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Premenstrual Disorders

Premenstrual Disorders. Premenstrual Syndrome / Premenstrual Dysphoric Disorders Folake V Falaki PGY 3 Emory Family Medicine November 19, 2009. Different Faces of Premenstrual Disorders. Table Of Content. Introduction Etiology Differential diagnosis Diagnosis Management Conclusion

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Premenstrual Disorders

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  1. Premenstrual Disorders Premenstrual Syndrome / Premenstrual Dysphoric Disorders Folake V Falaki PGY 3 Emory Family Medicine November 19, 2009

  2. Different Faces of Premenstrual Disorders

  3. Table Of Content • Introduction • Etiology • Differential diagnosis • Diagnosis • Management • Conclusion • References

  4. Clinical Scenario • A 30 yo old AAF female presents with symptoms of anxiety, sadness , unexplained crying spells which has been occurring for 6 months. Symptoms usually occur few days before the onset of her periods and improve by day 3 of her menses . She also noticed severe bloating , abdominal pain and back pain during these periods. She has had difficulty caring for her 2 young children due to intense fatigue and lack of energy. She also lacks interest in her daily activities and stays in bed all day She works as a cashier and she has used up her sick leave for the year. She is concerned that she might loose her job . A friend told her about some herbal supplements which she tried, but this did not help. She denies any history of depression and she is not on any medication . Lab tests: CBC, CMP, TSH, UDS and Urinalysis are all WNL

  5. Introduction • Premenstrual syndrome (PMS) is a group of physical and behavioral symptoms that occur in a cyclic pattern during the luteal phase of the menstrual cycle. • Premenstrual dysphoric disorder (PMDD) is a severe form of PMS • Millions of women in their reproductive years have recurrent emotional, physical and social symptoms during their menstrual cycle. It Affects up to 80 % of women. • PMS affects 20-30 % of women while PMDD occurs in about 2-10 % of these women. • Symptoms usually start between ages 25-35 years References 1, 2, 3

  6. Menstrual Cycle

  7. Premenstrual Dysphoric DisorderDSM –IV Criteria A. • Documentation of physical and behavioral symptoms present for most of the preceding year • 5 or more symptoms of the listed must be present . • At least 1 of the symptoms must be any of the first 4 symptoms. • Symptoms occurs in the luteal phase of the cycle, improve in the first few days of menstrual flow and resolves in post menstrual week. Reference 4

  8. At least one symptom Depressed mood, hopelessness and self deprecating thoughts Intense feeling of anxiety, tension and edged up Marked affective lability Persistent anger or irritability or increased self conflict Reference 4 With any of these symptoms Decreased interest in daily activities Difficulty with concentration Lethargy, lack of energy, easy fatigability Marked change in appetite Hypersomnia or insomnia Feeling overwhelmed or out of control Physical symptoms: Breast pain, headaches, Joint and muscle pain, bloating Premenstrual Dysphoric DisorderDSM –IV Criteria

  9. Premenstrual Dysphoric DisorderDSM –IV Criteria • B.Symptoms significantly interferes with work, School, daily social activities and relationships. • C. Symptoms are not due to an exacerbation of another psychological disorders. • D. The above criteria must be confirmed by prospective daily ratings in at least two consecutive symptomatic cycles. Reference 4

  10. Premenstrual Syndrome • Any of the above symptoms , but less severe. • Same timing • Most common physical manifestation are abdominal bloating and extreme sense of fatigue which occurs in 90 % of women with PMS; breast tenderness and headaches occur in 50%. • Minimally Interferes with work, school, social activities and relationship Reference 3

  11. Common Symptoms Of Premenstrual Syndrome • Behavioral symptoms: fatigue, insomnia, dizziness, changes in sexual interest, food cravings or overeating • Psychologic symptoms: irritability, anger, depressed mood, crying and tearfulness, anxiety, tension, mood swings, lack of concentration, confusion, forgetfulness, restlessness, loneliness, decreased self-esteem, tension • Physical symptoms: headaches, breast tenderness and swelling, back pain, abdominal pain and bloating, weight gain, swelling of extremities, water retention, nausea, muscle and joint pain References 1, 2

  12. Premenstrual DisordersEtiology • Cause is unknown! • Interactions of ovarian hormones with neurotransmitters – Alterations of serotoninergic and GABAnergic activity in the brain. • Imbalance between Estrogen and Progesterone levels • Serotonin deficiency • Effects of hormone shift on endogenous opiods • Biologic, physiologic, environmental and social factors all seems to be contributory • Genetic factors seems to play a role. References 1, 2, 3

  13. Affective disorders ( depression, anxiety, panic attacks, personality disorders, dysthymia) Anorexia/ Bulimia PTSD Schizophrenia References 1,2 Metabolic disorders ( Diabetes mellitus, Hypothyroidism) Dysmenorrhea Endometriosis Oral contraceptive pill use Perimenopause Substance abuse Migraine Anemia Premenstrual DisordersDifferential Diagnosis

  14. Premenstrual DisordersDiagnosis • Exclude medical, physical and psychiatric problems • TSH, Drug screening, Blood glucose level etc. • Keep symptoms calendar. - At least two consecutive menstrual cycles - Nature, and timing • Exclude simple Menstrual symptoms like breast tenderness and bloating, not affecting daily activities.

  15. Premenstrual DisordersDiagnosis Adapted from AFP Journal, April 15,2003

  16. Premenstrual DisordersDiagnosis Adapted from AFP journal, April 15,2003

  17. Premenstrual DisordersManagement • Goals of treatment - Reduction or elimination of symptoms - Improvement in social and occupational functioning. References 1,2

  18. Premenstrual DisordersManagement • Lifestyle Changes or Conservative treatment: - Aerobic exercise - Dietary changes; Frequent small meals, High complex carb., low salt - Reduce caffeine intake - Reduce substance abuse e.g. alcohol - Sleep Hygiene - Smoking cessation • Nutritional Supplements: - Vitamin B6 (100mg/day) and Vitamin E (600iu/day) May have some efficacy6 - Calcium carbonate ( 1,200- 1,600mg/day) placebo-controlled trial showed 48% reduction of sx in 466 women with PMS7 References 6, 7

  19. Premenstrual DisordersManagement • Nutritional Supplements: - Magnesium ( up to 500mg/day) -Tryptophan • Herbal Therapies: - Evening primrose oil - Chaste tree berry * May improve breast tenderness * Not FDA approved for this purpose * Safety data lacking

  20. Premenstrual DisordersManagement • Nonpharmacologic treatments: - Cognitive behavioral therapy - Anger management - Stress reduction and management - Education - Light therapy - Therapy - Support groups References 1,2, 8

  21. Premenstrual DisordersManagement • Pharmacologic Treatments: • Neurotransmitter modulation: -Selective serotonin reuptake inhibitors (SSRI’s) - GABA receptor modulators • Menstrual Cycle inhibition : - GnRH agonists - OCP

  22. Premenstrual DisordersManagement Adapted from AFP journal, October 1, 2002

  23. Premenstrual DisordersManagement Adapted from AFP journal October 1, 2002

  24. Premenstrual DisordersManagement Adapted from AFP journal October 1, 2002

  25. Premenstrual DisordersManagement • ACOG recommends the serotoninergic antidepressants as the first-line treatment of choice for severe PMS and PMDD. (Evidence level C) • The US FDA approved use of fluoxetine and sertraline for women with PMDD

  26. Effect of Fluoxetine In Women With PMDD Steiner M et al. N Engl J Med 1995;332:1529-1534

  27. Premenstrual Disorders Management Adapted from AFP journal, October 1, 2002

  28. Premenstrual DisordersConclusion • PMS and PMDD affects women in the reproductive age group • PMS and PMDD can be treated. • All women with PMS or PMDD should be offered nonpharmacological treatment first. • Symptoms diary to help monitor symptoms are recommended • SSRI is the first choice for pharmacological treatment.

  29. Premenstrual DisordersReferences • Bhatia, SC, Bhatia SK. Diagnosis and treatment of premenstrual disorder. American Family Physician Journal.2002 oct.1, 66(7) :1239-48 • Dickerson ,L Mazyck P, Hunter M. Premenstrual syndrome. American Family Physician. 2003 April 15,67(8): 1743-52 • Casper R, Yonkers K. Epidemiology and pathogenesis of premenstrual syndrome and premenstrual dysphoric disorder. UpToDate. 2009 May • American Psychiatric Association. Diagnostic and Statistical Manual of Mental disorders. 4th ed. Washington DC: APA,1994:717-8

  30. Premenstrual DisordersReferences • Steiner M , Steinberg S, Stewart D et al . New England Journal of Medicine. 1995 june;332:1529-1534 • Wyatt K, Dimmock P ,Jones Pet al. Efficacy of Vitamin B6 in the treatment of premenstrual syndrome. BMJ 1999;318:1375-81 • Ward M, Holliman T. Calcium treatment for premenstrual syndrome. Ann pharmacother 1999;33:1356-8 • Mclntyre- Seltman K. PMS and PMDD: Clinical Approaches. 2009 Nov; ppt.

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