PMS and PMDD

Charlene Baldwin

University Of Phoenix

NRP/560

Objectives

Define PMS and PMDD Relevance to woman's health Analyze research Discuss Treatment options Discuss diagnostic studies Discuss controversies with subject Define relevance of PMS/PMDD in

practice

Objectives

Discuss patient education materials and resources

Identify two relevant research questions raised as a result to of research

Define relevance of this topic for clinical practice

Definition of PMS

Pre-menstrual Syndrome refers to a group of physical, cognitive, and behavioral symptoms that occur during the luteal phase of the mentsraual cycle and resolve quickly at, or within, a few days of onset of menastration. Symptoms can be severe enough to cause interference with daily activities.

Premenstrual Dysphoric Disorder Definition

PMDD is the most severe form of PMS that results in significant impairment of daily living for women.

PMS and PMDD are used interchangeable in normal practice, although PMDD can be more debilitating.

Differential Diagnosis

Thyroid, adrenal and endocrine disorders

Depression, Personality disorder

Migraine,seizure disorder

IBS,anorexia,bulimia,endocrine tumors

Chronic fatigue syndrome

Psychiatric or pyschological disorders

Family or social problems

Sexual dysfunction, rape, molestation

Signs and Symptoms of PMS

Irritability

Fatigue

Depression

Abdominal bloating

Headache

Breast tenderness

Confusion

Internal tension

Anger

Body aches

Change of appetite

Difficulty concentrating

Sadness,hopelessness

Feeling of worthlessness

Anxiety or on edge

Variable moods and frequent tearfulness

Persistant iritibility, anger,conflicts with family or friends

Decreased interest in usual activities

Difficulty in concentrating

Binge eating or cravings

Feelings of being overwhelmed and out of control

Weight gain

Headaches

Skin changes, acne

Hypersomnia and insomnia

Lethargy ,fatigue, lack of energy

Signs and Symptoms of PMDD according to DSM-IV

Diagnostic and Statistical Manuel Disorders Criteria

PMS criteria needs one symptom

PMDD needs 5 of 11 symtoms to meet DMS IV criteria

PMS Tracker chart

PMS symptom tracker Mark the days when you have your period with an X, and give symptoms a ranking of 1-3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31Period__________________________________________________________________________________________________________Acne___________________________________________________________________________________________________________Breast symptoms_________________________________________________________________________________________________Tiredness or trouble_______________________________________________________________________________________________Cramps or upset__________________________________________________________________________________________________Bloating_________________________________________________________________________________________________________Constipation or diarrhea____________________________________________________________________________________________Food cravings____________________________________________________________________________________________________Headaches______________________________________________________________________________________________________Backaches______________________________________________________________________________________________________Joint or muscle pain_______________________________________________________________________________________________Mood changes___________________________________________________________________________________________________Anxiety_________________________________________________________________________________________________________Depression______________________________________________________________________________________________________Anger or irritability_________________________________________________________________________________________________Other symptoms__________________________________________________________________________________________________

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PMS QUIZ

Rate 0-4

0=no occurance

1=mild, Present but not a problem

2=moderate, tolerable

3=severe, really affects daily life

4=very severe, affects function of life

PMS QUIZ

Angry outbursts/Agression/interpersonal conflicts

Anxiety/Tension/ “On edge”

Avoidance of or withdrawal from social interactions

Decreased or no interest in usual activities

Feeling out of control or overwhelmed

PMS QUIZ

Irritability/ short tempered

Mood swings/ Moodiness

Sad/ Depressed/ Blue

Non Pharmacological Treatments

Exercise 20-30 min per day

Adequate sleep

Relaxation and stress reduction

Dietary changes: foods rich in complex carbohydrates

Avoid caffeine, alcohol and refined sugars

Evening Primrose Oil

Accupuncture

Emotional support, education,reassurance

Consider referral for counseling

Discuss disorder with family as needed

Pathophysiology of PMS/PMDD

Genetic vulnerability

Sensitiveity to hormonal fluctuations

Possibility of the rate of fluctuations of gonadal hormones

Changes in the function of the brain with lower serotonin levels

May have a genetic basis

Occurs during the luteal phase of cycle

Pharmacology for PMDD

NSAIDs Aleve,motrin,Naprosyn, and Advil

Yaz oral contraceptive is FDA approved for PMDD

SSRI's for deppression, initial drug of choice

Effective doses may be less than used for

treatment of depression

Started in the luteal phase 7-14 days prior to onset of menses

Prozac 20mg QD, Zoloft 50mg. QD,paxil 12.5mg.-25mg. QD

Pharmocological treatments for PMS

Calcium carbonate 1200mg. Daily

Magnesium 200-400mg. Daily

Vitamin E 400 IU daily

Vitamin B6 50mg. Daily

NSAIDS: Aleve, Motrin, and Advil

Relavance to woman's health

Support

Perscriptions

Referrals

Validation

Treatment

Diagnostic testing

No objective diagnostic testing for PMS/PMDD, only reported S/S

Important to rule out: Hyperthyroidism,hypothyroidism, adrenal problems,pregnancy and menopause

Baseline CBC, UA and PAP smear to rule out other illnesses

Relevance to NP Practice

Patients seek treatment, advise and support from their primary care provider

High volume of women go to NP for a variety of c/o surrounding PMS/PMDD

Education is the most important and valued thing that a primary NP can do with their patients

Ruling out other illnesses is another important role of the NP

The Nurse Practitioner's role is to first confirm a pattern of symptoms and R/O other illnesses

PMS/PMDD Symptoms must be present for 5 days prior to menses for 3 consecutive cycles

Symptoms must end within 4 days after menses started

Interferes with normal daily functions (work, school, social activities and etc.)

Provide psychological and emotional support

Recommend treatments and educate patient on treatments and pathophysiology

NP Role

Resources

PMS/PMDD handouts

Internet web sites referrals

Help lines

PMS take home quiz

Support groups

Counseling referral

Patient Resources

Go Ask Alice: 1-212-854-5453

www.goaskalice.columbia.eduTeens health: 1-904-232-4100

Common problemswww.teenhealth.org/teen/sexualhealth/girls/menstrual_problemshtml

PMSbuddy.com free online PMS reminder

PMS Comfort Education,Empowerment Natural relief

1-773-599-9767

Research

PMS occurs 20's to 40's, peaks 20-30yrs.old

Research sates 40% enriched calcium diet assist in PMS although there is no evidence how it works.Supplements proved not to be as effective

PMS/PMDD has no known causes except for the fluctuation of hormone activity and intolerance. Along with the diminished amount of seratonin neurotransmitters.

Research

Women with fewer pregnancies have a higher incidence of PMDD

Black woman report more food cravings tha white women

White women c/o more weight gain and mood chages than black woman

Vitamin and mineral deficiencies theory has been inconclusive

Research

Thys-Jacobs Research study showed elemental calcium 1,200mg alleviates tension, anxiety, fluid retension,pain,and food cravings

Benefit is that it is safe, good for bones, good for pregnancy

Magnesium help with mood and pain

Vitamin B6 cofactor of neurotransmitters, relieving mood swings

Research

Not all women respond to SSRI treatment, trying different ones may be necessary

Research states that 85% of women have some type of PMS symptoms, 5-10% with with serious difficulties with PMS

Most women report that PMS/PMDD increases after giving birth and advanced age

Research questions

What is the real cause of PMS/PMDD?

Debate on PMDD is a woman's health issue or a psychiatric illness?

Controversies

Yaz is recommeded by the FDA for PMDD

treatment, is it safe or too high a risk for blood clots?

Summary

Defined PMS and PMDD

Discussed treatment, non pharmacological and pharmacological

Research findings

Diognostic tests

Patient education/resources

Importance/relevance of NP practice reguarding PMS/PMDD

References

Cleveland Clinic Journal of Medicine April 2004 vol. 71 4 303-305. doi: 10.3949/ccjm.71.4.303. Electronically retrieved on April 8, 2012.

Dickey, Richard P., MD, PhD. (2010) Managing Contraceptive Pill/ Drug Patients. Fort Collins, CO. Emis Medical Publishers.

European Medicines Agency. (2010) Guideline on the treatment of Premenstrual Dysphoric Disorder (PMDD).

http://www.ema.europa.eu/docs/en_GB/document_library/Scientific_guideline/2010/05/WC500090882.pdf

Electronically retrieved on April 9, 2012.

Youngkin, Ellis Quinn, PhD, RNC, ARNP, Davis, Marcia Szmania, MS, MSED, RNC, WHCNP, ANP (2004) Women's Health A Primary Care Clinical Guide. Upper Saddle River, New Jersey. Pearson/ Prentice Hall

American College of Obstretricians and Gynecologists. FAQ - Premenstrual Syndrome. http://www.acog.org/~/media/For%20Patients/faq057.pdf?dmc=1&ts=20120411T2349405782

Electronically retrieved on April 10, 2012.