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Premenstrual Syndrome PMS and Premenstrual Dysphoric Disorder PMDD

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									     Premenstrual
  Syndrome(PMS) and
Premenstrual Dysphoric
    Disorder(PMDD)
    By Neena Yoyakey
         OMS III
            Introduction
•   PMS and PMDD refer to the same pathologic
    process at opposite ends of the symptom
    spectrum. PMDD is more severe form of PMS
•   In BOTH, pts experience adverse physical,
    psychological, and behavioral symptoms
    during luteal(2nd half) phase of the menstrual
    cycle.
•   As many as 80% of regularly ovulating
    women experience some degree of physical
    and psychological premenstrual
    symtomatology.
•   Exact cause of PMS/PMDD is unknown but it
    is most likely multifactorial (includes
    physical & psychological causes)
•   Estrogen and progesterone levels are similar
    in women with or without PMS/PMDD, but
    women with PMS/DD are highly sensitive to
    changes in hormone levels
Symptoms of PMS/PMDD
•   Fatigue and abdominal bloating are the most
    common
•   Common physical symptoms: breast
    tenderness, muscle pain, headache
•   Others: Irritability, tension, depressed mood,
    increased appetite, difficulty concentrating,
    anxiety
•   Acne, GI upset, hot flashes, dizziness, anger
•   PMDD: 1 of the following+4 others
      • Marked anxiety
      • Marked affective lability
      • Marked irritability
      • Depressed mood
•   There is complete resolution of symptoms
    when menstrual flow begins
                       Diagnosis
criteria based on DSM-IV for PMDD and Univ. Cali, San Diego for PMS


•   No single test
•   Symptoms must occur only during second
    half of menstrual cycle-usually 1-2 weeks
    before period.
•   For PMS: There must be physical as well
    as behavioral symptoms and should
    impair some facet of life. Diagnosis can
    only be made in absence of a concurrent
    psychiatric disorder
•   For PMDD: require only behavioral
    symptoms be present. Can be
    superimposed on other psychiatric
    disorders but not just an exacerbation of
    those disorders.
         Diagnosis cont
•   Symptoms should not be present btw
    days 4-12(7 day symptom-free period in
    first half) of 28 day cycle.
•   Blood test not needed, but recommended
    to screen for other conditions such as
    anemia, hypo/hyperthyroidism which
    have similar symptoms. (exclusion of
    other diagnoses)
•   For PMDD, can request pt to record
    symptoms for two full cycles and rate the
    severity of 10 physical symptoms and 12
    behavioral symptoms on a 4 pt scale.
            Criteria for PMDD
•    Symptoms seriously interfere with usual functioning and relationships
•    Premenstrual timing is confirmed by menstrual calendar in two
     consecutive cycles
•    More severe form of PMS
•    Symptoms resolve after onset of menses (also true with PMS)
•    Symptoms are not an exacerbation of another disorder.
•    At lease 5 premenstrual symptoms:
    1. At least one of the following:
         • Depressed mood
         • Marked anxiety
         • Marked affective lability
         • Marked irritability
    2. Other possible symptoms:
         • Decreased interest in regular activities
         • Difficulty in concentrating
         • Fatigue
         • Appetite change, food cravings
         • Sleep disturbance
         • Feelings of being overwhelmed
         • Physical symptoms (breast swelling and tenderness, bloating,
            weight gain, edema, or headache)
               Treatment
•   For PMS, try conservative txtmt
    first: regular exercise, relaxation
    techniques, and vitamin and
    mineral supplementation (calcium,
    vit B6,vit. D, and Mg).
     •   If little relief than prescription meds can be
         2nd option.
•   Can provide reassurance and mild
    diuretics for symptoms such as
    bloating.
•   Treat mild anxiety with anti-anxiety
    agent like Buspirone (most
    effective is SSRI)
•  Others
  1. calcium carbonate 9at 1200
     mg/day) for control of mood and
     behavioral symptoms,
  2. Spironolactone (at 100mg/day) for
     mood and bloating
  3. Bromocriptine for cyclic
     mastalgia.
• Carbohydrate-rich beverages have
   shown some improvement in
   psychological symptoms and
   appetite cravings.
• For PMDD, conservative txtmt with
   prescription meds is best
             Treatment
•    SSRIs(serotonin reuptake inhib) are
     highly effective for symptoms of
     PMS and PMDD-1st line therapy
    1. Fluoxetine(Prozac 20mg/day),
       sertraline(Zoloft 50-150mg/day),
       citalopram(Celexa 20-30mg/day),
       and paroxetine(Paxil 20-30
       mg/day)
    2. Take for two cycles to see
       benefit.
        Treatments cont
•   Oral contraceptive pills also
    effective however with variable
    results-most women have symptom
    relief while others feel worse.
    1. Yaz is approved for txtmt of PMDD
       because it has only 4 days of placebo
       compared to the usual 7 days (contains a
       progestin-drospirenone and low dose estrogen)
•   Ineffective treatment include
    progesterone, MAOIs and TCAs,
    and lithium. No benefit with ginkgo
    biloba.
       Treatment cont.
•   For PMDD, GnRH agonists(Lupron)
    improves bloating and irritability.
    causes ovaries to temporarily stop
    making estrogen and progesterone
    (temporary menopause). Inject
    every 1-3 months.
•   Those that fail the above can use
    danazol (has progestin-like effects)
    Also inhibits FSH, LH. Effective for
    PMS if given at doses that inhibit
    ovulation
          Treatment cont.
•   Oophorectomy (optional w/ hysterectomy)
    for severe, disabling PMDD
    symptoms.
    1. However, guidelines to consider before
       resorting to surgery:
      •   Diagnosis of PMDD must be confirmed
      •   GnRH agonist must be only approach that
          was effective, for a minimum of 6 months
      •   Childbearing is complete
      •   The need for several more years of therapy
          is predicted based on woman’s age
              References
•   Casper, RF. Treatment of premenstrual syndrome
    and premenstrual dysphoric disorder.
    In:UpToDate, Synder PJ(Ed), UpToDate,Waltham,
    MA 2010
•   Casper, RF. Clinical manifestations and diagnosis
    of premenstrual syndrome and premenstrual
    dysphoric disorder. In:UpToDate, Synder PJ(Ed),
    UpToDate,Waltham, MA 2010
•   Casper, RF. Patient information: Premenstrual
    syndrome (PMS) and premenstrual dysphoric
    disorder (PMDD) In:UpToDate, Synder PJ(Ed),
    UpToDate,Waltham, MA 2010
•   Hacker N., Gambone J. C., & Hobel C. J. (2010).
    Hacker and Moore’s Essentials of Obstetrics and
    Gynecology (5th ed.). Philadelphia: Saunders
    Elsevier.
•   AccessMedicine: Williams Gynecology

								
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