4. Premenstrual Syndrome / Pre- menstrual Dysphoric Disorder

Question 1

Define: PMS (1)

Answer 1

PMS is the regular monthly experience of physiologic, emotional, and behavioral Sx, which usually occur before the menstrual cycle and are relieved within a few days of its onset

Question 2

Name physical sx associated with PMS/PMDD (12)

Answer 2

• Swelling of ankles, hands, or feet
• Skin Ds/acne
• Insomnia
• Nausea/lack of appetite
• General malaise and clumsiness
• Fatigue, tiredness
• Breast tenderness or swelling
• Bloating/weight gain
• Abdo cramps
• ↑ Appetite
• Headaches/backaches
• Muscle spasms

Question 3

Name behavioural sx associated with PMS/PMDD (7)

Answer 3

• Slowed thinking
• Poor judgment
• Sleep disturbances
• Difficulty making decisions
• Confusion, forgetfulness
• ↑ Desire to be alone, ↓ interest in usual activities
• Poor concentration

Question 4

Name emotional sx associated with PMS/PMDD (7)

Question 5

Name emotional sx associated with PMS/PMDD (8)

Answer 5

• Low self-esteem
• Paranoia
• Moodiness, tearfulness
• Anger/rage/hostility
• Unwanted thoughts
• Sadness, depression
• Anxiety, nervousness, panic
• Irritability

Question 6

Name the most severe form of PMS (1)

Answer 6

Premenstrual dysphoric disorder (PMDS)

Question 7

Compare PMS and PMDD ()

Answer 7

• Mood symptoms predominant
• Difficulty conducting day-to-day activities
• Timing
• Incidence
• Severity of Sx

Question 8

Name causal conditions of PMS/PMDS (4)

Answer 8

• Not well understood
• Current theories:
  
  • Complex combination of environmental, metabolic, and behavioral factors produce an increased sensitivity to the hormonal changes associated with menstruation.
  • 5-HT interfaces with ovarian hormones: ↑ E → ↑ 5-HT versus ↑ progesterone → ↓ 5-HT
  • Must differentiate between normal premenstrual Sx and other causes of physical and mood changes (i.e., premenstrual exacerbation of underlying psychiatric disorder)

Question 10

Name Diagnostic Criteria of PMS (6)

Answer 10

American Congress of Obstetricians and Gynecologists (ACOG) criteria:
At least one of the following affective and somatic syndromes during the 5 d before menses in each of the three prior menstrual cycles:

• Affective → depression, anger (with possible outbursts), irritability, anxiety, confusion, social withdrawal
• Somatic → headache, tender/swollen/painful breasts, water retention/swelling of extremities, water retention/bloating of the abdomen
• Sx are relieved within 4 d of menses onset and not recur until at least day 13 of the subsequent cycle.
• Sx not due to any medications including hormones, or drugs or EtOH use
• Sx occur reproducibly during 2 cycles of prospective recording.
• Patient suffers from identifiable dysfunction in social or economic performance.

Question 11

Name Diagnostic Criteria of PMDD (4)

Answer 11

DSM-V criteria:

• A. Sx must occur during the week before menses and remit a few days after onset of menses and be absent the week after menses. Five of the following Sx must be present:
  
  • 1 of the following 4 Sx:
    
    • Markedly depressed mood, feelings of hopelessness, self-deprecating thoughts
    • Marked anxiety or tension
    • Affective lability (i.e., angry outbursts)
    • Persistent and marked anger, or irritability, or ↑ interpersonal conflicts
  • Along with any combination of the following Sx:
    
    • ↓ Interest in usual activities (social withdrawal)
    • Concentration difficulties
    • Marked lack of energy, lethargy, easily fatigued
    • Marked Δ in appetite, overeating, or food cravings
    • Hypersomnia or insomnia
    • Feeling overwhelmed or out of control
    • Other physical Sx (breast tenderness, Abdo bloating, headache, joint/muscle pain)
• B.Sx must interfere with work, school, usual activities, or relationships.
• C.Sx must not merely be an exacerbation of another disorder.
• D. Criteria A, B, and C must be confirmed by prospective daily ratings for at least two consecutive symptomatic menstrual cycles.

Question 12

Name medical DDX of PMS (10)

Answer 12

• Anemia
• AI diseases (i.e., SLE, MS)
• Endocrine disorders (i.e., hypothyroidism, diabetes)
• Seizure disorders (i.e., epilepsy)
• Migraines and other headaches
• Asthma
• Pain, IBS
• Dysmenorrhea (i.e., endometriosis)
• Chronic fatigue syndrome
• Collagen vascular disease

Question 13

Name psychiatric DDX of PMS (6)

Answer 13

• Major/minor depression (dysthymia)
• Generalized anxiety
• Panic disorder
• Bipolar illness (mood, irritability)
• Anorexia or bulimia
• Substance disorder

Question 14

Describe HX and physical exam of PMS (7)

Answer 14

• Onset, provoking/alleviating factors, severity of symptoms
• Timing of symptoms (i.e., premenstrual vs. menstrual)
• Elicit the severity of mood and physical symptoms
• Menstrual Hx: cycle length/regularity, duration, flow
• PMHx: psychiatric disorders, medical conditions
• Other: FHx, meds, substance abuse etc.
• Review of patients prospective daily ratings (at least 2 consecutive cycles)

Question 15

Describe investigations of PMS (4)

Answer 15

• CBC
• Serum TSH
• Electrolytes
• Any others indicated by Hx and physical exam

Question 16

Describe Non Pharmacological tx of PMS ()

Answer 16

1. Patient education
2. Diet: avoid; Na+, simple sugars, caffeine, alcohol
3. Supplements
   
   • CaCO3 (1,200 mg)—to ↓ bloating, depression, and aches;
   • Mg2+ supplementation (50–100 mg b.i.d.)—to ↓ pain, fluid retention, and improve mood
   • Vit E (400 IU)—may ↓ breast tenderness
4. Exercise: regular aerobic exercise
5. Psychotherapy (CBT)—may help ↓ negative emotions and ↑ problem-solving skills in relationships; use of symptom diary
6. Relaxation therapy

Question 17

Describe Pharmacological tx of PMS (4)

Answer 17

• 1. NSAIDs: (ie. naproxen) relieve cramps, headaches, muscle aches.
• SSRIs (citalopram, fluoxetine, sertraline) —start 14 d before onset of menses or taken daily
• Combined OCPs—continuous, or cyclic
• Spirinolactone (during luteal phase only) —↓ breast tenderness and fluid retention