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PMS

PMS. A Practical Evidence Based Approach in General Practice Kalpa Sundar. Psychological & Somatic disorder of unknown aetiology ? Endocrine origin ? Exaggerated end organ response. The Syndrome – basic facts. 95% Middle age, Multiparous, Middle Class

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PMS

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  1. PMS A Practical Evidence Based Approach in General Practice Kalpa Sundar

  2. Psychological & Somatic disorder of unknown aetiology • ? Endocrine origin • ? Exaggerated end organ response

  3. The Syndrome – basic facts • 95% • Middle age, Multiparous, Middle Class • Usual symptoms – irritability, aggression, depression, bloatedness, mastalgia, behavioural symptoms…

  4. Definition • 4 out of previous 6 cycles • Resolve by the end of menstruation • Symptoms begin in late luteal phase

  5. Types • Primary • Secondary – underlying psychopathology

  6. Aetiology Endorphins, Psychosomatic, Pyridoxine, Neurotransmitters, Prolactin Na+, H20 retention, ADH, ANP, Renin angiotensin Aldosterone Prostaglandins, Oestrogen ,Progest, SHBG

  7. Diagnosis • History – Corner stone & Challenge • Severity • Qol affected • Examination • Little contribution • Opportunistic screening • Reassure no cancer • Blood tests • Diagnostic tests • GnRh depot X 3 cycles

  8. Blood tests

  9. Counsel/ Educate/ Reassure Stress management / Relaxation techniques Physiological symptoms Pyridoxine, Primrose, Diuretics Mild SSRI Moderate Prog/Bromocrip COC Danazol E2 patches / implants Severe GnRH analogue Extreme TAH+BSO

  10. Mild • Pyridoxine • 30% self prescribed • 82% improvement compared to placebo 72% • Gr II evidence • Oil of evening primrose • Limited benefit over placebo • Gr I evidence • Diuretics • Spironolactone • 20% more than placebo • demonstrable improvement in oedema

  11. Moderate • SSRI • Significant improvement • 90% compared to 76% placebo • CCP • Logical • No large study or formal evaluation of CCP • Using the pill empirically and assessing effect is worthwhile • Progestrogens/ Progestrone • Uncontrolled studies • Failed to show improvement • Anectodal reports of efficacy • Bromocriptine • 5mg day 10 to day 26 • Improvement of cyclical mastalgia • 80-90% compared to 80% placebo

  12. Severe • Danazol • Effective in mastalgia • Balance with side effects • Oestradiol implants & patches • 85% relief with cyclical Prog • Reserved for perimenopausal age

  13. Extreme • GnRH analogues • Not a permanent cure • More of diagnostic value • Surgery • Controversial • TAH BSO is curative • Needs unapposed Oestrogen replacement

  14. Conclusions • Difficult to better placebo • Could be dealt with primarily by GP, Womens’ health units • Psychiatric input in selected cases • If very severe • Referral to a gynaecologist for manipulation or suppression of normal ovarian function

  15. Links

  16. Links • N.A.P.S Helpline- 08707772177 • www.pms.org.uk • www.rcog.org.uk • PMS symptometrics- ready reckoner package-Keele University. • P.M.S. O’Brien – literature search

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