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~ Premenstrual Syndrome ~
§ Definitions of premenstrual syndrome (PMS):
j The appearance of one or
more of a large constellation of symptoms (over 100) during the luteal phase,
occurring to such a degree that lifestyle or work is affected, followed by great diminishing or disappearance of
symptoms with the onset of menstruation or shortly afterward.
k The most frequently
encountered symptoms include the following: abdominal bloating, anxiety, breast tenderness, crying spells,
depression, fatigue, irritability, thirst and appetite changes, and variable
degrees of edema of the extremities ¾ usually
occurring in the last 7 to 10 days of the cycle.
ø Premenstrual
molimina:: Awareness of their menstrual cycle and knowing when their
period is about to start in
women.
ø Premenstrual
dysphoric disorder (PMDD): ~ emphasizing
affective symptoms
More impaired by premenstrual symptoms such as depression,
anxiety, mood swings, and
anger than by physical changes such as breast tenderness,
headaches, and bloating in
affected women.
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Whether PMS and PMDD are two points on a continuum or
represent biologically
distinct conditions is not known yet. However, researchers
suggest that they may
indeed be related conditions.
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§ Diagnosis:
Two qualities crucial
to the diagnosis: temporality and severity
PMS is diagnosed only
through clinical evaluation and prospective daily charting for at least two menstrual cycles.
Diagnostic evaluation:
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History and thorough
physical examination, including a pelvic examination, to rule outother causes of symptoms.
‚ Daily rating:
„ Ask
the patient to list 3 to 5 symptoms that bother her the most, and enter these
on a daily symptom checklist for PMS. Have the patient
tract these symptoms for 2 menstrual cycles and bring the checklist back to you.
„ Evaluate the
patient for PMDD. This is probably the best approach to the woman who reports marked impairment; it will allow you to see
if she meets formal diagnostic criteria and give you a sense of the nature and
severity of her symptoms.
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ø Diagnostic
criteria for PMDD:
The woman must have had 5 or more of the following 11
symptoms,
including at least 1 of the first four:
- Depression mood, feelings of hopelessness, or
self-deprecating thoughts
- Marked anxiety or tension; feeling “keyed up”
or “on edge”
- Significant mood lability
- Persistent anger or irritability; increased
interpersonal conflicts
- Decreased interest in usual activities
- Difficulty concentrating
- Lethargy, easy fatigability, or marked lack of
energy
- Changes in appetite, overeating, or food cravings
- Hypersomnia or insomnia
- A feeling of being overwhelmed or out of control
- Physical symptoms such as breast tenderness,
headache, joint or muscle pain,
bloating, or weight gain
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ƒ Avoiding diagnostic
pitfalls:
ò Do not diagnose
PMS too quickly.
ò Always think
about whether an unrelated medical condition may account for the patient’s symptoms, especially if the clinical
picture is atypical:
- Dysmenorrhea, endometriosis, perimenopausal
changes, thyroid dysfunction, diabetes, anemia, and lupus
erythematosus and other collagen vascular diseases
- Premenstrual exacerbation of a medical
disorder, such as migraine, asthma, allergies, irritable bowel
syndrome, arthritis, diabetes, and seizure disorders.
- A psychiatric disorder other than PMDD. The
psychiatric disorder may also be exacerbated premenstrually.
- Episodic symptoms not tied to the menstrual
cycle
§ Management:
Deciding on treatment:
ò For women who continue
to function without much impairment throughout the
luteal phase, even when symptoms are severe:
Ò Behavioral and
lifestyle interventions
ò For patients whose
symptoms cause psychosoical impairment or don’t respond to nonpharmacologic methods:
Ò Drug therapy
Nonpharmacologic
treatments:
² Patient education and
reassurance
² Stress reduction:
relaxation exercise, biofeedback, and reflexology.
² Diet:
- Carbohydrate-rich, low-protein foods during luteal
phase
- Avoid sources of caffeine
² Regular exercise
² Vitamin B6 and Calcium
Drug therapies:
² SSRIs
(selective serotonin reuptake inhibitors): - The first choice
² Anxiolytics: - Alprazolam
(XanaxR), the next choice when
SSRIs don’t work
² GnRH agonists
² Others: progesterone,
NSAIDs, bromocriptine mesylate, and diuretics.
Consider further
evaluation or referral in the following instances:
j You are
uncertain of the diagnosis after the patient has tracked her symptoms for 2
cycles.
k You suspect a comorbid
medical or psychiatric disorder.
l The patient is abusive,
violent, or suicidal.
m Standard dosages of
medication aren’t producing adequate relief.
n Psychiatric drugs
aren’t proving effective, and you’re uncomfortable prescribing GnRH agonists.
o The patient requires more
time than you’re able to give.
§ References:
1. PMS: new treatments that really work. Ellen W. Freeman,
PhD, Andrea M. Kielich, MD, and Steven S. Sondheimer, MD. Dec. 1999: 25-44.
Filename: Premenstrual Syndrome
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