Pre-menstrual syndrome Flashcards
Define PMS.
Premenstrual syndrome (PMS) is a condition characterized by…
- psychological,
- physical, and
- behavioural
…symptoms occurring in the luteal phase of the normal menstrual cycle (the time between ovulation and onset of menstruation).
Which phase of the menstrual cycle does PMS occur in?
Luteal phase
How common are premenstrual symptoms/PMS?
Symptoms occur in almost all women of reproductive age.
In 3–60% symptoms are severe, causing disruption to everyday life, in particular interpersonal relationships
How do you differentiate premenstrual symptoms from PMS?
To differentiate PMS from physiological premenstrual symptoms (experienced by 80–90% of women), it must be demonstrated that symptoms cause significant impairment to the woman during the luteal phase of the menstrual cycle.
What is the aetiology of PMS?
Precise aetiology unknown
Cyclical ovarian activity and the effects of oestradiol and progesterone on certain neurotransmitters, incl serotonin, may play a role.
What are the presenting features of PMS?
Psychological symptoms:
- depression,
- anxiety,
- irritability,
- loss of confidence,
- mood swings.
Physical symptoms:
- bloating
- cyclical weight gain
- breast pain.
- abdominal cramps
- headache
Behavioural symptoms:
- reduced cognitive ability
- aggression.
How is PMS diagnosed?
A diagnosis of PMS is supported by the:
- timing (rather than the types) of symptoms
- and the degree of impact on daily activity.
Ask patient to record a daily symptom diary for two or three cycles. Confirms PMS if:
- Symptoms during luteal phase with resolution after menses followed by symptom-free week
- Severe enough to affect daily functioning
- Absence of other condition e.g. depression, hypothyroidism, anaemia, IBS and endometriosis
What other causes of PMS-like symptoms should be excluded before diagnosis?
- depression,
- hypothyroidism,
- anaemia,
- IBS
- endometriosis
How is severity of PMS assessed?
Usually based on clinical judgement and the woman’s perception of symptom severity
What is the management of mild PMS?
Lifestyle advice -
- usual advice on sleep, exercise, smoking and alcohol
- specific advice includes regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates
Simple analgesia if required
Patient information on PMS
Vitamins: initial studies suggest that magnesium, calcium and isoflavones and vitamin B6 may be useful
in treating PMS.
What is the management of moderate PMS?
New-generation COCP - examples include Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg). Taking 2-3 packets in a row is most effective.
+/- CBT
What is the management of severe PMS?
SSRI - off label use:
- Fluoxetine 20-40mg/day
- Citalopram 10-20mg/day
- Escitalopram 10-20mg/day
When should follow-up for a woman with PMS be arranged for?
In 2 months - check effectiveness of treatment and if unsuccessful, consider referral to clinic with special interest in PMS
NB: resistant PMS may requre GnRH analogues, HRT or even surgery including hysterectomy and bilateral salpingo-oophorectomy
Why might transdermal oestrogen and GnRH analogues be useful in PMS?
GnRH analogues - turn off ovarian activity but will increase risk of osteoporosis so continuous HRT should be administered concurrently
Transdermal oestrogen - overcomes fluctuations of the normal cycle
What is the last-line treatment for PMS?
Hysterectomy with bilateral salpingo-oopherectomy:
- removes the ovarian cycle
- should only be performed if all other treatments have failed
- patients should have a preoperative trial of GnRH analogue as a ‘test’ to ensure that switching off ovarian function (by removing the ovaries at hysterectomy) will indeed cure the problem.
