Menstrual Disorders: PMS

Question 1

Premenstrual Disorders Background (what phase, occur when, sx)

Answer 1

• Cyclic physical, mood, and behavioral symptoms during luteal phase
• Occur any time after menarche
• Only occur during ovulatory cycles; disappear during pregnancy, breastfeeding, menopause
• Sx begin or peak near menses onset and resolve within several days
• Sx are consistent from month to month
• No sx during days 5-10 of menstrual cycle
• Sx may overlap with sx of dysmenorrhea

Question 2

Pathophysiology

Answer 2

• Cyclical fluctuations in estrogen and progesterone d/t normal
ovarian function
• Familial disposition + genetic differences in serotonin and estrogen receptor genes
• Serotonin, GABA, and vitamin deficiencies
• Hormonal oral contraceptives or post

Question 3

Differentiating between Disorders

Answer 3

Typical premenstrual symptoms
- Sx do not interfere with normal life functions

Premenstrual syndrome (PMS)
- ≥1 sx during 5 days before menses + negative effect on daily functioning and distress

Premenstrual dysphoric disorder (PMDD)
- Severe form of PMS with ≥ 5 sx that interferes w/ relationships and/or work

Question 4

PMS Clinical Presentation

Answer 4

Common negative symptoms
• Fatigue, lack of energy
• Irritability, anger
• Labile mood
• Depression, decreased interest 
• Anxiety, feeling stressed
• Crying spells, oversensitivity
• Difficulty concentrating
• Abdominal bloating, pedal edema
• Breast tenderness
• Appetite changes  
• Headache
• Hypersomnia/insomnia
• Joint/muscle pain
• Feeling out of control/overwhelmed 

Common positive symptoms
• Increased energy, more efficient at work
• Increased libido, more affectionate
• Increased sense of control
• Greater self assurance

Question 5

PMDD Clinical Presentation

Answer 5

• Similar to PMS but greater severity
• Impairs relationships or ability to function well at work/school greater than PMS

• Most common sx are mood-based; diagnosis requires:

• Marked anger or irritability or depressed mood, anxiety or emotional lability
• Difficulty concentrating, lethargy, hypersomnia/insomnia, breast tenderness, bloating

• Refer to PCP to ensure proper diagnosis and management

Question 6

PMS Treatment Nonpharmacologic

Answer 6

• Aerobic exercise
• Balanced diet and dietary modifications
- Avoid salty foods and simple sugars
- Avoid caffeine and alcohol
- Complex carbs may reduce sx and satisfy cravings
• Cognitive behavioral therapy
• Some benefit with light therapy, acupuncture, and massage

Question 7

PMS Pharmacologic Therapy Overview

Answer 7

1. Calcium and vitamin D
2. Pyridoxine
3. Magnesium
4. Vitamin E
5. Diuretics
6. Combination products
7. Complementary therapies

Question 8

Calcium and Vitamin D (dosing, daily diet first, AE, initial tx)

Answer 8

• Inverse relationship between both milk and vitamin D intake and PMS
• High dietary intake of both Ca and vitamin D may prevent PMS sx
• Efficacy of 600 mg BID
• Adverse effects: constipation, nausea
• Meet daily recommendations in diet first (1000-1300 mg); supplement PRN
• Good initial treatment: 500-600 mg calcium BID + 600 IU of vitamin D daily

Question 9

Other Supplements

Answer 9

• Pyridoxine (vitamin B6) 100 mg daily, max 100 mg

• Magnesium 360 mg daily during luteal phase (Mg oxide not helpful)
- AE: diarrhea

• Vitamin E 100 mg daily (use for 3 cycles)

Question 10

NSAIDs

Answer 10

• Reduce physical sx only (headache, MSK pains)

* Take several days before onset of and during 1st several days of menses

Question 11

Diuretics (3 products: dosing, contra)

Answer 11

• For abdominal bloating due to fluid shift/redistribution
• 3 products: caffeine, pamabrom, ammonium chloride
• Caffeine, 100-200 mg q3-4h
• Pamabrom, up to 50 mg 4x daily
• Ammonium chloride, 3 g daily divided into 3 doses (max 6 days)
• C/P: Avoid with MAOIs or theophylline
• AmCl: Avoid in renal/liver issues

Question 12

Special Considerations

Answer 12

• Initially try to manage with lifestyle changes and calcium
• Adolescents should avoid combo products with aspirin
• Lactating patients
- Avoid all herbal products
- Vitamins/minerals ok and Mg unlikely to cause infant diarrhea
- Avoid diuretics
• Patients using PPIs or HRAs should use calcium citrate

Question 13

Complementary Therapies

Answer 13

• Chasteberry (avoid in pregnant, lactating, if taking hormones or have hormone-sensitive cancers)
• St. John’s wort (reduce HC)
• Ginkgo (antiplatelet effects)
• Saffron