PMS Flashcards
Psychological symptoms of PMS (9)
Depression, anxiety, loss of confidence, lack of control, mood swings, irritability, apathy, hopelessness, suicidal ideation
Physical symptoms of PMS (9)
Breast tenderness, bloating, headache, skin disorder, weight gain, swelling, joint pain, fatigue, food cravings
2 important factors in PMS diagnosis
Timing of symptoms rather than character of symptoms & severity of impact
Classic PMS course
Symptoms in luteal phase, abate during mensuration then a symptom free week
_/10 women experience PMS
4/10
Behavioural symptoms of PMS (6)
sleep problems, change in appetite, restlessness, poor concentration, confusion, social withdrawal
List 4 examples of variants that don’t meet PMD criteria
Premenstrual exacerbation of an underlying disorder (e.g. asthma, diabetes, depression, migraine),
non-ovulatory PMDs,
Progestogen-induced PMDs (HRT or COC, exogenous so side effect),
PMDs with absent menstruation e.g. hysterectomy, endometrial ablation or IUDs
What are causes of PMS? (3 theories)
Sensitivity to progesterone hormone, serotonin receptors are responsive to oestrogen and progesterone and so SSRIs, GABA levels modulated by metabolite of progesterone, allopregnanolone, and levels of allopregnanolone are reduced in women with PMS
What is PMDD?
Premenstrual dysphoric disorder - DSM-V needs 5/11 symptoms one being mood, is more severe PMD
A symptom diary is useful when diagnosing PMD. What is the minimum number of symptomatic cycles for a diagnosis of PMD to be made? Is a hormone profile helpful for diagnosis?
Minimum of 2 cycles and hormone profiles are not helpful
If symptoms diary not conclusive, what can you use to help diagnosis?
GnRH analogues
Management of PMS is in primary care. When should referral to a gynaecologist be considered?
WHen simple measures e.g. COCs, vitamin B6 or SSRIs have failed
Who may be included in a MDT for women with severe PMS?
GP, gynaecologist, mental health professional (psychiatrist/psychologist) & dietician
Hormonal management of PMD?
Ovulation suppression with: Combined pill, GnRH agonists, Danazol , Oestrogen
or Bilateral oophrectomy and hysterectomy
Hormonal management of PMD is by progesterone opposition. What are the two hormonal options and how does each work?
COC: must be drospirenone-containing so new generation, (e.g. Yasmin), also have antimineralocorticoid and anti-androgenic properties. OR Estradiol as patch with cyclical progestogen & alternative contraceptive barrier e.g. IUD
GnRH inhibitor/analogues are used for managing PMD. Give an example of a GnRH inhibitor, how it works and pros and cons
Danazol - androgenic steroid and suppresses the pituitary-ovarian axis. Good for breast symptoms but bad side effects or GnRH analogue. Need contraception during treatment as potential virilising effect on female fetuses
Non-hormonal treatment for PMD?
SSRIs or spironolactone for symptoms
Surgical management for PMD?
Hysterectomy or bilateral oophrectomy
+/- HRT
What is first-line treatment for PMD?
exercise, CBT, vitamin B6, combined COC (Yasmin/eloine) (Cyclically or continuously), low dose SSRIs (continuous or luteal) e.g. citalopram/escitalopram 10mg
What is second-line treatment for PMD?
Estradiol patches + micronised progesterone or Mirena IUS (to protect endometrium) + higher SSRIs dose e.g. 20-40mg
Third-line treatment for PMD?
GnRH analogues + add back HRT (COC, patches) if under 45yrs for bone protection
How do GnRH analogues work?
Suppresses pulsatile nature of GnRH so suppresses ovaries and mimics temporary menopause
Complimentary therapies for PMD
Exercise, Vit B6, Calcium/Vit D - may be placebo and conflicting
CBT should be offered routinely as treatment option for PMD. True/false?
True
Second generation COC e.g. norethisterone and levonorgestrel improve PMD symptoms. True/false?
False. They worsen symptoms or induce them
Why is progestogen prescribed with estradiol and why is lowest dose first line?
To protect endometrium from hyperplasia/cancer as oestrogen stimulates endometrial growth. Lowest dose to prevent inducing PMS symptoms (due to progesterone) e.g. micronised
GnRH inhibitor/analogues are used for managing PMD. Give an example of a GnRH analogue, how it works and pros and cons
Zoladex/decapeptyl - highly effective, reserved for severe symptoms and help aid in diagnosis. Cons: effect on bone mass density/osteoporosis so can’t be used for >6months w/o add back HRT or tibolone. If long term need DEXA scan every year
GnRH agonists are useful for making a diagnosis and for short term treatment for women approaching menopause. They can only be used for a maximum of how many months without add back therapy? What are potential side effects?
Maximum of 6 months without add back therapy. Potential side effects are vasomotor symptoms such as hot flushes and osteoporosis.
