8th Edition APGO Objectives for Medical Students

Premenstrual Syndrome and Premenstrual

Dysphoric Disorder

Rationale

Premenstrual syndrome involves physical and emotional discomfort and may affect interpersonal relationships. Effective management of this condition requires an understanding of symptoms and diagnostic methods.

Objectives

The student will be able to cite: Definition of premenstrual syndrome Theories of etiology Methods of diagnosisManagement strategies

Definition

Group of physical/behavioral symptoms occurring in second 1/2 (luteal phase) of menstrual cycle and interfering with lifestyle

Cyclic, unprovoked, uncontrollable mood changes and somatic symptoms occurring within 5 days of onset of menses which have adverse effects on job or family

Occurs in greater than 2 consecutive cycles Relief within 4 days of menses onset Psychiatric diagnostic designation: luteal phase

dysphoric disorder

Incidence

Moderate to severe - 20-40% Debilitating disease/symptoms - 2.5-5% Generally age 30-40 yr.

Etiology Not known; personality traits and stress not

factors Some theories - disturbances in central

neurotransmitter regulation Decreased serotonin activity (central deficiency) β-Endorphins Role of GABA system B6 deficiency

Symptoms

Anxiety Mood changes/lability Irritability ImpatienceListlessness/fatigue

Symptoms

DepressionConfused Cry easily Social withdrawal Insomnia

Symptoms

Water retention Swelling Weight gain Abdominal bloating Breast tenderness

Symptoms

Cognition Forgetfulness Difficulty concentrating

Symptoms

Pain Cramps Backache Breast pain/tenderness

Symptoms

Hypoglycemia-like symptoms Craving for sweets Headache Voracious appetite Fatigue Decreased coordination

Diagnosis

History (must be consistent with ovulation)

Symptom calendar ﾐ 20-30% increase in luteal score symptoms over 2 mo.

Diagnosis

Rule out other diseases Depression Bipolar disorders Substance abuse Personality disorder Chronic fatigue syndrome Thyroid disease Irritable bowel syndrome True hypoglycemia

Treatment Aimed at relieving symptoms, as cause unknown

Conservative Self help strategies Nutritional changes

Frequent, small meals Avoid sweets, caffeine Magnesium sulfate 360 mg/d Evening primrose oil High-protein diet, B6

Exercise - milder symptoms

Treatment Aimed at relieving symptoms, as cause unknown

Medical Mood/other symptom relief

Naproxyn (prostaglandin inhibitor) Mefenamic Salt restriction for water retention Spironolactone for water retention Transdermal estrogen Bromocriptine for breast symptoms Anti-anxiety drugs

• Fluoxetine (Prozac) appears most promising as first-line medication

• Alprazolam (Xanax)

Treatment Aimed at relieving symptoms, as cause unknown

Medical Ovulation suppression

Oral contraceptives Depomedroxyprogesterone acetate (DMPA) Gonadotropin-releasing hormone (GnRH)

agonists

Treatment Aimed at relieving symptoms, as cause unknown

Surgical Oophorectomy not generally recommended Possibly indicated if symptoms respond to

GnRH agonists or danazol

Clinical Case

Premenstrual Syndrome and

Premenstrual Dysphoria Disorder

Patient presentation

GS, a 37-year-old married woman, comes to your office for an “annual checkup.” She has recently moved to town, and all her previous medical care was in a different city. She has not seen a gynecologist for 2 years and states that she wants to establish a relationship with a physician in her new surroundings.

Patient presentation

The patient is a gravida 3, para 3. She has regular periods, although they have gotten somewhat longer in the past year or so. She is currently not sexually active and is taking no medications or supplements.

Past history reveals that she underwent an appendectomy as a child and has had two diagnostic laparoscopies for pelvic pain, with the most recent done 3 years ago. She has no pain at the present time, has no medical conditions and is not allergic to any medications.

Patient presentationHer family history reveals that her mother suffered from

depression. Her 40-year-old sister was recently diagnosed with breast cancer. Upon review of systems, she describes occasional constipation and diarrhea. She has recently had difficulty sleeping and feels that she gets tired more easily than she should. Upon further questioning, she reveals that she has difficulty falling asleep, often because she is thinking about what has happened during the day and/or what may be coming up the next day. The patient and her three children have recently moved to town, while her husband has remained in their previous city to fulfill his job obligation. This domestic separation has been going on for approximately 6 months.

Patient presentationOn physical examination, all findings are normal. The patient did

appear to be a bit nervous and startled easily as you entered the room.

On further questioning, the patient thinks that her jitteriness and sleeplessness have led to increased irritability with the children. She worries a great deal, particularly about her domestic situation and being separated from her husband. She has difficulty concentrating at her job (she works as a bank teller) and also feels that her memory is failing her, as she loses her keys or misplaces items at home from time to time. Further questioning also reveals that the patient has observed no pattern indicating that the symptoms occur only during the luteal phase. You also note that at the time of the examination, when she presents with nervousness, GS is in the follicular phase of her cycle.

Patient presentationShe saw a physician assistant in a primary care practice regarding these

symptoms. He told her that he believes she has PMS. The patient does believe that her symptoms may get worse at different times of the month, but she has never been able to keep track of them long enough to know whether there is a specific cyclic pattern to these problems. General lab tests were performed and were normal. Under the assumption that it is PMS, he recommended a series of treatments, all of which have been unsuccessful, i.e. birth control pills, progesterone suppositories, vitamin B6 supplementation, diuretics and nonsteroidal anti-inflammatory drugs, specifically Ibuprofen and Naproxen Sodium. She has taken all of these medications and has also tried to get more exercise and “eat right.” She believes that the combination of being separated from her husband, moving to a new town, and the stress of doing her job accurately has overwhelmed her. She does not understand why the PMS has not improved and asks whether a hysterectomy might be the solution.

Treatment

Because the physical examination, thyroid function tests, electrolytes, liver function test and a complete blood count are normal, you are confident that the patient does not have any underlying medical conditions. You suggest to the patient that she may have an anxiety disorder, perhaps generalized anxiety disorder. You initially start her on Alprazolam, 0.25 mg, three times a day and suggest that she monitor her symptoms and return in one week.

Treatment

The patient returns in one week and reports significant improvement in her sleep patterns, as well as her mental functioning. She feels much calmer. You reassure the patient that there is no underlying medical problem and that she is not “going crazy,” but appears only to have an anxiety disorder that can be treated successfully. You explain to her that life stressors can exacerbate her underlying anxiety disorder.

TreatmentYou also recommend that she avoid caffeine and alcohol.

Although she feels better, the patient wishes to discontinue the medication to see if her lifestyle changes might make a difference.

She returns 1 month later, and her symptoms have returned. You then initiate therapy with Buspirone, 10 mg, three times a day, and explain to her that it will take 2 to 3 weeks for this medication to take effect. You also explain that it does not have any sedating qualities and will not be habit forming. The patient returns 3 months later, at which time she is functioning well and is quite comfortable with the current dosage of Buspirone.

Teaching points1. Differentiating PMS from anxiety may depend on prospective

documentation of symptoms. Without the documentation or with a history that is unclear, making a firm diagnosis of PMS/PMDD may be difficult. Alternatively, if symptoms are compatible with anxiety, this should be a primary consideration.

2. An empathetic, sensitive approach to the patient’s concerns is needed. Understanding the environment in which these patients find themselves is often helpful in making the diagnosis.

3. May women who believe they have PMS actually have a different condition. To some patients, PMS is a more acceptable diagnosis. This is certainly more commonly seen in an ob-gyn office than in the office of a mental health care professional.

4. Initial management with a benzodiazepine will provide an earlier response potential. The use of buspirone, with its benefits of not being sedating and not being habit forming, might be useful for long-term management.