Premenstrual syndrome

Question 1

What is premenstrual syndrome (PMS)?

Answer 1

Premenstrual syndrome (PMS) describes the psychological, physical and behavioural symptoms that women may experience in the luteal phase of the normal menstrual cycle

Question 2

PMS can be classified into two broad types. What are they?

Answer 2

Core premenstrual disorder

• Most common
• As with all PMDs, the symptoms experienced must be severe enough to cause significant personal, interpersonal, and functional impairment to the woman
• Symptoms must be present during the lutueal phase and cease as menstruation begins, which is then followed by a symptom-free week

Variant premenstrual disorder

• These are PMDs that do not meet the criteria for core PMDs and they fall into 4 subtypes:
  
  • Premenstrual exacerbation of an underlying disorder
    
    • Symptoms of an underlying disorder (e.g. diabetes, depression, epilepsy, asthma, and migraine) significantly worsen premenstrually
  • Non-ovulatory PMDs
    
    • Symptoms are caused by ovarian activity rather than ovulation. It is thought that follicular activity of the ovary can cause symptoms
  • Progestogen-induced PMD
    
    • Symptoms result from exogenous progesterone administration, for example hormone replacement therapy (HRT), or COCP
  • PMDs with absent menstruation
    
    • Symptoms arise from continued ovarian activity despite that menstruation has been suppressed, e.g. after a hysterectomy or endometrial ablation, or in women using levonorgestrel-releasing intrauterine system (LNG-IUS)

Question 3

Give one complication of PMS

What’s the DSM-V criteria for the complication mentioned?

Answer 3

Premenstrual dysphoric disorder (PMDD) - a severe form of PMS

DSM-V

• During most menstrual cycles throughout the past year, at least 5 of the following 11 symptoms (especially including at least 1 of the first 4 listed) must be present in the final week before the onset of menses, must start to improve within a few days after the onset of menses, and become minimal or absent in the week post-menses:
  
  • Marked lability (e.g. mood swings)
  • Marked irritability or anger
  • Markedly depressed mood
  • Marked anxiety and tension
  • Decreased interest in usual activities
  • Difficulty in concentration
  • Lethargy and marked lack of energy
  • Marked change in appetite (e.g. overacting or specific food cravings)
  • Hypersomnia or insomnia
  • Feeling overwhelmed or out of control
  • Physical symptoms (e.g. breast tenderness or swelling, joint or muscle pain, bloating and weight gain)

Question 4

Can you get PMS in before puberty, during pregnancy, or after menopause?

Answer 4

NO!

PMS ONLY occurs in the presence of menstrual cycles, which are absent in pre-pubscent girls, pregnant women and postmenopausal women!

Question 5

Give 5 risk factors for PMS

Answer 5

Risk factors of PMS:

The presence of menstrual cycles is the biggest risk factor (so basically women of child-bearing age that are NOT pregnant)

FHx of PMS

Depression - PMS or PMDD maybe a precursor to depression, or follow a diagnosis of depression

Smoking

Alcohol

Sexual abuse/ trauma

Stress

Weight gain

Question 6

How do you diagnose PMS?

How do you differentiate PMS from physiological premenstrual symptoms?

Answer 6

a) . The diagnosis of PMS is supported by the timing (rather than the types) of symptoms and the degree of impact on daily activity (i.e. severity of symptoms)
b) . To differentiate PMS from physiological premenstrual symptoms (which are experienced by 90% of women), it must be demonstrated that symptoms cause significant personal, interpersonal, and/or functional impairment to the woman during the luteal phase of the menstrual cycle

Therefore, women who experience minor, transient premenstrual symptoms (e.g. bloating, breast tenderness, headache, acne, constipation, minor mood changes) that do NOT cause impairment of ADLs are said to be experiencing physiological premenstrual symptoms

Question 7

The diagnosis of PMS depends on ______ and _______?

Answer 7

Timing of symptoms

Degree of impact on daily life

Question 8

To aid diagnosis of PMS, what can you ask the woman to do?

Answer 8

Ask the woman to record a daily symptom diary for 2-3 cycles, and review the woman with the diary - can use the ‘Daily Record of Severity of Problems’ (DRSP) questionnaire for tracking symptoms related to PMS

Question 9

If the completed symptom diary is inconclusive (quite common if women have variant PMDs), what can you do to help confirm the diagnosis of PMS?

Answer 9

Refer the woman to secondary care

Gynaecologists can offer patients a 3-month course of GnRH agonists (a month for the agonist to generate a complete hormonal suppressive effect leading to anovulation, plus 2 months’ worth of symptom diaries). If symptoms resolve after ovarian suppression (i.e. patients get better when they don’t have menstruation), then the patient is diagnostic of PMS

Question 10

How does GnRH agonists cause ovarian suppression?

Answer 10

GnRH agonists interact with the GnRH receptor and stimulate the release of FSH and LH. However, after the initial “flare” response, continued stimulation with GnRH agonists desensitizes the pituitary gland (by causing downregulation of GnRH receptors) to GnRH. Pituitary desensitization reduces the secretion of LH and FSH and thus induces a state of hypogonadotropic hypogonadal anovulation (AKA “pseudomenopause”)

GnRH agonists –> pseudomenopause!

Question 11

What are the clinical features of premenstrual syndrome?

Answer 11

Presentations:

Symptoms are present during the luteal phase and abate (become less intense)/ resolve as menstruation begins, which is then followed by a symptom-free week

• Psychological symptoms - mood swings, irritability, depression, anxiety, feeling out of control, poor concentration, fatigue, change in libido, and food cravings
• Physical symptoms - breast tenderness, bloating, headaches, backache, acne, weight gain, and GI disturbance
• Behavioural symptoms - reduced visuo-spatial and cognitive ability, aggression, and increase in accidents
• In the Hx, ensure to ask about the severity of symptoms and the degree of impact on daily activity. In particular, ask about the woman’s work, school, family life, and interpersonal relationships. Also ask questions related to variant PMD, for example:
  
  • PMHx - any underlying chronic illness and whether symptoms of the illness significantly worsen premenstrually –> ‘Premenstrual exacerbation of underlying disorder’
  • PSHx - any surgical procedures in the past e.g. hysterectomy or endometrial ablation –> ‘PMD with absent menstruation’
  • DHx - has she tried progestogen treatment such as hormone replacement therapy, COCP –> ‘Progestogen-induced PMD’
  • Ask about risk factors of PMS including smoking, alcohol

Question 12

Give 5 differential diagnoses of PMS

Answer 12

Depression

Anxiety and panic disorder

Hypothyroidism

Anaemia

IBS

Chronic fatigue syndrome

Fibromyalgia

Question 13

What is the management for PMS?

Answer 13

Mx of PMS depends on the severity of symptoms:

There is no formal criteria for defining mild, moderate, or severe PMS, so it’s all down to clinical judgement.

For ALL women with PMS:

• Offer lifestyle advice
  
  • Regular, frequent (2-3 hourly), small, balanced meals rich in complex carbohydrates
  • Regular exercise and sleep
  • Stress reduction
  • Smoking cessation and alcohol restriction
• Simple analgesia if pain (e.g. headache, generalised aches and pains) - paracetamol/ NSAID
  
  • ​If breast tenderness:
    
    • Consider a better-fitting bra during the day and a soft support bra at night + offer simple analgesia

For moderate PMS symptoms:

• Prescribe a new-generation COCP, esp if the woman requires contraception
  
  • Example: Yasmin (drospirenone + ethinylestradiol)
• Arrange referral for CBT if you think the woman would benefit from psychological intervention

For severe PMS symptoms:

• Prescribe a SSRI (sertraline, fluoxetine, or citalopram) to be taken continuously or just during the luteal phase (for example days 15-28 of the menstrual cycle, depending on its length)
• Offer a follow-up appointment 1 week after starting treatment with the SSRI to assess for increased anxiety
• Note that sertraline can increase the risk of suicide in patients < 30 yrs so they need frequent reviews (at least once a week)
• Advise the woman on how to safely stop SSRI treatment: women taking luteal phase SSRIs can discontinue the treatment safely at any time, whereas women using a continuous regimen should taper the dose over a 4 week period!
• Arrange referral for CBT if you think the woman would benefit from psychological intervention

Review the woman after 2 months to assess the effectiveness of the treatment!

Question 14

What’s the DSM-5 criteria of Premenstrual Dysphoric Disorder (PMDD)

Answer 14

Mnemonic for PMDD:

(SAIL Over CASPIAn SEA 5 Times In 2 months)

• Sad
• Anxiety
• Irritability
• Lability (mood swings)
• Overwhelmed or out of control
• Concentration poor
• Appetite changes
• Sleep changes
• Physical symptoms
• Interest decreased
• Anergia (lack of energy)
• 5 - at least 5 symptoms present
• Times - final week before onset of menses, improve within a few days of menses, and minimal after onset of menses
• In - Interfere with work and are distressing
• 2 months - at least 2 symptomatic menstrual cycles