Premenstrual Syndrome Flashcards
Define PMS
- Psychological symptoms: depression, anxiety, mood swings
- Physical symptoms: bloatedness, mastalgia
- Severe enough to affect daily functioning or interfere with work/school/interpersonal relationships
- Symptoms must be present during the luteal phase of menstrual cycle, and abate as menstruation begins
- Followed by a symptom-free week
How is PMS diagnosed?
Prospective patient-rated questionnaire
- Daily record of severity of problems (DRSP)
- Record this over 2 cycles
If inconclusive, GnRH analogues for 3 months and then provide 2 months worth of symptom diaries
Describe physiological (mild) PMS
- Cyclical symptoms, relieved by menstruation
- No influence on quality of life
- Counselling and reassurance, no need for treatment
Describe core PMS / PMDD
- Cyclical symptoms, relieved by menstruation
- Affects quality of life
- Consider all approaches to treatment
Describe what is meant by premenstrual exacerbation, and how it is treated
- Symptoms cyclical and relieved by menstruation, but no symptom-FREE week
- Existing non-menstrual condition (i.e. diabetes, depression, epilepsy, asthma, migraine)
- Treat the underlying disorder and/or suppress ovulation
Describe premenstrual disorder with absent menstruation
- Symptoms cyclical, but no menstruation
- Can be non-ovulatory (like PCOS)
- Can be physical causes for amenorrhoea, like hysterectomy / ablation / LNG-IUS
- Affects quality of life
- Treat the same as core PMS / PMDD
Describe progestogen-induced premenstrual disorder
- Symptoms cyclical and relieved by menstruation
- Affects quality of life
- Must be on a progestogen treatment
- NOT including those which will inhibit ovulation/cycles
- Treat with an alternative progestogen treatment
Describe how someone may have an underlying psychological disorder and NOT PMS
- Non-cyclical symptoms, no symptom-free week
- Constant influence on quality of life
- Menstruation is more random
- Treat with psychiatric care
Describe some first-line non-pharmaceutical treatments of PMS
- Exercise
- Reflexology
- Complementary medicines such as unsaturated fatty acids (evening primrose oil) and vitamin B6 (biotin)
- CBT routinely
Describe two first-line pharmaceutical treatments of PMS
COC
- Drospirenone-containing (Yasmin)
- Use continuously rather than cyclically
SSRIs
- Women with PMS have been shown to have low concentrations of serotonin
- Can trial luteal phase dosing (days 15-28) or continuous
- Low-dose citalopram/escitalopram 10mg OD
- Side effects nausea, insomnia, fatigue, reduced libido
Describe a second-line hormonal pharmaceutical management for PMS
Estradiol patches and micronised progesterone (or LNG-IUS)
- Estradiol patches 100ug will suppress ovarian activity
- Micronised progesterone 100mg OD or 200mg OD days 17-28 (can be given orally or vaginally)
- This regime is NOT a contraceptive
- LNG-IUS would be a contraceptive as well as treating any HMB/dysmenorrhoea
How might you escalate SSRI treatment in PMS?
Higher dose
Continuously or luteal
Citalopram / escitalopram 20-40mg OD
Discontinue prior to pregnancy if used only for PMS
What is the third-line pharmaceutical management for PMS?
GnRH analogues and add-back HRT
HRT can be
- continuous combined
- tibolone 2.5mg OD
Very effective in severe PMS
Annual DEXA scans needed if continuing long-term
What is the fourth-line treatment of PMS/PMDD
Hysterectomy and BSO
- Only when medical management has failed and long-term GnRH analogues are required, or if other gynae reason indicated surgery
Do not perform without preoperative use of GnRH as a test of cure
Endometrial ablation with conservation of ovaries is not recommended
How can danazol be used in PMS/PMDD?
- An androgenic steroid which can achieve cycle suppression
- Benefit for breast symptoms in PMS but not for other symptoms
- Low dose (200mg BD) during luteal phase
- Androgenic side effects
- Contra-indicated in pregnancy due to irreversible virilising effects so give contraception
