PMS Flashcards
What are the psychological symptoms of PMS?
- depression
- anxiety
- irritability
- loss of confidence
- mood swings
What are the physical symptoms of PMS?
Bloating, mastalgia, headache, generalised aches, fluid retention
What is the timing of symptoms due to PMS?
Must be present in the luteal phase
And abate as menstruation begins
Which is then followed by a symptom-free week
How many women (of reproductive age) experience PMS?
40%
How many women (of reproductive age) experience severe PMS?
5-8%
What are the two aetiological theories of PMS?
- Some women are sensitive to progesterone and progestogens
- Neurotransmitter involvement
- Serotonin: serotonin receptors are responsive to E+P, and SSRIs are effective in treating PMS
- GABA: GABA levels are modulated by the metabolite of progesterone, allopregnanolone, and in women with PMS, the allopregnanolone levels appear to be reduced
How is PMS diagnosed?
Prospectively over at least two consecutive cycles using a symptom diary
- Daily Record of Severity of Problems is the most widely used
OR GnRH analogue suppression test over 3 months for definitive diagnosis if diary unclear.
What are first line complementary management options for PMS?
Exercise
CBT
Vit B6 (risk peripheral neuropathy with high doses)
vitex- unclear safety profile, evidence that it works but preparation variable therefore can’t be recommended
What are first line pharmaceutical options for the management of PMS?
COCP - cyclically or continuously, ideally containing Drospirenone
- emerging data suggest continuous rather than cyclical use
SSRIs - continuous or luteal phase
- low dose e.g. Citalopram 10mg
What are the virilising effects of Danazol on female foetuses?
Cliteromegaly
Labial fusion
Urogenital sinus abnormalities
What are the second line management options for PMS?
Estradiol patches (100mcg) \+ micronised progesterone (100mg or 200mg Day 17-28) OR LNG-IUS
SSRIs higher dose e.g. citalopram 20-40mg
Side-effects of SSRIs: nausea, insomnia, somnolence, fatigue, low libido.
Utrogestan preferred as least likely to cause PMS symptoms.
Needs alternative contraception.
What is the third line management option for PMS?
GnRH analogues + add-back HRT (continuous-combined E + P OR tibolone).
Indication: severe PMS.
Side-effects: reduces BMD.
Advice: regular and weightbearing exercise, diet, avoid smoking, reduce alcohol intake.
If long term treatment: needs DEXA scan every year.
What is the fourth line management option for PMS?
BSO +/- Hysterectomy
Needs pre-op GnRH analogue suppression test for 3 months to ensure withdrawal of oestrogen and progesterone improves sx
Will need add-back HRT particularly If <45 years old
BSO alone not recommended as need to use progestogen for endometrial protection which may provoke PMS symptoms.
If hysterectomy performed can give oestrogen-only HRT.
Consider post-op testosterone replacement as risk of low libido.
What are the differential diagnoses of core PMS (PMS and PMDD)?
Premenstrual disorder with absent menstruation (Treat as core PMS)
Physiological premenstrual disorder - no influence on quality of life
Premenstrual exacerbation - of an underlying medical condition
Progestogen induced premenstrual disorder - on progesterone treatment
What is the criteria for premenstrual dysphoric disorder?
Content: 5 out of 11 symptoms, 1 must be mood-related and 1 must be somatic/functional.
Cyclicity: onset in the week preceding menses, and resolution with onset of menses with symptom free week after
Severity: affects ability to function and affect work/relationships/ADLs
Chronicity: majority of cycles within last 12 months
What are the mood-related symptoms included in the PMDD criteria?
- Marked affective lability
- Marked irritability or anger or increased interpersonal conflicts
- Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts
- Marked anxiety, tension, and/or feelings of being keyed up or on edge
What are the somatic/functional symptoms included in the PMDD criteria?
- Decreased interest in usual activities
- Subjective difficulty in concentration
- Lethargy, easy fatigability, or marked lack of energy
- Marked change in appetite; overeating or specific food cravings
- Hypersomnia or insomnia
- A sense of being overwhelmed or out of control
- Physical symptoms such as breast tenderness or swelling; joint or muscle pain, a sensation of “bloating” or weight gain
Why are second generation COCPs not recommended as treatment for PMS?
LNG and NET progestogens may regenerate PMS-type symptoms
How does SSRIs improve PMS
Normalises altered premenstrual serotonin.
Alters metabolism of progesterone.
Definition: ‘Premenstrual exacerbation of an underlying disorder’
such as diabetes, depression, epilepsy, asthma
and migraine. These patients will experience symptoms relevant to their disorder throughout the menstrual
cycle.
Definition: ‘Non-ovulatory PMDs’
occur in the presence of ovarian activity without ovulation. This is poorly understood
due to a lack of evidence, but it is thought that follicular activity of the ovary can instigate symptoms.
Definition: ‘Progestogen-induced PMDs’
are caused by exogenous progestogens present in hormone replacement therapy (HRT) and the combined oral contraceptive (COC) pill.
This reintroduces symptoms to women who
may be particularly sensitive to progestogens. Although progestogen-only contraceptives may introduce symptoms, as they are noncyclical they are not included within variant PMDs and are considered adverse effects (probably with similar mechanisms) of continuous progestogen therapy.
Definition: ‘PMDs with absent menstruation’
include women who still have a functioning ovarian cycle, but for reasons such as hysterectomy, endometrial ablation or the levonorgestrel-releasing intrauterine system (LNG-IUS) they do not menstruate.
Definition: premenstrual dysphoric disorder (PMDD)
five out of 11 stipulated symptoms, one of which must include mood. The symptoms must strictly occur in
the luteal phase and must be severe enough to disrupt daily functioning
What screening tool is used to identify PMS?
Daily Record of Severity of Problems (DRSP)
