemorrhoids – usually because of the bleeding – when, in fact, they have a fissure. The tell-tale sign is pain during or after defecation.

Acute fissures are easier to treat than chronic ones. Sitz baths, suppositories and stool-bulking agents might be tried first, and hydrocortisone may be prescribed to reduce inflammation. However, one study found that sitz baths were of limited benefit. On analyzing anal pressures before and after the bath, and comparing the results with those who didn’t have a bath, the researchers found no differences between the groups (Dis Colon Rectum, 1993; 36: 273-4).

Topical nitroglycerin ointment can provide pain relief, and so allow the anus to relax. In one trial of 80 patients, 68 per cent of those given glyceryl trinitrate ointment reported fissure healing within eight weeks compared with just 8 per cent who used a placebo (Lancet, 1997; 349: 11-4).

Although such studies have made topical glyceryl trinitrate a first-line therapy for chronic fissures, an Australian study was more circumspect. By questioning 31 treated patients, the study team found that just 15 of them could be said to be cured; symptoms recurred in four of them. Side-effects were reported by 21 patients, and two of these had effects so severe that they stopped the treatment (Dis Colon Rectum, 1999; 42: 1007-10).

Another study found that, while glyceryl trinitrate was successful in 70 patients with either chronic or acute fissures, higher doses did not speed the healing – and many of the patients had recurring fissures afterwards, and complained of headaches during the treatment (Gut, 1999; 44: 727-30).

Fissure recurrence was further highlighted in another study of 43 patients: 22 used nitroglycerin and 21 had surgery. Nearly 80 per cent of those given nitroglycerin reported headaches, and most of the chronic sufferers had a recurrence (Tech Coloproctol, 2001; 5: 143-7).

It also seems not to work on children. One study tested it against placebo and, perhaps surprisingly, pain reduction was similar in both groups, suggesting that time might be as much of a healer as the ointment (Arch Dis Child, 2001; 85: 404-7).

Another ointment, isosorbide dinitrate, was tried on 16 chronic-fissure sufferers. Although all reported mild, transient headaches, pain from the fissures stopped within three weeks in all cases. After three months of treatment, the fissures had healed in all but one case (Ned Tijdschr Geneeskd, 1995; 139: 1447-9).

The latest treatment uses botulinum toxin (botox) injections. This bacterial toxin – usually responsible for food poisoning – causes muscle paralysis. Botox is injected into the anal sphincter muscle. Early data suggest that the therapy improves symptoms in 80 per cent of patients. No long-term data are yet available.

One study found botox to be more effective than topical nitroglycerin as an alternative to surgery. Fifty patients were given either botox or a six-week course of nitroglycerin ointment. After two months, the fissures were healed in 24 of 25 patients given the injection vs 15 of the 25 using the ointment. Five patients in the ointment group stopped because it was causing moderate-to-severe headaches whereas none of the botox group reported any side-effects (N Engl J Med, 1999; 341: 65-9).

Similarly, in a study of 40 patients with chronic fissures, most reported pain relief within a few days of the botox injections, which continued for six months (Gastroenterol Hepatol, 1999; 22: 163-6). The only adverse reaction with botox was reported in a study of 20 patients with chronic fissures, where two people had transient, mild incontinence (Dig Dis Sci, 1999; 44: 1588-9).

A new ointment containing diltiazem has shown success in treating anal fissures. Tested on 71 patients for 2-16 weeks, 75 per cent reported healing after two to three months of treatment (Br J Surg, 2001; 88: 553-6).

Your doctor may prefer a more interventionist treatment. In acute cases, an anal dilator, lubricant and local anesthetic may be tried twice daily by the patient at home, or the doctor may dilate the anus using his fingers while the patient is under a general anesthetic. However, this procedure can cause incontinence for 7-10 days.

For fissures that won’t heal, surgery is usually required. One involves disruption of the internal anal sphincter muscle, causing a reduced pressure in the anal canal. This is supposed to prevent fissures from forming by improving blood flow to the anus. With surgery, the fissure heals in one to four weeks and remains healed in 95 per cent of cases. Incontinence can result in 15 per cent of patients.

These procedures, which include lateral anal sphincterectomy or dorsal fissurectomy and sphincterectomy, involve cutting away the internal anal sphincter. The latter procedure is generally reserved for very bad cases of chronic fissures.

Although sphincterotomy has been the standard treatment for chronic fissures for over 20 years, one study found that anal dilation, using either a retractor or a balloon, helped to cure fissures in 93 and 94 per cent, respectively, and with fewer complications than surgery (Dis Colon Rectum, 1992; 35: 322-7).

There’s little scientific evidence to support the use of alternative and complementary medicine for fissures. Traditional Chinese medicine may offer symptom relief through herbs and acupuncture, while temperature-lowering products such as Anurex – biodyne plus shark liver oil – might give instant relief, even though they cannot cure the ulcer.

Perhaps the best approach is prevention rather than cure. Constipation is one of the main causes of anal fissures, and there’s plenty on offer from alternative medicine to treat it.

A number of factors can contribute to constipation, such as prolonged immobility due to bedrest, inadequate exercise, a low fibre and fluid intake, irregular eating habits and stress. Other possibilities include the use of drugs such as aluminium hydroxide antacids and antihypertensives, narcotics such as codeine and morphine, and iron supplements. Constipation can also indicate a more serious condition, such as colon cancer or diabetes, so it’s worth having it checked out.

You should drink 8-10 glasses of fluids every day. Tea and coffee can be effective laxatives, though caffeine can contribute to constipation, but should not be included in your daily count of fluids. High-fibre diets can also help – eat plenty of fresh fruits and vegetables, cooked wholegrain cereals with added bran, and foods containing whole grains such as amaranth, quinoa, oat bran and rye (Ther Umsch, 1997; 54: 190-2).

Take more exercise; walking for half an hour after a meal can be helpful.

Things to avoid or cut down on are milk, refined sugar such as sweets and soda, and calcium-rich products; you should also reduce your iron intake.

Some practitioners find mineral oil beneficial. Helpful herbs include alfalfa, barberry, butternut root bark, cascara sagrada (not to be taken by an IBS sufferer), dandelion, flaxseed oil, ginger root, Irish moss, liquorice, Psyllium, rhubarb root, senna leaves and slippery elm. Supplements such as acidophilus and Miller’s bran may also prove helpful.

What harmless alternatives do you suggest? I go to sleep okay, but wake up after four or five hours. – Grace Vincent, Sheffield

WDDTY replies: Products such as Nytol are only meant for occasional use. They have side-effects such as constipation, dry mouth and difficulty passing urine, and interact with other medications such as Benadryl. If you need something long term, we suggest Lehning Passiflora drops, a homoeopathic combination herbal remedy that is both safe and effective.

An advisory panel to the Food and Drug Administration (FDA), the American drug regulator, is recommending the reintroduction of Lotronex (alosetron hydrochloride), manufactured by GlaxoSmithKline.

The panel says that there should be restrictions on who can prescribe it, and patients need to be carefully followed up. The FDA may not endorse the panel’s recommendations, but it is likely to do so.

Lotronex was withdrawn in November 2000 – just nine months after it received a licence – following reports of five deaths and 70 cases of serious adverse reactions. These reactions included ischaemic colitis (fever and gut pain caused by an insufficient blood supply) and severe constipation.

Peter Traber, chief medical officer of the drug company, described the panel’s recommendation as ‘a very positive step forward for patients who need this drug’. This view was countered by Sidney Wolfe, of Public Citizen’s Health Research Group, a medical watchdog group in the States, who said the decision would ‘lead to more cases of ischaemic colitis and more deaths’.

Lotronex was the first drug required to come with a full treatment guide under ‘patient-power’ regulation. The guide warned that the principal side-effect revealed in trials was constipation.

Hailed as ‘a promising aid for irritable bowel syndrome’ (Drug Infoline, December 1999), a 12-week trial of 370 IBS sufferers found that the drug was effective in women compared with a placebo.

As well as being a drug intended only for women, it was also only supposed to treat the diarrhoea form of IBS.

However, the trial didn’t pick up the serious adverse reactions with Lotronex that were soon reported to the FDA. These included cases of intestinal damage due to a reduced blood flow, and severely obstructed or ruptured bowels as a complication of severe constipation.

Within four months of its launch, six women needed hospital treatment and three of those underwent surgery after taking the drug.

By the time GlaxoWellcome agreed to withdraw it, 34 patients had been treated in hospital, 10 others had undergone surgery and three had died (Lancet, 2002; 359: 1491-2).

I discovered that she had been suffering with constipation most of her adult life, so I concentrated on sorting out this problem first.

As soon as her bowels started to function properly, the ganglion started to get smaller. After 10 weekly treatments, it disappeared completely. – R. Shawcross, Deal, Kent

In one instance a two and a half year old was admitted to hospital, after receiving an enema for chronic constipation. She was subsequently diagnosed as having absorbed the contents of the enema, which nearly killed her, although she was eventually saved.

This is one of several similar instances in North America, including the death of an eight month old baby.

Although the British National Formulary only recommends that the dosage for a phosphate enema be reduced in children, Pharmax, its manufacturer, does not recommend its use in children under 3 and then cautions about its use in children over that age according to body weight.

Writing in the Lancet, the Department of Child Health and Welsh National Poisons Unit, at the University of Wales College of Medicine, concluded: “We recommend that phosphate enemas should not be used in children aged under 3 years, and that they should be used only with caution at reduced doses in older children.”

Researchers in Hawaii monitored the bowel movements of 6790 men from 1971 to 1974, then continued to monitor them for another 24 years to observe which ones developed Parkinson’s.

They found that men who had difficulty producing one bowel movement a day had a 2.7-fold increased risk of developing Parkinson’s disease compared with men who had one movement per day. This rose to a 4.1-fold increase compared with men reporting two bowel movements daily.

The risk was independent of other factors, such as age, cigarette smoking, coffee consumption, diet, exercise and laxative use. The researchers noted the presence of Lewy bodies – the primary central nervous system neuropathological finding in Parkinson’s patients – in both the oesophagus and colon (Neurology, 2001; 57: 456-62).

* More links between the gut and disease were found in a study revealing that non-Hodgkin’s lymphoma is the leading cause of death among coeliacs. Italian researchers found that gluten-intolerant individuals have twice the risk of dying from the disease as those who are not gluten-intolerant, including their own relatives. The risk was highest in those with malabsorption symptoms, but not significant in those who had minor symptoms (Lancet, 2001; 358: 356-61).

Like other health professionals, homeopaths honor the special role that surgery and surgeons have in health care. Homeopaths are not against surgery, because certain conditions are simply not treatable without it. At the same time, however, surgery is often performed unnecessarily. It is performed when other, safer measures can be effectively used. It is performed too early when the body can sometimes heal itself. And it is performed inappropriately, primarily because surgeons only know surgery and don’t know what else to do (the law of hammers pervades many professions: when you are a hammer, everything becomes a nail).

Even when surgery is successful, this does not necessarily mean that the person is “cured.” Surgery may, for instance, remove an abscess, a tumor, kidney stones or gallstones, or other diseased parts, but because this removal doesn’t change the underlying pathological processes that created them in the first place, it is understandable and even predictable that people tend to reexperience their ailments.

Even if the ailment seems to have disappeared, homeopaths do not believe that a curative process has always taken place. While the initial complaint may have been eradicated, sometimes more serious pathology develops shortly after the surgery. Although doctors tend to believe that this is a “new” disease, homeopaths theorize that the surgery probably suppressed the original ailment.

This critique of surgery is not meant to devalue its appropriate use in treating various congential deformities, structural problems, severe injuries, or life-threatening pathological conditions. As previously stated, homeopaths are not against the judicious use of surgery.

When possible, homeopaths first attempt to to see if treatment with an individualized homeopathic medicine can prevent the need for surgery. Patients and even homeopaths are sometimes surprised and impressed at the significant results that homeopathic medicines can provide–not that they can do the impossible, but they can often elicit a healing response when conventional therapeutics cannot.

The integration of homeopathic medicines with surgical care uses the best of both worlds to create comprehensive and ultimately more effective health care.



Homeopathic Medicines Before and After Surgery

Once it is determined that surgery is medically necessary, homeopathic medicines can reduce complications of surgery and augment healing so that people can recover more quickly afterward.

Surgeons commonly ask patients not to take any food, drink, or drugs prior to surgery. While it makes sense to avoid food, drink, and conventional drugs, there have never been any reported problems from taking homeopathic remedies prior to surgery.

Some homeopaths recommend Ferrum phos 6, four times a day for two days, prior to surgery in order to prevent infection and hemorrhaging.

Homeopathic medicines can also help people deal with the various emotions they are experiencing prior to surgery. Gelsemium 6 or 30 is a common remedy for the person who experiences great anxiety, apprehension, weakness, and trembling prior to surgery. Aconitum 6 or 30 is indicated when the person is terrified about surgery and thinks that he will die from it.

Take either Gelsemium or Aconitum the night before the surgery and another dose upon waking in the morning. If fear and/or anxiety is felt after surgery, take one to three more doses.

One double-blind, randomized trial on 50 children who underwent surgery showed that 95% of those given the homeopathic medicine Aconitum experienced significantly less post-operative pain and agitation.¹ Aconitum was chosen because it is a common remedy for ailments in which sudden and violent onset of shock or trauma is a primary indication, as well as symptoms of fear and anxiety, which are especially common emotions experienced by children prior to surgery.

Arnica is another common homeopathic medicine given to people before and after surgery because of its ability to reduce surgical shock and minimize bleeding. Surgical shock is a condition that trauma or surgery can cause in which all the capillaries and small blood vessels are filled with blood at the same time. A randomized, placebo-controlled, crossover study showed that Arnica significantly decreased bleeding time.²

The late British homeopathic physician Donald Foubister recommended Arnica 30 the night before surgery, another dose the morning of the surgery, another dose just prior to the surgery, and different medicines afterward, depending upon the type of surgery and the symptoms the patient feels.

Homeopathic medicines can also be beneficial for patients who undergo long-term intravenous (IV) therapy. Frequent insertion of an IV commonly causes phlebitis (inflammation of the vein) and hematoma (the pooling of blood under the skin); a double-blind study using Arnica 5c found that it can effectively reduce and prevent such problems.³ The study showed significant benefits from Arnica, including reduced pain. Besides subjective improvement, there were also objectively measured increases in blood flow and in blood coagulation factors.

While Arnica is the primary remedy to be taken just prior to the majority of surgeries, there are a certain number of operations for which Dr. Foubister commonly recommended other remedies. For surgery involving cartilage and periosteum, as is often occurs in the knee or elbow, it is recommended to take Ruta 30 the evening before, the morning of the operation, and immediately afterward. For hemorrhoidal surgery, it is recommended to take either Staphysagria 30 or Aesculus 30 in a similar pattern as described for Ruta. And for circumcision, Staphysagria 30 and Arnica 30 should be given similarly as above.

The following are common recommendations for after surgery. Please note that the length of time of treatment can and should be different with each patient, depending upon the intensity of symptoms. Doses should generally be taken as long as pain persists, though they should not be taken for more than a couple of days, unless the person is still in pain and the remedy is providing obvious relief. Arnica 6, 12, or 30 should be given for at least two doses after surgery, approximately one hour apart. In addition to this remedy, the following remedies should be given one hour after the last dose of Arnica:



Gynecological surgery:

–Dilation and curettage: Belladonna 30, every 6 hours

–Hysterectomy: Causticum 30, three times a day (some homeopaths
recommend Staphysagria 6 or 30, three times a day)

–Caesarean section or episiotomy: Staphysagria 30 or Bellis perennis 30,
three times a day

–Abortion or miscarriage: Ignatia 30, every four hours

–Plastic surgery on the breast: Bellis perennis 6 or 30, three times a day

–Amputation of the breast or a lump: Hamamelis 30, every 4 hours


Circumcision: Staphysagria 30 and Arnica 30, every four hours for a day.


Prostate surgery: Staphysagria 30, three times a day


Abdominal surgery: Staphysagria 30 or Bellis perennis 30, three times a
day


Appendectomy: Rhus tox 30, three times a day


Gastrectomy: Raphanus 30, three times a day


Gall bladder surgery: Lycopodium 30, three times a day


Eye surgery: Ledum 30, every four hours


Tonsillectomy and adenoidectomy: Rhus tox 30, every four hours


Orthopedic surgery

–involving cartilage or periosteum: Ruta 30, every four hours

–involving the spine: Hypericum 30, every four hours

–Surgery for bullet wounds and/or stab wounds: Staphysagria 30, four
times a day


Plastic surgery: Arnica 30 (internally) and Calendula, (externally) four
times a day


Amputation: Hypericum 30, every four hours


Hemorrhoids: Staphysagria 30 or Aesculus 30, every four hours for two

or three days* Varicose veins: Ledum 30, three times a day


Dental surgery: Hypericum 30 and Ruta 30, alternating every two to four
hours



Homeopathy for Specific Ailments After Surgery

Readers who experience symptoms or syndromes discussed elsewhere in this book should review those chapters. For instance, if you have urinary symptoms after surgery, which is common when catheterization takes place, consult the section on bladder infection in the section on Women’s Conditions (even if you are a man; see: WOMEN). If you are now suffering from acute insomnia, consult the chapter on Insomnia (sorry, not included online).

Some common conditions after surgery for which homeopathic medicines are often effective include the following:


Fear of Death
Aconitum 30 is indicated (every hour for up to four doses).



Bleeding

Arnica 30 helps to slow or stop bleeding after surgery. Phosphorus 30 is the primary remedy for helping to stop bleeding when Arnica does not work adequately. Ipecacuanha 30 is indicated when there is much bleeding of bright red blood, often accompanied by nausea. Secale 30 is effective in treating uterine bleeding that is aggravated by heat and relieved by cold. Cinchona 30 is helpful for people whose bleeding and general loss of fluids lead them to feel weak and faint and have ringing in the ears. This remedy is sometimes indicated several weeks, months, or years after much fluid has been lost, after either an illness or an operation. Arsenicum 30 is useful when profuse bleeding leads to great weakness, burning pains, restlessness, anxiety, and fear, along with a characteristically large thirst for only sips at a time.

Dose: Take the remedy every hour until bleeding stops, not more than four doses. If bleeding has not significantly slowed, consider another remedy. The next day, take one more dose of whichever works to reduce the possible complications of blood loss.



Trauma to Tissue

Arnica topically and Arnica 6 or 30 are useful when the muscle feels bruised or swollen and when there is any pooling of blood under the skin. Hamamelis topically and Hamamelis 6 or 30 are effective when the person has weak veins, passive hemorrhage, bleeding hemorrhoids, or varicose veins. Capillaries are enlarged and congestion is marked. Calendula in external application (gel, ointment, tincture, spray) is indicated to heal wounds or incisions. Bellis perennis 6 or 30 is a remedy for use after abdominal surgery and when deep internal tissue has been traumatized.

Dose: Apply external remedies at least once a day, and apply again if bathing washes them off. Generally, only two to eight doses of the internal remedy over a two day period will be necessary to complete the healing process.



Wound Infection

External applications of Calendula and Hypericum, either alone or preferably together, help to both prevent and treat infection of surgical wounds. If pus has developed and caused hypersensitivity of the wound, Hepar sulphur 30 is recommended. Because Hepar sulphur is an effective remedy for helping to push out splinters, pieces of glass, and various foreign objects that get stuck under the skin, it also has a tendency to push out surgical stitches. Thus it is not recommended to use this remedy when there are stitches, except towards the end of the healing process, when their removal is part of the healing. If the wound becomes purplish, Lachesis 30 or Gunpowder 30 is indicated. If there is much burning in the wound or wound area, Sulphur 30 is helpful.
Dose: Apply external remedies at least once a day, and apply again if bathing washes them off. Take internal remedies every two to four hours during the first 24 hours and four times a day for two to five more days.



Scarring and Adhesions:

Apply Thiosinaminum tincture externally or use an external combination formula that also contains Calendula (some injury gels include these ingredients). Take Graphites 12 internally.

Dose: Apply external remedies at least once a day, and apply them again if bathing washes them off. You may need to do this for several weeks or months. Internal remedies should be taken three times a day for two days, and if necessary, repeated one month later.



Constipation

Raphanus 6 or 30 is indicated when there is constipation with no urgings for a stool and/or when there is painful gas; see also the chapter on Digestive Disorders for other potential medicines for constipation.

Dose: Take this remedy three times a day for up to four days.



Nausea and Vomiting

Nux vomica 6 or 30 is good for violent retching, especially when there is generally ineffectual retching that does not lead to vomiting. Phosphorus 6 or 30 helps to prevent or treat nausea after surgery; it is indicated when the patient has a strong thirst for ice drinks; he or she may also have a concurrent headache. Ipecac 6 or 30 is effective for persistent nausea with vomiting, when vomiting does not provide relief. Arsenicum 6 or 30 treats violent and incessant vomiting which is made worse by drinking water, especially cold water, or eating. There may also be burning pain in the stomach. See also chapter on Digestive Disorders.

Dose: Take a remedy every two hours during intense symptoms and every four hours during less intense discomfort. If improvement is not obvious after 24 hours, consider another remedy.



Gas
Carbo veg 6 or 30 helps people who suffer from great distension and offensive gas, who get some relief from release of gas, and who desire carbonated drinks because they seem to help them release gas. Cinchona 6 or 30 is useful when there is more pain than distension, frequent rumbling in the abdomen, and no relief from releasing gas. Raphanus 6 or 30 is a common remedy for people who have a distended abdomen but are unable to expel gas. Because this condition is extremely common after surgery, especially abdominal surgery, this remedy is often indicated. Colocynthis 6 or 30 is effective when there is more pain than distension, and also cramps that are relieved by bending over.

Dose: Take a remedy every two hours during intense pain and every four hours during mild discomfort. If improvement is not obvious after 24 hours, consider another remedy.

Bedsores
(see the chapter on Conditions of the Elderly for details)

Resources

¹J.P. Alibeau and J. Jobert, “Aconit en Dilution Homeopathique et Agitation Post-Operatoire de l’enfant,” Pediatrie, 1990, 45 (7-8): 465-66.

²J. Baillargeon, et.al., “The Effects of Arnica Montana on Blood Coagulation: A Randomized Controlled Trial,” Canadian Family Physician, November 1993, 39:2362-67.

³C. Amodeo, et.al., “The Role of Arnica in the Prevention of Venous Pathology from Long-term Intravenous Therapy: Evaluation of Platelet Aggregation,” Ninth National Conference of the Italian Society for Vascular Pathology, Capanello, June 6-9, 1987. The study included 39 patients, including 21 undergoing intravenous feeding, nine in infusion protracted beyond 72 hours, and nine in chemotherapeutic treatment.

dandelion

burdock

yellow dock

cascara sagrada

Chinese rhubarb (caution, use small amounts, for not more than 2 weeks)


Intestinal Gas (Flatulence)

In other words the name describes a broad range of symptoms that
occur cyclically which are severe enough to disturb a woman’s life patterns
or cause her to seek help from a health practitioner. Most women experience
some body change cyclically during the menstruating years corresponding
to the pattern of cycling hormones. The subtle shift in mental and emotional
focus as well as body response is observed and ritualized in many cultures.
Women often express a positive attitude toward the conscious observance
of these patterns within their own bodies, however when the hormonal and
chemical changes result in debilitating symptoms they may disrupt functioning
in virtually all body systems.

The symptom picture may include:

Behavioral Symptoms: personality alteration in the form of nervousness,
irritability, agitation, unreasonable temper, fatigue, depression. Violent
crimes and suicide are often committed in the premenstruum. Symptoms that
suggest clinical depression such as anxiety, palpitations, tightening in
the chest, hyperventilation are common.

• Neurological Symptoms: headache, vertigo, syncope, paresthesias
  of the hands or feet, aggravation of seizure disorders have all been recorded.
  

• Respiratory Symptoms: asthma may be intensified.
  

• Gastro-intestinal Symptoms: constipation, and increase or decrease
  in appetite, carbohydrate craving particularly sugar and chocolate.
  

• Miscellaneous: edema, weight gain, backache, enuresis, oliguria,
  capillary fragility, exacerbations of dermatologic disease, breast changes,
  and eye complaints
  

Four categories of PMT have been identified corresponding to the major symptoms
patterns :

• PMT-A (80%): predominantly anxiety, associated with excess estrogen,
  and CNS stimulation resulting in anxiety. Excess estrogen can be caused
  by deficiency in progesterone (high estrogen/progesterone ratio), or by
  inability of the body to break down estrogen (poor liver function, or Vitamin
  B deficiency resulting in same).
  

• PMT-H (60%): predominantly hyperhydration (bloating, edema),
  increased ACTH, water/salt saving by kidneys.
  

• PMT-C (40%): carbohydrate craving, due to increased responsiveness
  to insulin.
  

• PMT-D (5%): depression, due to excess progesterone, CNS depression
  PMS is diagnosed on the basis of when symptoms are present. There is (by
  definition) a period of time when symptoms are absent, usually just after
  the onset or end of menses. PMS occurs during the proliferative or luteal
  phase of the menstrual cycle when levels of estrogen and progesterone are
  relatively high. Estrogen is a central nervous system stimulant. Progesterone
  is a CNS depressant. What is important in the relationship of estrogen to
  progesterone during the luteal phase.
  

A number of etiological factors have been identified for primary PMT:

• Estrogen excess.
  

• Progesterone deficiency.
  

• Fluid retention: it is believed that many of the symptoms of
  PMS relate to a shift in the fluid in the water compartments, intra and
  extracellular and intravascular with increased retention of water and water
  moving into the extracellular spaces. Mediated by increased ACTH and aldosterone.
  

• Hypoglycemia: the cells are more receptive to insulin in the
  premenstruum, causing relative hypoglycemia resulting in carbohydrate craving.
  

• Decreased production of Prostaglandin E1: researched by David
  Horrobin; advocates the use of Gamma-linolenic acid, which is found naturally
  in human milk and oil of evening primrose. Other nutrients encouraging the
  conversion of fatty acids to Prostaglandin E1 are: Magnesium, B6, Zinc,
  Niacin, and Vitamin C.
  

• Increased production of other prostaglandins.
  

• Magnesium deficiency leading to decreased dopamine in the brain
  resulting in increase levels of CNS stimulators (norepinephrine and serotonin).
  

• Increased prolactin levels causing decreased progesterone.
  

NOTE: post partum depression is very similar to PMS both in symptoms, and
in the hormonal picture of progesterone deficiency.

Actions indicated for the processes behind this disease :

Nervine herbs will usually remove the symptoms, but rarely
clear the recurrent pattern.

Anti-spasmodic herbs will ease any dysmenorrhoea that accompanies
the PMT.

Diuretic remedies would be indicated if water retention is part of
the picture.

Hormonal Normalizers would be indicated if the diagnosis suggests
a pivotal contribution by hormonal imbalance.

System Support :

In addition to the reproduction system, the nervous system usually needs
aid. In some intransigent cases attention must be given to endocrine function.

Specific Remedies :

Different remedies may act as specifics for specific women, so generalizations
are problematic. From my clinical experience I would suggest Scutellaria
spp. in the short term is as close to a specific for relief of symptoms
as possible. Longer term `specific’ herbs would be the hormonally focused
ones such as Vitex agnus-castis.

One possible prescription :

Scutellaria spp. 2 parts

Valeriana officinalis 1 part

Taraxacum officinalis fol. 1 part 5ml of tincture taken as needed
to alleviate symptoms.

Vitex agnus-castis 2 parts

Cimicifuga racemosa 1 part 5ml of tincture taken once a day throughout
cycle.

The dosage of the symptomatic medication may be increased until the desired
relief is experienced. The dosage regime may be altered as necessary, varying
time of day and quantity of dose to suit individual needs. For example this
may be the whole dose first thing in the morning, or smaller amounts at
frequent intervals throughout the day. The womens’ experience is the guiding
principle here. Always treat the human being and not the theory about
the `disease’!

This supplies the following actions :

Nervine (Scutellaria spp., Valeriana officinalis,
Cimicifuga racemosa)

Anti-spasmodic (Scutellaria spp., Valeriana officinalis, Cimicifuga
racemosa)

Diuretic (Taraxacum officinalis fol.)

Uterine Tonic (Cimicifuga racemosa, Vitex agnus-castis)

Hormonal normalizer (Vitex agnus-castis)

If water retention predominates symptomatically, then more focus should
be given to diuretics. Palpitations would suggest Leonurus cardiaca
as a relevant herb. As an example of how this basic approach can be modified
to address specific symptoms consider the following.

One possible prescription : PMT associated with transitory skin problems

Scutellaria spp. 2 parts

Anemone pulsatilla 1 part

Galium aparine 1 part

Taraxacum officinalis fol. 1 part 5ml of tincture taken as needed
to alleviate symptoms.

Vitex agnus-castis 2 parts

Cimicifuga racemosa 1 part 5ml of tincture taken once a day throughout
cycle.

This supplies the following actions :

Nervine (Scutellaria spp., Anemone pulsatilla, Cimicifuga
racemosa)

Anti-spasmodic (Scutellaria spp., Anemone pulsatilla, Cimicifuga
racemosa)

Diuretic (Taraxacum officinalis fol., Galium aparine)

Alterative (Galium aparine, Anemone pulsatilla)

Uterine Tonic (Cimicifuga racemosa, Vitex agnus-castis)

Hormonal normalizer (Vitex agnus-castis)

Broader Context of Treatment :

The whole gamut of issues that the holistic practitioner can address must
be focussed upon. The herbal treatment can be exceptionally effective, but
will benefit from appropriate stress management techniques and possibly
dietary support. The following dietary guidelines have been suggested by
Dr. Karen Bilgrai Cohen D.C. in Clinical Management of Women In
the Childbearing years.

• Limit refined sugar as it increases excretion of B Vitamins, Magnesium,
  and Chromium, and contributes to increased insulin secretion resulting in
  hypoglycemia.

• Limit salt to under 3 grams per day.

• Limit red meat because of high sodium & high fat content, to 3 oz.
  per day. Some evidence shows that the hormones in red meat contribute to
  fibrocystic disease & menstrual cramps.

• Limit alcohol to I oz. per day. Alcohol destroys B Vitamins, Magnesium
  and Chromium, and may be a potent depressant in some people.

• Limit Caffeine: it intensifies anxiety and contributes to fibrocystic
  disease.

• Limit dairy products. They are high in fat, interfere with magnesium
  absorption, & may constipate.

• Limit fats to 30% of total calories. * Limit cold foods.

• Limit protein to 1 gram per kilogram of body weight.

• Avoid licorice: it stimulates the production of aldosterone.

• Minimize spinach, beet greens and other oxalates as they interfere with
  mineral absorption.

• Increase complex carbohydrates to 40% of diet, with whole grains, green
  leafy vegetables and legumes. They are high in fiber, B Vitamins and release
  sugar slowly.

• Increase potassium rich foods, which are beneficial against water retention:
  sunflower seeds, dates, figs, peaches, bananas, tomatoes.

• Increase intake of natural diuretics: artichokes, asparagus, parsley,
  watercress.