Premenstrual Syndrome Flashcards
Premenstrual Syndrome is defined as…
A cyclic recurrence of physical +/- behavioural symptoms that occur during the luteal phase of the menstrual cycle
After ovulation, Before onset of menses
DOES affect ~90% of people who menstruate at some point
PMDD (premenstrual dysphoric disorder) is different from PMS by being…
More severe, disruptive of daily life, and greater presence of mood symptoms
Premenstrual exacerbation refers to…
Worsening of other disorders during the premenstrual phase
Ex: thyroid, migraine
Cognitive symptoms associated with PMS include…
Agression, anger, irritability
Anxiety, depression, panic attacks
Fatigue, lethargy
Sudden mood changes
Physical symptoms associated with PMS may include…
Nausea, vomiting, constipation - appetite changes
Breast pain, headaches, muscle aches, pelvic heaviness
Dizziness, hot flashes
Weight gain, bloating, fluid retention
Theories to explain PMS include…
Hormonal fluctuations (oversensitivity to progestins)
Dysregulation of neurotransmitter systems (serotonin)
Nutritional deficiencies (calcium)
In order for a PMS diagnosis, nature of symptoms need to be…
Present during luteal phase and absent during follicular phase
Reach peak shortly before beginning of menstruation + subside at onset of menses
Severe enough to interfere with daily functioning + interpersonal relationships
Also consider exclution of other disorders
PMS diagnosis requires…
5+ symptoms that change in severity throughout cycle
NEEDS to be cyclic for at least 2 cycles
Remember to consider exclusion of other disorders
PMDD diagnosis requires…
5+ symptoms, with at least 1 severe mood symptom for at least 2 cycles
Needs to result in functional impairment
Remember to consider exclusion of other disorders
Goals of therapy for PMS treatment include…
Relieve symptoms
Minimize functional impairment
Lifestyle modifications for PMS may include…
Reflexology, massage, acupuncture, etc. (not rigourously studied, likely in combination with Rx)
Appropriate sleep hygiene
Moderate exercise may help with breast tenderness, fluid retention, stress, depression
Dietary modifications are not well studied but could potentially be worth a try. Some dietary modifications and how they may help include…
Decreasing methylxanthine containing foods + caffeine - may improve breast symptoms
Increasing complex carb intake - lessen appetite changes + cognitive symptoms
Decreasing salt intake - help with fluid retention, weight gain, bloating, breast swelling + tenderness
May be appropriate for mild symptoms and combination with other therapies
Mainstay of therapy for PMS is…
2
Calcium carbonate
SSRI’s
Effective for some symptoms
Calcium carbonate may help with the following PMS symptoms:
Negative affect
Fluid retention
Food cravings
Pain
Also helps to prevent osteoporosis
Dose of calcium carbonate that was studied is ____. Important factors regarding proper absorption includes…
1200mg (elemental) daily
<500mg elemental per dose for absorption purposes, separate from other medication, Vitamin D to aid in absorption
Main AE with calcium is…
Constipation
SSRI’s tend to be more effective for ____ symptoms rather than ____ symptoms
Cognitive rather than physical
Therefore tend to be more effective for PMDD over PMS
Doses of SSRI’s show effectiveness…
At both low and high doses
Effectiveness of an SSRI for PMS/PMDD does not equate…
A diagnosis of depression
Onset of effect for SSRI’s in PMS/PMDD is…
In the 1st cycle, can be seen within days and usually within 4 weeks
Potentially may be due to cyclical nature of PMS, or SSRI action at different receptor site compared to those in other disorders
Reasonable trial for calcium is…
3 months
SSRI’s can be used…
Timeline?
Continuously OR limited to luteal phase OR at symptom onset
Consider that symptom relapse can occur upon longer discontinuation
Small/minimally effective doses of SSRI’s are best because…
We can minimize transient AE’s
Notable AE’s with SSRI’s include…
HANDS (headache, anxiety, nausea, diarrhea, sleep issues)
Risk of serotonin syndrome
Sexual dysfunction
Always a good idea to check for drug interactions
NSAID’s can be helpful for these PMS symptoms…
Headache, breast pain, muscle aches
NSAID’s should be started at ____, and the dose should be…
Onset of pain - lowest effective dose for short-term
Thjs could help with differential diagnosis of dysmenorrhea
Pyridoxine (vitamin B6) may be helpful for…
Excitatory symptoms - anxiety, irritability, panic attacks
VItamin B6 may help with PMS excitatory symptoms because it is…
A co-factor in synthesis of tryptophan and tyrosine, helping with formation of serotonin and dopamine and certain prostaglandins
Balances inhibitory:excitatory amine ratio
Evidence of pyridoxine for PMS is…
Mixed + inconsistent
Pyridoxine should not exceed certain doses because ____ was reported.
Peripheral neuropathy
Otherwise, safe and well-tolerated
Oral contraceptives for PMS may help with…
Physical + cognitive symptoms
Option for those who suffer from severe PMDD AND want contraception
This type of oral contraceptive is preferred…
Monophasic, combined.
NOT progestin only
Most common oral contraceptives for PMS is…
Any with estrogen + drosperinone: has anti-mineralocorticoid progestin (which can help with fluid retention)
Are we concerned about VTE with COC usage for PMS?
Slightly higher incidence in the first few months… however, low-quality observational evidence
Pamabrom, caffeine, or pyrilamine for PMS showed…
Mild benefit at best
Would other antidepressants have a benefit for PMS?
All have less support than SSRI’s
Benzodiazepines could be used…
PRN - potential concern for dependence/tolerance
Spironolactone could be used for PMS, only for…
Fluid retention
Watch potassium !!
For severe, unresponsive cases of PMDD, we could try…
GnRH analogues
Danazol
Will result in a pseudomenopausal state + side effects
Natural health products that patients may try for PMS may include…
And their evidence?
Chasteberry (potentially similar to fluoxetine)
Magnesium (fluid retention, causes diarrhea)
Evening primrose oil
St. John’s Wort
Vitamin E
Ginkgo
Provide realistic expectations, and remember product quality concerns
