PMS

Question 1

What is premenstrual syndrome?

Answer 1

Distressing physical, psychological and behavioural symptoms in the absence of organic or psychiatric disease, regularly occurring during the luteal phase of menstrual cycle
Significant improvement by the end of menstruation

Question 2

What percentage of women with PMS have major disrupting to their lives?

Answer 2

5%

Question 3

How many women experience PMS?

Answer 3

Estimated PMS affects 95% women to varying degrees

Those on hormonal contraception less likely to experience

Question 4

What causes PMS?

Answer 4

Suggested to be due to hormonal imbalance - exogenous progesterone causes PMS in women who previously experience PMS but previously well women demonstrate no response to exogenous progesterone
Some studies suggest cause due to abnormal CNS response to progesterone during luteal phase
allopregnanolone and pregnenolone (progesterone metabolites) are psychoactive and anxiolytic, so lower levels may be associated with anxiety
This is the Rapkin hypothesis

Question 5

What is the putative conclusion for aetiology of PMS?

Answer 5

Neurons in PMS patients preferentially metabolise progesterone to pregnenolone (heightens anxiety) rather than allopregnanolone (anxiolytic, upregulates serotonin, eases depression)

Question 6

Based on the Rapkin hypothesis, what would the recommended management be?

Answer 6

Alprazolam, augmenting GABA-a receptor function (substitute for allopregnanolone)

Question 7

What are the symptoms of PMS?

Answer 7

Mood swings, irritability, depression
Bloating and breast tenderness
Headache
Reduced visuospatial ability, increasing accidents

Question 8

How is PMS examined?

Answer 8

Psychological evaluation

No biomarkers available

Question 9

How can PMS be diagnosed?

Answer 9

Symptom diary over 2 prospective cycles (e.g. daily record of severity of problem) as recall retrospectively is unreliable

Question 10

What general measures can be used to manage PMS?

Answer 10

General (exercise, smoking cessation, diet improving, weight loss, reducing stress)
Psychiatric referral for exacerbation of psychopathology
Symptom diaries
If fail, referral to gynaecologist

Question 11

What are the first line treatments for PMS?

Answer 11

Exercise
CBT
Vitamin B6 10mg/24hr PO
COCP 
Continuous or luteal-phase SSRIs at low dose

Question 12

What are the second line treatments for PMS?

Answer 12

Estradiol patches (100mcg) + progesterone (e.g. didrogesterone 10mg PO day 17-28 or Mirena)
Higher dose SSRI continuous or luteal-phase e.g. fluoxetiene 20mg/day PO

Question 13

What are the third line treatments for PMS?

Answer 13

GnRH analogues + addback HRT (e.g. goserelin 3.6mcg SC every 28d with tibolone 2.5mg PO daily)
Use of goserelin over long periods should be limited as after 6m bone thinning may be detected (tibolone can prevent this)

Question 14

What is the fourth line treatment for PMS?

Answer 14

Total hysterectomy + bilateral salpingo-oopherectomy with HRT, including testosterone replacement

Question 15

What complimentary therapies may be considered?

Answer 15

Calcium with vit D, magnesiu and Agnus castus (not funded on NHS)
Evening primrose oil may help with mastalgia but not other PMS symptoms
B6 may help in mild PMS, but evidence base is inconclusive