Premenstrual syndrome Flashcards
Definition of premenstrual syndrome
- A condition characterised by psychological, physical and behavioural symptoms occurring in the luteal phase of the normal menstrual cycle (between ovulation and the onset of menstruation)
- A diagnosis of PMS is supported by the timing (rather than the types) of symptoms and the degree of impact on daily activities.
How can premenstrual syndrome be differentiated from physiological premenstrual symptoms (experienced by 80-90% of women)
- By demonstration that symptoms cause significant personal, interpersonal and/or functional impairment to the women during the luteal phase
- Women who experience minor, transient premenstrual symptoms such as bloating, breast tenderness, headache, acne, constipation or minor mood change (that does not cause functional impairment) are said to be experiencing physiological premenstrual symptoms
Incidence of PMS
40-90% of women report having at least 1 PMS symptom. The proportion of women reporting severe PMS symptoms or symptoms that interfere with daily activities ranges between 3–30%
The prevalence is NOT associated with age educational achievement or employment
Cause of PMS
The exact cause is unknown, but may be due to sensitivity to progesterone or by serotonergic/ GABAergic effects (SSRIs decrease severity, and GABA appears to upregulated in PMS)
How are PMDs classified
Can be classified into core premenstrual disorders (PMDs) and variant PMDs:
* Core PMDs: are the most commonly encountered and widely recognized type of PMS
What are the four variant PMDs
- Premenstrual exacerbation of an underlying disorder- symptoms of an underlying disorder (such as diabetes, depression, epilepsy, asthma, and migraine) significantly worsen premenstrually.
- Non-ovulatory PMD- symptoms result (rarely) from ovarian activity other 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 HRT or COCP. Progestogen-only contraceptives may also cause symptoms but because they are noncyclical, these symptoms are not included within variant PMDs and are considered adverse effects (probably with similar mechanisms)
- PMDs with absent menstruation- symptoms arise from continued ovarian activity even though menstruation has been suppressed, for example after a hysterectomy or endometrial ablation, or in women using LNG-IUS
Risk factors for PMS
- The strongest risk factor for PMS is the presence of ovulatory menstrual cycles
- Family history of PMS- possible genetic component suggested by monozygotic twin studies
- Mood disorders- may be a precursor to major depression or follow a diagnosis of depression
- Cigarette and alcohol intake
- Sexual abuse and/or trauma
Presentation of PMS
There are over 150 different psychological, physical and behavioural symptoms that may be associated with PMS:
* Psychological symptoms include depression, anxiety, irritability, loss of confidence, and mood swings.
* Physical symptoms include bloating and breast pain.
* Behavioural symptoms include reduced cognitive ability and aggression
Investigations for PMS
- Take a history to ascertain: the types of symptoms experienced (as about psychological, physical and behavioural symptoms specifically), the timing of symptoms in relation to the menstrual cycle and the severity of symptoms and the degree of impact on daily activity.
- The woman should be asked to record a daily symptom diary for 2 to 3 cycles (DRSP is validated)
- GnRH agonists can be used to establish a definitive diagnosis of PMS by inhibiting cyclical ovarian function (3 month test)
Management of all women with PMS
- Offer lifestyle advice including: regular, frequent small balanced meals, regular exercise, regular sleep, stress reduction, smoking and drinking cessation (if applicable)
- If the predominant symptom is pain- prescribe a simple analgesic, such as paracetamol or an NSAID
- Advise that there is limited evidence supporting the use of complementary treatments and dietary supplements (including reflexology, acupuncture, calcium and vitamin D)
Management of women with moderate PMS (severity determined by clinical judgement)
- Consider prescribing a new-generation COCP, especially if the woman requires contraception (off-label use)- Evidence supports the use of Yasmin
- (Should be used continuously rather than cyclically)
- CBT if the woman might benefit from psychological intervention
Management of women with severe PMS
Consider prescribing an SSRI to be taken continuously or during the luteal phase of their menstrual cycle (days 15-28 of a natural cycle)
* Only prescribe on specialist advice in patients younger than 18 years old
* Give an initial trial of 3 months treatment- if there is benefit continue for 6 months to 1 year
* Monitor for risk of self-harm and other SEs
CBT if the woman might benefit from psychological intervention
Review the woman after 2 months to assess the effectiveness of the treatment. The success of the treatment should be established using a validated symptom diary, such as the Daily Record of Severity of Problems (DRSP) questionnaire.
Overview of PMS
