Stroke vs. Heart Attack...Do You Know the Difference?

After writing my last post about heart disease or cardiovascular disease, I realized that I hear many people use the words stroke and heart attack interchangeably, as if they are the same.  But in all reality, a stroke has to deal with your brain (tissue damage to your brain), while a heart attack has to deal with your heart (tissue damage to your heart)...which sounds pretty simple...but it gets a little more complicated and simplified in that strokes and heart attacks are both usually caused by a process called "Atherosclerosis".

So...What is Atherosclerosis?
Atherosclerosis is the process of one's large arteries (the vessels that carry blood from the heart to all of our other organs) becoming narrow due to the accumulation of cholesterol plaque and/or thrombus (blood clots).  So imagine, a water hose being connected to your house in order to transfer water from the water tank to any place within your yard.  Now, depending on where you live your water supply may have a number of chemicals or organic particles that are normal for your home location.  Due to a number of factors like the material of the hose you use, the length of the hose, the force of which your water supply flows through the hose (I could go on and on with listing the factors) all contribute to a build up of elements along the inside of the hose that decreases the internal diameter of the hose, and affects the passage of the water traveling through the hose.  Over time, the build up within the hose gets thicker and your water doesn't make it to its destination as fast or as forceful as it once did.  This ultimately leads to the hose becoming completely blocked causing it to burst or causing the water to flow backwards.  At any rate...you need a new hose!

This same idea can be applied to our arteries in that blood that has circulated through our body in order to supply our organs with nutrients and oxygen, returns to the right side of our heart, the right side of our heart then sends the blood (that has little to no oxygen remaining in it) to our lungs where oxygen is added and the newly oxygenated blood is then pumped to the left side of our heart.  At the end, the left side of our heart pumps the newly oxygenated blood into our body circulation to delivery nutrients and oxygen to our entire body.  Sooooo, by the time the blood has completed an entire body circulation cycle it reaches the right side of our heart to start the oxygenation cycle all over again.

Blood flow through the heart. (www.yournursingtutor.com, 2015)

So, your arteries are the hoses and your heart is the water tank, and due to a number of individual factors such as genetics, diet, exercise, etc. your arteries begin to accumulate build up that narrows the passage way of your blood (oxygen, nutrients, etc.) circulation through your body.

Narrowing of Artery, Atherosclerosis.  (National Heart, Lung, and Blood Institute, 2014)

Stages of Atherosclerosis. (www.dreamstime.com, 2015)

Stages of Atherosclerosis. (www.3deducation.com, 2015)

As soon as atherosclerosis begins it becomes open season for complications throughout your body.  This is the reason behind preventative health measures such eating healthy, exercising, etc., as these actions help minimize the risks for atherosclerosis that we can control.

The Infamous "Heart Attack"
In the medical world heart attacks can be referred to as "Myocardial Infarction" or an MI (total blockage of an artery), or "Angina Pectoris" (partial blockage of an artery) and they occur when a coronary (related to the arteries that supply and surround the heart) artery becomes blocked, leading to prolonged restriction of blood supply to tissue, cell death, and infarction (tissue death due to lack of oxygen) to the heart wall (Gould & Dyer, 2011, pp. 287-290).

Warning Signs of Heart Attack. (Gould & Dyer, 2011, pp. 291)

If you experience ANY of the above symptoms, IMMEDIATELY call 9-1-1, as the size of the blockage, the location of the blockage, as well as the amount of passed since symptom onset; determine the severity of damage done to your body.  Also, if blood supply can be restored within the first 20-30 minutes, irreversible damage may be prevented (Gould & Dyer, 2011, pp. 291).  If action is not taken fast enough the area of tissue death tends to increase or spread.  The faster you seek medical help, the better chances of survival!

The Infamous "Stroke"
In the medical world strokes can be referred to as "Cerebrovascular Accident" or a CVA (total blockage of an artery) and they occur when carotid (related to the arteries that supply oxygen-rich blood to your face, scalp, and neck) or cerebral (related to the arteries that supply oxygen-rich blood to the cerebrum of your brain) arteries become blocked, leading to tissue death, irreversible nerve cell damage, and empty cavities in the brain.  The causes of strokes are thrombus, embolus, or hemorrhage.

Types of Strokes. (Gould & Dyer, 2011, pp. 487)

Atherosclerosis in Carotid Artery. (National Heart, Lung, and Blood Institute, 2010)

The symptoms of a stroke are as follows:

Warning Signs of Stroke. (Gould & Dyer, 2011, pp. 488)

The Common Link...
Even though strokes and heart attacks are not the same, their common factor is atherosclerosis!  So, why not just minimize your chances of getting atherosclerosis??!!  SCORE!!!!!!! Well...to drizzle on this parade...both stroke and heart attack have other predisposing factors that can not be mitigated AND there are predisposing factors of atherosclerosis.  Hooooowwwwever, there are more modifiable factors for atherosclerosis than non-modifiable factors!

Modifiable and Non-Modifiable Factors of Atherosclerosis. (Gould & Dyer, 2011, pp. 287-288)

Now that I have overloaded you with so much information, I think it's fair to say that preventing negative obstacles is key with respect to anything we treasure in life.  If there is a small possibility that I can plan ahead and prevent health issues prior to experiencing the negative external symptoms, then in my mind I have won a small battle.  Unfortunately, in most cases by the time we experience external symptoms, the internal damage has already been done.  So, just keep this information in mind the next time you are presented with a "red or blue pill"...yes...I love The Matrix ;)  Feel free to comment and share this post.  Until next time!

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References

Gould, B. E., & Dyer, R. M. (2011). Pathophysiology for the Health Professions. St. Louis, Missouri, USA: Saunders Elsevier.

National Heart, Lung, and Blood Institute. (2014, April 4). Explore Atherosclerosis. Retrieved May 1, 2015, from National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov/health/health-topics/topics/atherosclerosis

National Heart, Lung, and Blood Institute. (2010, November 1). Explore Carotid Artery Disease. Retrieved May 1, 2015, from National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov/health/health-topics/topics/catd

www.3deducation.com. (2015, January 1). www.3deducation.com. Retrieved May 3, 2015, from www.3deducation.com: www.3deducation.com

www.dreamstime.com. (2015, February 12). www.dreamstime.com. Retrieved May 3, 2015, from www.dreamstime.com: www.dreamstime.com

Yournursingtutor.com. (2015). Yournursingtutor.com. Retrieved May 1, 2015, from Yournursingtutor.com: https://www.pinterest.com/source/yournursingtutor.com/

Wearing Your Heart on Your Shoulder

Do you wear your heart on your shoulder?!!!?????  I'm kind of being silly, but not really...I ask this question in relation to your heart health versus your emotional health.  In the past few months I have lost a number of exceptional women in my life due to heart disease, or cardiovascular disease (CVD), and the statistics in addition to the need for educating women about our vulnerability to this disease has inspired this post.  

In my opinion, it's important for us to take notes on our bodies and its response to our daily activities, interactions, and stress levels.  I'm not saying you need to meditate, participate in yoga, see a therapist, etc....I'm just suggesting that when something about your body feels "off" make a mental note of it and maybe even have a seat and live in the "offness" you feel to be able to describe to it to a medical professional.  The more moments we take to listen to our bodies and educate ourselves about them; provides us with more tools to utilize when our bodies are responding in unusual patterns.

For International Women’s Day the World Health Organization (WHO) presented 10 illnesses that were significant to women and their health.  Those 10 health issues were:

World Health Organization (WHO) 10 Health Issues of Women. (Bustreo, 2015)

In researching more, I found an additional list of health concerns related to women, which listed the top 5 female health issues as:

1. Heart disease 
2. Breast cancer
3. Osteoporosis
4. Depression
5. Autoimmune diseases (Zamora, 2015)

For the sake of not overloading you with ALL of the health concerns for women, I’m going to address cardiovascular disease (CVD) in women in this post, as it is one of our top health issues and causes of death.  Just to put things into perspective, 

• In 2006, 26% of women died from CVD, which is equivalent to more than 1 out of every 4 women you may know dying from CVD (Moran & Walsh, 2013).
• If we fast-forward to more recent years, statistics show that CVD is responsible for 29% of deaths in women  (Bustreo, 2015).  
• About 5.8% of all white women, 7.6% of all black women, and 5.6% of mexican-american women have coronary artery disease (CDC, 2015).

In talking about what may make noticing CVD symptoms difficult for women...the short of it is that CVD symptoms present very differently in women than they do in men AND our CVD symptoms are NOT usually presented as the “classical/standard” symptoms.  But just as a general rule of thumb, any symptoms that appear as

• pain, pressure or discomfort in the chest, neck, jaw, upper stomach, or back,
• feeling weak light-headed or faint,
• pain or discomfort in arms or shoulder,
• shortness of breath, and 
• nausea (Centers for Disease Control and Prevention, 2015)

that can appear while resting, at the start of physical activity, or during periods of high stress.  These are significant signs that should prompt you to seek medical advice and/or call 9-1-1.

In our case, the female body already has so many functions playing the balancing dance that CVD symptoms could be very subtle or even absent…which definitely makes me and should make you uneasy!  But, studies have shown that a large percentage of women experience

• fatigue,
• sleep disturbance, and
• shortness of breath

prior to experiencing a heart attack (Moran & Walsh, 2013).  After reading this, I instantly thought...I experience at least two of those three on a weekly basis...which would make me a prime candidate for ignoring such indicative signs.  The more disappointing research shows that close to two-thirds or 64% of women who die suddenly from CVD had absolutely NO symptoms (Moran & Walsh, 2013).  With that in mind, we need to pay close attention to our body with respect to symptoms or feelings of being “off or icky” that may appear and disappear spontaneously.  If and when you ever feel chest discomfort, or any of the symptoms listed above, it is EXTREMELY important that we seek medical advice, and if you suspect that you or someone near you is having a heart attack INSTANTLY call 9-1-1.  NEVER brush off or ignore any of the above symptoms as indigestion or stress (which is what I might I have the tendency to do...considering life doesn't really slow down!) as the faster you seek medical assistance the larger your chances are of surviving.

Just a Few Facts…

• Heart disease is the leading cause of death for African American and White women in the United States (Centers for Disease Control and Prevention, 2015).
• Illness symptoms can be broken down by:

CVD and Related Symptoms. (CDC, 2015)

Your Risks for Being Affected by CVD...

CVD Risk Factors. (CDC, 2015)

How to Limit or Minimize Your Risk...

By educating ourselves and listening to our bodies, we can reduce our chances of heart disease by:

Minimizing CVD Risk Factors. (CDC, 2015)

There are a number of initiatives at work to educate on CVD, check out these links below for more information:

• State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health
• Million Hearts
• WISEWOMAN
• The American Heart Association
• The Heart, Lung, and Blood Institute

Also, I wanted to point out that none of the listed symptoms related to CVD had an age stamp attached, which is VERY significant, as women of any age as well as those at a "healthy" weight with unhealthy fat proportions can be affected in large numbers.  Hopefully this post will help someone along their journey to optimal health.  Please feel free to comment or re-post.  Until next time ;)

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References:

Bustreo, F. (2015 8-March). Promoting health through the life-course. Retrieved 2015 13-May from World Health Organization (WHO): http://www.who.int/life-course/news/2015-intl-womens-day/en/

Centers for Disease Control and Prevention. (2015 30-April). Division for Heart Disease and Stroke Prevention. Retrieved 2015 1-May from Centers for Disease Control and Prevention: http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_women_heart.htm

Centers for Disease Control and Prevention. (2015 19-February). Heart Disease. Retrieved 2015 1-May from Centers for Disease Control and Prevention: http://www.cdc.gov/heartdisease/signs_symptoms.htm

Moran, B., & Walsh, T. (2013 February/March). Cardiovascular Disease in Women. Nursing for Women's Health , 63-67.

Zamora, D. (2015). Women's Health. Retrieved 2015 1-May from WebMD: http://www.webmd.com/women/features/5-top-female-health-concern

Pesticides + Health = What to Buy Organic??!!

I've been purchasing organic produce for close to 9 years now, and this was prompted by pregnancy.  Nine years ago finding organic produce was hard, and I had to travel at least 30 - 45 miles to purchase them.  Fast forward to the present, finding organic goods isn't nearly as hard as being able to pay for them!  So, each time I needed to purchase groceries I would go through this mental process of debating which produce were my favorite, and deciding if it would be worth it to purchase them in their organic form?  After going through this process too many times...I was over it and decided to research which produce were likely to be the most dangerous if eaten in a non-organic form, and I was able to put this list together.

Table 1. Products to buy organic

The pesticides that can be found on our produce affect our overall health in a number of ways.  In many cases when we eat non-organic produce we are digesting approximately 30 different pesticides, and this only takes in to account the number of pesticides that remain on the skin of the item (it does not account for the pesticides that may have seeped into the flesh of the produce).  Those digested pesticides just hang out in your colon until they are released at a very slow pace, slowly damaging your body.  The damage includes, but may not be limited to the items in the table listed below.

Table 2. Affects of Pesticide Digestion

A study conducted on women in 2014, presented that there was no significant evidence that suggested eating organic produce decreased the diagnosis of cancer overall.  However, eating organic produce did show a decrease of Non-Hodgkins Lymphoma diagnoses in women.  This is a very interesting topic, and I'll post more regarding it as information becomes available.  Feel free to check these pages fro additional information:

• The Dangers of Pesticides
• Pesticide-Induced Diseases Database
• Pesticide Injury & Illness Surveillance

In the meantime, choose your produce wisely!  Please feel free to comment, share your thoughts, and follow ;)

Update to Body Wash

Since our move to California, I have had to change a lot of our hair and skin products, as the air is dryer here than in Maryland, and our water is very hard.  In order to keep our skin clean and moisturized I added the following to our body wash...

• Refined Mango Butter - rich in antioxidants, vitamins A and E, restores and maintains skin moisture, as well as promotes cell generation.  It arrives as a crumbled butter material, that can be melted to mix with other ingredients.

Refined Mango Butter

• Tucuma Butter - rich in fatty acids to protect and moisturize skin.  It arrives as extra-virgin coconut oil would in a white/clear wax material.

Tucuma Butter

• Kukui Nut Oil - helps with soothing sunburn and chapped skin.  It arrives as a yellow oil.

The base of our body wash changed a bit also.  I fill the blender with...

1. 1 cup of Castor oil
2. 1 cup of Olive Oil
3. 1 cup of Honey
4. 1 cup of melted Refined Mango Butter
5. 1 cup of melted Tucuma Butter
6. 1 cup Dr. Bonner's Castile liquid Soap
7. 1/2 cup of Safflower oil
8. 1/2 cup of Jojoba oil
9. A few drops of Eucalyptus oil (this is just to give it a soothing smell)

I blend them up, and pour into a pump bottle...and we have our lovely body wash!  The end result is usually very creamy, and it does not produce bubbles.  I'm okay without bubbles as long as my skin is clean and moisturized.  This mixture needs to be altered according to your skin needs, and remember if you feel itching or experience hives while using these ingredients, please discontinue use and seek advice from your health care provider.  I hope this helps someone, until next time ;)  Please feel free to comment and follow!

The Infamous "Period" and PMS

Over the past few years, I have noticed a number of changes surrounding my menstrual cycle. I'm not sure if it's the fact that I use a hormone free IUD, or if it's my aging process (wine gets finer with time)...I'm pleading the fifth on the aging process...lol ;) So, I decided to dig a little into the actual pathophysiology behind my "Horrible Headaches" or H² surrounding my menstrual periods. Yes, I named them H²...I was a Math major and I'm a SUPER nerd!  

It is absolutely undisputed how miraculously our bodies function, and I'm always in awe of the many variations of beauty our body's represent.  A portion of the female body's beauty stems from its ability to manage stress, hormones, emotions, and reproduction with ease.  "With ease" is a bit of an under statement, when I actually think about the monthly process our bodies are subject to upon reaching our first menstrual cycle.  I remember entering middle school and all of my friends and female family members of my age group were all discussing their "period"... and I remember looking at them with my "shut the front door" face, thinking "it can't really be that bad...seriously...it's so bad that we have to have a full blown conversation instead of riding bikes"?  Anddddd 15 years later, I must confess that at least "MY" menstrual cycle needs/deserves/will occupy more than a full blown conversation...besides who would I be kidding if I didn't recognize that it basically runs things!  MY definition of running things doesn't exactly mean that I "bow down" to it...I just understand my body's natural process and I don't fight it nor do I attempt to agitate it because ultimately...my body WILL win (hands down) every time!  And I only know that my body's a winner because in my younger, not so in tune with my body self...I thought it was possible to live around my monthly cycle, as in not listening to my body and its needs during this very pivotal period of time.  However, my body had a way of ever so gently knocking me on my butt, at which point I had no choice but to listen.

In my younger days, I would battle with very painful cramping, but after child birth I started to notice a new pattern, and yet another pattern began after I started using a hormone free IUD.  So, I would go through periods of time where I thought I had my monthly cycles and symptoms all figured out, when in actuality just like any life long process my monthly cycles were evolving with my lifestyle environment.  In order to get in touch with and to understand my monthly cycles better, I had to call on my nursing background to research a few topics.  Mentally, I understand that my body is very complex, and it needs to be taken care of as such, but physically (in the real world) there are so many things that need to be taken care of in addition to "ME", which implies that my body may suffer from "I'm gonna start that next week" syndrome from time to time!  But, I'm human and this will occur from time to time, and I'm okay with that as long as I learn from my experiences and in turn share with you ;)

What is the "Menstrual Cycle" Exactly

In the most basic explanation, our menstrual cycle is a 4 week or 28 day cycle where our reproductive hormones participate in an automatic balancing act initiated by the hypothalamus to:

• mature an egg within one of our ovaries for release during ovulation, and to
• build a foundational endometrial lining along the wall of our uterus for future egg implantation1

The Hormones of Our Menstrual Cycle

1. Luteinizing Hormone (LH) - causes the complete maturation of follicles and pushes the follicles through ovulation.  It is also responsible for the development of the area on the ovum where the ovum exited during ovulation.  This exit area or ruptured follicle turns into a corpus luteum that excretes progesterone.
2. Estrogen - produced by the mature follicle, and suppresses the release of the FSH 
3. Progesterone - maintains the layer of the uterus that supplies blood circulation in preparation for fertilization and implantation for a developing fetus.  
4. Follicle-Stimulating Hormone (FSH) - stimulates the growth and maturity of the ovarian follicles necessary for ovulation1

For symptom identification reasons, I am going to focus on estrogen and progesterone along with serotonin.  Serotonin is a neurotransmitter that is involved with moods, emotions, and sleep; these levels are usually elevated in those with schizophrenia1

How Hormones & Neurotransmitters Affect Premenstrual Syndrome (PMS)

The fluctuations of our hormones has been mentioned by many as the foundation of our PMS symptoms.  Recently, I read a few articles that introduced a new variable to the PMS equation; the neurotransmitter serotonin.  In the Monthly Hormone Chart below, I have tried to illustrate the fluctuations of our key hormones (estrogen and progesterone), and serotonin with respect to our monthly menstrual cycle.

Monthly Hormone Chart.  Displays our typical monthly menstrual cycle from day 1 through day 31.  Where mensing (bleeding) or our "period" starts approximately on day 28 and continues through day 3 of our new cycle.  Each colored line represents a significant hormone and its fluctuation throughout our menstrual cycle.  Serotonin has two lines, where the green line represents its levels in women without PMS, and the purple line represents its levels in women with PMS.

In an ideal health situation, our serotonin levels remain steady (as seen with the green line) throughout our monthly menstrual cycle.  However, research has shown that women who experience PMS also experience a drop in their serotonin levels as their estrogen levels drop2 (as seen with purple line).  In my case, my PMS symptoms begin around the 14th day before my "period" starts.  Just for clarification, our menstrual cycle is a 4 week time frame that ends with a 3-7 day mensing interval.  This 3-7 day mensing interval is the portion of our menstrual cycle that we call or have come to know as our "period" because it's the most external evidence of our internal reproductive cycle.  At the end of our mensing interval or "period", our menstrual cycle starts again!  I felt the need to clarify this because at times we may forget that our body is ALWAYS in a menstrual cycle, but we tend to only acknowledge or pay attention to the portions of this continuous cycle that affects our activities of daily living (cramping, mood swings, bleeding, bloating, etc).

Soooo, back to these serotonin levels...serotonin levels tend to reach their lowest levels during the 2 weeks prior to mensing2.  Ultimately, women who experience this drop in serotonin also experience PMS.  And there lies the supposed connection...

The Infamous PMS Progression.  Displays the supposed relationship between hormones and PMS.  Granted it is not known what causes serotonin levels to mimic the decrease of estrogen levels.  However when serotonin does decide to follow the drop in estrogen, the decreased level of serotonin has been linked to PMS.

What Can We Do About It?

There are a number of options for limiting and alleviating symptoms related to PMS.

If you are anything like me, you want the justification behind as many of these options as possible.  So, here is my attempt at providing justification...

• Stress - this is problem if you are a person with great health, so imagine adding the element of stress to your body when it's in a state of imbalance...enough said!
• Avoiding caffeine and refined carbohydrates - this allows your body to minimize nervous system arousal.
• Increasing complex carbohydrates, high fiber, foods rich in vitamin B6, dairy, and poultry - these diet options are supposed to promote serotonin production.
• Exercise - enables the release of endorphins, which elevates your mood.  Aerobic exercises are especially good for relaxing the body.
• Calcium and magnesium - help with alleviating psychological and physiological symptoms.

Now for the "Happy" foods list...

• Sweet potatoes - loaded with folate, and B vitamins that increase serotonin and dopamine (neurotransmitters) levels, leading to better moods,
• Bananas - loaded with tyrosine, which is a building block for neurotransmitters,
• Eggs - have ideal proportions of fat and protein which will keep your blood sugar from jumping all over the place, preventing extreme mood highs and lows,
• Quinoa - (my favorite rice/noodle replacement) loaded with protein, B vitamins, magnesium, and iron, all of which regulate serotonin levels, evening out your moods,
• Tomatoes (cooked) - loaded with lycopene which prevents inflammation that can accompany PMS, leading to stress on your body...not to mention discomfort and pain,
• Avocados - loaded with healthy fat like Omega-3's which increases a positive mood,
• Coconut oil - (the only oil I use for cooking) loaded with medium-chain triglycerides which improves the brain's production of serotonin 3
• Chocolate, eggplant, pineapples, plantains, red plums, and walnuts - increase serotonin levels 5

After all of the information provided, I have to say that regular exercise, eating healthy, and taking a daily multi-vitamin seem to handle my mood swings and fatigue related to PMS.  I also take an iron supplement Floradix Iron + Herbs in order to prevent fatigue related to low iron levels due to heavy mensing.  It's perfect for me because it does not cause constipation or hard stools, however the taste isn't that great and I have to remember to take it 30 minutes prior to eating.  When my symptoms are severe and I'm experiencing migraines and severe cramping, I utilize Tylenol for cramping (because I can't take Ibuprofen...but if I could I would take an NSAID instead), Frova which is a prescription medication for migraines, and my old faithful heating pad ;) Frova works really well for immediate relief as soon as I feel a migraine coming on or after one has started.  The multi-vitamin I use is Ola Loa, and it comes in a powder form that you mix with water and drink.  I'd rather drink my vitamins in a powder form versus swallowing them in a pill form, as the pill forms can be inefficient and lead to additional free radicals roaming around in my system.  I'm also a heating pad snob, so I figured out the exact heating pads that work best for me and they happen to be made by Sunbeam.  You can find more information about the heating pads I use here, and here.  I also use a few applications to track my menstrual cycle and symptoms, they all have their strengths, it just depends on which is more comfortable for you.  My tracking apps are...

Period Tracker, by GP International LLC

I've been using this app the longest.

Period Calendar/Tracker by ABISHKKING
This app has grown on me, and it's presentation is really cute.

Period & Ovulation by SMSROBOT LTD

LoveCycles Menstrual Calendar by Plackal Tech

Another random note...there was also a study done recently that showed significant improvements in PMS with the usage of a medication named Fluoxetine (also named Sarafem and Prozac) in the place of Calcium supplements, please contact me for information if you can't find the article on the web4

In short, my monthly "horrible headaches" are related to PMS that has been linked to a decrease in my serotonin levels that happens to decrease with my estrogen levels prior to mensing!  As always, please consult with your physician prior to starting any new exercise regimens or prior to starting new medications or supplements.  This information has been provided for educational purposes, and I hope you find it helpful.  Please feel free to follow and share ;)  Until next time!

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¹  Dunn, J. (2015, March). Bad Moods, If you’re sometimes Ms. Grouchypants (and who new ways to head off downer feelings and bring. Health.com.

²  Lewis, S., Heitkemper, M., Dirksen, S., O'Brien, P., & Bucher, L. (2007). Medical Surgical Nursing Assessment and Management of Clinical Problems (Seventh ed.). St. Louis, Missouri, USA: Mosby Elsevier.

³  University of Minnesota Health Center. (2014). Understanding PMS and Your Cycle. Retrieved April 1, 2015, from University of Minnesota Health Center: http://www.uofmmedicalcenter.org/healthlibrary/Article/85704

⁴  Yonkers, K. (2014, January). Fluoxetine better than calcium in premenstrual syndrome. Journal of Clinical Psychopharmacological.

⁵   Leeuwen, A. M., & Poelhuis-Leth, D. J. (2009). Davis's Comprehensive Handbook of Laboratory and Diagnostic Tests with Nursing Implications (Third ed.). Philadelphia, PA, USA: F. A. Davis Company.