PMS Flashcards
Evidence re PMS and vitamin B6?
Sudies for vitamin B6 efficacy in PMS are contradictory.
Advise dose restriction to 10mg
Risk of high dose of vitamin B6?
Peripheral neuropathy
restrict dose to 10mg OD
What is Core premenstrual disorder (PMD)
(premenstrual syndrome, PMS
or premenstrual dysphoric
disorder)
Core PMD also known as premenstrual syndrome, PMS
or premenstrual dysphoric disorder)
Cyclical pre-menstrual symptoms present during the luteal phase
Abate as menstruation begins
Followed by a symptom-free week
Affects quality of life
what is Premenstrual exacerbation?
The pre-menstrual exacerbation of an underlying disorder.
Symptoms cyclical and relieved by menstruation
But NO symptom-free week
Affects quality of life
Regular menstruation
Existing non-menstrual condition
what is Non-ovulatory PMD?
PMS symptoms occur in presence of ovarian activity without ovulation.
Mechanism not fully understood
Progestogen induced PMDs
Cyclical pre-menstrual symptoms
Symptom-free week
Affects quality of life
Associated with exogenous progestogen treatment
what is PMDs with absent menstruation
Functioning ovarian cycle No menstruation - Reasons such as hysterectomy, endometrial ablation or LNG-IUS cyclical symptoms Symptom-free week Affects QOL
what are symptoms of PMS?
Combination of psychological and physical symptoms. Impact on daily activity during the luteal phase Fatigue Headaches Anxiety Low mood Irritability Mood swings Bloating Mastalgia Altered appetite Altered libido
Prevalence of PMS?
Prevalence PMS 24-40%.
How is PMS diagnosed?
Diagnosis is confirmed using a symptom diary
The symptom diary should not be done retrospectively
Daily Record of Severity of Problems (DRSP) is the preferred tool.
GnRH analogues may be used for three months to establish diagnosis if symptom diary inconclusive.
First line treatments for PMS
First line treatments for PMS are
- Exercise
- Cognitive behavioural therapy (CBT)
- Vitamin B6
- Combined new generation pill (cyclically or continuous)
- Continuous or luteal phase (day 15-28) low dose SSRI e.g. citalopram 10 mg
Second line treatment for PMS
Second line treatment for PMS
- Estradiol patches (100 micrograms) WITH micronised progesterone (100-200 mg on day 17-28 orally or vaginally) ORLNG-IUS 52 mg
- Higher dose SSRI continuously or luteal phase e.g. citalopram 20-40 mg
Third line treatment for PMS
Third line treatment for PMS
- GnRH analogues AND add-back HRT (continuous combined oestrogen + progesterone)
- Tibolone
Fourth line treatment for PMS
Surgical treatment ± HRT
When should women with PMS be referred to a gynaecologist?
Referral to a gynaecologist should be considered when simple measures have failed
(e.g. combined oral contraceptives, vitamin B6, selective serotonin reuptake inhibitors, exercise)
And when the severity of the PMS justifies gynaecological intervention.
What is the role for CBT in PMS management
CBT should be considered routinely as one of the first line treatment options
Which COC has the best evidence for managing PMS, including regimens delivering ethinylestradiol?
drospirenone-containing COCs
should be considered as a first-line intervention
What is the optimum COC pill regimen
e.g. continuous, cyclical or flexible?
When treating women with PMS, emerging data suggest use of the contraceptive pill continuously rather than cyclically
How efficacious is percutaneous estradiol for treating PMS?
Percutaneous estradiol combined with cyclical progestogens has been shown to be effective for
the management of physical and psychological symptoms of severe PMS.
A barrier or intrauterine method of contraception
should be used alongside
What is the safety of using estradiol for PMS on the premenopausal endometrium and breast tissue?
When treating women with PMS using estradiol, women should be informed that there is insufficient data to advise on the long-term effects on breast and endometrial tissue.
What is the evidence for efficacy and adverse effects of danazol in the treatment of PMS?
Danazol low dose - 200mg BD - is effective in the luteal phase for breast symptoms
Potential SE = irreversible virilising effects.
Advise to use contraception due to its potential virilising effects on female fetuses
what is danazol?
Synthetic androgen
Danazol inhibits pituitary gonadotrophins;
combines androgenic activity with antioestrogenic and antiprogestogenic activity
How effective are GnRH analogues for treating severe PMS?
GnRH analogues are highly effective in treating severe PMS.
When treating women with PMS, GnRH analogues should be reserved for women with
severe symptoms.
Not recommended routinely unless they are being used to aid diagnosis or treat severe cases.
when is add-back HRT advised for Women using GnRH analogues for severe PMS?
Severe PMS treated with GnRH analogues for more than 6 months should have addback hormone therapy s
Continuous combined hormone replacement
therapy (HRT)
or tibolone
what advice should be given regarding BMD for Women using longterm GnRH analogues and add-back HRT for severe PMS?
General advice regarding bone mineral density and the effects of
exercise,
diet
smoking
Offer measurement of BMD - DEXA - annually e
Stop treatment if BMD declines
significantly
What is the role for progesterone and progestogens in treating PMS?
Evidence suggests treating PMS with progestogens is NOT appropriate.
No evidence to support LNG-IUS 52 mg alone - Its role should be confined to opposing action of estrogen therapy on the endometrium.
What are the risks and adverse effects of SSRIs?
Women with PMS treated with SSRIs should be warned of the possible adverse effects
- nausea,
- insomnia,
- somnolence,
- fatigue
- reduction in libido
Is there evidence for one SSRI regimens over another in treatment of PMS?
SSRI for PMS can be given continuously or luteal-phase.
Efficacy may be improved and adverse effects minimised by luteal-phase regimens with newer agents
What preconception and early pregnancy advice should be given regarding SSRIs/ SNRI treatment for PMS?
Provide pre-pregnancy counselling at every opportunity.
Inform that PMS symptoms will abate during pregnancy and SSRIs should be discontinued prior to and during pregnancy
Are diuretics efficacious in the treatment of PMS?
Spironolactone can be used in women with PMS to improve mood and somatic
symptoms
Can PMS be managed surgically?
In severe PMS - hysterectomy and bilateral oophorectomy has been shown to be of benefit.
Can be considered when medical management has failed, long-term GnRH analogue treatment is required or other gynaecological conditions indicate surgery
Can then use estrogen only HRT.
If considering surgical treatment for PMS, should efficacy always be predicted by the prior use of GnRH analogues?
For severe PMS, surgery should not be contemplated without pre-operative use of GnRH analogues as a test of cure and to ensure that HRT is tolerated.
What is the role of HRT after surgical management of PMS with hysterectomy and BSO?
Women being surgically treated for PMS should be recommended to use HRT
Especially if younger than 45 years of age
Is there a role for endometrial ablation, oophorectomy or hysterectomy alone in mamangement of PMS?
For severe PMS
endometrial ablation or
hysterectomy with conservation of the ovaries are not recommended
Bilateral oophorectomy, without removal of the uterus, will necessitate use of progestogen as part of HRT which risks reintroducing PMS-like symptoms (progestogen-induced premenstrual disorder)
What is physiological (mild)
premenstrual disorder
Symptoms cyclical and relieved by menstruation Symptom-free week No influence on quality of life Menstruation No additional factors
What management is advised for physiological (mild)
premenstrual disorder
Counselling and reassurance
No need for treatment
what features would suggest an underlying psychological disorder, not a premenstrual disorder
Non-cyclical symptoms No symptom-free week Constant influence on quality of life Menstruation not associated with symptom severity No additional factors
Management strategy for pre-menstrual exacerbation
Treatment should aim to treat the underlying medical,
physical. or psychiatric condition
OR suppress ovulation
(or both)
Management of premenstrual disorder
with absent menstruation
Managed as Core PMS
1st line = Exercise, cognitve behavioural therapy, vitamin B6, Combined new generaton pill (cyclical or continuous)
Low dose SSRI - Continuous or luteal phase (day 15–28) e.g. citalopram/escitalopram 10 mg
Are complementary therapies effective in treating PMS?
Calcium/ vitamin - beneficial Saffron - beneficial Evening primrose oil - some benefit Vitex agnus castus L. (chasteberry) - some benefity but inadequate safety data Reflexology - Some benefit Ginkgo biloba - Some benefit Acupuncture - Some benefit Lemon balm - Some benefit Curcumin - Some benefit Wheat germ - Some benefit Exercise - some benefit Vitamin B6 - mixed results Isoflavones - Mixed results St John’s Wort - Mixed results
Magnesium - ?some benefit
Peak age prevelence of severe PMS
40 - 50 yrs
