Transcript Premenstrual Syndrome

Premenstrual Syndrome
Dr Patel
GP VTS
Aims
• To make an accurate diagnosis of
premenstrual syndrome (PMS)
• To provide appropriate advice to women
with PMS
• To offer options for treatment that are
appropriate for initiation in primary care
• To refer the woman when primary care
treatment is not adequate
Premenstrual Syndrome
Modern Definition
‘Distressing physical, psychological and
behavioural symptoms, not caused by
organic disease, which regularly recur
during the same phase of the menstrual
(ovarian) cycle and which significantly
regress or disappear during the remainder
of the cycle’
•Magos & Studd (1984)
What is Premenstrual Syndrome
(PMS)
• distressing physical, behavioural, and psychological symptoms
• Regularly occur in the luteal phase of the menstrual cycle
• Significantly improved or resolved by the end of menstruation.
• Mild PMS 
– symptoms do not interfere with the woman's personal, social, and professional
life.
• Moderate PMS 
– symptoms interfere with the woman's personal, social, and professional life. Daily
functioning is possible, although maybe not to the usual level.
• Severe PMS 
– the woman withdraws from social and professional activities and cannot function
normally.
– If symptoms are predominantly emotional and behavioural, this is sometimes
referred to as premenstrual dysphoric disorder
Common Symptoms
• More than 100 different symptoms of PMS
have been recorded, but the most
common are listed below.
Physical symptoms
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Fluid retention and feeling bloated
Pain and discomfort in your abdomen
Headaches
Changes to your skin and hair
Backache
Muscle and joint pain
Breast tenderness
Insomnia (trouble sleeping)
Dizziness
Tiredness
Nausea
Weight gain (up to 1kg)
Psychological symptoms
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Mood swings
Feeling upset or emotional
Feeling irritable or angry
Depressed mood
Crying and tearfulness
Anxiety
Difficulty concentrating
Confusion and forgetfulness
Restlessness
Decreased self-esteem
Behavioural symptoms
• Loss of interest in sex
• Appetite changes or food cravings
• Any chronic (long-term) illnesses, such as
asthma or migraine, may get worse.
Premenstrual Dysphoric Disorder
• The symptoms of PMDD are similar to those of PMS, but more
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exaggerated.
a small percentage of women have symptoms that are severe
enough to stop them living their normal lives.
They can include:
feelings of hopelessness
persistent sadness or depression
extreme anger and anxiety
decreased interest in usual activities
sleeping much more or less than usual
very low self-esteem
extreme tension and irritability
• PMDD can be particularly difficult to deal with because it can have a
negative effect on your daily life and relationships.
What causes it ?
• The exact cause of premenstrual
syndrome (PMS) is uncertain, but because
it does not occur before puberty, in
pregnancy, or after the menopause,
cyclical ovarian activity is thought to
contribute [RCOG, 2007].
Suggested theory
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Hormone changes
Chemical changes
Weight and exercise
Stress
Diet
How common ?
• Mild PMS is experienced by many women.
• Around 5% of women have severe premenstrual
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symptoms [RCOG, 2007].
In the UK, only about a fifth of women
experiencing PMS symptoms seek medical help.
However, up to 13% of working women with
PMS symptoms take time off during the year
because of PMS [MeReC, 2003].
Risk Factors
• Common in women whose mothers also
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experienced PMS symptoms (70%)
Monozygotic twins  93% concordance rate
Dizygotic twins  44%[Bhatia and Bhatia,
2002].
More common in women who are obese, do not
exercise, and who have a lower level of
academic achievement [RCOG, 2007].
Women using hormonal contraception are less
likely to experience PMS [RCOG, 2007].
Diagnosis of PMS
• Diagnosis  Clinical
• Difficulty in diagnosis often occurs because PMS
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can present with a large number of symptoms
which are common to a range of conditions
[Rapkin and Mikacich, 2008].
Ask the woman to record a daily symptom diary
for two or three cycles [MeReC, 2003].
Investigations are not usually helpful in making
the diagnosis.
Conditions to exclude
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Depression
Anxiety and panic disorders
Hypothyroidism
Anaemia
Dysmenorrhoea
Irritable bowel syndrome
Interstitial cystitis
Endometriosis
Chronic fatigue syndrome
Fibromyalgia
Systemic lupus erythematosus
Managment
• Management should be tailored according to the severity
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and type of symptoms, and the woman's preferences and
any desire to become pregnant.
Mild symptoms
Offer lifestyle advice.
Regular, frequent (2–3 hourly), small balanced meals rich in complex
carbohydrates.
Regular exercise.
Smoking cessation.
Alcohol restriction.
Regular sleep.
Stress reduction.
Management
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Moderate PMS
Offer lifestyle advice and consider:
A new-generation combined oral contraceptive
UNLICENSED  if used solely to treat PMS symptoms
Can be used cyclically or continuously
But the first-line choice of COC is not clear.
– More evidence to support :
• the use of drospirenone-containing COCs (for example Yasmin®) than other
preparations
• desogestrel (for example Marvelon®)
• norgestimate (for example Cilest®) or gestodene (for example Femodene®), may also
be effective, especially if they have been used before and have been found to be of
benefit.
– Inform the woman that it is not possible to predict whether her PMS symptoms
will respond.
• Paracetamol or a nonsteroidal anti-inflammatory drug - if the
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predominant problem is pain
Cognitive behavioural therapy (CBT; referral is likely to be required) if it
is thought the woman would benefit from psychological intervention.
Management
• Severe PMS
• Offer lifestyle advice and consider:
• The treatment options outlined above for
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moderate PMS
A selective serotonin reuptake inhibitor (SSRI)
– Unlicensed use
– Do not prescribe an SSRI  doubt about the diagnosis, < 18 yrs
without advice a specialist
– taken either continuously or just during the luteal phase (for
example days 15–28 of the menstrual cycle, depending on its
length).
– initial trial of 3 months' treatment  benefit  continue
6 months to 1 year.
– Monitor the woman's response to treatment closely, including
asking about any thoughts of self-harm.
Managment
• 12 yrs onwards
• 1st line : Lifestyle advice :
– The following things may help to ease PMS.
– Eat regular, frequent, small balanced meals rich in
complex carbohydrates.
– Take regular exercise.
– Stop smoking.
– Don't drink too much alcohol.
– Get regular sleep.
12yrs +
• Paracetamol
• NSAIDs
• Mefanemic acid 500mg tds
Combined Oral Contraception
• Age from 13 to 50 years:
• COCs monophasic:
– EE 30-35mcg with drospirenone or
norgestimate eg :
• Yasmin: drospirenone 3mg + ethinylestradiol 30mcg
• Cilest: norgestimate 250mcg + ethinylestradiol 35mcg
– EE 30mcg with gestodene or desogestrel
• Femodene: gestodene 75mcg + ethinylestradiol 30mcg
Selective Serotonin Receptor Inhibitors
• 18yrs + :
• Fluoxetine 20mg od, Sertraline 50mg od,
paroxetine 20mg od, citalopram 20mg od
• Luteal phase selective serotonin reuptake
inhibitors (SSRIs)
• Fluoxetine, citalopram: 20mg each morning on
days 15-28 of cycle
When should I refer a woman
with premenstrual syndrome?
• Refer the woman to a psychiatrist if there is
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marked underlying psychopathology in addition
to premenstrual syndrome (PMS).
Consider referral to a clinic with a specific
interest in PMS (or a general gynaecology clinic
if this is not available) if the symptoms are
severe and appropriate primary care measures
have been explored but have failed.
Evidence on treatments not
recommended in primary care
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Progesterone or progestogens used alone
Antidepressants other than SSRIs
Transdermal oestradiol
Diuretics
Vitamin B6 (pyridoxine)
Calcium and vitamin D
Magnesium
Evening primrose oil
Agnus castus (chaste tree)
Alprazolam
Gonadotrophin releasing hormone analogues eg Danazol
• Hysterectomy and bilateral salpingo-oophorectomy may be considered
under certain circumstances in secondary care for women with severe PMS.