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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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