PMS/PMDD Flashcards
what is PMS/PMDD
Cyclic recurrence of sx during luteal phase of menstrual cycle- often sx dissipate with onset of menses (mix of mood, physical, cog sx)
when does PMS/PMDD start
25-35yrs, maybe earlier
PMDD could be categorized as
severe PMS
estrogen effects on NT
+ effect on 5HT- increased synthesis, 5HT1 receptors, binding affinity
progesterone effect on hormones
increased 5HT uptake and turnover
what are the pathophysiology theories of PMS/PMDD
Correlation of hormones and + central NT (5HT)
Greater susceptibility to normal cyclic changes in hormones or ratio of estrogen to progesterone
Progesterone key mediator of PMS/PMDD: allopregnanolone is a metabolite of progesterone and an agonist of GABAr
RF for PMS/PMDD
genetics, traumatic or major life events/ stressors, comorbidity with depression/ anxiety, psychosocial factors (ex- fewer social supports)
diagnosis of PMS/PMDD must include
characteristic of PMS/PMDD
Limited to luteal phase- often worse few days before menses
Impacting daily life
Sx present for at least 2 previous cycles
Not explained by some other dx
what is the dx if the pt has sx consistent with PMS but do not interfere with daily functioning
mild premenstrual sx
nonpharm options for PMS/PMDD
Pt education on bio basis of PMS- may help give pt sense of control + establish expectations
Daily charting of sx = greater awareness of sx by pt
Exercise: regular, aerobic, reduces severity of sx
Adequate rest + relaxation
Stress reduction (CBT)
Diet: sodium restriction (if fluid retention, bloating, breast swelling), caffeine restriction (if irritability or insomnia), complex carb diets, some foods (maybe bananas)
NHPs for PMS/PMDD
Calcium 1200mg daily for improvement in mood and physical sx (esp fluid retention)
Most evidence
Magnesium 200-400mg daily to reduce fluid retention/ bloating
Vit B6 100mg daily for mild mood and physical sx
Vit E 400IU daily for mild sx of breast tenderness and mood
Chasteberry fruit - breast tenderness, mood
Evening primrose oil (EPO)- prostaglandin precursor, no better than placebo
St John’s wort- open label found benefit in mood
Gingko- 1 RCT showed improved physical and mood
what has the most evidence as a NHP for PMS/PMDD
calcium
calcium is used in PMS for
mood and physical sx- esp fluid retention
magnesium is used in PMS for
reducing fluid retention/ bloating
vit B6 is used in PMS for
mild mood and physical sx
vit E is used in PMS for
breast tenderness and mood
how long should pharm therapies be trialed in PMS/PMDD
2-3 cycles, ~3 mths
pharm options for PMS/PMDD
NSAIDs
spironolactone
CHC
POP (no benefit)
SSRIs
anxiolytics
GnRH agonists
danazol
bilateral oophorectomy
what is teh drug of choice for PMS/PMDD
SSRIs
how to use SSRIs for PMS/PMDD
Intermittent: start on luteal phase or sx day, then d/c on first day of menses or 1-3 days after
Not assoc with SSRI d/c sx
If interim not eff = switch to cont
with SSRIs for PMS/PMDD sx may improve within ____ but may take ___menstrual cycles to see full benefit
24-48hrs
3
If initial SSRI not tolerated/ ineff for PMS/PMDD= try _______before abandoning class + switch to ______
2 additional SSRIs
cont if on interm
how to use NSAIDs for PMS/PMDD
Start in luteal phase, stop 1-2 days after menses starts
how to use diuretics in PMS/PMDD
spironolactone 25-10mg/d during luteal phase
Most helpful for fluid retention, bloating, and breast tenderness
how effective are CHCs in PMS/PMDD
50% see no change, 25% improvements, 25% worsened
how should CHCs be used in PMS/PMDD
Use continuous to prevent hormone fluctuations
Consider drospirenone containing CHC for those with fluid retention
which CHC should be considered for those with fluid retention
Consider drospirenone containing CHC for those with fluid retention
progesterone eff on PMS/PMDD
SR of progesterone in PMS found no benefit
how to use anxiolytics for PMS/PMDD
BZs like alprazolam during luteal phase has been shown to be eff for PMS/PMDD esp for anxiety
Usually reserved for those who do not respond or used in conj with antidepressants
Can also premedicate if known anxiety
what pharm therapy can be used if nothing else worked- what is alst line
ovarian suppression with GnRH agonists, danzol ,or bilateral ophorectomy
