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
Commonly reported symptoms in women with PMS
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

 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 patients 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 starting
Treatment
women with marked underlying psychopathology as
well as PMS should be referred to a
Psychiatrist
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 1528)
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
Changing lifestyle( Behavioral therapies)
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, problemsolving 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)

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 2550 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.

Surgical management
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.

Dietary supplements
Calcium-symptoms. More recent studies have
shownthat the use of calcium (10001200 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 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 womens life can be affected by
this condition.

 Q, How you are going to diagnose PMS?

Evaluate the management options
available for PMS.