JNP

224 The Journal for Nurse Practitioners - JNP Volume 6, Issue 3, March 2010

DiagnosingPremenstrual

Syndrome

Premenstrual symptoms are common among men-struating women, with approximately 75% reportingsome discomfort with their cycles. However, anestimated 10% of women experience premenstrualsyndrome (PMS), which is characterized by symp-toms severe enough to interfere with daily life.While PMS can have a devastating impact on thequality of a woman’s life and work, this complexdisorder is poorly understood and can be challeng-ing to diagnose. Nurse practitioners (NPs), regard-less of practice specialty, are more likely than not tosee patients suffering from PMS.

DEFINITIONPMS is defined by the appearance of one or moregroups of symptoms that occur with cyclical pre-dictability during the second half (luteal phase) ofmenstruation, followed by resolution within a fewdays after the onset of bleeding. A definitive diagno-sis requires the presence of symptoms during mostcycles over the past year, with enough severity todisrupt daily activities.1 Since it was first described60 years ago, PMS has often been the subject ofcontroversy regarding whether it is a physical ormental disorder. The PMS debate made headlines in1994 when premenstrual symptoms were added as a

classification in the Diagnostic and statistical manual ofmental disorders.1

The most severe form of PMS is premenstrualdysphoric disorder (PMDD). PMDD is differentiatedfrom PMS by the severity of emotional symptoms,such as marked depression and anxiety. Functionalimpairment caused by PMDD is significant.1

RISK FACTORSProper assessment of any woman with premenstrualcomplaints is critical, as PMS is often overlooked ordisregarded as “normal.” As always, a detailed familyand medical history is necessary. Ask about risk factors,such as emotional stress; poor nutritional habits; sideeffects while taking combined hormonal contracep-tives; increased alcohol, salt, and caffeine intake; tobac-co use; history of depression, pre-eclampsia, or eclamp-sia; and family history of PMS. Women over 30 are athigher risk for PMS than their younger counterparts.

SYMPTOMS When questioning the patient about symptoms, keepin mind that complaints must be distinguished fromsimple premenstrual symptoms (eg, bloating, breasttenderness) that do not interfere with daily function-ing and are characteristic of normal ovulatory cycles.

Over 150 symptoms have been associated withPMS. When taking a medical history, include ques-tions regarding the most common physical, emo-tional, and cognitive symptoms (Table 1). Pay closeattention to symptom timing. PMS symptoms canmimic other disorders and the NP must consideralternative diagnoses for each major symptom. Forexample, a recent study shows common features ofpremenstrual symptoms and fibromyalgia.2

The list of differential diagnoses for PMS is along one: migraine, chronic fatigue syndrome,lupus, irritable bowel syndrome, and thyroid dis-orders. Psychiatric diagnoses such as depression

DIAGNOSTIC TIPS

Kimberly Raines

and mood disorders should be ruled out as well.A complete physical and gynecological examshould be performed in an effort to rule outunderlying medical conditions.

DIAGNOSTIC STUDIESWhile there are no diagnostic techniques that con-firm PMS, some laboratory results can evaluate theseverity of symptoms and should include completeblood count, serum chemistry, Pap smear, thyroidstudies, and fasting blood glucose.3

The most helpful diagnostic tool for PMS is thesymptom diary. If PMS is suspected, the patientshould document symptoms, timing, and severityfor at least 2 months. Some women report thatmaintaining a symptom diary can also be helpfullater in the management of PMS.

TREATMENT OPTIONSThere is no consensus regarding PMS treatment; how-ever, all current interventions focus on management ofthe most troubling symptoms. PMS management ishighly individualized and consists of lifestyle changesor medications, or a combination of the 2 approaches.Patient preferences and treatment costs must also beconsidered. The good news is that the prognosis forthe woman with PMS can be excellent with propercounseling and an individualized treatment plan.

The first step in effective treatment is knowl-edgeable and compassionate counseling. Your patientshould first be reassured that the symptoms she isexperiencing are legitimate and have valid patho-physiological causes.

Nonpharmacologic options such as dietarymodifications, regular exercise, and stress-reductiontechniques should be attempted first. Recommend abalanced diet that includes whole grains, fresh fruits,and vegetables, while avoiding excess salt, sugar, caf-feine, and alcohol, particularly when experiencingPMS symptoms. Nutritional supplements such ascalcium, magnesium, and vitamins B6 and E havebeen helpful in alleviating symptoms.

Recommended activities for regular exerciseinclude brisk walking, swimming, cycling, orother aerobic activity for at least 30 to 60 min-utes 3 to 5 days a week. Suggest stress-reductiontechniques such as biofeedback, massage therapy,and yoga. Although the safety and efficacy of

herbal remedies have not been established, manywomen report relief with black cohash root andevening primrose oil.

The most effective pharmacological treatmentoptions are the non-steroidal anti-inflammatory drugs(NSAIDs). Oral contraceptives (OCs) are often pre-scribed to eliminate cyclic fluctuations in estrogen andprogesterone. While approximately 25% of womentaking OCs find improvement, 50% report noimprovement, and the remainder may even experienceexacerbation of symptoms. A growing body ofresearch supports the role of selective serotonin-reup-take inhibitors (SSRIs) for women experiencing moresevere emotional symptoms. Taken in lower-rangedoses 2 weeks before the period begins, at the onset ofsymptoms, or daily during menses, SSRIs can be aneffective and well-tolerated treatment for moderate-to-severe PMS and PMDD.

References

1. American Psychiatric Association. Diagnostic and statistical manualof mental disorders. 4th ed. Washington, DC: American PsychiatricAssociation; 1994:715-718.

2. Amital D, Herskovitz C, Fostick L, et al. The premenstrual syndromeand fibromyalgia—similarities and common features. Clin RevAllergy Immunol. 2009. doi: 10.1007/s12016-009-8143-0.

3. American College of Obstetricians and Gynecologists. Premenstrualsyndrome. Washington, DC: American College of Obstetricians andGynecologists. ACOG Practice Bulletin No. 15; 2000.

1555-4155/10/$ see front matter© American College of Nurse Practitionersdoi:10.1016/j.nurpra.2009.12.013

www.npjournal.org The Journal for Nurse Practitioners - JNP 225

Table 1. Common PMS Symptoms

Category SymptomPhysical Headache, backache, cramps

Abdominal bloatingWeight gainBreast swelling/tendernessAcne, hirsuitismFood cravingsDecreased/increased libidoJoint and/or muscle pain

Emotional AnxietyMood swingsDepressionIrritability

Cognitive Memory lossDifficulty concentratingConfusion

Kimberly Raines, MSN, CRNP, teaches in the AuburnUniversity School of Nursing in AL. She can be reached atrainekh@auburn.edu.