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Bushra's gyne GTG > Premenstrual Syndrome > Flashcards

Premenstrual Syndrome Flashcards

1
Q

How is premenstrual syndrome (PMS) diagnosed?

A
  • When clinically reviewing women for PMS, symptoms should be recorded prospectively, over two cycles using a symptom diary, as retrospective recall of symptoms is unreliable.
  • A symptom diary should be completed by the patient prior to commencing treatment.
  • Gonadotrophin-releasing hormone (GnRH) analogues may be used for 3 months for a definitive diagnosis if the completed symptom diary alone is inconclusive
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2
Q

When should women with PMS be referred to a gynaecologist?

A

Referral to a gynaecologist should be considered when simple measures (e.g. combined oral contraceptives [COCs], vitamin B6, selective serotonin reuptake inhibitors [SSRIs]) have been explored and failed and when the severity of the PMS justifies gynaecological intervention.

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3
Q

Who are the key health professionals to manage women with severe PMS?

A

Women with severe PMS may benefit from being managed by a multidisciplinary team comprising a general practitioner, a general gynaecologist or a gynaecologist with a special interest in PMS, a mental health professional (psychiatrist, clinical psychologist or counsellor) and a dietician.

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4
Q

Are complementary therapies efficacious in treating PMS?

A

Women with PMS should be informed that there is conflicting evidence to support the use of some complementary medicines.

  • An integrated holistic approach should be used when treating women with PMS.
  • Interactions with conventional medicines should be considered.
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5
Q

Is there a role for cognitive behavioural therapy (CBT) and other psychological counselling techniques?

A

When treating women with severe PMS, CBT should be considered routinely as a treatment option.

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6
Q

Which COC has the best evidence for managing PMS, including regimens delivering ethinylestradiol?

A

When treating women with PMS, drospirenone-containing COCs may represent effective treatment for PMS & should be considered as first-line pharmaceutical intervention.

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7
Q

What is the optimum COC pill regimen, e.g. continuous, cyclical or flexible?

A
  • When treating women with PMS, emerging data suggest use of the contraceptive pill continuously rather than cyclically.
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8
Q

How efficacious is percutaneous estradiol?

A
  • Percutaneous estradiol combined with cyclical progestogens has been shown to be effective for MX of physical and psychological symptoms of severe PMS.
  • When treating women with PMS, alternative barrier or intrauterine methods of contraception should be used when estradiol is used to suppress ovulation.
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9
Q

How can the return of PMS symptoms be avoided during estrogen therapy with progestogenic protection?

A
  • When using transdermal estrogen to treat women with PMS, lowest possible dose of progesterone or progestogen is recommended to minimise progestogenic adverse effects.
  • Women should be informed that low levels of LNG released by LNG-IUS 52 mg can initially produce PMS-type adverse effects (as well as bleeding problems).
  • Micronised progesterone is theoretically less likely to reintroduce PMS-like symptoms and should therefore be considered as first line for progestogenic opposition rather than progestogens.
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10
Q

What is the optimum regimen for prevention of endometrial hyperplasia?

A
  • When treating women with percutaneous estradiol, cyclical 10–12 day course of oral or vaginal progesterone or long-term progestogen with LNG-IUS 52 mg should be used for prevention of endometrial hyperplasia.
  • When using a short duration of progestogen therapy, or in cases where only low doses are tolerated, there should be a low threshold for investigating unscheduled bleeding
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11
Q

What is the safety of estradiol on the premenopausal endometrium and breast tissue?

A

When treating women with PMS using estradiol, women should be informed that there are insufficient data to advise on the long-term effects on breast and endometrial tissue.

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12
Q

For how long can estradiol be used safely and what is the risk of recurrence?

A

Due to the uncertainty of the long-term effects of opposed estradiol therapy, treatment of women with PMS should be on an individual basis, taking into account the risks and benefits.

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13
Q

What is the evidence for efficacy and adverse effects of danazol in the treatment of PMS?

A
  • Women with PMS should be advised that, although treatment with low dose danazol (200 mg twice daily) is effective in the luteal phase for breast symptoms, it also has potential irreversible virilising effects.
  • Women treated with danazol for PMS should be advised to use contraception during treatment due to its potential virilising effects on female fetuses.
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14
Q

How effective are GnRH analogues for treating severe PMS?

A
  • GnRH analogues are highly effective in treating severe PMS.
  • When treating women with PMS, GnRH analogues should usually be reserved for women with most severe symptoms and not recommended routinely unless they are being used to aid diagnosis or treat particularly severe cases
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15
Q

How should women with PMS receiving add-back therapy be managed?

A
  • When treating women with severe PMS using GnRH analogues for more than 6 months, addback hormone therapy should be used.
  • When add-back hormone therapy is required, continuous combined HRT or tibolone is recommended.
  • Women should be provided with general advice regarding the effects of exercise, diet and smoking on bone mineral density (BMD).
  • Women on long-term treatment should have measurement of BMD (ideally by dual-energy X-ray absorptiometry [DEXA]) every year. Treatment should be stopped if bone density declines significantly.
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16
Q

Can GnRH analogues be useful in clarification of diagnostic category?

A

When the diagnosis of PMS is unclear from 2 months’ prospective Daily Record of Severity of Problems (DRSP) charting, GnRH analogues can be used to establish and/or support a diagnosis of PMS.

17
Q

What is the role for progesterone and progestogen preparations in treating PMS?

A
  • There is good evidence to suggest that treating PMS with progesterone or progestogens is not appropriate.
  • There is no evidence to support the use of the LNG-IUS 52 mg alone to treat PMS symptoms. Its role should be confined to opposing the action of estrogen therapy on the endometrium.
18
Q

How do selective SSRIs work in PMS and how should they be given?

A

SSRIs should be considered one of the first-line pharmaceutical management options in severe PMS.

19
Q

What is the efficacy of SSRIs in treatment of PMS?

A

When treating women with PMS, either luteal or continuous dosing with SSRIs can be recommended.

20
Q

Is there any evidence on how SSRIs should be discontinued when used in PMS?

A

SSRIs should be discontinued gradually to avoid withdrawal symptoms, if given on a continuous basis.

21
Q

What are the risks and adverse effects of SSRIs?

A

Women with PMS treated with SSRIs should be warned of the possible adverse effects such as nausea, insomnia, somnolence, fatigue and reduction in libido

22
Q

Is there evidence for improved efficacy with other SSRI regimens?

A

When using SSRIs to treat PMS, efficacy may be improved and adverse effects minimised by use of luteal-phase regimens with the newer agents.

23
Q

What preconception & early pregnancy advice should be given regarding SSRIs/serotonin–noradrenaline reuptake inhibitors (SNRIs)?

A
  • Women should be provided with prepregnancy counselling at every opportunity. They should be informed that PMS symptoms will abate during pregnancy and SSRIs should therefore be discontinued prior to and during pregnancy.
  • Women should be informed how to safely stop SSRIs.
  • Women with PMS who become pregnant while taking an SSRI/SNRI should be aware of possible, although unproven, association with congenital malformations. They should be reassured that if such an association does exist, it is likely to be extremely small when
    compared to the general population.
24
Q

Are diuretics efficacious in the treatment of PMS?

A

Spironolactone can be used in women with PMS to treat physical symptoms.

25
Q

Can surgical management of PMS be justified and is it efficacious?

A
  • When treating women with severe PMS, hysterectomy and bilateral oophorectomy has been shown to be of benefit.
  • When treating women with PMS, hysterectomy and bilateral oophorectomy can be considered when medical management has failed, long-term GnRH analogue treatment is required or other gynaecological conditions indicate surgery.
26
Q

Should the efficacy of surgery always be predicted by the prior use of GnRH analogues?
.

A

When treating women with PMS, surgery should not be contemplated without preoperative use of GnRH analogues as a test of cure and to ensure that HRT is tolerated

27
Q

What is the role of HRT after surgical management?

A

Women being surgically treated for PMS should be advised to use HRT, particularly if they are younger than 45 years of age.

28
Q

Is there a role for endometrial ablation, oophorectomy or hysterectomy alone?

A
  • When treating women with severe PMS, endometrial ablation and hysterectomy with conservation of the ovaries are not recommended.
  • Bilateral oophorectomy alone (without removal of the uterus) will necessitate the use of progestogen as part of any subsequent HRT regimen and this carries a risk of reintroduction of PMS-like symptoms (progestogen-induced premenstrual disorder).
29
Q

First line MX of PMS

A
  • Exercise, cognitve behavioural therapy, vitamin B6
  • Combined new generaton pill (cyclically or continuously)
  • Contnuous or luteal phase (day 15–28) low dose SSRIs, e.g. citalopram/escitalopram 10 mg
30
Q

Second line MX of PMS

A
  • Estradiol patches (100 micrograms) + micronised progesterone (100 mg or 200 mg [day 17–28], orally or vaginally) or LNG-IUS 52 mg
  • Higher dose SSRIs contnuously or luteal phase, e.g. citalopram/escitalopram 20–40 mg
31
Q

Third line MX of PMS

A
  • GnRH analogues + add-back HRT (contnuous combined estrogen + progesterone [e.g. 50–100 micrograms estradiol patches or 2–4 doses of estradiol gel combined with micronised progesterone 100 mg/day] or Tbolone 2.5 mg)
32
Q

Fourth line MX of PMS

A

Surgical treatment ± HRT

33
Q 
Symptoms cyclical and  relieved by menstruation
Symptom-free week
- No influence on quality of life
Menstruation
No additonal factors
A
  • Physiological (mild) premenstrual disorder

- Counselling and reassurance required, no need for treatment

34
Q 
Symptoms cyclical and  relieved by menstruation
Symptom-free week
- Affects quality of life
Menstruation
No additonal factors
A
  • Core premenstrual disorder (premenstrual syndrome
    or premenstrual dysphoric disorder)
  • Consider all alternative approaches to treatment
35
Q 
Symptoms cyclical and  relieved by menstruation
- No symptom-free week
- Affects quality of life
Menstruation
- Existing non-menstrual condition
A
  • Premenstrual exacerbation
  • Treatment should aim to treat underlying medical,
    physical. or psychiatric condition or suppress ovulation (or both)
36
Q 
Symptoms cyclical, 
Symptom-free week, 
- Affects quality of life, 
- No menstruation,
No additional factors
A
  • Premenstrual disorder with absent menstruation

- Treat as core premenstrual disorder

37
Q 
Symptoms cyclical and relieved by menstruation
Symptom-free week
- Affects quality of life 
Menstruation
- Progestogen treatment
A
  • Progestogen induced premenstrual disorder

- Alternative progesterone treatment

38
Q 
Non-cyclical symptoms, 
No symptom-free week
- Constant influence on quality of life
Menstruation
No additional factors
A
  • Underlying psychological disorder, not premenstrual disorder
  • Psychiatric referral

Bushra's gyne GTG (11 decks)

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