PMS_PMDD_Dysmenorrhea 20Cooksey 20Edits4 1 11 by HC111111052513

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									  Premenstrual Syndrome and
Premenstrual Dysphoric Disorder
             UNC School of Medicine
        Obstetrics and Gynecology Clerkship
            Case Based Seminar Series
              Objectives for PMS and PMDD
 Identify the criteria for making the diagnosis of
  Premenstrual Syndrome (PMS) and Premenstrual
  Dysphoric Disorder (PMDD)
 List treatment options for PMS and PMDD
                      Definition

PMS is a group of physical, mood-related, and behavioral
  changes that occur in a regular, cyclic relationship to
  the luteal phase of the menstrual cycle and interfere
  with some aspect of the patient’s life

PMDD identifies women with PMS who have more
  severe emotional symptoms (such as anger, irritability,
  and depression) that may require more extensive
  therapy
                    Incidence

 PMS symptoms - 75%- 85% of women
 Severe/debilitating PMS - 5-10% of women
 PMDD - 3-5% of women
          Spectrum of Premenstrual Syndromes



                                                                         Severe (PMDD)
                      Premenstrual                                      Moderate (PMS)
                       Syndrome
                         Severity
                                                                              Mild (PMS)
                                                                                   None




Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C
Gambone, Calvin J Hobel. Chapter 36 (387).
              PMS/PMDD: Symptoms

Somatic Symptoms
     Breast tenderness
     Abdominal bloating – most common, occurs in 90%
     Headache
     Swelling of extremities
     Weight gain
              PMS/PMDD: Symptoms

Affective Symptoms
     Depression
     Angry outbursts
     Irritability
     Anxiety
     Confusion
     Social withdrawal
     Decreased concentration
     Sleep disturbance
     Appetite change/food cravings
PMS/PMDD: Symptoms

           Sample: Daily Symptoms
                  Calendar

              Diagnostic tool used
              to assist the patient
               with recording her
            premenstrual symptoms
                      diary




        Endicott and Harrison 2006. 5.Endicott, J., & Harrison, W. Daily Record
        of Severity of Problems Calendar.
                   PMS: Diagnosis

 Patient reports 1 affective symptom and somatic symptom(s)
  during the luteal phase before menses
 Symptoms relieved within 4 days of onset of menses, without
  recurrence until at least cycle day 13
 Symptoms occur in 2 consecutive menstrual cycles
 Patient suffers from identifiable dysfunction in social or
  economic performance
                   PMDD: Diagnosis

DSM-IV Criteria
 Symptoms interfere with usual functioning and relationships
 Symptoms are not an exacerbation of another disorder
 Symptoms resolve at onset of menses
 Premenstrual timing is confirmed by menstrual calendar in 2
  consecutive cycles
                          PMDD: Diagnosis

DSM-IV Criteria
 At least 5 of 11 premenstrual symptoms
    At least 1 of the following:
          Depressed mood
          Marked anxiety
          Marked affective lability
          Marked irritability
    Other possible symptoms
          Decreased interest in regular activities
          Difficulty concentrating
          Lethargy/fatigue
          Appetite change/food cravings
          Sleep disturbance
          Feelings of being overwhelmed
          Physical symptoms (bloating, weight gain, breast tenderness, edema)
       PMS/PMDD: Differential Diagnosis

Rule out other diseases:
    Psychological disorders
       Depression, Bipolar disorders, Personality disorders, Anxiety
    Gynecologic disorders
       Dysmenorrhea, Endometriosis, Pelvic Inflammatory Disease, Perimenopause
    Endocrine disorders
       Thyroid disease, Adrenal disorders, True hypoglycemia
    GI conditions
       Inflammatory bowel disease, Irritable bowel syndrome
    Drug or substance abuse
    Chronic fatigue states
    PMS/PMDD: Treatment (Conservative)

 Supportive therapy
 Lifestyle changes
    Frequent exercise
 Nutritional supplements
      Magnesium sulfate 360 mg/d
      Calcium 1200 mg/d
      Vitamin E 400 IU/d
      Vitamin B6 100 mg/d
             PMS: Treatment (Medical)

 NSAIDs
 Anti-depressants
    SSRI’s (Fluoxetine or Sertraline)
    Buspirone
 Spironolactone - bloating
 Bromocriptine or Danocrine – mastalgia
 Ovulation suppression
    GnRH agonists (e.g. Lupron)
    Danazol
    OCPs
           PMDD: Treatment (Medical)

 SSRIs
 Can be taken throughout the cycle or during the luteal phase
  of the cycle
    Fluoxetine 20-60 mg qd
    Sertraline 50-150 mg qd
      PMS/PMDD: Treatment (Surgical)

 Oophorectomy
   Not generally recommended
      Irreversible
   Reserved for severely affected patients who only respond to
    GnRH agonists
                         Bottom Line Concepts
 PMDD identifies women with PMS who have more severe emotional
  symptoms that may require intensive therapy.
 The physiologic mechanism that results in the occurrence of PMS and
  PMDD is not well understood.
 The diagnosis of PMS and PMDD is based on documentation of the
  relationship of the patient’s symptoms to the luteal phase.
 DSM-IV criteria are used to establish the diagnosis of PMDD.
 In addition to lifestyle changes, behavioral therapies, and dietary
  supplementation, some pharmacologic agents have been shown to
  have symptom relief.
 As an overall clinical approach, treatments should be employed in
  increasing orders of complexity.
                  References and Resources

 APGO Medical Student Educational Objectives, 9th edition, (2009),
  Educational Topic 49 (p104-105).

 Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010),
  Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William
  NP Herbert, Douglas W Laube, Roger P Smith. Chapter 39 (p347-352).

 Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and
  Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone,
  Calvin J Hobel. Chapter 36 (p386-388).
Dysmenorrhea
     UNC School of Medicine
Obstetrics and Gynecology Clerkship
    Case Based Seminar Series
               Objectives for Dysmenorrhea
 Define dysmenorrhea and distinguish primary and
  secondary dysmenorrhea
 Describe the pathophysiology and identify the etiologies
  of dysmenorrhea
 Discuss the steps in the evaluation and management
  options for dysmenorrhea
                       Definition

Painful menstruation that prevents a woman from
  performing normal activities
   Primary dysmenorrhea – no readily identifiable cause
   Secondary dysmenorrhea – identifiable organic cause
  Primary Dysmenorrhea: Pathophysiology

 Caused by excess prostoglandin F2α (PGF2α ) and PGE2
  produced from shedding endometrium
 Prostoglandins are potent smooth-muscle stimulants that
  cause uterine contractions and ischemia
 Prostoglandin F2α causes contractions in smooth muscle
  elsewhere in the body, resulting in nausea, vomiting, and
  diarrhea
         Primary Dysmenorrhea: Symptoms

 Pain
      Onset within 2 years of menarche
      Begins a few hours before or just after onset of menses
      Lasts 48 – 72 hours
      Described as “cramp-like”
      Strongest over lower-abdomen
      Radiates to back or inner thighs
 Associated symptoms
      Nausea and vomiting
      Fatigue
      Diarrhea
      Lower backache
      Headache
         Primary Dysmenorrhea: Treatment

 Reassurance and explanation
 Medical
      NSAIDs
      Hormonal contraceptives (e.g. OCPs, IUD, Vaginal rings, Patches)
      Progestins (e.g. Medroxyprogesterone acetate)
      Tocolytics (e.g. Salbutamol)
      Analgesics
 Other Measures
      Transcutaneous nerve stimulation
      Acupuncture
      Psychotherapy
      Hypnotherapy
Secondary Dysmenorrhea: Pathophysiology

 Depends on underlying (secondary) cause and in most cases
  is not well understood

 Causes of secondary dysmenorrhea:
      Endometriosis
      Pelvic inflammation
      Adenomyosis
      Fibroid tumors (benign, malignant)
      Ovarian cysts (e.g. endometriosis, luteal cysts)
      Pelvic congestion
    Secondary Dysmenorrhea: Symptoms

 Pain
    Develops in older women (30’s to 40’s)
    Not limited to menses
 Associated symptoms
    Dyspareunia
    Infertility
    Abnormal uterine bleeding
      Secondary Dysmenorrhea: Symptoms

Condition             Signs and Symptoms
Endometriosis         Pain extends to premenstrual and postmenstrual phase
                      Deep dyspareunia
                      Tender pelvic nodules (e.g. uterosacral ligaments)
                      Onset in 20’s – 30’s
Pelvic inflammation   Pain initially menstrual, with each cycle extends into premenstrual phase
                      Intermenstrual bleeding
                      Pelvic tenderness
                      Fever, chills, malaise
Adenomyosis,          Pain + menorrhagia
                      Uterus symmetrically enlarged, mildly tender, “boggy”
Uterine fibroids      Pain + menorrhagia
                      Firm, irregularly enlarged uterus
Ovarian cysts         Mid-cycle, unilateral pain
Pelvic congestion     Dull, ill-defined pelvic ache
                      Pain worse premenstrually and relieved by menses
                      History of sexual problems
    Secondary Dysmenorrhea: Treatment

 Management consists of treatment of the underlying disease
 Treatment used for primary dysmenorrhea often helpful
                         Bottom Line Concepts
 Primary and secondary dysmenorrhea are a source of recurrent
  disability for a significant number of women in their early reproductive
  years.
 Primary dysmenorrhea is caused by excess prostoglandin produced by
  the shedding endometrium.
 Secondary dysmenorrhea is due to organic pelvic disease, including;
  endometriosis, PID, adenomyosis, uterine fibroids, and pelvic
  congestion.
 Primary dysmenorrhea presents within 2 years of menarche, where as
  secondary dysmenorrhea more often presents in older women.
 For patient’s with dysmenorrhea, the physical exam is directed at
  uncovering possible causes of secondary dysmenorrhea.
 Treatment of secondary dysmenorrhea should be directed at the
  underlying condition.
                  References and Resources

 APGO Medical Student Educational Objectives, 9th edition, (2009),
  Educational Topic 46 (p98-99).

 Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010),
  Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William
  NP Herbert, Douglas W Laube, Roger P Smith. Chapter 30 (p277-279).

 Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and
  Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone,
  Calvin J Hobel. Chapter 21 (p256-259).

								
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