PMS Flashcards
What is premenstrual syndrome (PMS)?
A cyclic recurrence of physical and/or behavioural symptoms that occurs during the luteal phase of the menstrual cycle (after ovulation and before the onset of menses) (affects 90% of people who menstruate at some point)
What is premenstrual dysphoric disorder (PMDD)
More severe, disruptive of daily life, ++ mood
What is premenstrual exacerbation?
Worsening of other disorders during the premenstrual phase
What are some potential cognitive symptoms of PMS? (5)
- Aggression
- Depression
- Fatigue
- Irritability
- Sudden mood changes
What are some potential physical symptoms of PMS? (5)
- Acne
- Breast pain or swelling
- Hot flashes
- Muscle aches
- Pelvic heaviness or pressure
Read this card for examples of PMS patterns
- Symptoms at ovulation and gradually worsen
- Symptoms begin during 2nd week of luteal phase (right before menses)
- Brief episode of symptoms at ovulation, some symptom-free days, then recurrence in late luteal phase
- Symptoms at ovulation, worsen during luteal phase, stop only once menses over
What are 3 theories for PMS causes?
- Hormonal fluctuations
- Dysregulation of neurotransmitter systems
- Nutritional (calcium) deficiencies
What are 3 risk factors for PMS?
- High BMI –> BMI >= 30 had 3x risk for PMS than <30
- History of domestic violence, physical or emotional trauma, and substance use
- Twice as prevalent in identical twins than with fraternal twins (genetic component)?
How can symptoms be used to diagnose PMS? (4) (i.e., timing mostly)
- Present during luteal phase
- Reach peak shortly before the beginning of menstruation and subside at the onset of menses
- Severe enough to interfere with daily functioning and interpersonal relationships
- Absent during follicular phase
PMS is defined as _ or more symptoms that ______ in severity throughout the cycle - must be ______ - for at least _ cycles
5, change, cyclic, 2
PMDD is defined as __ symptoms with at least _ severe ____ symptom for at least _ cycles - resulting in __________ ___________
5+, 1, mood, 2, functional impairment
What should be ruled out when diagnosing PMS? (10)
- Anemia
- Diabetes
- Thyroid disorder
- Chronic fatigue syndrome
- Endometriosis
- Polycystic ovaries
- Adverse effects from OCPs
- Perimenopause
- Fibrocystic breast changes
- Various psychiatric disorders
How does timing differ between PMS and dysmenorrhea?
PMS:
- Luteal phase of cycle (generally)
Dysmenorrhea:
- During or shortly before menses
How does cause differ between PMS (3) and dysmenorrhea (1)?
PMS:
- Hormonal fluctuations?
- Neurotransmitters?
- Nutritional deficiencies?
Dysmenorrhea:
- Prostaglandins
How do symptoms differ between PMS (3) and dysmenorrhea (1)?
PMS:
- Physical
- Psychological
- Behavioural
Dysmenorrhea:
- Physical only (pain, cramping)
How does treatment differ between PMS and dysmenorrhea?
PMS:
- Varied options focusing on specific symptoms; varied effectiveness
Dysmenorrhea:
- NSAIDs and OCPs very effective
What are the goals of therapy for PMS treatment? (2)
- Relieve symptoms
- Minimize functional impairment
What are some lifestyle modifications that can be tried for PMS? (8)
- Reflexology
- Massage
- Acupuncture
- Light therapy
- Aromatherapy
- CBT
- Appropriate sleep hygiene
- Moderate exercise can help breast tenderness, fluid retention, stress, and depression
What are 3 dietary modifications that can be tried for PMS? (3)
- Decrease methylxanthine-containing foods and caffeine may improve breast symptoms
- Tea, coffee, chocolate - Increase complex carb intake may lessen appetite changes and cognitive symptoms
- Beans, peas, whole grains, vegetables - Decreased salt intake can help fluid retention, weight gain, bloating, breast swelling, and tenderness (not studied, just recommended)
List the pharmacologic therapy options for PMS (7)
1-3 are effective for some symptoms
1. Calcium carbonate
2. SSRIs
3. NSAIDs
4-7 has inconclusive evidence (for PMS)
4. Pyridoxine (B6)
5. Oral contraceptives
6. Miscellaneous
7. Natural Health Products
Which PMS symptoms can Ca carbonate help with? (4)
- Negative affect
- Fluid retention
- Food cravings
- Pain
What is the dosing of Ca carbonate for PMS?
1200mg (elemental) daily
(Remember to separate from other meds, Vit D to aid in absorption, <= 500 mg elemental per dose)
Plan for a 3-month trial
What ADE to be aware of with Ca carbonate?
Constipation
Which PMS symtpoms are SSRIs potentially useful for?
Cognitive > physical symptoms
(PMDD > PMS)
What to note about effectiveness of SSRIs in PMS? (3)
- Effective at low or high doses
- Effectiveness does not equate diagnosis of depression
- Effect in 1st cycle
What are the 3 regimens for SSRIs in PMS?
- Continuous use
- Limited to luteal phase
- At symptom onset
* all regimens effective
What is an adequate trial for SSRIs in PMS?
2 cycles; increase dose if partial response; switch SSRI if no response
NSAIDs are effective for which PMS symptoms? (3)
- Headache
- Breast pain
- Muscle aches
How to use/dose NSAIDs for PMS? (3)
- Start at onset of pain
- Use short-term
- Lowest effective dose (same dosage range as analgesia)
(Stop if pregnancy is suspected)
What symptoms of PMS might pyridoxine (B6) help with?
Excitatory symptoms (anxiety, irritability, panic attacks)
What is the theoretical MOA of pyridoxine (B6) in PMS?
Decreased B6 leads to increased prolactin which leads to edema and psychological symptoms. So add B6 to prevent that
Despite mixed evidence, oral contraceptives are the most widely prescribed for PMS. Why? (2)
- Inhibit ovulation, but PMS symptoms not connected to ovulation like dysmenorrhea is
- May help physical and cognitive symptoms - monophasic preferred
Yay or nay for PMS:
Continuous use oral contraceptives
Progestin-only
- Not well studied for PMS
- No
Oral contraceptives are an option for those who suffer from ______ ____ AND want _____________
severe PMDD; contraception
(Has not shown efficacy in women with less severe PMS)
What are the miscellaneous drugs that might be used in PMS? (5)
- Pamabrom or caffeine or pyrilamine (benefit mild at best)
- Non-SSRI antidepressants
- BZDs - PRN only
- Spironolactone - fluid retention only; watch K+
- GnRH analogues or danazol - severe, unresponsive cases of PMDD only
What are some potential NHPs that might be used in PMS? (6)
- Chasteberry - potentially similar to fluoxetine but varied doses makes a recommendation difficult
- Magnesium - maybe for fluid retention; causes diarrhea
- Evening Primrose Oil - cyclical mastalgia only; no better than placebo
- St. John’s Wort - considered insufficient evidence for PMS
- Vitamin E
- Ginkgo
Using calcium carbonate for PMS - what to expect?
No effect in 1st cycle; relief by 3rd cycle
On all PMS drugs, how do we/the patient monitor?
Charting
(OCP is charting and VTE symptoms)
Using SSRI for PMS - what to expect?
Relief in 1st cycle of cognitive symptoms
Using NSAID for PMS - what to expect?
Immediate relief of muscle aches or headaches
Using OCP for PMS - what to expect?
Maybe for physical symptoms - if desire contraception
