PMS_Flashcards
What is premenstrual syndrome (PMS)?
Premenstrual syndrome (PMS) describes the emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle.
When does premenstrual syndrome (PMS) occur?
PMS only occurs in the presence of ovulatory menstrual cycles; it doesn’t occur prior to puberty, during pregnancy, or after menopause.
What are the emotional symptoms of PMS?
Emotional symptoms of PMS include anxiety, stress, fatigue, and mood swings.
What are the physical symptoms of PMS?
Physical symptoms of PMS include bloating and breast pain.
How can mild symptoms of PMS be managed?
Mild symptoms of PMS can be managed with lifestyle advice.
What lifestyle advice is recommended for managing mild PMS symptoms?
Lifestyle advice for managing mild PMS symptoms includes sleep, exercise, avoiding smoking and alcohol, and eating regular, frequent (2-3 hourly), small, balanced meals rich in complex carbohydrates.
What is recommended for managing moderate symptoms of PMS?
Moderate symptoms of PMS may benefit from a new-generation combined oral contraceptive pill (COCP).
What is an example of a new-generation combined oral contraceptive pill (COCP) used for PMS?
An example of a new-generation combined oral contraceptive pill (COCP) used for PMS is Yasminµ (drospirenone 3 mg and ethinylestradiol 0.030 mg).
How can severe symptoms of PMS be managed?
Severe symptoms of PMS may benefit from a selective serotonin reuptake inhibitor (SSRI).
How can selective serotonin reuptake inhibitors (SSRIs) be taken for severe PMS symptoms?
Selective serotonin reuptake inhibitors (SSRIs) for severe PMS symptoms may be taken continuously or just during the luteal phase (for example, days 15-28 of the menstrual cycle, depending on its length).
Summarise PMS
Premenstrual syndrome
Premenstrual syndrome (PMS) describes the emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle.
PMS only occurs in the presence of ovulatory menstrual cycles - it doesn’t occur prior to puberty, during pregnancy or after the menopause.
Emotional symptoms include:
anxiety
stress
fatigue
mood swings
Physical symptoms
bloating
breast pain
Management
Options depend on the severity of symptoms
mild symptoms can be managed with lifestyle advice
apart from the usual advice on sleep, exercise, smoking and alcohol, specific advice includes regular, frequent (2-3 hourly), small, balanced meals rich in complex carbohydrates
moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP)
examples include Yasminµ (drospirenone 3 mg and ethinylestradiol 0.030 mg)
severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI)
this may be taken continuously or just during the luteal phase (for example days 15-28 of the menstrual cycle, depending on its length)
A 21-year-old woman present to her GP due to lethargy, breast tenderness, and bloating in the week before her period. She also reports mildly reduced concentration and occasional mood swings at this time. These symptoms do not occur at any other time during the month.
The patient has a past medical history of migraines with aura. She takes sumatriptan as needed and has no allergies.
Whilst her symptoms do not significantly affect her daily life, she does find them irritating and is keen to find a way to improve them.
What is the most appropriate management of these symptoms?
Advise reduction of dietary fats and dietary carbohydrates
Advise regular exercise and small, regular meals rich in complex carbohydrates
Prescribe as required diazepam to use in the luteal phase
Prescribe sertraline to take during the luteal phase
Prescribe the combined oral contraceptive pill
Advise regular exercise and small, regular meals rich in complex carbohydrates
Specific lifestyle changes to manage premenstrual syndrome include 2-3 hourly small balanced meals rich in complex carbohydrates
The correct answer is advise regular exercise and small, regular meals rich in complex carbohydrates. The first-line management of premenstrual syndrome advised by the Royal College of Obstetrics and Gynaecology (2016) is lifestyle changes, such as smoking cessation, alcohol reduction, regular sleep, regular exercise, and sleep reduction. They also advise eating regular meals rich in complex carbohydrates. Much of these suggestions are based simply on what constitutes a healthy lifestyle. There is some evidence that exercise reduces symptoms of premenstrual syndrome. The advice to eat meals rich in complex carbohydrates is based on the hypothesis that they increase levels of tryptophans and subsequently levels of serotonin.
Advise reduction of dietary fats and dietary carbohydrates is incorrect. As discussed, it is a diet rich in complex carbohydrates that is recommended. Furthermore, there is no evidence that eating a low-fat diet improves symptoms of premenstrual syndrome. On the contrary, there is actually evidence that fatty acids may improve premenstrual symptoms.
Prescribe as required diazepam to use in the luteal phase is incorrect. Benzodiazepines are prescribed with extreme caution due to the risk of dependence. They are not part of the routine management of the premenstrual syndrome. They may be used in a select subset who experience significant anxiety. In this case, they are used for a short time period (e.g. 2-3 days) and other treatments such as antidepressants or psychological intervention would be the mainstay of management. This patient does not have any significant anxiety symptoms.
Sertraline and other selective serotonin reuptake inhibitors can be used for premenstrual symptoms. They are given either throughout the whole month or just during the luteal phase. However, they are a treatment for severe premenstrual syndrome. This patient has few, mild symptoms and her symptoms do not interfere with her daily life. Therefore, she is likely to only require lifestyle changes to notice an improvement.
Prescribe the combined oral contraceptive pill is an option for moderate premenstrual syndrome. What constitutes moderate symptoms depends on clinical judgment and the impact the patient feels that the symptoms are having on her life. In this case, the patient’s symptoms appear mild and may well improve with lifestyle measures alone. However, more significantly, this patient has migraines with aura. This means she should not take any combined hormonal contraception due to the increased risk of thromboembolic events. Therefore, whilst in a patient without this history it may seem appropriate to discuss the combined contraceptive pill, it is incorrect for this patient.
A 35-year-old woman who has a regular 28-day menstrual cycle complains of mood changes in the week before her period. She describes increasing anxiety and irritability. Her symptoms are severe and have an impact on her life, making it difficult to maintain her work or social life. She has a past medical history of migraine with aura.
Which of the following interventions is most appropriate to help reduce her pre-menstrual symptoms?
Combined oral contraceptive pill
Non-steroidal anti-inflammatory drug
Progesterone only pill
Contraceptive implant
Selective serotonin re-uptake inhibitor (SSRI)
Selective serotonin re-uptake inhibitor (SSRI)
SSRIs, either continuously or during the luteal phase, may help premenstrual syndrome
Important for meLess important
The patient in this question is suffering from pre-menstrual syndrome.
NICE guidance suggests that women with severe premenstrual symptoms should be managed using SSRIs. They can be taken continuously or just during the luteal phase (for example days 15-28 of the menstrual cycle, depending on its length). The prescription should be for an initial 3 month period and patients should be monitored closely during initiation.
The combined oral contraceptive pill is the wrong option because this patient has a history of migraine with aura which contra-indicates the prescription of the combined contraceptive pill.
Giving this patient a non-steroidal anti-inflammatory drug would be inappropriate as she does not have symptoms of dysmenorrhoea and it would not have any effect on her mood or pre-menstrual symptoms.
Progesterone only pills or the contraceptive implant are not indicated in the management of pre-menstrual syndrome.
Lifestyle advice for all women with PMS should include regular, frequent meals rich in complex carbohydrates, regular exercise and sleep, smoking cessation, and stress reduction.
A 25 year old woman with a known diagnosis of premenstrual syndrome (PMS) attends her GP requesting some medical treatment. She has made the suggested lifestyle modifications, with little improvement in her symptoms. She is not planning on starting a family any time soon. Which of the following treatments would be most suitable to offer her, assuming that there are no contraindications?
Amitriptyline
Depo-Provera
Combined oral contraceptive pill
Progesterone only pill
Pyridoxine (vitamin B6)
Combined oral contraceptive pill
PMS is defined as a condition which manifests with distressing physical, psychological and behavioural symptoms in the absence of an organic disease. These symptoms regularly occur during the luteal phase of the menstrual cycle and improve at the end of menstruation.
Symptoms include depression, anxiety, irritability, bloating and mastalgia. The precise aetiology is unknown, however it is associated with the hormonal changes that occur following ovulation. The absence of PMS before puberty, in pregnancy and after the menopause further support this theory.
The type of treatment is determined by the severity of symptoms, patient preference and desire for pregnancy.
Management of PMS includes lifestyle advice - healthy diet, exercise, reduction in stress levels and regular sleep.
The combined oral contraceptive pill and selective serotonin re-uptake inhibitors are recommended for moderate to severe symptoms.
Progesterone alone is not recommended for women with PMS, due to insufficient evidence on efficacy.
Most complementary treatments, for example pyridoxine (vitamin B6) are not recommended due to little evidence on their benefits and weak or inconclusive evidence regarding safety.
(Source - CKS PMS)
