Premenstrual Syndrome Flashcards by Jordan Cyr

What is premenstrual syndrome?

a cyclic recurrence of physical and/or behavioral symptoms that occurs during the luteal phase of the menstrual cycle
-after ovulation and before the onset of menses

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What is PMDD?

premenstrual dysphoric disorder
-more severe, disruptive of daily life, ++ mood

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What is premenstrual exacerbation?

worsening of other disorders during the premenstrual phase
-i.e. migraine flare-up

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What are examples of cognitive PMS symptoms?

aggression
anger
anxiety
depression
fatigue
forgetfulness
hostility
irritability
lethargy
sudden mood changes
panic attacks
poor concentration
reduced coping skills

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What are examples of physical PMS symptoms?

acne
appetite change
bloating, fluid retention
breast pain or swelling
constipation
dizziness
fatigue
headache
hot flashes
muscle aches
NV
pelvic heaviness or pressure
weight gain

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What are the theories for the cause of PMS?

hormonal fluctuations
-oversensitivity to circulating progestins (highest during luteal phase)
dysregulation of neurotransmitter release
-HPO-axis, involvement of 5HT
nutritional (calcium) deficiences
-related to PTH secretion (would be high if Ca is low)
-explored but not substantiated: A, B6, E

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What are the risk factors for PMS?

high body mass index (BMI > 30 3x risk than < 30)
history of domestic violence, physical or emotional trauma, and substance use (i.e. stress)
genetic component

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Describe the typical timeframe of PMS symptoms.

present during the luteal phase
reach peak shortly before the beginning of menstruation and subside at the onset of menses
absent during follicular phase

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What can the symptoms of PMS interefere with?

daily functioning and interpersonal relationships

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What is the diagnosis for PMS?

5 or more symptoms that change in severity throughout the cycle
-must be cyclic, for at least 2 cycles
and the exclusion of other disorders

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What is the diagnosis for PMDD?

5+ symptoms with at least 1 severe mood symptom for at least 2 cycles
-resulting in functional impairment
and the exclusion of other disorders

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Differentiate PMS and dysmenorrhea.

timing:
-dysmenorrhea: during or shortly before menses
-PMS: luteal phase of cycle
cause:
-dysmenorrhea: prostaglandins
-PMS: ?hormonal fluctuations, ?NTs, ?nutritional deficiencies
symptoms:
-dysmenorrhea: physical only (pain, cramping)
-PMS: physical, behavioral, psychological
treatment:
-dysmenorrhea: NSAIDs and OCPs very effective
-PMS: varied options focusing on specific sx, varied efficacy

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What are the goals of therapy for PMS?

relieve symptoms
minimize functional impairment

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What are some lifestyle modifactions that can be made for PMS?

reflexology, massage, acupuncture, light therapy, CBT
appropriate sleep hygiene
moderate exercise
not be used as monotherapy, not that effective

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Which symptoms of PMS can exercise help with?

breast tenderness
fluid retention
stress
depression

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What are some dietary modifications that can be made for PMS?

decrease methylxanthines
-tea, coffee, cocoa, chocolate
increase complex carb intake
-beans, peas, whole grains, vegetables
decrease salt intake

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What are the benefits of dietary modifications for PMS?

decreasing methylxanthines: may improve breast symptoms
increasing complex carbs: may lessen appetite changes and cognitive sx
decreasing salt: helps fluid retention, weight gain, bloating, breast swelling and tenderness

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What are the pharmacological options for PMS?

effective for some symptoms:
-calcium carbonate
-SSRIs
inconclusive evidence:
-NSAIDs
-pyridoxine (B6)
-oral contraceptives
-miscellaneous
-natural health products

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Which symptoms of PMS can calcium carbonate help with?

negative affect
fluid retention
food cravings
pain

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What is the recommended intake of calcium for PMS?

1200 mg (elemental) daily

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How long should calcium carbonate be trialed for PMS?

plan for a 3 month trial

What is an adverse effect of calcium carbonate?

constipation

What are 3 key counselling points with calcium?

separate from other meds
vitamin D to aid in absorption
< 500 mg elemental per dose

Which SSRIs have been shown to help with PMS?

citalopram
escitalopram
fluoxetine
paroxetine
sertraline

Which symptoms of PMS can SSRIs help with?

cognitive > physical -PMDD > PMS

Which doses of SSRIs are effective for PMS?

effective at low or high doses

Does the effectiveness of SSRIs in PMS mean the patient has depression?

effectiveness does not equate diagnosis of depression

What is the onset of SSRIs in PMS?

effect in 1st cycle -can be effective within days and usually within 4 weeks

What is the evidence for SNRIs in PMS?

less support for SNRIs

How are SSRIs dosed for PMS?

continuous use OR limited to luteal phase OR @ symptom onset

Why dont SSRIs take 6-8 weeks to work in PMS?

the cyclical nature of PMS and may reflect SSRI action at a different receptor site than those involved in affective disorders

What is an adequate trial of SSRIs for PMS?

2 cycles -increase dose if partial response; switch SSRI if no response

Which doses of SSRIs are preferred for PMS?

small doses to minimize transient adverse effects

What is symptom relapse associated with for SSRIs in PMS?

severity of symptoms

When should an SSRI taper be considered in PMS?

if using higher doses to minimize withdrawal

Which symptoms of PMS can NSAIDs help with?

headache breast pain muscle aches

How should NSAIDs be initiated in PMS?

start at onset of pain

How should NSAIDs be dosed in PMS?

short-term, lowest effective dose

If headache is a main complaint in PMS, which OTC agent can be tried?

acetaminophen

Which symptoms of PMS might pyridoxine help with?

excitatory symptoms -anxiety, irritability, panic attacks

What is the theory for how pyridoxine works in PMS?

decreased B6 --> increased prolactin --> edema + psychological symptoms

What is the role of pyridoxine in the body?

co-factor in the synthesis of tryptophan and tyrosine --> serotonin and dopamine, certain PGs -balances the inhibitory : excitatory amine ratio

What is the dose of pyridoxine for PMS?

50-100 mg po daily - > 200 mg = peripheral neuropathy reported

What is the most widely prescribed therapy for PMS?

oral contraceptives -despite mixed evidence

What is the MOA of oral contraceptives in PMS?

inhibit ovulation -but PMS symptoms not connected to ovulation like dysmenorrhea is

Which symptoms of PMS might oral contraceptives help with?

physical and cognitive symptoms

Which type of oral contraceptive product is preferred for PMS?

monophasic

True or false: progestin only products are a good option for PMS

false

What is an option for those who suffer from severe PMDD and want contraception?

estrogen + drosperinone

What is the benefit of estrogen + drosperinone in PMS?

modest at best for fluid retention

What are some miscellaneous agents that might be used for PMS?

pamabrom or caffeine or pyrilamine -benefit mild at best other antidepressants -all less support than SSRIs benzodiazepines -prn only, concern for dependence/tolerance spironolactone -fluid retention only GnRH analogues or danazol -severe, unresponsive cases of PMDD only

What are some natural health products that might be used for PMS?

chasteberry -potentially similar to fluoxetine; varied doses magnesium -maybe for fluid retention; causes diarrhea evening primrose oil -cyclical mastalgia only, no better than placebo St Johns Wort -considered insufficient evidence for PMS vitamin E ginkgo