Premenstrual syndrome

INTRODUCTION

• Until relatively recently, to accept premenstrual syndrome (PMS) as a serious condition.

• Failure to distinguish PMS from the milder physiological premenstrual true symptoms, which occur in the normal menstrual cycle of the majority of women

• Premenstrual dysphoric disorder (PMDD) is the extreme, predominantly psychological end of the PMS spectrum.

• Premenstrual symptoms occur in 95% of all women of reproductive age.

• Premenstrual syndrome occurs in about

5% of those women.

Definition of PMS

condition which manifests with distressing physical, behavioral and psychological symptoms, in the absence of organic or underlying psychiatric disease, which regularly recurs during the luteal phase of each menstrual (ovarian) cycle and which disappears or significantly regresses by the end of menstruation’

AETIOLOGY

• Definitive etiological cause of PMS is not known.

• The concept of hormonal imbalance has been popular, but there is no supportive evidence.

• increased sensitivity may be due to neurotransmitter dysfunction (possibly serotonin).

• However, PMS patients are more susceptible to their normal ovarian hormone cycle

• only seen in women of reproductive age and is not present before puberty, during pregnancy or after the menopause

• Women with PMS appear to have an exaggerated form of the normal or physiological premenstrual symptoms

• Accordingly, approaches to treatment fall into two broad strategies:

correction of the neuroendocrine anomaly or suppression of ovulation

• No associations have been found between PMS and parity, employment, education or income,

• but associations between the use of an intrauterine contraceptive device, and having long menstrual cycles and a heavy menstrual flow.

• Genetic factors are also pertinent

SYMPTOMS

Psychological symptoms Irritability, depression, crying/tearfulness, anxiety, tension, mood

swings, lack of concentration, confusion, forgetfulness,

unsociable ness, restlessness, temper outbursts/anger,

sadness/blues, loneliness

Behavioral symptoms Fatigue, dizziness, sleep/insomnia, decreased efficiency, accident

prone, sexual interest changes, increased energy, tiredness

Physical symptoms: pain Headache/migraine, breast tenderness/soreness/pain/swelling (collectively known as premenstrual mastalgia), back pain, abdominal cramps, general pain

Physical symptoms: Bloatedness and swelling

Weight gain, abdominal bloating or swelling, oedema of arms and legs, water retention

Appetite symptoms Increased appetite, food cravings, nausea

Commonly reported symptoms in women with PMS

• The character of the symptoms is less important than their timing and severity.

• For the diagnosis of PMS the symptoms must: . occur in the luteal phase of the cycle; . resolve by the end of menstruation; . be severe enough to have major impact on normal functioning; . have occurred in at least four of the six previous cycles.

Assessment and diagnosis• made on history and by the patient keeping a

prospective symptom chart identify the type of symptoms

• their severity and their timing in relation to the menstrual- period-calendar of premenstrual experience (COPE)/Daily Record of Severity of Problems (DRSP)

• Quantifying the degree to which the patient’s life is affected is critical but difficult.

• cyclical symptoms are most precisely measured using visual analogue scales or menstrual distress questionnaire

• underlying psychopathology can be quantified using established psychiatric questionnaires

• no biochemical tests available to diagnose PMS,

• physical examination will make little contribution to diagnosis

• Examination, including mental state, and investigations are done to exclude psychiatric

and medical disorders such as depression

• exclusion of disorders, which may mimic somatic symptoms

.• blood tests may be useful to exclude other

disorders, e.g.; menopause, polycystic ovary syndrome, hyper- and hypothyroidism and anaemia.

How should severe PMS be treated

When treating women with PMS:● general advice about exercise, diet and stress reduction should be considered before startingTreatment

● women with marked underlying psychopathology as well as PMS should be referred to aPsychiatrist

● symptom diaries (DRSP) should be used to assess the effect of treatment

Possible treatment regimen for the management of severe PMS

• First Line Exercise, cognitive behavioral therapy, vitamin B6 Combined new generation pill, such as Yasmin®, (cyclically or continuously)

Continuous or luteal phase (day 15–28) low-dose SSRIs

• Second Line Estradiol patches (100 micrograms) + oral progestogen such as duphaston 10 mg D17-D28 or Mirena®

• Higher-dose SSRIs continuously or luteal phase

• Third Line GnRH analogues + addback HRT (continuous combined estrogen + progestogen or tibolone)

• Fourth Line Total abdominal hysterectomy and bilateral oophorectomy + HRT (including testosterone

Management

)• taking more exercise• eating a healthy balanced diet – decrease sugar, salt, caffeine and alcohol and increase fruit and vegetables. eat whole foods lean meat, fish and chicken.• Cognitive behavioral therapy (CBT). treatment involves attempting to find more adaptive ways of coping with premenstrual symptoms finding ways to reduce stress•Support groups. Focus on psychoeducation, problem-solving approaches or empathetic, listening, talking with your partner or someone else you trust (RCTs have found that exercise and lifestyle changes may improve symptoms of PMS)

Changing lifestyle( Behavioral therapies)

Clinical management

• medical treatment is mainly aimed at either suppression of ovulation or correction of the neuroendocrine anomaly.

Hormonal treatment• Progesterone and progestogens:• slightly better than placebo for managing physical

symptoms but not behavioral symptoms.• Combined oral contraceptives: - work by suppressing ovulation, thereby preventing the

occurrence of PMS -New oral contraceptive formulation consisting of

ethinyloestradiol and drospirenone has been found to effect a significant reduction in PMS symptoms.

• Oestrogen. Oestradiol suggest that oestrogenic ovarian suppression may eliminate PMS

progestogen given locally in the form of a levonorgestral intrauterine system

• Danazol. - an effective treatment for PMS by suppressing ovulation.

-Luteal phase danazol seems to be effective for premenstrual breast pain without significant short term adverse effects

. - possible significant risks associated with long term use, such as

cardiovascular risks .

- Common side effects include nausea, dizziness, skin changes and masculinizing changes such as hirsutism, weight gain and, rarely,

clitoral hypertrophy.

(Several RCTs have shown danazol is effective for ovulation suppression)

• Tibolone - a synthetic steroid; - real value as add-back therapy during treatment with GnRH

analogues

• GnRH analogues. - effectively suppress ovulation. - continued administration is followed by down-regulation of GnRH

receptors

-induces a menopausal state and is thus effective in treating all symptoms of PMS

- side effects experienced include menopausal symptoms and - for restricting this treatment to 6 months is to avoid reduction in

trabecular bone density

-offers effective short term therapy in particular circumstances, such as women who are soon to reach their menopause and women in whom oestrogens are contraindicated

Non-hormonal treatment• Selective serotonin re-uptake inhibitors (SSRIs). -both the physical and psychological, respond fairly quickly

RCTs show; -administration during the luteal phase can be effective as continuous

dosing.

-Lower doses of the drug appear to be as effective as higher doses but with fewer and less severe adverse effects.

-Common adverse effects include gastrointestinal upset , anorexia and

weight loss, nervousness, insomnia and sexual dysfunction. - no associated dependence.

Systematic Review says:SSRIs are an effective first-line therapy for severe PMS. The safety of these drugs has

been demonstrated in trials of affective disorder, and the side-effects at low doses are generally acceptable.

• Diuretics. - majority of women experience bloating and a

feeling of weight increase

- no objectively demonstrable premenstrual weight increase or sodium and water retention

- for the small group of women who experience true premenstrual water retention

- small dose of 25–50 mg/d of spironolactone has beneficial effects on breast tenderness and bloating.

• Prostaglandin inhibitors.

Mefenamic acid and naproxen

found to be effective in improving physical and mood symptoms

• . Anxiolytics and other antidepressants.

Women tend to stop because of adverse effects such as drowsiness, anxiety and nausea.

• Before surgery -GnRH depot for 3 months to distinguish

to what degree the ovarian cycle contributes to symptoms.

• Hysterectomy -associated with reduction in symptoms.

• Oophorectomy induces an irreversible menopause and a complete cure

.• indicated if there are coexisting gynaecological

problems of sufficient severity to justify pelvic surgery.

Surgical management

Dietary supplements• Calcium-symptoms. More recent studies have

shownthat the use of calcium (1000–1200 mg/d) reduces premenstrual symptoms,

Calcium is relatively inexpensive, making it an attractive treatment option.

• Magnesium. supplemented during the second half of the cycle reduces total PMS symptoms

specifically symptoms related to mood changes

• Vitamin B6 (pyridoxine). a cofactor in neurotransmitter synthesis, particularly of serotonin

Small doses, possibly 50 mg/d relieve premenstrual symptoms including depression

• Vitamin E. Some reports have claimed that women who take vitamin E regularly experience significant improvements in some affective and physical symptoms

• Long chain fatty acids. PMS symptoms. Evening primrose oil has a high content of γ-linoleic acid

currently the most popular ‘self-help’ remedy for PMS

the treatment of premenstrual mastalgia

The diagnosis of PMS still arouses a certain degree of scientific dilemma because of the inability to demonstrate specific biochemical physical abnormalities .

Clinicians often fail to realize the extent to which a women’s life can be affected by this condition.

• Q, How you are going to diagnose PMS?

Evaluate the management options available for PMS.