Premenstrual Syndrome Flashcards
What is premenstrual syndrome (PMS)?
Premenstrual syndrome (PMS) describes the psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation. These symptoms can be distressing and significantly impact quality of life.
Most women will experience some of the symptoms of premenstrual syndrome. The critical aspects are the severity of the symptoms, and the impact these symptoms have on the woman’s functioning and quality of life.
When do the symptoms of PMS resolve?
The symptoms of PMS resolve once menstruation begins. Symptoms are not present before menarche, during pregnancy or after menopause. These are key things to note when you take a history.
What causes PMS?
Premenstrual syndrome is though to the caused by fluctuation in oestrogen and progesterone hormones during the menstrual cycle. The exact mechanism is not known, but it may be due to increased sensitivity to progesterone or an interaction between the sex hormones and the neurotransmitters serotonin and GABA.
What are the symptoms of PMS?
There is a long list of symptoms that can occur with premenstrual syndrome, and these will vary with the individual. Common symptoms include:
- Low mood
- Anxiety
- Mood swings
- Irritability
- Bloating
- Fatigue
- Headaches
- Breast pain
- Reduced confidence
- Cognitive impairment
- Clumsiness
- Reduced libido
Other than physiological menstruation, when can PMS occur?
These symptoms can occur in the absence of menstruation after a hysterectomy, endometrial ablation or on the Mirena coil, as the ovaries continue to function and the hormonal cycle continues. They can also occur in response to the combined contraceptive pill or cyclical hormone replacement therapy containing progesterone, and this is described as progesterone-induced premenstrual disorder.
What name is given to severe PMS symptoms?
When features are severe and have a significant effect on quality of life, this is called premenstrual dysphoric disorder.
How is PMS diagnosed?
Diagnosis is made based on a symptom diary spanning two menstrual cycles. The symptom diary should demonstrate cyclical symptoms that occur just before, and resolve after, the onset of menstruation. A definitive diagnosis may be made, under the care of a specialist, by administering a GnRH analogues to halt the menstrual cycle and temporarily induce menopause, to see if the symptoms resolve.
What management options for PMS can be intiated by a GP?
The following management options can be initiated in primary care:
- General healthy lifestyle changes, such as improving diet, exercise, alcohol, smoking, stress and sleep
- Combined contraceptive pill (COCP)
- SSRI antidepressants
- Cognitive behavioural therapy (CBT)
What is the first line COCP that can be given for PMS?
RCOG recommends COCPs containing drospirenone first line (i.e. Yasmin). Drospironone as some antimineralocortioid effects, similar to spironolactone. Continuous use of the pill, as opposed to cyclical use, may be more effective.
In severe cases of PMS, who is invovled in the management?
Severe cases should be managed by a multidisciplinary team, involving GPs, gynaecologists, psychologists and dieticians.
What is the role of oestrogen and progestogens in managing PMS?
Continuous transdermal oestrogen (patches) can be used to improve symptoms. Progestogens are required for endometrial protection against endometrial hyperplasia when using oestrogen. This can be in the form of low dose cyclical progestogens (e.g. norethisterone) to trigger a withdrawal bleed, or the Mirena coil.
What is the role of GnRH analogues in managing PMS?
GnRH analogues can be used to induce a menopausal state. They are very effective at controlling symptoms; however, they are reserved for severe cases due to the adverse effects (e.g. osteoporosis). Hormone replacement therapy can be used to add back the hormones to mitigate these effects.
What is the role of hysterectomy and bilateral oophorectomy in managing PMS?
Hysterectomy and bilateral oophorectomy can be used to induce menopause where symptoms are severe and medical management has failed. Hormone replacement therapy will be required, particularly in women under 45 years.
What is the role of danazole and tamoxifen in managing PMS?
Danazole and tamoxifen are options for cyclical breast pain, initiated and monitored by a breast specialist.
What is the role of spironolactone in managing PMS?
Spironolactone may be used to treat the physical symptoms of PMS, such as breast swelling, water retention and bloating.
