Premenstrual SyndromePremenstrual Syndrome

Dr PatelDr Patel

GP VTSGP VTS

AimsAims

• To make an accurate diagnosis of To make an accurate diagnosis of premenstrual syndrome (PMS)premenstrual syndrome (PMS)

• To provide appropriate advice to women To provide appropriate advice to women with PMSwith PMS

• To offer options for treatment that are To offer options for treatment that are appropriate for initiation in primary careappropriate for initiation in primary care

• To refer the woman when primary care To refer the woman when primary care treatment is not adequate treatment is not adequate

Premenstrual Syndrome Premenstrual Syndrome Modern DefinitionModern Definition

‘‘Distressing physical, psychological Distressing physical, psychological and behavioural symptoms, not caused and behavioural symptoms, not caused by organic disease, which regularly by organic disease, which regularly recur during the same phase of the recur during the same phase of the menstrual (ovarian) cycle and which menstrual (ovarian) cycle and which significantly regress or disappear during significantly regress or disappear during the remainder of the cycle’the remainder of the cycle’

• Magos & Studd (1984)Magos & Studd (1984)

What is Premenstrual What is Premenstrual Syndrome (PMS)Syndrome (PMS)• distressing physical, behavioural, and psychological symptoms distressing physical, behavioural, and psychological symptoms • Regularly occur in the luteal phase of the menstrual cycleRegularly occur in the luteal phase of the menstrual cycle• Significantly improved or resolved by the end of menstruation.Significantly improved or resolved by the end of menstruation.

• Mild PMS Mild PMS – symptoms do not interfere with the woman's personal, social, and symptoms do not interfere with the woman's personal, social, and

professional life.professional life.• Moderate PMS Moderate PMS

– symptoms interfere with the woman's personal, social, and professional symptoms interfere with the woman's personal, social, and professional life. Daily functioning is possible, although maybe not to the usual life. Daily functioning is possible, although maybe not to the usual level.level.

• Severe PMS Severe PMS – the woman withdraws from social and professional activities and the woman withdraws from social and professional activities and

cannot function normally.cannot function normally.– If symptoms are predominantly emotional and behavioural, this is If symptoms are predominantly emotional and behavioural, this is

sometimes referred to as sometimes referred to as premenstrual dysphoric disorderpremenstrual dysphoric disorder

Common SymptomsCommon Symptoms

• More than 100 different symptoms of More than 100 different symptoms of PMS have been recorded, but the PMS have been recorded, but the most common are listed below.most common are listed below.

Physical symptomsPhysical symptoms

• Fluid retention and feeling bloatedFluid retention and feeling bloated• Pain and discomfort in your abdomenPain and discomfort in your abdomen• HeadachesHeadaches• Changes to your skin and hairChanges to your skin and hair• BackacheBackache• Muscle and joint painMuscle and joint pain• Breast tendernessBreast tenderness• Insomnia (trouble sleeping)Insomnia (trouble sleeping)• DizzinessDizziness• TirednessTiredness• NauseaNausea• Weight gain (up to 1kg)Weight gain (up to 1kg)

Psychological symptomsPsychological symptoms

• Mood swingsMood swings• Feeling upset or emotionalFeeling upset or emotional• Feeling irritable or angryFeeling irritable or angry• Depressed moodDepressed mood• Crying and tearfulnessCrying and tearfulness• AnxietyAnxiety• Difficulty concentratingDifficulty concentrating• Confusion and forgetfulnessConfusion and forgetfulness• RestlessnessRestlessness• Decreased self-esteemDecreased self-esteem

Behavioural symptomsBehavioural symptoms

• Loss of interest in sexLoss of interest in sex

• Appetite changes or food cravingsAppetite changes or food cravings

• Any chronic (long-term) illnesses, Any chronic (long-term) illnesses, such as asthma or migraine, may get such as asthma or migraine, may get worse.worse.

Premenstrual Dysphoric Premenstrual Dysphoric DisorderDisorder• The symptoms of PMDD are similar to those of PMS, but The symptoms of PMDD are similar to those of PMS, but

more exaggerated. more exaggerated. • a small percentage of women have symptoms that are a small percentage of women have symptoms that are

severe enough to stop them living their normal lives. severe enough to stop them living their normal lives. • They can include:They can include:• feelings of hopelessnessfeelings of hopelessness• persistent sadness or depressionpersistent sadness or depression• extreme anger and anxietyextreme anger and anxiety• decreased interest in usual activitiesdecreased interest in usual activities• sleeping much more or less than usualsleeping much more or less than usual• very low self-esteemvery low self-esteem• extreme tension and irritabilityextreme tension and irritability

• PMDD can be particularly difficult to deal with because it PMDD can be particularly difficult to deal with because it can have a negative effect on your daily life and can have a negative effect on your daily life and relationships.relationships.

What causes it ?What causes it ?

• The exact cause of premenstrual The exact cause of premenstrual syndrome (PMS) is uncertain, but syndrome (PMS) is uncertain, but because it does not occur before because it does not occur before puberty, in pregnancy, or after the puberty, in pregnancy, or after the menopause, cyclical ovarian activity menopause, cyclical ovarian activity is thought to contribute [is thought to contribute [RCOG, 2007RCOG, 2007]. ].

Suggested theorySuggested theory

• Hormone changesHormone changes

• Chemical changesChemical changes

• Weight and exerciseWeight and exercise

• StressStress

• DietDiet

How common ?How common ?

• Mild PMS is experienced by many women.Mild PMS is experienced by many women.

• Around 5% of women have Around 5% of women have severesevere premenstrual symptoms [premenstrual symptoms [RCOG, 2007RCOG, 2007].].

• In the UK, only about a fifth of women In the UK, only about a fifth of women experiencing PMS symptoms seek medical experiencing PMS symptoms seek medical help. However, up to 13% of working help. However, up to 13% of working women with PMS symptoms take time off women with PMS symptoms take time off during the year because of PMS [during the year because of PMS [MeReCMeReC, 2003, 2003]. ].

Risk FactorsRisk Factors

• Common in women whose mothers also Common in women whose mothers also experienced PMS symptoms (70%) experienced PMS symptoms (70%)

• Monozygotic twins Monozygotic twins 93% concordance rate 93% concordance rate• Dizygotic twins Dizygotic twins 44%[ 44%[

Bhatia and Bhatia, 2002Bhatia and Bhatia, 2002].].• More common in women who are obese, do More common in women who are obese, do

not exercise, and who have a lower level of not exercise, and who have a lower level of academic achievement [academic achievement [RCOG, 2007RCOG, 2007].].

• Women using hormonal contraception are Women using hormonal contraception are less likely to experience PMS [less likely to experience PMS [RCOG, 2007RCOG, 2007]. ].

Diagnosis of PMSDiagnosis of PMS

• Diagnosis Diagnosis Clinical Clinical• Difficulty in diagnosis often occurs because Difficulty in diagnosis often occurs because

PMS can present with a large number of PMS can present with a large number of symptoms which are common to a range of symptoms which are common to a range of conditions [Rapkin and Mikacich, 2008].conditions [Rapkin and Mikacich, 2008].

• Ask the woman to record a daily symptom Ask the woman to record a daily symptom diary for two or three cycles [MeReC, 2003].diary for two or three cycles [MeReC, 2003].

• Investigations are not usually helpful in Investigations are not usually helpful in making the diagnosis. making the diagnosis.

Conditions to excludeConditions to exclude

• DepressionDepression• Anxiety and panic disordersAnxiety and panic disorders• HypothyroidismHypothyroidism• AnaemiaAnaemia• DysmenorrhoeaDysmenorrhoea• Irritable bowel syndromeIrritable bowel syndrome• Interstitial cystitisInterstitial cystitis• EndometriosisEndometriosis• Chronic fatigue syndromeChronic fatigue syndrome• FibromyalgiaFibromyalgia• Systemic lupus erythematosus Systemic lupus erythematosus

ManagmentManagment

• Management should be tailored according to the Management should be tailored according to the severity and type of symptoms, and the woman's severity and type of symptoms, and the woman's preferences and any desire to become pregnant.preferences and any desire to become pregnant.

• Mild symptoms Mild symptoms • Offer lifestyle advice.Offer lifestyle advice.• Regular, frequent (2–3 hourly), small balanced meals rich in Regular, frequent (2–3 hourly), small balanced meals rich in

complex carbohydrates.complex carbohydrates.• Regular exercise.Regular exercise.• Smoking cessation.Smoking cessation.• Alcohol restriction.Alcohol restriction.• Regular sleep.Regular sleep.• Stress reduction.Stress reduction.

ManagementManagement

• Moderate PMSModerate PMS• Offer lifestyle advice and consider:Offer lifestyle advice and consider:• A new-generation combined oral contraceptiveA new-generation combined oral contraceptive • UNLICENSED UNLICENSED if used solely to treat PMS symptoms if used solely to treat PMS symptoms• Can be used cyclically or continuouslyCan be used cyclically or continuously• But the first-line choice of COC is not clear.But the first-line choice of COC is not clear.

– More evidence to support : More evidence to support : • the use of drospirenone-containing COCs (for example Yasmin®) than other the use of drospirenone-containing COCs (for example Yasmin®) than other

preparationspreparations• desogestrel (for example Marvelon®) desogestrel (for example Marvelon®) • norgestimate (for example Cilest®) or gestodene (for example Femodene®), may norgestimate (for example Cilest®) or gestodene (for example Femodene®), may

also be effective, especially if they have been used before and have been found to be also be effective, especially if they have been used before and have been found to be of benefit.of benefit.

– Inform the woman that it is not possible to predict whether her PMS symptoms Inform the woman that it is not possible to predict whether her PMS symptoms will respond.will respond.

• Paracetamol or a nonsteroidal anti-inflammatory drug - if the Paracetamol or a nonsteroidal anti-inflammatory drug - if the predominant problem is painpredominant problem is pain

• Cognitive behavioural therapyCognitive behavioural therapy (CBT; referral is likely to be required) if (CBT; referral is likely to be required) if it is thought the woman would benefit from psychological intervention.it is thought the woman would benefit from psychological intervention.

ManagementManagement

• Severe PMSSevere PMS• Offer lifestyle advice and consider:Offer lifestyle advice and consider:• The treatment options outlined above for The treatment options outlined above for

moderate PMSmoderate PMS • A selective serotonin reuptake inhibitorA selective serotonin reuptake inhibitor (SSRI) (SSRI)

– Unlicensed use Unlicensed use – Do not prescribe an SSRI Do not prescribe an SSRI doubt about the diagnosis, < 18 doubt about the diagnosis, < 18

yrs without advice a specialist yrs without advice a specialist – taken either continuously or just during the luteal phase (for taken either continuously or just during the luteal phase (for

example days 15–28 of the menstrual cycle, depending on its example days 15–28 of the menstrual cycle, depending on its length). length).

– initial trial of 3 months' treatment initial trial of 3 months' treatment benefit benefit continue continue 6 months to 1 year.6 months to 1 year.

– Monitor the woman's response to treatment closely, including Monitor the woman's response to treatment closely, including asking about any thoughts of self-harm.asking about any thoughts of self-harm.

ManagmentManagment

• 12 yrs onwards12 yrs onwards

• 11stst line : Lifestyle advice : line : Lifestyle advice :– The following things may help to ease PMS.The following things may help to ease PMS.– Eat regular, frequent, small balanced meals Eat regular, frequent, small balanced meals

rich in complex carbohydrates. rich in complex carbohydrates. – Take regular exercise. Take regular exercise. – Stop smoking. Stop smoking. – Don't drink too much alcohol. Don't drink too much alcohol. – Get regular sleep. Get regular sleep.

12yrs +12yrs +

• ParacetamolParacetamol

• NSAIDsNSAIDs

• Mefanemic acid 500mg tdsMefanemic acid 500mg tds

Combined Oral Combined Oral ContraceptionContraception• Age from 13 to 50 years:Age from 13 to 50 years:

• COCs monophasic: COCs monophasic: – EE 30-35mcg with drospirenone or EE 30-35mcg with drospirenone or

norgestimate eg :norgestimate eg :• Yasmin: drospirenone 3mg + ethinylestradiol 30mcgYasmin: drospirenone 3mg + ethinylestradiol 30mcg

• Cilest: norgestimate 250mcg + ethinylestradiol Cilest: norgestimate 250mcg + ethinylestradiol 35mcg 35mcg

– EE 30mcg with gestodene or desogestrelEE 30mcg with gestodene or desogestrel• Femodene: gestodene 75mcg + ethinylestradiol Femodene: gestodene 75mcg + ethinylestradiol

30mcg 30mcg

Selective Serotonin Receptor InhibitorsSelective Serotonin Receptor Inhibitors

• 18yrs + :18yrs + :•Fluoxetine 20mg od, Sertraline 50mg od, Fluoxetine 20mg od, Sertraline 50mg od,

paroxetine 20mg od, citalopram 20mg odparoxetine 20mg od, citalopram 20mg od

• Luteal phase selective serotonin Luteal phase selective serotonin reuptake inhibitors (SSRIs)reuptake inhibitors (SSRIs)

•Fluoxetine, citalopram: 20mg each morning Fluoxetine, citalopram: 20mg each morning on days 15-28 of cycle on days 15-28 of cycle

When should I refer a When should I refer a woman with premenstrual woman with premenstrual syndrome?syndrome?

• Refer the woman to a psychiatrist if there is Refer the woman to a psychiatrist if there is marked underlying psychopathology in marked underlying psychopathology in addition to premenstrual syndrome (PMS).addition to premenstrual syndrome (PMS).

• Consider referral to a clinic with a specific Consider referral to a clinic with a specific interest in PMS (or a general gynaecology interest in PMS (or a general gynaecology clinic if this is not available) if the symptoms clinic if this is not available) if the symptoms are severe and appropriate primary care are severe and appropriate primary care measures have been explored but have failed.measures have been explored but have failed.

Evidence on treatments not Evidence on treatments not recommended in primary carerecommended in primary care

• Progesterone or progestogens used aloneProgesterone or progestogens used alone• Antidepressants other than SSRIsAntidepressants other than SSRIs• Transdermal oestradiol Transdermal oestradiol • DiureticsDiuretics• Vitamin B6 (pyridoxine)Vitamin B6 (pyridoxine)• Calcium and vitamin D Calcium and vitamin D • Magnesium Magnesium • EvEvening primrose oil ening primrose oil • Agnus castus (chaste tree)Agnus castus (chaste tree)• AlprazolamAlprazolam• Gonadotrophin releasing hormone analogues eg DanazolGonadotrophin releasing hormone analogues eg Danazol

• Hysterectomy and bilateral salpingo-oophorectomy may be Hysterectomy and bilateral salpingo-oophorectomy may be considered under certain circumstances in secondary care for considered under certain circumstances in secondary care for women with severe PMS.women with severe PMS.