week 3- PMS and PMDD Flashcards
premenstrual syndrome (PMS)
a group of physical (somatic) and behavioural (affective) changes that are cyclical and repetitive, leading to substantial distress and impairment in functional capacity in the luteal phase
premenstrual dysphoric disorder (PMDD)
severe mood and physical symptoms usually starting about one to two weeks before the start of menses (during the luteal phase) with symptoms subsiding within a few days of menses onset.
Premenstural exacerbation (PME)
premenstrual worsening of the symptoms of another disorder, such as MDD, GAD, IBS, migraines and asthma, in the luteal phase (not an official DSM diagnosis)
when does PMS occur
luteal phase
how are PMS and PMDD related
PMDD is a severe extension of PMS (more symptoms, distress, and impairment)
% of premenopausal women with PMS and PMDD (in the US)
20-32% PMS
3-8% PMDD
who gets most PMS
female university students
factors to PMS
physiological, psychosocial, and hormonal
genetics
nutritional deficients
stress, high BMI, PPTSD, substance use, affect disorders (i.e MDD), caffeine
PMS mechanism
altered sensitivity to the normal hormonal fluctuations
which nutritional deficiencies are in PMS
Ca***
Ca, Mg, Mn, vitamins: D, B6, E; linoleic acid
PMDD mechanism
altered CNS sensitivity to normal hormonal changes
normal gonadal steroid hormones (estrogen, progesterone) but enchanced amygdala and diminished frontocortical activation to emotional stimuli
PMDD and risk
genetics
history of depression
brain mechanism in PMDD
more amygalda less frontocortical
symptoms of PMS/ PMDD
cognitive/behavioural:::
aggression, irritability, anger lethargy
anxiety
mood lability
depression
panic attacks
fatigue
poor concentration, forgetfulness reduced coping skills
hostility
physical:::
acne
headache
appetite change, craving sweets
hot flashes
bloating, fluid retention, oliguria muscle aches, breast pain or swelling nausea and vomiting, constipation pelvic heaviness or pressure dizziness or vertigo
weight gain
symptoms of PMS with highest odds ratio
anxiety/tension
no interest in usual activities
aches
mood swings
food cravings
cramps
symptom timing of PMS
at each ovulatory cycle (for ~6 days)
usually in 20s
ACOG criteria for PMS
> =1 affective and somatic symptom during 5 days before menses (and disappear within 4 days of onset of menses) for 3 previous menstrual cycles
- affective symptoms: angry outbursts, anxiety, confusion, depression, irritability, social withdrawal
- somatic symptoms: abdominal bloating, breast tenderness/swelling, headache, joint or muscle pain, swelling of extremities, weight gain
**in absence of hormone injections, drugs, pharm etc
**symptoms need to be in 2 cycles of prospective recording
**dysfunction in social, academic or work
DSM-5 criteria for PMDD
> 5 symptoms 1 week before menses and gets better within a few days of menses
1 or more of these:::
a. Marked affective lability (e.g. mood swings, feeling suddenly sad or
tearful, or increased sensitivity to rejection)
b. Marked irritability or anger or increased interpersonal conflicts
c. Marked depressed mood, feelings of hopelessness, or self-depreciating
thoughts
d. Marked anxiety, tension, and/or feelings of being keyed up or on edge
1 or more of these:::
a. Decreasedinterestinusualactivities(e.g.work,school,friends,hobbies)
b. Subjectivedifficultyinconcentration.
c. Lethargy, easy fatigability, or marked lack of energy.
d. Marked change in appetite; overeating; or specific food cravings.
e. Hypersomnia or insomnia.
f. Physical symptoms such as breast tenderness or swelling, joint or
muscle pain, a sensation of “bloating” or weight gain.
**criteria met for most menstural cycles the preceding year
**cause distress or interfere with activiites
**not exacerbation of other disorder (i.e. depressive, panic)
**give daily rating for 2 cycles
**not from drugs or medicines
retrospective vs prospective tools for PMS tracking
retrospective questionnaires
- Premenstrual Symptom Screening Tool (PSST)
- Premenstrual Assessment Form (PAF)
- Rating Scale for Premenstrual Tension Syndrome (PMTS)
prospective symptom tracking/diaries
- Daily Record of Severity of Problems (DRSP)
- Calendar of Premenstrual Experiences (COPE)
- Premenstrual Experience Assessment (PEA)
- Menstrual Distress Questionnaire (MDQ)
- Prospective Record of the Impact and Severity of
Menstrual Symptomatology (PRISM)
Premenstrual Symptoms Screening Tool (PSST)
rank severity of the following
i.e.
anger
anxiety
depressed mood
decrease interest
overwhelmed
hypersomnia
weight gain, bloat, headache
interfere with-
etc.
most accurate way to diagnose PMS and PMDD
prospective questionnaire
daily record of severity of problems (DRSP)
depressed, anxious, mood swings, concentrate, activities, cravings, tender breast, headache etc
score > 50 on first day of menses = PMS ????? idk slide 33
LR+
premsntural symptoms screening tool LR+=1.18
daily record of severity of problems LR+= 4.07
Carolina premenstrual assessment scoring system (C-PASS)
to make DSM-5 diagnosis of PMDD using 2 cycles of symptoms on the daily record of severity of problems (DRSP)
Carolina premenstrual assessment scoring system (C-PASS) looks at which weeks of data from daily record of severity of problems (DRSP)
compares data from days -7 to -1 (premenstrual week) and days 4 to 10 (postmenstrual week)
DDX for PMS or PMDD
- dysmenorrhea
- endometriosis
- physiologic ovarian cysts or
polycystic ovary syndrome - hypothyroidism (sometimes hyper)
- anemia
- fibrocystic breast changes
- diabetes
- chronic fatigue syndrome
- perimenopause
- substance abuse disorders
- affective disorders (e.g. anxiety,
depression) - migraine headaches
- irritable bowel syndrome - arthritis or arthralgia
- anorexia or bulimia
- adverse effects from oral contraceptive (OCP)
different between PMDD vs PME vs stable affective disorder (diagram of slide 37)
the affective disorder is consistent throughout the month but the PMDD spikes right before menses and is low rest of month
DDX difference for PMS/PMDD and
dysmenorrhea
pain associated with menstrual flow
DDX difference for PMS/PMDD and
endometriosis
pain can occur at any time in menstrual cycle, but often intense pain with menstrual flow; may also have digestive or mood symptoms
DDX difference for PMS/PMDD and
polycystic ovaries
menstrual irregularity, acne/elevated androgens, ovarian cysts
DDX difference for PMS/PMDD and
hypothryoidism
non-cyclic fatigue, mood and weight changes
DDX difference for PMS/PMDD and
anemia
non-cyclic fatigue, mood, weakness and difficulty concentrating
DDX difference for PMS/PMDD and
fibrocystic breast changes
pain can vary throughout the cycle, increased discomfort in premenstrual phase
DDX difference for PMS/PMDD and
diabetes
changes in appetite, urination and weight
DDX difference for PMS/PMDD and
perimenopause
life stage, symptoms can be more persistent
DDX difference for PMS/PMDD and
affective disorder
absence of symptom-free week in follicular phase
DDX difference for PMS/PMDD and
adverse effect of oral contraceptive pill
more persistent effects on mood, headache, breast tenderness, nausea and weight starting from initiating treatment - esp. in initial months
follicular phase in PMS/ PMDD is
symptoms free
only bad during luteal phase
iron deficiency anemia
low level of red blood cells or hemoglobin on complete blood count
how many menstruating females have iron deficiency anemia
10%
sx of iron deficiency anemia
fatigue, tachycardia, palpitations, dyspnea on exertion
blood work of iron defiicney anemia
pallor
low hemoglobin
low hematocrit
low ferritin
in iron deficiency anemia how long to restore ferritin and hemoglobin levels after treatment
typically ferritin restored after 6 months of iron therapy, Hb in 6-8 weeks
primary hypothryoid TSH and T4 levels
high TSH, low T4
sx of primary hypothryoid
weight gain, fatigue, lethargy, depression, weakness, dyspnea on exertion, arthralgias or myalgias, muscle cramps, menorrhagia, constipation, dry skin, hair changes (dryness, thinning, loss), headache, paresthesias, carpal tunnel syndrome, raynaud syndrome, cold intolerance, voice changes
major depressive disorder (MDD)
1+ episodes with 5+ symptoms (1 being dysphoria or anhedonia) for at least 2 consecutive weeks
sx of depression
weight gain, fatigue, lethargy, depression, weakness, dyspnea on exertion, arthralgias or myalgias, muscle cramps, menorrhagia, constipation, dry skin, hair changes (dryness, thinning, loss), headache, paresthesias, carpal tunnel syndrome, raynaud syndrome, cold intolerance, voice changes
diagnose depression
PHQ-9
- frequency: most of the day, nearly every day for at least (≥) 2 weeks
- character: ≥ 5 depressive symptoms, including dysphoria or anhedonia
how to diagnose PMS or PMDD
diagnosis of exclusion
NO labs recommended
use PSST to screen
follow 2 month prospective monitoring of sx
labs to help rule out of things from PMS or PMDD
- CBC, B12, ferritin - anemia
- TSH (possibly free T4) - hypothyroidism
- FSH, LH, E2 - perimenopause
- FSH, LH, testosterone - PCOS
- FBS, HbA1c - diabetes
- urine drug screen - substance abuse
- ultrasound or mammography - fibrocystic breast changes
- PHQ-9 - major depressive disorder
- GAD-7 - generalized anxiety
physical exam in PMS PMDD
unremarkable; rarely clinically detectable edema
how many cycles does a woman have in her reproductive years? days of PMS symptoms? how many days of suffering?
459-481 cycles
6.2 days of severe PMS sx
2800 days (7.1 yrs) of suffering
PMS prognosis
sx return after stopping treatment
psych issue- suicide, depression (78.8% of passive suicidal ideation in PMDD)
what is considered effective treatment of PMS/PMDD
at least a 50% reduction of luteal phase symptoms, or the difference between follicular and luteal phase symptoms are decreased by at least 30%
universal screening question for PMS
“do your symptoms change across your cycle?”
if yes or unsure –> Premenstrual Symptoms Screening Tool (PSST) –> if moderate/ severe –> daily tracking for 2 cycles
PMS vs PMDD vs PME diagnosis
PMS is applicable if at least 1 somatic and 1 affective symptom present.
PMDD is applicable if 5 or more symptoms are moderate to severe in luteal
phase, then remit to minimal to absent by end of menses.
PME is applicable if chronic symptoms become worse before or during menses.
PMS diagnosis (ACOG)
> = 1 affective and somatic symptom
distress
for 2 cycles
NOT exacerbation of other disorder
NOT from medical condition
PMDD diagnosis (DSM5)
5 symptoms, >= 1 emotional
distress or impair
2 cycles
NOT exacerbation of other disroder
NOT from meds
