premenstrual syndrome and premenstrual dysphoric disorder

Question 1

A 34 yo patient reports a history of emotional lability, crying, irritability and anger one to two weeks prior to menses for about six months. She denies difficulty at work or at home when she is not premenstrual.

Answer 1

You ask the patient to keep a symptom diary for two or three cycles. When the patient returns, her diary reflects a likely diagnosis of premenstrual syndrome. You counsel her about the disorder and offer her treatment with fluoxetine for two weeks prior to menses. The patient begins treatment and notices that her symptoms improve.

Question 2

Premenstrual syndrome (PMS)

Answer 2

-Changes in physical and mental well-being that occur in a cyclical manner and are related to the luteal phase of the menstrual cycle
-Affects up to 80% of cisgender women of reproductive age
-May present at any time in reproductive life
-Increased risk among twins

-Etiology
-Unknown
-May involve physiologic hormonal changes due to ovarian cycles
-Possibly due to changes in serotonin due to cyclic hormonal fluctuation
-Less serotonin available in luteal phases due to effects of estrogen and progesterone

Question 3

premenstrual syndrome: sx

Answer 3

-abdominal bloating
-fatigue
-mastodynia
-H/A
-acne
-GI upset
-dizziness

-Common mental sx:
-Anxiety
-Depressed mood
-Irritability
-Sadness
-Hostility
-Increased appetite
-Difficulty in concentration
-Changes in libido

Question 4

dx criteria of premenstrual syndrome

Answer 4

-at least 1 of the following affective and somatic symptoms during the 5 days before menses in each of 3 menstrual cycles
-Symptoms are relieved within 4 days of onset of menses
-Symptoms do not recur until cycle day 13
-The patient suffers from identifiable dysfunction in social or economic performance

-Somatic sx:
-Mastalgia
-Abdominal bloating
-Headache
-Swelling of extremities
-Weight gain
-Joint or muscle pain

-Affective sx:
-Depression
-Angry outbursts
-Irritability
-Anxiety
-Confusion
-Social withdrawal

-Symptom diary documenting defining symptoms as noted above for at least two consecutive menstrual cycles
-Document all symptoms that occur as well as onset of bleeding and when symptoms abate
-Also have the patient monitor severity of symptoms

Question 5

PMS diff dx

Answer 5

-breast disorders
-chronic fatigue
-anemia
-lyme ds
-connective tissue disorders
-substance abuse
-endocrinologic disorders
-Cushing’s syndrome and hypoadrenalism
-Thyroid disorders
-Stress
-Gastrointestinal conditions
-Irritable bowel disease
-Pelvic inflammatory disease

Question 6

management of PMS

Answer 6

-Dietary and lifestyle changes
-More fresh fruits and vegetables
-Minimize refined sugars, fats
-Decreased alcohol consumption
-Smoking cessation
-Increased aerobic exercise
-Calcium supplementation
-Vitamin B6 and vitamin E supplementation
-Other alternative therapies (yoga, acupuncture, etc.) may be of benefit (or not)

-Additional tx:
-Spironolactone for fluid retention
-Bromocriptine for mastalgia
-NSAIDs for physical symptoms
-Oral contraceptives- Consider strongly using an extended cycle OC
-Danazol
-GnRH agonists

Question 7

management of severe sx

Answer 7

-Selective serotonin reuptake inhibitors (SSRIs)
-May be used continuously or only during the luteal phase
-Sertraline
-Paroxetine
-Other SSRIs and serotonin-norepinephrine reuptake inhibitors (off label use)

-Atypical antipsychotics to be used continuously for 3 menstrual cycles
-Oral contraceptives (esp. extended cycle OCs)

Question 8

premenstrual dysphoric disorder (PMDD)

Answer 8

-<5% of women of reproductive age
-may occur at any time in reproductive life
-affects pts more significantly than PMS
-similar or identical to sx to PMS however ->

-In most cycles in past year, ≥5 of the following were present most of the time in last week of the luteal phase, improved within a few days of menses, and were absent in the first week after menses
-One of the first 4 symptoms listed below in ! is present:

!-1. Markedly depressed mood, feeling hopeless, self-deprecation
!-2. Marked anxiety, tension, feeling “on edge”
!-3. Suddenly feeling sad or tearful, increased sensitivity to personal rejection
!-4. Persistent and marked irritability, anger, increased interpersonal conflicts
-5. Decreased interest in usual activities
-6. Subjective sense of difficulty in concentration
-7. Lethargy, fatigue or marked lack of energy
-8. Marked change in appetite and cravings for certain foods
-9. Hypersomnia or insomnia
-10. Feeling overwhelmed or out of control
-11. Physical symptoms (mastodynia, H/A, myalgia, bloating, weight gain)

-Disturbance markedly interferes with daily activities (work, school, social life, etc.)
-Disturbance is not merely an exacerbation of another disorder
-All of the above, including symptoms, must be confirmed by prospective daily ratings (symptom diary) during at least 2 consecutive symptomatic cycles

Question 9

management of PMDD

Answer 9

-May try remedies recommended under treatment of PMS
-SSRI (fluoxetine, sertraline are particularly recommended)
-Consider anxiolytic if the patient does not respond

-Oral contraceptives
-Ethinyl estradiol and drospirenone found to be effective in PMDD

-GnRH agonists
-There is no long term study demonstrating the benefit of these agents, which may have significant side effects