PMS

Question 1

Psychological symptoms of PMS (9)

Answer 1

Depression, anxiety, loss of confidence, lack of control, mood swings, irritability, apathy, hopelessness, suicidal ideation

Question 2

Physical symptoms of PMS (9)

Answer 2

Breast tenderness, bloating, headache, skin disorder, weight gain, swelling, joint pain, fatigue, food cravings

Question 3

2 important factors in PMS diagnosis

Answer 3

Timing of symptoms rather than character of symptoms & severity of impact

Question 4

Classic PMS course

Answer 4

Symptoms in luteal phase, abate during mensuration then a symptom free week

Question 5

_/10 women experience PMS

Answer 5

4/10

Question 6

Behavioural symptoms of PMS (6)

Answer 6

sleep problems, change in appetite, restlessness, poor concentration, confusion, social withdrawal

Question 7

List 4 examples of variants that don’t meet PMD criteria

Answer 7

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

Question 8

What are causes of PMS? (3 theories)

Answer 8

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

Question 9

What is PMDD?

Answer 9

Premenstrual dysphoric disorder - DSM-V needs 5/11 symptoms one being mood, is more severe PMD

Question 10

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?

Answer 10

Minimum of 2 cycles and hormone profiles are not helpful

Question 11

If symptoms diary not conclusive, what can you use to help diagnosis?

Answer 11

GnRH analogues

Question 12

Management of PMS is in primary care. When should referral to a gynaecologist be considered?

Answer 12

WHen simple measures e.g. COCs, vitamin B6 or SSRIs have failed

Question 13

Who may be included in a MDT for women with severe PMS?

Answer 13

GP, gynaecologist, mental health professional (psychiatrist/psychologist) & dietician

Question 14

Hormonal management of PMD?

Answer 14

Ovulation suppression with: Combined pill, GnRH agonists, Danazol , Oestrogen
or Bilateral oophrectomy and hysterectomy

Question 15

Hormonal management of PMD is by progesterone opposition. What are the two hormonal options and how does each work?

Answer 15

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

Question 16

GnRH inhibitor/analogues are used for managing PMD. Give an example of a GnRH inhibitor, how it works and pros and cons

Answer 16

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

Question 17

Non-hormonal treatment for PMD?

Answer 17

SSRIs or spironolactone for symptoms

Question 18

Surgical management for PMD?

Answer 18

Hysterectomy or bilateral oophrectomy

+/- HRT

Question 19

What is first-line treatment for PMD?

Answer 19

exercise, CBT, vitamin B6, combined COC (Yasmin/eloine) (Cyclically or continuously), low dose SSRIs (continuous or luteal) e.g. citalopram/escitalopram 10mg

Question 20

What is second-line treatment for PMD?

Answer 20

Estradiol patches + micronised progesterone or Mirena IUS (to protect endometrium) + higher SSRIs dose e.g. 20-40mg

Question 21

Third-line treatment for PMD?

Answer 21

GnRH analogues + add back HRT (COC, patches) if under 45yrs for bone protection

Question 22

How do GnRH analogues work?

Answer 22

Suppresses pulsatile nature of GnRH so suppresses ovaries and mimics temporary menopause

Question 23

Complimentary therapies for PMD

Answer 23

Exercise, Vit B6, Calcium/Vit D - may be placebo and conflicting

Question 24

CBT should be offered routinely as treatment option for PMD. True/false?

Answer 24

True

Question 25

Second generation COC e.g. norethisterone and levonorgestrel improve PMD symptoms. True/false?

Answer 25

False. They worsen symptoms or induce them

Question 26

Why is progestogen prescribed with estradiol and why is lowest dose first line?

Answer 26

To protect endometrium from hyperplasia/cancer as oestrogen stimulates endometrial growth. Lowest dose to prevent inducing PMS symptoms (due to progesterone) e.g. micronised

Question 27

GnRH inhibitor/analogues are used for managing PMD. Give an example of a GnRH analogue, how it works and pros and cons

Answer 27

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

Question 28

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?

Answer 28

Maximum of 6 months without add back therapy. Potential side effects are vasomotor symptoms such as hot flushes and osteoporosis.