Premenstrual Syndrome

1
Premenstrual Syndrome

• Dr Patel
• GP VTS

2
Aims

• To make an accurate diagnosis of premenstrual
  syndrome (PMS)
• To provide appropriate advice to women with PMS
• To offer options for treatment that are
  appropriate for initiation in primary care
• To refer the woman when primary care treatment is
  not adequate

3
Premenstrual Syndrome Modern Definition

• Distressing physical, psychological and
  behavioural symptoms, not caused by organic
  disease, which regularly recur during the same
  phase of the menstrual (ovarian) cycle and which
  significantly regress or disappear during the
  remainder of the cycle
• Magos Studd (1984)

4
What is Premenstrual Syndrome (PMS)

• distressing physical, behavioural, and
  psychological symptoms
• Regularly occur in the luteal phase of the
  menstrual cycle
• Significantly improved or resolved by the end of
  menstruation.
• Mild PMS ?
• symptoms do not interfere with the woman's
  personal, social, and professional life.
• Moderate PMS ?
• symptoms interfere with the woman's personal,
  social, and professional life. Daily functioning
  is possible, although maybe not to the usual
  level.
• Severe PMS ?
• the woman withdraws from social and professional
  activities and cannot function normally.
• If symptoms are predominantly emotional and
  behavioural, this is sometimes referred to as
  premenstrual dysphoric disorder

5
Common Symptoms

• More than 100 different symptoms of PMS have been
  recorded, but the most common are listed below.

6
Physical symptoms

• Fluid retention and feeling bloated
• Pain and discomfort in your abdomen
• Headaches
• Changes to your skin and hair
• Backache
• Muscle and joint pain
• Breast tenderness
• Insomnia (trouble sleeping)
• Dizziness
• Tiredness
• Nausea
• Weight gain (up to 1kg)

7
Psychological symptoms

• Mood swings
• Feeling upset or emotional
• Feeling irritable or angry
• Depressed mood
• Crying and tearfulness
• Anxiety
• Difficulty concentrating
• Confusion and forgetfulness
• Restlessness
• Decreased self-esteem

8
Behavioural symptoms

• Loss of interest in sex
• Appetite changes or food cravings
• Any chronic (long-term) illnesses, such as asthma
  or migraine, may get worse.

9
Premenstrual Dysphoric Disorder

• The symptoms of PMDD are similar to those of PMS,
  but more exaggerated.
• a small percentage of women have symptoms that
  are severe enough to stop them living their
  normal lives.
• They can include
• feelings of hopelessness
• persistent sadness or depression
• extreme anger and anxiety
• decreased interest in usual activities
• sleeping much more or less than usual
• very low self-esteem
• extreme tension and irritability
• PMDD can be particularly difficult to deal with
  because it can have a negative effect on your
  daily life and relationships.

10
What causes it ?

• The exact cause of premenstrual syndrome (PMS) is
  uncertain, but because it does not occur before
  puberty, in pregnancy, or after the menopause,
  cyclical ovarian activity is thought to
  contribute RCOG, 2007.

11
Suggested theory

• Hormone changes
• Chemical changes
• Weight and exercise
• Stress
• Diet

12
How common ?

• Mild PMS is experienced by many women.
• Around 5 of women have severe premenstrual
  symptoms RCOG, 2007.
• In the UK, only about a fifth of women
  experiencing PMS symptoms seek medical help.
  However, up to 13 of working women with PMS
  symptoms take time off during the year because of
  PMS MeReC, 2003.

13
Risk Factors

• Common in women whose mothers also experienced
  PMS symptoms (70)
• Monozygotic twins ? 93 concordance rate
• Dizygotic twins ? 44Bhatia and Bhatia, 2002.
• More common in women who are obese, do not
  exercise, and who have a lower level of academic
  achievement RCOG, 2007.
• Women using hormonal contraception are less
  likely to experience PMS RCOG, 2007.

14
Diagnosis of PMS

• Diagnosis ? Clinical
• Difficulty in diagnosis often occurs because PMS
  can present with a large number of symptoms which
  are common to a range of conditions Rapkin and
  Mikacich, 2008.
• Ask the woman to record a daily symptom diary for
  two or three cycles MeReC, 2003.
• Investigations are not usually helpful in making
  the diagnosis.

15
Conditions to exclude

• Depression
• Anxiety and panic disorders
• Hypothyroidism
• Anaemia
• Dysmenorrhoea
• Irritable bowel syndrome
• Interstitial cystitis
• Endometriosis
• Chronic fatigue syndrome
• Fibromyalgia
• Systemic lupus erythematosus

16
Managment

• Management should be tailored according to the
  severity and type of symptoms, and the woman's
  preferences and any desire to become pregnant.
• Mild symptoms
• Offer lifestyle advice.
• Regular, frequent (23 hourly), small balanced
  meals rich in complex carbohydrates.
• Regular exercise.
• Smoking cessation.
• Alcohol restriction.
• Regular sleep.
• Stress reduction.

17
Management

• Moderate PMS
• Offer lifestyle advice and consider
• A new-generation combined oral contraceptive
• UNLICENSED ? if used solely to treat PMS symptoms
• Can be used cyclically or continuously
• But the first-line choice of COC is not clear.
• More evidence to support
• the use of drospirenone-containing COCs (for
  example Yasmin) than other preparations
• desogestrel (for example Marvelon)
• norgestimate (for example Cilest) or gestodene
  (for example Femodene), may also be effective,
  especially if they have been used before and have
  been found to be of benefit.
• Inform the woman that it is not possible to
  predict whether her PMS symptoms will respond.
• Paracetamol or a nonsteroidal anti-inflammatory
  drug - if the predominant problem is pain
• Cognitive behavioural therapy (CBT referral is
  likely to be required) if it is thought the woman
  would benefit from psychological intervention.

18
Management

• Severe PMS
• Offer lifestyle advice and consider
• The treatment options outlined above for moderate
  PMS
• A selective serotonin reuptake inhibitor (SSRI)
• Unlicensed use
• Do not prescribe an SSRI ? doubt about the
  diagnosis, lt 18 yrs without advice a specialist
• taken either continuously or just during the
  luteal phase (for example days 1528 of the
  menstrual cycle, depending on its length).
• initial trial of 3 months' treatment ? benefit ?
  continue 6 months to 1 year.
• Monitor the woman's response to treatment
  closely, including asking about any thoughts of
  self-harm.

19
Managment

• 12 yrs onwards
• 1st line Lifestyle advice
• The following things may help to ease PMS.
• Eat regular, frequent, small balanced meals rich
  in complex carbohydrates.
• Take regular exercise.
• Stop smoking.
• Don't drink too much alcohol.
• Get regular sleep.

20
12yrs

• Paracetamol
• NSAIDs
• Mefanemic acid 500mg tds

21
Combined Oral Contraception

• Age from 13 to 50 years
• COCs monophasic
• EE 30-35mcg with drospirenone or norgestimate eg
  
• Yasmin drospirenone 3mg ethinylestradiol 30mcg
• Cilest norgestimate 250mcg ethinylestradiol
  35mcg
• EE 30mcg with gestodene or desogestrel
• Femodene gestodene 75mcg ethinylestradiol
  30mcg

22
Selective Serotonin Receptor Inhibitors

• 18yrs
• Fluoxetine 20mg od, Sertraline 50mg od,
  paroxetine 20mg od, citalopram 20mg od
• Luteal phase selective serotonin reuptake
  inhibitors (SSRIs)
• Fluoxetine, citalopram 20mg each morning on days
  15-28 of cycle

23
When should I refer a woman with premenstrual
syndrome?

• Refer the woman to a psychiatrist if there is
  marked underlying psychopathology in addition to
  premenstrual syndrome (PMS).
• Consider referral to a clinic with a specific
  interest in PMS (or a general gynaecology clinic
  if this is not available) if the symptoms are
  severe and appropriate primary care measures have
  been explored but have failed.

24
Evidence on treatments not recommended in primary
care

• Progesterone or progestogens used alone
• Antidepressants other than SSRIs
• Transdermal oestradiol
• Diuretics
• Vitamin B6 (pyridoxine)
• Calcium and vitamin D
• Magnesium
• Evening primrose oil
• Agnus castus (chaste tree)
• Alprazolam
• Gonadotrophin releasing hormone analogues eg
  Danazol
• Hysterectomy and bilateral salpingo-oophorectomy
  may be considered under certain circumstances in
  secondary care for women with severe PMS.