Premenstrual syndrome

Question 1

PMS - definition (3)

Answer 1

1. Distressing psychological, physical, and/or behavioural symptoms
2. Occurrence during the luteal phase of the menstrual cycle (or cyclically after hysterectomy with ovarian conservation)
3. Significant regression of symptoms with onset of or during the period

Question 2

PMS - symptoms

Answer 2

1. Affective symptoms = depression, irritability, anxiety, increased appetite/food cravings
2. Most common physical symptoms = abdominal bloating and an extreme sense of fatigue
3. Other common somatic symtpoms = breast pain, bloating, swelling, headache
4. Recurrent onset of symptoms during the end of the luteal phase of the menstrual cycle with a symptom-free period shortly after menses has begun (usually when menstrual flow has ended)
5. Symptoms usually consistent across cycles. Last for average of 6d/mo. Moderate to severe PMS symptoms = disruption of work and interpersonal relationships, or interference with normal activities.

Question 3

PMS - dx (2)

Answer 3

1. If woman has one to four symptoms - may be physical, behavioural or affective/psychological in nature
2. Note - if a woman has five or more symptoms and one of them is an affective symptom (e.g. mood swings, anger, irritability), it is more accurate to dx her with premenstrual dysphoric disorder (PMDD)

Question 4

PMS - mx

Answer 4

Mild symptoms
1. Exercise
2. Relaxation techniques
Note - these may be from placebo effect. Limited evidence from rigorous controlled studies

Moderate to severe symptoms
(Note - before considering drug therapy, the presence of other conditions such as depression or anxiety disorder, substance abuse, or hypothyroidism should be investigated)
3. SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors). Typically use fluoxetine or sertraline. Beneficial effect can be expected in first cycle. Most problematic side effect = sexual dysfunction.
4. Second-line therapy = oral contraceptives, GnRH agonist therapy + low-dose estrogen-progestogen replacemenent if SSRIs or oral contraceptives ineffective (but there are significant masculinising side effects)
5. Surgery - last resort, in refractory cases with severe, disabling symptoms. Bilateral oophorectomy usually with concomitant hysterectomy. For PMDD only. GnRH must be the only medical approach that has been effective. Childbearing must be complete