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Pre-menstrual Syndrome

Premenstrual Syndrome is a combination of physical and emotional disturbances that occur after a woman ovulates and ends with menstruation ” ( Khajehei M 2015 )

” PMS can be broadly defined as any constellation of psychological and
 physical symptoms that recur regularly in the luteal phase of the menstrual cycle , remit for atleast one week in the follicular phase and cause distress 
and functional impairment ” ( Carol A. Henshaw 2007 )



Premenstrual Dysphoric Disorder ( PMDD ) is a more severe form of 
PMS that occurs in a small number of women and leads to remarkable 
disability and loss of function.

How common ? Most women who ovulate experience PMS RCOG quotes that 40 % ( 4 in 1) would suffer with PMS and 5-8 % of these
 suffer with severe PMS It can affect women throughout the reproductive cycle One study ( Cormac J Sammon et al 2016 ) has shown that
○ proportion of ♀ reproductive age reporting atleast one PMS symptom or symptoms is between 50-90 %
○ proportion reporting severe symptoms or symptoms that interfere with daily activities is between 10-30 %
○ proportion meeting the strict DSM PMDD criteria is between 1-8 %

Cause – Various theories have been proposed over years regarding aetiology Ovarian hormone theory suggests an imbalance in the estrogen to progesterone ration with a relative deficiency in progesterone Serotonin theory states that estrogen and progesterone seem to affect the brain’s neurotransmitters , modulate the levels of monoamines such as serotonin and alternate serotinergic activity in the brain Psycho-social theory -PMS is a conscious demonstration of a woman’s unconscious conflict about femininity and motherhood Cognitive & social learning theory – onset of menstrual bleeding can be an aversive psychological event for some women Sociocultural theory -PMS is a manifestation of conflict.

Core PMDs- Core premenstrual disorders are the most 
commonly seen and widely recognised type of PMS
 like all PMDs the symptoms must be severe enough that it interferes with daily life , functioning , work , school performance or interpersonal relationships the symptoms of core PMD are non-specific symptoms recur in oculatory cycles and must be present during the luteal phase and stop as menstruation begins followed by a symptom free period.

Presentation Symptoms may include a constellation of over 200 reported premenstrual complaints that typically do not cause functional impairment Several conditions may have similar symptoms as

depression
anxiety
chronic fatigue syndrome
irritable bowel syndrome
thyroid disease

It is also known that 1/2 of women seeking help for PMS have atleast one of these conditions
 Symptoms should cause impairment of daily activities at work , social activities and interpersonal relationship For an accurate diagnosis the symptoms should occur regularly in ovulating women during the luteal phase of the cycle , with resolution by the end of menstruation.

Psychological and behavioural-mood swings depression tiredness , fatigue or lethargy irritability anxiety , feeling out of control reduced cognitive ability , aggression , anger sleep disorders , food craving.

Physical symptoms –breast tenderness skin rashes bloating, weight gain clumsiness headache backache.

History-History taking would be tailored to elicit the above features
 What predominant symptoms does she experience Timing of symptoms in relation to the menstrual cycle It is also stated that PMS leads to
drug addiction
increased tendency to have an accident and to commit crime
economic losses
decline in academic achievement

You may explore above Explore the impact on QOL that PMS may be causing as it is known that PMS may also cause
a change in body perception 
decrease in self confidence
social isolation
disrupted interpersonal relationship Medical and surgical history Social history- alcohol , smoking

Several papers recommend using a validated questionnaire for a minimum of 2 months – prospective charting of symptoms. Daily Record of Severity of of Problems ( DRSP ) is a well validated scale used in the diagnosis of PMS.

Apps are also available to chart PM symptoms 

Tests and examination -No laboratory test reliably assists in the diagnosis of PMS You may consider tests if there is a clinical suspicion of an underlying medical condition such as thyroid disease or anaemia Imaging – not indicated unless clinical suspicion of other possible causes Clinical examination should be performed as indicated based on patients age and may include a gynecological and medical exam.

Diagnosis –Diagnose PMS after reviewing the daily symptom diary if symptoms are prominent during the luteal phase-Symptoms resolve with the onset of menses or soon after that- followed by a symptom free period.

If the symptoms do no appear cyclical – r/o other conditions and if the pattern remains inconclusive -refer her to secondary care

Treatment should be considered once 
 diagnosis has been estabilished other underlying medical and psychiatric conditions have been addressed.

Management of PMS is generally done in a step-wise fashion which ranges from non-pharmacological strategies , antidepressant medications , hormonal strategies and surgical measures as a last option.

Patient education and lifestyle changes-Non-pharmacological measures – like CBT and using supplements as Calcium and Magnesium-Pharmacological treatment- can be non-hormonal and hormonal-Surgical treatment which may include hysterectomy and BSO.

RCOG has proposed the following algorithm –Exercise , CBT , Vitamin B6
Combined new generation pill ( cyclically or continuously )
Continuous or luteal phase ( day 15-28 ) low dose SSRI e.g citalopram / escitalopram 10 mg.

Estradiol pathces ( 100 mcg ) + micronised progesterone ( 100 mg or 200 mg on days 17-28 ) orally or vaginally OR LNG-IUS 52 mg.

GnRH analogues + add-back HRT ( combined continous estrogen + progesterone ) for e.g 50-100 mcg estradiol patches or 2-4 doses of estradiol gel combined with micronised progesterone 100 mg / dat or Tibolone 2.5 mg- surgical options

LINKS AND RESOURCES

PATIENT INFORMATION

Daily record of severity of problems – pdf version http://checkupfromtheneckup.ca/wp-content/uploads/2016/02/drsp_month.pdf

A well written comprehensive page from RCOG– consider referring all to this https://www.rcog.org.uk/en/patients/patient-leaflets/managing-premenstrual-syndrome-pms/

Another detailed resource from US Department of Health and Human Services – Office on Woman’s Health https://www.womenshealth.gov/menstrual-cycle/premenstrual-syndrome

Jean Hailes on PMS https://www.womenshealth.gov/menstrual-cycle/premenstrual-syndrome

Victoria State Govt Better health channel https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/premenstrual-syndrome-pms

References 

  1. Diagnosis, pathophysiology and management of premenstrual syndrome Sally Walh et al The Obstetrician & Gynaecologists 2015 ; 17 :99-104
  2. Abay H, Kaplan S.Current approaches in Premenstrual Syndrome Management Halime Benzmialem Science 2019 ; 7 (2) : 150-6 http://cms.galenos.com.tr/Uploads/Article_20600/BezmialemScience-7-150-En.pdf
  3. CKS NHS Premenstrual syndrome https://cks.nice.org.uk/premenstrual-syndrome
  4. RCOG Management of Premenstrual Syndrome Green Top Guideline No 48 November 2016 https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg48/

 

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