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I have issues with perimenopausal anxiety a couple of weeks per month and don’t want to turn to SSRIs.

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My challenges with anxiety have been hormonal. I’ve had issues with both postpartum anxiety and now perimenopausal anxiety a couple of weeks per month as I’m approaching menopause. I don’t want to turn to SSRIs but some days are pretty miserable and most other days I feel fine. Any info you have to share regarding this topic or any natural solutions would be of great interest.

When I’m working with a client who reports symptoms like this we start with serotonin and GABA support; determine if they have low zinc, low vitamin B6 and low iron. I also always ask the question: are you on the birth control pill (now or in even in the past).

I’ve blogged about much of this in the past so I’m going to share snippets and blogs for further reading.

Serotonin support with tryptophan for immediate worry-type anxiety relief

In a study published in 1999, A placebo-controlled clinical trial of L-tryptophan in premenstrual dysphoria, tryptophan was found to reduce symptoms of PMS when used in the luteal phase or second half of the cycle (i.e. after ovulation).

This is very typical when I’m working with someone with both PMS (premenstrual syndrome) and perimenopausal anxiety, depression, irritability and mood swings. It typically takes 2 to 3 cycles for an amino acid like tryptophan to have an impact on the cyclical nature of your perimenopausal symptoms.

However, tryptophan does typically start to work right away on the less severe anxiety and mood symptoms assuming you find the ideal dose for your needs. I use the trial method to help my clients figure this out.

When you boost serotonin you also reduce the worry-in-your-head and ruminating type of anxiety, and end to panic attacks and phobias, a boost of confidence, no more depression and negativity, imposter syndrome that is no more, an end to your anger issues and irritability, an improvement in sleep and no more afternoon/evening cravings for something sweet.

You can read more about tryptophan here: Tryptophan for the worry-in-your-head and ruminating type of anxiety

GABA support for relief from tension-type anxiety

During perimenopause progesterone is often low and when it is low, we can expect GABA to be low too. Research confirms low GABA and high glutamate-glutamine in premenstrual dysphoric disorder (PMDD) and that shifting hormones may lead to dysregulation of GABA which contributes to HPA axis dysfunction. The HPA (hypothalamic pituitary adrenal) axis is your stress response system and when it’s not functioning well you are more susceptible to the effects of stress and more likely to feel depressed and anxious.

If your GABA levels are low you will feel increased physical tension and insomnia. The amino acid GABA, opened on to the tongue, can provide calming results within minutes.

Dee likes the instant calm and compares how it worked as well as Xanax had worked for her in the past:

I have taken Xanax in the past for panic attacks. My functional medicine doctor suggested this product as I wanted a natural product. I was amazed how it works just like the Xanax did – instant calm feeling within 10 mins of taking 2 capsules. I use them as needed when I am having heightened stress and anxiety.

Low zinc, low vitamin B6 and/or low iron?

Low iron/ferritin is common if you’re still having a period and it’s one of the important -cofactors for making serotonin, thyroid hormones and the sex hormones. Low iron, together with low vitamin B6 plays a role in anxiety and panic attacks. In one study premenopausal women who had been admitted to the emergency room with panic attacks were found to have both low iron and low vitamin B6. I have an entire blog post on this topic here

The other key co-factor for making serotonin is zinc. You’ll want to look into and address pyroluria if you feel more anxious in social situations like family gatherings, going to church events or community picnics, or even while doing business networking or in work meetings. The key nutrients for pyroluria are zinc and vitamin B6 and both help with PMS and perimenopausal anxiety, and hormone balance.

Are you on the birth control pill?

I recently reviewed Beyond the Pill A 30-Day Program to Balance Your Hormones, Reclaim Your Body, and Reverse the Dangerous Side Effects of the Birth Control Pill by Dr. Jolene Brighten.

If you currently on the pill or have been in the recent past read the above review and get the book to give you an excellent understanding of what may be going on with your body.

Dr. Jolene shares that mood disruption is common and mentions a study in the Journal of the American Medical Association which reports the following:

women who began the pill were more likely to be prescribed an antidepressant – which means it contributes to a bit more than moodiness

She writes in great detail about Post–birth control syndrome (PBCS) which is “is a constellation of symptoms women experience when they discontinue hormonal birth control.” She has found the symptoms of PBCS typically occur in the first 4-6 months after stopping the pill. As well as mood swings and anxiety, you may also experience heavy bleeding or no period, acne, headaches, infertility, pill-induced PCOS (polycystic ovarian syndrome), hypothyroidism, gut issues and even autoimmune symptoms.

You also want to reduce your stress levels. Here are some ideas for you:

All the above is a great starting point. You also want to consider adrenal support if needed; and support liver health, together with dietary changes, addressing gut health and thyroid health, getting toxins out of your life and figuring out whatever your own root causes may be.

Here is the link to the amino acids and pyroluria supplements I use with my clients.

Have you found that any of the above has helped you with your PMS or perimenopausal anxiety?

Do you have any stress-relief tips to share with other women who find themselves so stressed out at this age?

Feel free to post questions here too.

The role of low serotonin, low vitamin B6 and low iron in anxiety and panic attacks

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Low serotonin can cause anxiety and panic attacks. Because vitamin B6 and iron are required raw materials for making serotonin, we know that low levels of these two nutrients often contribute to anxiety and panic attacks.

We have some pretty recent research supporting all this: Low serum concentrations of vitamin B6 and iron are related to panic attack and hyperventilation attack

Reduced serotonin level is known as one of the causes of panic attacks and hyperventilation attacks ….

In the serotonin synthesis system of the brain, vitamin B6 is a coenzyme for tryptophan hydroxylase, which is involved in the conversion of tryptophan into 5-hydroxytryptophan and iron serves as a cofactor for aromatic L-amino acid decarboxylase involved in the formation of serotonin from 5-hydroxytryptophan. Therefore, a reduction in vitamin B6 and iron levels can suppress the progression of the serotonin synthesis.

The study authors measured serum levels of vitamins B2, B6, and B12 and iron in 21 premenopausal women who had been admitted to the emergency room with panic attacks.

The results were compared with lab values from 20 volunteers, also premenopausal women, and this is what they reported:

We found that both vitamin B6 and iron levels were significantly lower in the panic attack/hyperventilation attack group than in the volunteer group. There was no significant difference in the serum levels of vitamins B2 or B12.

These results suggest that low serum concentrations of vitamin B6 and iron are involved in panic attacks and hyperventilation attacks.

This certainly confirms what I see with my clients. When I’m working with someone with anxiety, we always assess for low serotonin, low iron and low vitamin B6 levels, and when we address low levels we almost always see improvements – both in the reduction of anxiety and panic attacks. We’ll often see a mood boost too, sleep improvements and a reduction in carb cravings.

Here are some additional factors to consider:

  • Vitamin B6 can be challenging to measure in serum so I like to also use the pyroluria questionnaire and poor dream recall as a clue. The authors mention that serum pyridoxal 5-phosphate (PLP) is often used as an indication of B6 status, however they opted to use pyridoxal (PAL) after conversion from PLP.
  • Supplementing with vitamin B6 can often lead to some improvements in a few weeks with many folks who have pyroluria reporting feeling less anxious and more social within a week.
  • There is the potential for vitamin B6 toxicity. I have yet to see any signs of toxicity in my clients, but I have also not ever recommended more than 500mg/day. However, there are some individuals who have issues with very small amounts of vitamin B6. Unfortunately, I do not know why this happens.
  • Testing ferritin levels are an excellent way to assess iron levels and iron should never be supplemented unless iron is low. Dr. Izabella Wentz, shares in her book Hashimoto’s Protocol and blog that the optimal ferritin level for thyroid function is between 90-110 ng/m. Addressing low iron levels can take awhile to see a shift in labs.
  • Because zinc and magnesium are also cofactors for making serotonin, low levels may also need to be addressed. I would have loved to see these included in this study,
  • As always, we assess for low serotonin levels using the amino acid questionnaire and start on tryptophan or 5-HTP right away, based on doing trials – so we can see anxiety reduction and relief from panic attacks right away, while the other changes are starting to provide the raw materials for serotonin production.

Keep in mind that low serotonin and low iron and/or low vitamin B6 – although very common with anxiety and panic attacks – are not the only root cause and many other factors may also need to be addressed.

We’d love to hear if addressing low iron and/or low vitamin B6 levels have helped you? Did you use tryptophan and/or 5-HTP at the same time?

If you’re a practitioner, are often do you see low iron and/or low vitamin B6 in your anxious clients/patients?

Help! I’m worried all the time! Soothe with supplements and tame worry with food!

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Some of my simple tips for worry were shared in the April edition of Women’s World so here they are for you to enjoy in case you didn’t see them in the magazine. I’m quite chuffed to see it’s for a piece called “Ask America’s Ultimate Experts.”

I share tips about the benefits of a B- complex vitamin (for adrenal support), vitamin B6 (especially for PMS-type anxiety and worry, the calming amino acid called GABA, plus the mood-boosting and calming benefits of a grass-fed burger (loaded with zinc, iron and omega-3s) and pumpkin seeds as a snack (because they’re rich in both tryptophan and zinc)

Here are my tips from the article:

#1 Soothe with supplements

Here are some supporting articles and research for some of the above tips. A good B- complex vitamin for adrenal support has been shown to minimize psychological stress after a natural disaster and vitamin B6 (or pyridoxine) helps with PMS-type anxiety and worry.

A paper titled Pyridoxine in the treatment of premenstrual syndrome: a retrospective survey in 630 patients, reports the following results:

The daily doses of pyridoxine hydrochloride varied from 40 to 100 mg early in the study and from 120 to 200 mg in the later period of the investigations. The response to treatment was recorded as good (no significant residual complaints) in 40 per cent or more of patients taking 100-150 mg pyridoxine daily and in 60 per cent of patients treated with 160-200 mg daily. Together with partial response (useful benefit but still some significant complaints), the positive effect of the treatment increased to 65-68 per cent and 70-88 per cent respectively. No symptoms consistent with a diagnosis of peripheral neuropathy were reported

The calming amino acid called GABA helps with the physical-tension and stiff-and-tense-muscles type of anxiety and helps with worry and inhibition of unwanted thoughts.

#2 Tame worry with foods

Professor Felice Jacka, nutritional psychiatry researcher, discusses the mood-boosting and calming benefits of grass-fed beef (loaded with zinc, iron and omega-3s) on our Anxiety Summit interview: The Research – Food to prevent and treat anxiety and depression?

Pumpkin seeds are rich in tryptophan and zinc and research shows that a functional food made from these seeds actually helps with social anxiety.

Here are a few minor discrepancies in the above sections:

  • In #1 dopamine is not a calming brain chemical but instead it’s stimulating and helps with focus and motivation. The B vitamin mentioned contain folic acid whereas methyl folate is the preferred choice.
  • In #2 the GABA product recommended is 500mg and I find starting much lower is a more effective approach with my clients.

#3 Cue calm – open a worry window

Opening a worry window is a new approach for me and I’d love to hear if it helps you now or has helped you in the past.

Anti-anxiety gummies and low serotonin

Ali Miller, RD, shares a recipe for anti-anxiety gummies (you can see it in the PDF) and I love that it includes coconut water, ginger and turmeric. I’d replace the cup of orange juice (which is high in sugar) with water and use 2 tablespoons instead. Be sure to watch that these gelatin gummies don’t make your anxiety (or depression or sleep worse). It’s a small amount of gelatin but if you’re eating a lot of them and you’re prone to low serotonin, this may be a problem for you. I write about this in a blog post here – Collagen and gelatin lower serotonin: does this increase your anxiety and depression? If it does cause an adverse reaction it doesn’t mean you can’t eat them, instead it simply means you may need to take tryptophan when eating them (if low serotonin is the issue.

If you’d like a PDF of the article you can grab a copy here.

I’d love to hear if any of these approaches have helped you or your clients/patients. Keep in mind that it’s a fun article that is by no means comprehensive in terms of addressing all the possible root causes of anxiety.

An “omnivore” like diet or Paleo diet is associated with reduced anxiety and depression

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A new study published last month, Do patterns of nutrient intake predict self-reported anxiety, depression and psychological distress in adults? SEPAHAN study, reports that

An “omnivore” like diet high in amino acids, cobalamin, zinc, phosphorus, saturated fat, cholesterol and pantothenic acid is associated with reduced psychological disorders.

This was a cross-sectional study, meaning it was a type of observational study design where the outcome and the exposures in the study participants are measured at the same time. The aim was to find an association (rather than causal relationship) between patterns of nutrients intake and psychological disorders such as anxiety and depression.

The study authors had 3846 Iranian adults between 18 and 55 of age complete questionnaires in order to assess their diets and nutrient patterns, as well as psychological factors including anxiety, depression, and overall health in general. This group comprised 1712 males and 2134 females.

The study results

After calculating the daily intakes of 57 nutrients (including individual amino acids,

starch, dietary fiber, simple sugars, different fatty acids, vitamins, minerals, and bioactive substances), 3 nutrient patterns were identified:

1) the “omnivore” pattern

high in individual amino acids, cobalamin, zinc, phosphorus, saturated fatty acids, cholesterol and pantothenic acid

in both women and men, with pyridoxine (vitamin B6) high in men only

2) the “grains and dairy” pattern

high in thiamin, folate, selenium, iron, starch, maltose, betaine, calcium, riboflavin, and niacin

and low in the following

mono-unsaturated fats, vitamin E and polyunsaturated fats

3) “fruits and vegetables” pattern

high in copper, vitamin C, glucose, fructose, potassium, dietary fiber, sucrose, vitamin A, magnesium and vitamin K.

These are the associations that were observed after adjusting for confounding factors:

  • Men in the top tertile of the omnivore nutrient pattern had lower anxietyand depression scores than those in the bottom tertile
  • Women in the top tertile of the omnivore nutrient pattern had better overall poor health scores than those in the bottom tertile and had lower odds of psychological distress, such as anxiety and depression.

This type of diet is also referred to as a Paleo or cave-man type of diet. Even though this study was only showing associations and not a cause-and-effect, it’s still very encouraging to see new research in the field of nutritional psychiatry, further supporting the results we see in clinical practice.

What are the mechanisms?

The high amino acids provide the building blocks for the production of our feel-good neurotransmitters such as serotonin, GABA, dopamine and endorphins, with zinc being a key co-factor for making these brain chemicals. The authors share some of the mechanisms for the association in the discussion section of the paper:

Dietary protein intake and also individual amino acid status have been linked to psychological status in previously published studies. For instance, methionine in the form of S-adenosyl-L-methionine, tryptophan and serine were inversely associated to depression. Lysine, arginine, beta-alanine, tryptophan and tyrosine have been shown to have anxiolytic effects. As amino acids are important precursors for neurotransmitters; they might affect psychological condition. Important neurotransmitters like dopamine and serotonin are made from amino acids tyrosine and tryptophan, respectively.

Pantothenic acid is a B vitamin that is key for stress and adrenal health. Low levels of B12 or cobalamin can be associated with both anxiety and depression, as well as fatigue. Both zinc and B12 are common deficiencies, and more so in vegetarian and vegan diets. The authors discuss some possible zinc mechanisms:

  • zinc has antidepressant-like activities such as up-regulation of the expression of brain derived neurotrophic factor (BDNF) gene
  • zinc is an antagonist of the glutamate/N-methyl-D-aspartate (NMDA) receptor

Seeing saturated fat and high cholesterol mentioned in favorable terms in a study – both of which are needed for a healthy brain and for good blood sugar control – is always exciting. The authors discuss these possible mechanisms:

low serum total cholesterol may increase the risk of depression and suicide attempts. It is hypothesized that low cholesterol intake might cause a depressed central serotonergic activity which in turn leads to depression.

Here is my addition to the discussion: in our interview on a prior Anxiety Summit, Dr. Kurt Woeller and I discuss the link between low cholesterol and low oxytocin and the role this plays in anxiety, social bonding and depression.

One area I’m a little confused about is the findings on pyridoxine (vitamin B6). They report it was high only in men in the omnivore group, and not in women. As they report, vitamin B6 is also a key co-factor in the serotonin-tryptophan pathway and we know it’s important for alleviating anxiety- related PMS symptoms in women. It’s mentioned in the concluding paragraph for playing a role in the association for both men and women and yet it is not mentioned in the abstract. I’ll report back as I find out more.

Here are some actual real-life results from someone eating this way

I blogged about anxiety and depression success stories on Paleo and grain free diets around this time last year. I shared Andrea’s feedback about her diet-mood results with a grain-free and high fat diet:

I happened upon a fat loss diet that had me cut out grains, most dairy, and sugar while focusing on mostly meat, fish, fats from nature such as butter, olive, and coconut oils. Nuts, seeds, and legumes were allowed too. These rules made it so I had to avoid processed foods. There was one day a week of eating anything.

Within 6 weeks I was shocked that I got much much more than fat loss. My depression, anxiety, mood swings, sleep issues and all but one pesky health symptom disappeared. I was stronger, faster, and felt energy I never remember having.

Have you found benefits with an omnivore or Paleo diet? Less anxiety and depression? Better overall health? More energy? Better sleep?

If you’re a practitioner have you found this approach works with your clients/patients?

Oral contraceptives cause low vitamin B6 and zinc, reduce serotonin levels and increase anxiety

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Oral contraceptives i.e. the birth control pill, cause low vitamin B6 and zinc, thereby reducing serotonin levels and can increase anxiety and depression in susceptible women.

Dr. Daniel Amen sees the association between the birth control pill and anxiety/depression in his practice and shared this when I interviewed him during season 3 of the Anxiety Summit.

Unfortunately, they drop serotonin levels. You’ve got to ask yourself why are 23 percent of women between the ages of 20 and 60 taking antidepressants? In large part, it’s the birth-control pills that are changing the hormones in their brain, the neurotransmitters in their brain. All of a sudden they’re more anxious and they’re more depressed.

Oral contraceptives lower serotonin due to various nutrient depletions and can also impact mood due effects on the progesterone/estrogen ratio.

Drug-induced nutrient depletions, especially vitamin B6

Many medications cause drug-induced nutrient depletions and oral contraceptives do this too. In this 2013 paper, Oral contraceptives and changes in nutritional requirements, the authors report:

It has been shown that the key nutrient depletions concern folic acid, vitamins B2, B6, B12, vitamin C and E and the minerals magnesium, selenium and zinc.

Zinc, magnesium, folate, vitamin C and vitamin B6 are all needed for the conversion of tryptophan to serotonin and can therefore impact both anxiety and depression, accentuating or precipitating the development of depression (and presumably anxiety too) in susceptible women.

The World Health Organization (WHO) report, Advances in Fertility Regulation, states that:

It has been shown that about 80% of women taking oral contraceptives have abnormal tryptophan metabolism suggestive of relative B6 deficiency.

Many of these same nutrients have a major impact on how women handle stress:

Magnesium and vitamin B6 may be effective in combination in reducing premenstrual stress, and vitamin B6 alone may reduce anxiety effectively in older women. High-dose sustained-release vitamin C may reduce anxiety and mitigate increased blood pressure in response to stress.

Zinc and copper imbalances occur very quickly

In this paper published in 1980, Serum copper and zinc in hormonal contraceptive users, it is reported that

Use of combined estrogen-progestogen contraceptives resulted in a significant decrease in serum zinc levels within 3 days and an increase in serum copper levels within 10 days.

In users of combined estrogen-progestogen contraceptives the magnitude and time of occurrence of the decrease in zinc levels and the increase in copper levels was unaltered by chemical composition, dosage, route of administration, and duration of use beyond 3 months.

We know zinc plays a role in the serotonergic system, reducing depression and anxiety.

Zinc and vitamin B6 are also key nutrients for alleviating symptoms of the social anxiety condition called pyroluria.

Lowered levels of endogenous estradiol and progesterone

Other mechanisms on how oral contraceptives lower serotonin relate to lowered levels of endogenous estradiol and progesterone (i.e. the estradiol and progesterone our bodies make), as well as out of balance progesterone/estrogen ratios leading to negative moods and emotional changes. The decreased prolactin response mentioned in this paper suggests reduced serotonergic activity.

High clinical relevance

The WHO report mentioned in the 2013 paper (mentioned above), states that this topic of nutrient depletions with oral contraceptives has high clinical relevance and should be receiving the attention it deserves.

Unfortunately, the nutrient-depletion with oral contraceptives conversation is not something many of my clients have ever had with their doctors, despite this being old news. The WHO report was published over 40 years ago, in 1975!

I’m particularly concerned about teens starting on birth control at such a young age and starting down this very slippery slope with no awareness of what they are getting into.

My recommendation is to NOT use oral contraceptives because of this increased risk in depression and anxiety. I write about this and FAM as an alternative here.

However, if you (or your daughter or grand-daughter or sister or friend) chooses to use oral contraceptives we need this awareness and you/they will very likely need to address these nutrient deficiencies. 

This awareness is also needed if you are using oral contraceptives (or have used them in the recent past) and have found you’ve needed to continuing using tryptophan or 5-HTP long-term.

And finally, this awareness is needed if you know you have pyroluria and the pyroluria protocol doesn’t seem to be working for you.

Nutritional and lifestyle support for mercury toxicity and detoxification in general

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I’ve poured through most of the transcripts of the Heavy Metals Summit and there is so much information on nutritional and lifestyle support for mercury toxicity and the detoxification process in general:

  • sweating and using a sauna in order to detox through the skin
  • broccoli sprouts (due to a glutathione boost from sulforaphane, an organosulfur compound – in Julie Matthews’s interview)
  • reducing EMF/ELF and microwave exposure – in Dr. Mercola’s talk! He shares how all this can make matters worse and has some simple approaches like turning off power in the bedroom at night! This was new to me and a brilliant approach!
  • eating organic (to minimize GMO/glyphosate effects on a leaky gut and a leaky blood brain barrier) and never using Roundup
  • addressing low zinc and low selenium
  • supporting methylation so the body can detox on it’s own
  • supporting the liver and increasing bile production which is needed for detoxification
  • addressing low stomach acid which is needed for bile production and absorption of minerals like zinc (which is depleted by heavy metals)
  • avoiding meds like PPIs (which reduce stomach acid) and NSAIDs (which contribute to leaky gut)
  • thyroid support/iodine (as needed)
  • getting the brain’s glymphatic system working with sufficient sleep, melatonin (liposomal) and even liposomal GABA (in Dr. Christine Schaffer’s interview)
  • supporting the vagus nerve in order to improve digestion and detoxification
  • using an air filter and water filters
  • using foods/products like curcumin, ginger, probiotics, apple pectin
  • adding DPP-4 enzyme for gluten issues (mercury depletes this)
  • avoid energy-efficient bulbs (they are high mercury)
  • having Epsom salts baths
  • improving elimination from the bowels and much more

This is the support I offer as a nutritionist and it’s wonderful to hear all these doctors/practitioners discuss about all this with a tie back to mercury, lead and other metals.

Whey is not mentioned on the summit but since someone shared how it’s benefiting her (in the comments of the Boyd Haley blog) I’m sharing here too since it helps with glutathione production. In this paper “a case is made for the use of hydrolyzed whey protein to support metal detoxification and neurological function.” I recommend whey to clients if tolerated.

Many years ago I heard a presentation by a biological dentist who then became a nutritionist – he shared that he used whey with mercury toxic patients (together with other nutrients) and saw metals go up in hair analysis and then come down as their symptoms improved.

As I’ve mentioned in the past, mercury chelation is a controversial topic and you’ll see comments very divided on what the safest approach is. This is not my area of expertise and I’m very cautious with recommendations in this area as I’ve had reports of harm from individuals using all the approaches you’ll hear about on the summit (and even the Andy Cutler protocol which is not covered). My best advice is to follow all the nutritional/lifestyle recommendations and if you do decide to go the chelation root, do your homework, find a practitioner to work with and listen to your gut. If what you’re doing doesn’t feel right then stop doing it.

As with any chronic health condition, mercury detox is a comprehensive approach and very individualized.

There is also a discussion about safe removal of amalgams/mercury fillings. They do need to be done safely so as not to cause further issues. The IOMT also offers excellent guidelines.

The summit also covers other metals like copper (Ann Louise Gittleman covers this and I blog about it here), arsenic (Dr. Joseph Pizzorno covers this – reducing consumption is a big factor; and non-organic chicken is a source) and aluminum.

You can still register here to hear day 7 interviews and the encores: The Heavy Metals Summit.

Have you seen benefits with a nutritional approach?