Transcript PREMENSTRUAL SYNDROME

PREMENSTRUAL SYNDROME
Ozgul Muneyyirci-Delale
Premenstrual Syndrome
Premenstrual Syndrome (PMS) is defined as “the
cyclic recurrence in the luteal phase of the
menstrual cycle of a combination of distressing
physical, psychological, and/or behavioral
changes of sufficient severity to result in
deterioration of interpersonal relationships and/or
interference with normal activities. Nearly 200
symptoms have been associated with this
definition and it is the clustering of these signs
and symptoms that is the hallmark of PMS.
Catamenial
The term “catamenial” is derived from the Greek
and signifies around menses. In general an
instance where a single recognized medical
condition presented in the premenstruum was
referred to as a catamenial disorder while a
cluster of symptoms was referred to as PMS.
Premenstrual Magnification
Many patients with psychiatric disorders also
complain of worsening of their symptoms around
the premenstrual phase, called “premenstrual
magnification” (PMM).
PMS
Milder symptoms are believed to occur in about 30%
to 80% of reproductive-age women, while severe
symptoms are estimated to occur in 3% to 5% of
menstruating women.
Concordance Rate
The concordance rate (if both twins have PMS) was
found to be significantly higher in monozygous
twins (93%) than dizygous twins (44%) and in
non-twin control women (31%).
Common Symptoms of PMS
Women with PMS
Symptom
(%)
Behavioral
Fatigue
Irritability
Labile mood with alternating
sadness and anger
Depression
Oversensitivity
Crying spells
Social withdrawal
Forgetfulness
Difficulty concentrating
Showing Symptoms
92
91
81
80
69
65
65
56
47
Common Symptoms of PMS
(Continued)
Physical
Abdominal bloating
Breast tenderness
Acne
Appetite changes and
food cravings
Swelling of the extremities
Headache
Gastrointestinal upset
90
85
71
70
67
60
48
Differences Between PMS and PMDD
Diagnostic criteria Tenth Revision of
the International
Classification of
Disease (ICD-10)
Diagnostic and
Statistical Manual
of Mental
th
Disorders, 4 ed.
(DSM-IV)
Providers using
these criteria
Obstetrician/gynec Psychiatrists, other
ologists, primary
mental health care
care physicians
providers
Number of
symptoms
required
One
5 of 11 symptoms
Differences Between PMS and PMDD
(Continued)
Functional
impairment
Not required
Interference with
social or role
functioning
required
Prospective
charting of
symptoms
Not required
Prospective
daily charting of
symptoms
required for two
cycles
Patterns of PMS
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Premenstrual symptoms can begin at ovulation
with gradual worsening of symptoms during the
luteal phase (pattern 1).
PMS can begin during the second week of the
luteal phase (pattern 2).
Patterns of PMS
(Continued)
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Some women experience a brief, time-limited
episode of symptoms at ovulation, followed by
symptom-free days and a recurrence of
premenstrual symptoms late in the luteal phase
(pattern 3).
The most severely affected women have
symptoms that at ovulation worsen across the
luteal phase and remit only after menses cease
(pattern 4). These women describe having only
one week a month that is symptom-free.
Differential Diagnosis
Psychiatric disorders
 Major depression
 Dysthymia
 Generalized anxiety
 Panic disorder
 Bipolar illness (mood
irritability)
 Other
Medical disorders
 Anemia
 Autoimmune disorders
 Hypothyroidism
 Diabetes
 Seizure disorders
 Endometriosis
 Chronic fatigue
syndrome
 Collagen vascular
disease
Differential Diagnosis
(Continued)
Premenstrual
exacerbation
 Of psychiatric
disorders
 Of seizure disorders
 Of endocrine disorders
 Of cancer
 Of systemic lupus
erythematosus
 Of anemia
 Of endometriosis
Psychosocial
spectrum
 Past history of sexual
abuse
 Past, present, or
current domestic
violence
Diagnosis of PMS
PMS
A. Does not meet DSM-IV
criteria but does meet
ICD-10 criteria for PMS
B. Symptoms occur only in
the luteal phase, peak
shortly before menses,
and cease with
menstrual flow or soon
after
C. Presence of one or more
of the following
symptoms
 Mild psychological
discomfort
 Bloating and weight gain
 Breast tenderness
 Swelling of hands and
feet
 Aches and pains
 Poor concentration
 Sleep disturbance
 Change in appetite
PMDD (DMS-IV Criteria)
A. At least five of the symptoms below, with at
least one being a core symptom, are
present a week before menses and remit a
few days after onset of menses:
 Depressed mood or dysphoria (core
symptom)
 Anxiety or tension (core symptom)
 Affective lability (core symptom)
 Irritability (core symptom)
 Decreased interest in usual activities
PMDD (DMS-IV Criteria)
(Continued)
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Concentration difficulties
Marked lack of energy
Marked change in appetite, overeating, or
food cravings
Hypersomnia or insomnia
Feeling overwhelmed
Other physical symptoms (e.g., breast
tenderness, bloating, headache, joint or
muscle pain)
PMDD (DMS-IV Criteria)
(Continued)
B. Symptoms must interfere with work, school,
usual activities, or relationships
C. Symptoms must not merely be an
exacerbation of
D. Criteria A, B and C must be confirmed by
prospective daily ratings for at least two
cycles
See Attached Menstrual Symptom Diary
Treatment of PMS
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Oral contraceptives
Vitamin B6
Bromocriptine
Monoamine oxidase inhibitors
Synthetic progestational agents
Spironolactone
Massage therapy
Chiropractic therapy
Calcium
Treatment of PMS
(Continued)
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Primrose oil
Prostaglandin synthesis inhibitors
Medical and surgical oophorectomy
Alprazolam (Xanax)
Naltrexone: opiate antagonist
Fluxetine (Prozac)
With a placebo response rate in patients with
PMS ranging between 20% and 50%, it is
essential that double-blind, randomized trials
be conducted to assess therapeutic
effectiveness.