Premenstrual Syndrome

Question 1

Define premenstrual syndrome.

Answer 1

The psychological, emotional and physical symptoms that occur during the luteal phase of menstrual cycle, particularly in the days prior to the onset of menstruation.

Question 2

What is key when identifying if symptoms are PMS?

Answer 2

The symptoms of PMS resolve once menstruation begins. Symptoms are not present before menarche, during pregnancy or after menopause.

Question 3

What causes PMS?

Answer 3

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.

Question 4

List common symptoms of PMS.

Answer 4

1. Low mood
2. Anxiety
3. Mood swings
4. Irritability
5. Bloating
6. Fatigue
7. Headaches
8. Breast pain
9. Reduced confidence
10. Cognitive impairment
11. Clumsiness
12. Reduced libido

Question 5

Can PMS symptoms occur in the absence of menstruation (e.g. post hysterectomy, endometrial ablation or Mirena coil)? What about on the pill?

Answer 5

Yes as ovaries continue to function and 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.

Question 6

What is premenstrual dysphoric disorder?

Answer 6

When PMS features are severe and have a significant effect on quality of life.

Question 7

How is PMS or premenstrual dysphoric disorder diagnosed? How is a definitive diagnosis made?

Answer 7

Symptom diary spanning two menstrual cycles.

Specialist can definitively diagnose by administering a GnRH analogues to halt the menstrual cycle and temporarily induce menopause, to see if the symptoms resolve.

Question 8

How can PMS be managed in the community?

Answer 8

1. General health lifestyle changes e.g. diet, exercise, alcohol, smoking, stress, sleep
2. COCP
3. SSRI antidepressants
4. CBT

Question 9

What COCP is recommended first line for PMS? Should it be used continuously or cyclically?

Answer 9

Drospirenone (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.

Question 10

What patches can help with PMS?

Answer 10

Continuous transdermal oestrogen patches.

Question 11

What needs to be given alongside oestrogen patches?

Answer 11

Progestogens required for endometrial protection against endometrial hyperplasia when using oestrogen.

E.g. low dose cyclical progestogens e.g. norethisterone to trigger withdrawal bleed or Mirena coil

Question 12

What can be used to induce a menopausal state?

Answer 12

GnRH analogues

Question 13

What is an adverse effect of GnRH analogues? How can this be mitigated against

Answer 13

Osteoporosis.

Hormone replacement therapy can be used to add back the hormones to reduce osteoporosis risk.

Question 14

What can be done if symptoms are severe and medical management has failed? What will these patients require afterwards?

Answer 14

Hysterectomy and bilateral oophorectomy.

Will require hormone replacement therapy (particularly in women under 45).

Question 15

Name two medications which can be used for cyclical breast pain (monitored by breast specialists)?

Answer 15

1. Danazole

2. Tamoxifen

Question 16

What medication can be used to treat physical symptoms of PMS e.g. breast swelling, water retention and bloating?

Answer 16

Spironolactone