Before the 2nd Edition of Dr. Lolas’ book, “Premenstrual Syndrome From a New Perspective”, is published, we’d like to excerpt the Prologue by Dr. Lafaja, based either in her personal relationship with this Specialist, and in her own experience operating under this innovative concept. The book is expected to be released soon.
Sometimes life presents you with an unexpected gift. That was what I experienced in January 2014 when I learned about the work of Dr. Jorge Lolas and later when I had the great pleasure to meet him personally in Santiago, Chile. I can say without hesitation that it was one of the most exciting and unforgettable moments of my professional life. It was also the beginning of an incredible personal adventure that I still enjoy to this day. Today, December 18, 2016, almost 3 years later, in my 5th or 6th revision of this never-ending prologue, I just want to thank him for all that I have learned about gynecological pathology and the women I have met. I want to thank him again for all his work for women and our families. With his relentless battle to shed light on this disorder, as he did as an international speaker, sharing a table with other great doctors like Dr. John Studd in the NAPMDD Conference in Philadelphia, USA, I can say with confidence that there is hope.
I never would have suspected that on that late January day, I would encounter a turning point in my understanding and consideration of the obstetric-gynecological pathology. On that day, I read an interesting article about Dr. Jorge Lolas in a Spanish medical magazine. I expected to read about some recommendations on supplements or herbal medicine for the treatment of Premenstrual Syndrome (PMS), but instead I found a whole organic theory on the non-neoplastic pathology of chronic inflammation/infections of the cervix and its close relationship with the development of extreme PMS or Premenstrual Dysphoric Disorder (PMDD).
Unlike other colleagues, who might have had access to this information but who underestimated it due to it not being linked with the operational paradigm of this illness, I thought it was, at the very least, worthy of further study. If someone had spent more than four decades developing this medical protocol and exclusively treating seriously ill patients with this disorder, he could not be entirely wrong. After all, patients with this disease are still looking for effective solutions because, although some have found some relief with classic symptomatic treatments such as contraceptives, anti-inflammatories, antidepressants, anxiolytics, diuretics, besides others, a large percentage of them have been completely resistant to these measures. The same was true with many patients who resorted to complementary therapies and dietary changes.
Being aware of these issues, I wanted to know more and delve into this pathology. I had to contact Dr. Jorge Lolas. Although we were separated by about 6,800 miles (11,000 km), there could be no other plan than to meet him personally. I went to Santiago in mid-April of that same year. Once there, I had the opportunity to observe firsthand the work he was doing, as well as gain access to his immense medical file. I talked with many of his patients and from one day to another I could see the actual results of the procedure. But as important as this was, I came to know this syndrome, their master. Up until that time, PMS/PMDD was almost a complete stranger to me. It was clear to me that this significant and common condition was under-diagnosed. Today I am aware that this happens with most medical specialists: we still fail to diagnose these patients. Without a diagnosis, we can not create a treatment plan. Without a diagnosis, the patient’s “medical pilgrimage” begins in an attempt to find a credible explanation for their symptoms and of course, to seek symptomatic relief. Without a diagnosis, the patient will continue to remain ill forever.
Each patient begins by looking for a specialist most related to their key symptom: a neurologist if you suffer from migraines or cognitive problems; a gynecologist if you have sexual dysfunction or chronic pelvic pain; a rheumatologist if what predominates is fibromyalgia or chronic fatigue; the psychiatrist if half of the month is spent suffering from depression, mood swings or generalized anxiety disorder. The psychiatric section is especially dramatic for many of them, who have come to receive up to four different diagnoses, such as bipolar disorder, borderline personality disorder, generalized anxiety disorder, or major depression, before a particular clever psychiatrist might identify the cyclical pattern of symptoms and finally reach the diagnosis of PMDD.
In sum, as described throughout Dr. Jorge Lolas’ book, and in my own experience in the clinical setting, PMS and PMDD are the consequence of genital inflammation, I would say that it’s almost always due to an infectious origin (although we cannot always pinpoint the pathogen) which begins in the cervix, manifesting itself as cervicitis. This inflammation/infection could ultimately affect the rest of the genital tract, leading to endometritis, myometritis, or even annexitis; in other words, a real pelvic inflammatory disease that is more difficult to treat the more extensive it is.
The infectious/inflammatory process, always in susceptible patients, generates a systemic inflammatory cascade responsible for various metabolic pathways, directly or indirectly, of the most diverse symptoms, not only of the genitals – including gonadal dysfunction – but also other areas: psychiatric, digestive, neurological, rheumatological, dermatological, immuno-allergic, etc. But why would a theory with reasonable empirical basis, a structured protocol and with outstanding results in seriously ill patients, had not found its place in the field of medicine? Why had this theory not come to arouse the curiosity of other colleagues? I do not have all the answers to these and other questions, but in the light of current developments in the field of inflammation, subclinical infection and immunity, perhaps Dr. Lolas was ahead of his time, with theories that had been difficult to substantiate so far.
When many of our patients, and even other colleagues, wonder how a finding of this size has gone unnoticed by all other gynecologists, history reminds us that paradigm shifts can take decades. I must relate one of the most recent examples: the causal relationship between Helicobacter pylori (H. pylori) and gastroduodenal ulcer. In 1875 German scientists detected a bacteria within gastroduodenal ulcers, but it was not until 1994 that the idea was recognized as valid. The Nobel Prize did not come until 2005. How many deaths due to gastrointestinal bleeding or perforation could have been avoided? How many lives were disrupted by chronic digestive ulcers? Yet it is estimated that 25% of H. pylori is resistant to antibiotic therapy. We encounter the same problems in the treatment of PMDD: difficulty isolating the causal agent, antibiotic resistance and recurrence. We are now directing our efforts to solve them.
I remember that at the beginning of this long story, I attempted, with little success, to share this new viewpoint with other colleagues and how, at times “aggravated,” they told me that what I believed would have to be demonstrated. Of course, that’s how it should be, and it is, but as Kant would say, “In the temporal order, no knowledge precedes experience and all knowledge begins with it”. Maybe our professors at University didn’t explain well enough how to generate knowledge, as many times it’s a simple observation, often at just the right moment. It’s always been that way! All of the knowledge is there. We just work to find it.
There may be various reasons why this very organic theory has not been sufficiently analyzed by the medical community:
- First, the medical profession as a whole is not familiar with the complex mechanisms of inflammation nor how the immune system operates. New concepts such as “low grade chronic inflammation” or “silent inflammation” are still poorly developed in everyday medical practices.
Autoinflammatory diseases also appear in this complex scenario where inflammation, genetic inheritance, environmental factors (including infectious agents) and the immune response are interconnected, but poorly explained. It is not uncommon for these patients to suffer concomitant diseases such as celiac disease, atrophic gastritis, thyroiditis and other autoimmune processes.
While today it is technically possible to measure levels of inflammatory cytokines in clinical laboratories, availability is scarce and there is inadequate medical training regarding the usefulness of these expensive tests. Still, the advancement of personalized preventive medicine is unstoppable, and that includes knowing the degree of inflammation, oxidation, poisoning, and possible nutritional deficiencies of our patients in order to reduce the development of chronic diseases such as PMS or PMDD, diabetes, Alzheimer’s (and other neurodegenerative diseases), coronary artery disease, rheumatism, etc.
In July 2014, a study by Dr. Bertone-Johnson of the University of Massachusetts in Amherst, USA, found a correlation between PMS symptom severity and high levels of certain cytokines. Although the study failed to clarify the origin of this proinflammatory state, it is encouraging that studies are beginning to slowly look in this direction.
- The inflammatory pathology of the cervix is often considered “normal” given its prevalence and apparent harmlessness, implying that such cervical condition is the one expected or desirable. In Dr. Lolas’ opinion, cervicitis is only said to be “normal” due to its frequency (according to this theory, cavities would also be normal), but when treated accordingly, clinical improvement of the associated symptoms are frequently observed. Chronic cervicitis may cause localized symptoms such as chronic vaginal discharge, lumbo-pelvic pain or dyspareunia, as Dr. J Ma (2015) showed in the study Female Sexual Dysfunction in Women with Non-Malignant Cervical Diseases: A Study from an Urban Chinese Sample. But as Dr. Lolas suggests, and daily clinical experiences show me, other undesirable symptoms like headache/migraine or psychiatric disorders are common.
Cervicitis is probably the one chronic inflammatory process to which we pay the least attention, likely due to the large number of inflammatory smears that we find in gynecological checkups. However, although the Pap Smear does not seem to be a good screening method for PMS or PMDD, we cannot overlook such findings, particularly in symptomatic patients with recurrent inflammatory smears. How often have we refused to recognize the relationship between an inflammatory smear and the discomforts that led our patients to us, saying that since the inflammation developed at the microscopic level, it could not be behind those various symptoms? If dentists were to overlook gingivitis, cavities, or abscesses (as we gynecologists usually do on the cervices we explore), what would happen to our oral health? The clinical diagnosis of cervicitis should be given with just one cervical examination, without even a smear, which, although essential for early detection of cancer, it is not necessary to comprehend when a cervix is healthy or, in contrast, suffers from inflammation, which leads to bleeding, tenderness, pain or abnormal secretions.
The development and implementation of the program of early detection of cervical cancer has been successful in reducing cervical cancer, but on the other hand has managed benign infectious/inflammatory disease of the cervix to be ignored. We have been so focused on identifying precancerous lesions that frankly, we have been blind to everything else.
- Moreover, pelvic inflammatory disease (PID) remains a misunderstood, misdiagnosed and poorly treated condition, as some studies have exposed. Most of the genital tract infections that pass the cervix, particularly those that do not usually cause a high fever, either remain untreated or are barely treated with vaginal suppositories (treatments that only reach the cervical surface and have no ability to act on the reservoir of bacteria in the cervical crypts), or are tentatively treated with a too-short course of antibiotics. The consequences: infertility/sterility, pelvic algias, sexual dysfunction, menometrorrhagia, polymenorrhea, oligomenorrhea, leukorrhea, and, as we are trying to explain, the development of PMS or PMDD in susceptible cases.
- The massive use of gynecological ultrasound has resulted in a progressive abandonment of genital examination. We again learned that if we did not suspect cancer, a polyp or a myoma, the rest of the ultrasound findings were irrelevant. And that’s not true.
Certainly there are ultrasonographic signs that indicate genital inflammation, but they are subtle and you must adapt to identify them. This we have learned from observation, since after timely medical treatment, the US scan changes are objectively measurable: the dimensions of the uterus and cervix, hypervascularization decreases or disappears, tissue refractivity is attenuated, Nabothian cysts (a recognized ultrasonographic sign of chronic cervicitis) have been drained, the uterine axis is realigned, etc.
- The fragmentation of knowledge in the medical field has undoubtedly been a necessary step in solving concrete and complex problems. However, we have failed to pool the knowledge generated in other specialties. We study only subjects in our field: advances in dentistry have not helped gynecologists understand how mucosae behave (as gateways to infection); The role of H. pylori infection in the development of ulcers and in the associated gastroenterology field has not “turned the light on” for gynecologists; The PANDAS syndrome, an autoimmune neuropsychiatric pediatric disorder associated with group A β-hemolytic streptococcal tonsillar infection, is completely unknown to many specialists and seems to me to be tremendously representative of the ability of “banal” infections to produce psychiatric symptoms in susceptible patients.
Studies that link some schizophrenias with Toxoplasma or Chlamydia infections, among other microorganisms, continue to be published. A study was recently published (Pisa et al., 2015) alerting us to the possible relation between fungal infections in the brain and Alzheimer’s disease.
Does this mean that in the coming decades we will identify the etiological agents, often of infectious origin, of many chronic diseases, whose victims were unnecessarily lacking treatment or had only received palliative or symptomatic treatments? Possibly yes.
- The cyclical nature of this syndrome has always put female hormones in the spotlight as the direct cause of symptoms. How to connect infection and inflammation of the genital tract with hormonal dysfunction, which certainly is an underlying issue in these women, is no simple task. Authors such as Dr. Attila Toth, gynecologist and American pathologist, suggest genital infections with possible ovarian involvement as the primary cause of hormonal alteration.
Women’s immune system behaves differently depending on the timing of the cycle: it becomes tolerant after ovulation to facilitate the nesting of the embryo, which is still a foreign tissue. This physiological change in the immune response also leaves the door open to infections.
- The fact that there is little or no response to standard antibiotic therapy protocols has led to airily underestimate the infectious-inflammatory theory in PMS or PMDD. What we are observing and learning in practice with these very chronic patients (many of them affected for decades) is that these standard protocols are clearly insufficient. Longer and more intense antibiotic therapy markedly increases the success rate. Early termination of treatment leads to symptomatic relapse. The use of cryotherapy also stabilizes the achievements of antibiotics, although the mechanisms are not fully explained as we will see.
- Special mention should be made of cervical cryosurgery: the use of deep cervical cryotherapy, including the cervical canal, may be a key piece in solving the puzzle. Although many patients may be successfully treated by administering antibiotics and anti-inflammatories exclusively, there is always a subgroup that does not feel relief until the cervix is treated with physical measures, with cryocautery being the main method. What role does the woman’s cervix play in the immune system? Will the cervix be a new “amygdala” to which we have not yet paid any attention? Far from being a mere “channel of passage,” the cervix seems, in the light of its behavior when manipulated, a true nerve center. It is not uncommon to observe in the course of cryosurgery that, at some point, the freezing “disconnects” the patient from the unpleasant symptoms for which she has consulted, such as sadness and languor, migraine, “the black cloud hanging over their head” (terminology used by many patients to describe the feeling that does not allow them to think or concentrate), joint pain, muscle aches, etc.
- Finally, without wanting to start a debate, we can say that the appearance of hormonal contraceptives has contributed to the masking of the true etiopathogenesis of PMS or PMDD. We have managed to alleviate some symptoms, but at the same time have worsened others, and we end up normalizing them.
The so-called “women’s liberation” has brought with it the chronic use of hormones and drugs. Soon we will have to tell patients that the daily use of contraceptives decreases the activity of the immune system at the cervical level, leaving the genital system devoid of defense mechanisms and exposing it to infection. With genital infection we put ourselves at risk of developing PMS or PMDD.
I would like to be able to say that we have found the way to plan our pregnancies without any side effects, effects that most of women have already assumed as normal. In this sense and for this particular pathology, I encourage the use of condoms, even at the risk of some “accusing” me of defending an overly hygienic sexuality. We are free to choose, but a doctor has an obligation to inform.
Trivializing the problem for which patients with Dysphoric Disorder consult their doctor, labeling it “normal for women, normal for their age…” has become the standard response of many doctors, and at the same time converts women into a tailor’s box of illnesses and chronic symptoms, silently forcing them to accept their condition and settle for a low or very poor quality of life.
In any case, by going directly to symptomatic relief instead of repairing the damage of the genital system, we lose the opportunity to treat the disease in its early stage.
It’s for these reasons and certainly due to other causes outside my ability to analyze, that the theory of Dr. Jorge Lolas has not yet finished coming into the spotlight.
Personally I believe that our greatest efforts should focuse on the early diagnosis and the establishment of groups at risk of developing this syndrome. If we are able to advance the diagnosis and treat it early, much harm can be prevented.
I wholeheartedly believe that this theory will find its full development in the next decade. We already have a solid base to treat this serious disease and I am sure that we will go far and provide effective coverage to the female population if we combine our efforts, deepen our knowledge of how the immune system affects daily life, improve microbiological studies, change our lukewarmness in the face of the benign inflammatory pathology of the cervix and simple infections of the genital system, and involve ourselves in formative and preventive campaigns about this inflammatory-infectious pathology.
On the other hand, it should be remembered that the “official” postulates, based on the hormonal paradigm, do not clarify the definitive etiology of this syndrome and, therefore, do not provide any etiological treatment, only symptomatic relief, of which these women become dependent nearly for life.
Patients who come to our clinic usually do so when they are not relieved by classic measures, falling into a kind of “limbo:” they are neither healthy nor sick, they are “invisible.” In my opinion, may patients continue coming to us like this, it is sufficient motivation to not to overlook any clue, any theory, any body of work, simply because we do not know how to fit it into the predominating paradigm.
I encourage new scientific studies that will provide improvements to this protocol, that will complement it and help remove any doubts of skeptics who, with reason, need quantified evidence of what to us is already palpable every day. As Jorge Lolas has always said, he made the road, but it is our job to build the highways.
I would like to draw the attention of specialists in microbiology. We need to make available to the community simple and effective methods for the identification of pathogens, such as selective endometrial culture, which is scarcely used in humans. Clinical immunologists should also help us to improve the immune response capacity against microorganisms, since weakened immunity also seems to be a major factor predisposing some to the disease.
Another chapter that I can not resist talking about, because of its great importance as I understand it, is that of the axis between the digestive and immune systems. And it is very simple to understand: if we have an infection of the urogenital system (and I purposely introduce the term “uro” because a genital infection is almost always accompanied by the urological and vice versa), we should start by asking where it came from. Well, by over simplifying it, there are two large groups of pathogens: those that are sexually transmitted and bacterias that are simply part of our flora. A leaky intestine with intestinal dysbiosis can easily contaminate the genitals. Without effectively restoring the digestive flora (through special diets, probiotics, etc.), we greatly increase the risk of reinfection. Likewise, if we do not avoid the reinfection of sexually transmitted pathogens with the use of condoms or by extending the treatment to both partners, we will also suffer new relapses.
Finally, I want to especially mention the true protagonists of this work that was first published by my teacher in 1995: women, our patients. How can I explain, from the deepest recesses of my heart, that the pain you have felt since your first period was not normal, and it was for nothing? Two days ago one of you, one of us, told me that it felt strange to have “an anesthetized pelvis” because she had always sensed a “heaviness” in her pelvic region. No one had explained to her that viscerae are not felt if they are in perfect condition. How much pain has been felt in the viscera par excellence, the only one that perpetuates life… From this standpoint, we assure you of our firm commitment to continue studying and learning to reach real solutions to this problem. We do not yet have all the answers but every day we ask questions in our eagerness to help your life stop being impossible to live.
Thank you teacher. Your greatest achievement has been your perseverance in paving the way to this knowledge. Thank you for sharing and thank you for continuing to fight. I know that someday you will be thanked as you deserve. Your patients have already done so. I do too.
18 December 2016. Elche (Spain)
“You never change things by fighting the existing reality.
To change something, build a new model that makes the existing model obsolete.”
Richard Buckminster Fuller (1895-1983). Designer, architect, visionary and inventor.Dr. Juani Lafaja. NG Clínicas.