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PMS and PMDD: Clinical Approaches Kathleen McIntyre-Seltman, MD

Learning Objectives. As a result of this presentation the participant will be able to:Describe PMS and PMDDCounsel patients about lifestyle managementCounsel patients about the risks and benefits of medical management. In the Past. ?hysteria" ? mad behavior because the womb was wandering in searc

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PMS and PMDD: Clinical Approaches Kathleen McIntyre-Seltman, MD

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    1. PMS and PMDD: Clinical Approaches Kathleen McIntyre-Seltman, MD

    2. Learning Objectives As a result of this presentation the participant will be able to: Describe PMS and PMDD Counsel patients about lifestyle management Counsel patients about the risks and benefits of medical management

    3. In the Past “hysteria” – mad behavior because the womb was wandering in search of a baby, resolved with onset of menstruation Premenstrual tension – 1930’s Premenstrual syndrome – K. Dalton 1960’s PMDD – 1990’s DSM IV 1994

    4. Premenstrual Dysphoric Disorder DMS-IV American Psychiatric Association 1994 At least 5 sx, with at least 1 of the first 4 sx Most cycles in last year Occur week before menses, remit first few days of menses, absent in post menstrual week Confirmed by prospective daily ratings in at least 2 cycles Sx must interfere with work, school, social activies, relationships Sx NOT due to exacerbation of other psych disorder

    5. Premenstrual Dysphoric Disorder DMS-IV American Psychiatric Association 1994 At least 1 of these Depressed mood or hopelessness Anxiety or tension Affective lability Irritability or anger Along with any of these Decreased interest in activities Difficulty concentrating Lack of energy Change in appetite Change in sleep patterns Feeling out of control or overwhelmed Physical sx – breast pain, bloating, headache

    6. Premenstrual Syndrome Any of these sx - but less severe Interfere with school, work, social activities, relationships – but not as much Timing - same

    8. Premenstrual Dysfunction

    9. Etiology Balance of estrogen to progesterone: relative low levels of progesterone Impact of catecholestrogens or other hormone-bound neurotransmitters Effect of hormone shifts on endogenous opiods Effect of hormones on serotonergic receptors Increased sensitivity to subtle neurotransmitter alterations modulated by hormones ?

    10. Political Issues PMDD used as legal defense for murder, other crimes Feminist perspective Medicalization of normal changes Medicalization of learned / cultural expectations Labeling behaviors such as anger, assertiveness as abnormal, reinforcing passive, “nice”, serene as normal feminine behavior Labeling women with psych disorder Excuse to limit women’s professional achievement Excuse for relationship issues

    11. Differential Diagnosis Psychiatric Disorders Major depressive disorder Anxiety / panic attack Bipolar disorder Personality disorder PTSD schizophrenia Other Medical Concerns Substance abuse Hypothyroidism Migraine Hypoglycemia Other endocrine or metabolic disorders

    12. Evaluation Rule out medical / psych disorders History and physical exam, including pelvic TSH glucose if indicated, drug testing, other metabolic assessment as indicated Occasionally – assessment of ovulation Psychiatric evaluation if indicated Symptom Calendar Prospective for at least 2 menstrual cycles Nature ,severity , and timing of sx

    13. Management Identify the problem and its cyclic nature Defer big decisions, confrontations etc if feasible Exercise Diet – frequent small meals, high carbs Sleep hygiene Limitation of caffeine Limitation of substance use (alcohol especially)

    14. Management Vitamens – B6, D, E Minerals – calcium and magnesium Herbs Chasteberry Dong qai

    15. Cognitive Behavioral Therapy

    16. Pyridoxine B6 meta analysis Wyatt K et al BMJ 318:1375 1999 25 trials, 9 suitable for meta-analysis 940 women Overall OR 1.57 (1.40-1.77) Doses 50 – 500 mg daily No dose response effect No difference daily or luteal phase only

    17. Calcium

    18. Chasteberry Meta-analysis CAM 5:246 2008 Summary of Evidence AFP 72:821 2005 Good efficacy for cyclic breast pain Moderate evidence for effficy for other PMS sx Side effects: nausea, GI distress, headache, fatigue, dizziness – infrequent and mild

    19. Management - Pharmacologic Inhibit cycles OCP GnRH agonists Neurotransmitter modulation SSRI’s GABA

    20. SSRI’s

    21. Response to Fluoxetine in women with PMDD

    22. SSRI’s 2008 Meta-analysis 29 studies, 2964 women SSRI’s are effective for PMS 53% improvement OR 0.38 (0.22 – 0.66) SSRI’s are effective for PMDD 51% improvement OR 0.40 (0.30 – 0.53)

    23. SSRI’s 2008 Meta-analysis Intermittent dosing less effective than continuous dosing regimens OR 0.55 vs 0R 0.28 No difference among fluoxetine, paroxetine, sertraline, citalopram

    24. Alprazolam Small number randomized trials Decrease in sx used in luteal phase 50% (vs 30% placebo) JAMA 1995 274-51 1/3 for tension, anxiety 2/3 for irritability, “out of control” vs placebo ObGyn 1994 84:379

    25. OCP Generally more effective than placebo (50-60% vs 30% ) Most studies with drosperinone (Yasmin / Yaz) Other OCP also effective but less studies

    26. OCP Meta-analysis

    27. Progesterone Meta-analysis Wyatt k BMJ 3223:776 2001

    28. Practical Clinical Management History and physical, r/o other etiologies Assess severity of impairment Prospective symptom charting is important Can begin lifestyle management during charting

    29. Practical Clinical Management If behavioral measures not enough: OCP with drosperinone Consider extended cycle SSRI Continuous Luteal phase only If still symptomatic: Consider GnRH agonist

    30. Practical Clinical Management

    31. Appendix - doses

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