Premenstrual Syndrome

1. Premenstrual Syndrome Dr Patel GP VTS

2. Aims • To make an accurate diagnosis of premenstrual syndrome (PMS) • To provide appropriate advice to women with PMS • To offer options for treatment that are appropriate for initiation in primary care • To refer the woman when primary care treatment is not adequate

3. Premenstrual Syndrome Modern Definition ‘Distressing physical, psychological and behavioural symptoms, not caused by organic disease, which regularly recur during the same phase of the menstrual (ovarian) cycle and which significantly regress or disappear during the remainder of the cycle’ • Magos & Studd (1984)

4. What is Premenstrual Syndrome (PMS) • distressing physical, behavioural, and psychological symptoms • Regularly occur in the luteal phase of the menstrual cycle • Significantly improved or resolved by the end of menstruation. • Mild PMS  • symptoms do not interfere with the woman's personal, social, and professional life. • Moderate PMS  • symptoms interfere with the woman's personal, social, and professional life. Daily functioning is possible, although maybe not to the usual level. • Severe PMS  • the woman withdraws from social and professional activities and cannot function normally. • If symptoms are predominantly emotional and behavioural, this is sometimes referred to as premenstrual dysphoric disorder

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

6. Physical symptoms • Fluid retention and feeling bloated • Pain and discomfort in your abdomen • Headaches • Changes to your skin and hair • Backache • Muscle and joint pain • Breast tenderness • Insomnia (trouble sleeping) • Dizziness • Tiredness • Nausea • Weight gain (up to 1kg)

7. Psychological symptoms • Mood swings • Feeling upset or emotional • Feeling irritable or angry • Depressed mood • Crying and tearfulness • Anxiety • Difficulty concentrating • Confusion and forgetfulness • Restlessness • Decreased self-esteem

8. Behavioural symptoms • Loss of interest in sex • Appetite changes or food cravings • Any chronic (long-term) illnesses, such as asthma or migraine, may get worse.

9. Premenstrual Dysphoric Disorder • The symptoms of PMDD are similar to those of PMS, but more exaggerated. • a small percentage of women have symptoms that are severe enough to stop them living their normal lives. • They can include: • feelings of hopelessness • persistent sadness or depression • extreme anger and anxiety • decreased interest in usual activities • sleeping much more or less than usual • very low self-esteem • extreme tension and irritability • PMDD can be particularly difficult to deal with because it can have a negative effect on your daily life and relationships.

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

11. Suggested theory • Hormone changes • Chemical changes • Weight and exercise • Stress • Diet

12. How common ? • Mild PMS is experienced by many women. • Around 5% of women have severe premenstrual symptoms [RCOG, 2007]. • In the UK, only about a fifth of women experiencing PMS symptoms seek medical help. However, up to 13% of working women with PMS symptoms take time off during the year because of PMS [MeReC, 2003].

13. Risk Factors • Common in women whose mothers also experienced PMS symptoms (70%) • Monozygotic twins  93% concordance rate • Dizygotic twins  44%[Bhatia and Bhatia, 2002]. • More common in women who are obese, do not exercise, and who have a lower level of academic achievement [RCOG, 2007]. • Women using hormonal contraception are less likely to experience PMS [RCOG, 2007].

14. Diagnosis of PMS • Diagnosis  Clinical • Difficulty in diagnosis often occurs because PMS can present with a large number of symptoms which are common to a range of conditions [Rapkin and Mikacich, 2008]. • Ask the woman to record a daily symptom diary for two or three cycles [MeReC, 2003]. • Investigations are not usually helpful in making the diagnosis.

15. Conditions to exclude • Depression • Anxiety and panic disorders • Hypothyroidism • Anaemia • Dysmenorrhoea • Irritable bowel syndrome • Interstitial cystitis • Endometriosis • Chronic fatigue syndrome • Fibromyalgia • Systemic lupus erythematosus

16. Managment • Management should be tailored according to the severity and type of symptoms, and the woman's preferences and any desire to become pregnant. • Mild symptoms • Offer lifestyle advice. • Regular, frequent (2–3 hourly), small balanced meals rich in complex carbohydrates. • Regular exercise. • Smoking cessation. • Alcohol restriction. • Regular sleep. • Stress reduction.

17. Management • Moderate PMS • Offer lifestyle advice and consider: • A new-generation combined oral contraceptive • UNLICENSED  if used solely to treat PMS symptoms • Can be used cyclically or continuously • But the first-line choice of COC is not clear. • More evidence to support : • the use of drospirenone-containing COCs (for example Yasmin®) than other preparations • desogestrel (for example Marvelon®) • 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 of benefit. • Inform the woman that it is not possible to predict whether her PMS symptoms will respond. • Paracetamol or a nonsteroidal anti-inflammatory drug - if the predominant problem is pain • Cognitive behavioural therapy (CBT; referral is likely to be required) if it is thought the woman would benefit from psychological intervention.

18. Management • Severe PMS • Offer lifestyle advice and consider: • The treatment options outlined above for moderate PMS • A selective serotonin reuptake inhibitor (SSRI) • Unlicensed use • Do not prescribe an SSRI  doubt about the diagnosis, < 18 yrs without advice a specialist • taken either continuously or just during the luteal phase (for example days 15–28 of the menstrual cycle, depending on its length). • initial trial of 3 months' treatment  benefit  continue 6 months to 1 year. • Monitor the woman's response to treatment closely, including asking about any thoughts of self-harm.

19. Managment • 12 yrs onwards • 1st line : Lifestyle advice : • The following things may help to ease PMS. • Eat regular, frequent, small balanced meals rich in complex carbohydrates. • Take regular exercise. • Stop smoking. • Don't drink too much alcohol. • Get regular sleep.

20. 12yrs + • Paracetamol • NSAIDs • Mefanemic acid 500mg tds

21. Combined Oral Contraception • Age from 13 to 50 years: • COCs monophasic: • EE 30-35mcg with drospirenone or norgestimate eg : • Yasmin: drospirenone 3mg + ethinylestradiol 30mcg • Cilest: norgestimate 250mcg + ethinylestradiol 35mcg • EE 30mcg with gestodene or desogestrel • Femodene: gestodene 75mcg + ethinylestradiol 30mcg

22. Selective Serotonin Receptor Inhibitors • 18yrs + : • Fluoxetine 20mg od, Sertraline 50mg od, paroxetine 20mg od, citalopram 20mg od • Luteal phase selective serotonin reuptake inhibitors (SSRIs) • Fluoxetine, citalopram: 20mg each morning on days 15-28 of cycle

23. When should I refer a woman with premenstrual syndrome? • Refer the woman to a psychiatrist if there is marked underlying psychopathology in addition to premenstrual syndrome (PMS). • Consider referral to a clinic with a specific interest in PMS (or a general gynaecology clinic if this is not available) if the symptoms are severe and appropriate primary care measures have been explored but have failed.

24. Evidence on treatments not recommended in primary care • Progesterone or progestogens used alone • Antidepressants other than SSRIs • Transdermal oestradiol • Diuretics • Vitamin B6 (pyridoxine) • Calcium and vitamin D • Magnesium • Evening primrose oil • Agnus castus (chaste tree) • Alprazolam • Gonadotrophin releasing hormone analogues eg Danazol • Hysterectomy and bilateral salpingo-oophorectomy may be considered under certain circumstances in secondary care for women with severe PMS.