4 slide revision for O&G examination question on PMS

1. O&G Revision in 4 slides
Premenstrual syndrome (PMS)
Dr KA

2. Background
• PMS = self-limiting cyclical (luteal phase) physical and psychological symptoms occurring
in the luteal phase (pre-menses).
• Physical: increased appetite, abdominal bloating, breast tenderness, sweats, back ache, fatigue,
dizziness, sweats
• Psychological: labile mood, irritability, anxiety, depression, feeling out of control, cognitive
impairment
• Premenstrual dysphoric syndrome (PMDD) = severe form of PMS with functional
impairment. DSM-IV criteria requiring 4 symptoms (depressed mood, anxiety, labile
mood, irritability), and 1 or more of other symptoms (e.g. sleep disturbance, feeling out
of control, lack of energy). These symptoms are required to last most menses over 12
months. It is used in the US only and for research purposes.
• ~90% of women have PMS symptoms, and ~5% clinically significant having functional
effects

3. Pathophysiology
• Uncertain; likely multifactorial:
• Abnormal neuroendocrine response to normal hormonal changes of menses;
serotonin implicated
• Genetics, e.g. PMDD has an association with ESR1 gene
• Abnormal progesterone metabolites (preg-neno-lone and allopregnenolone)
levels which have effects on anxiety
• Abnormal immune system response to menstrual cycle
• Abnormal aldosterone function (sodium and water retention)
• Abnormal prostaglandin function
• Nutritional deficiency
• Environmental (education, smoking)
• Mental health history (anxiety, traumatic event)

4. Diagnosis and investigations
• Diagnosis based on history
• Self-assessment by patient over 2 prospective menstrual cycles using
tools such as ‘Daily Record of Severity of Problems’
• Exclude medical disease such as anaemia or thyroid disease
• Assess for mental health disease such as depression or anxiety

5. Management
• Multidisciplinary team involvement: gynaecologist, psychologist, dietitian
• Note high placebo response rate
• Conservative
• Exercise, improved nutrition, relaxation (e.g. acupuncture), and cognitive therapy (E.g. CBT). Overall mixed evidence but low risk.
• Medical
• Vitamins and herbals: vitamin B6 100mg/d (NB risk neurotoxicity in high doses), calcium carbonate, evening primrose oil and chaste
tree extract. Overall mixed evidence.
• SSRIs (e.g. sertraline 20mg/d); start low dose; prescribe in luteal phase (pre-menstrual) or continuous; side effects common (nausea,
headache, loss of libido, insomnia); withdrawal effects can occur (GI, anxiety, sweaty, dizzy, paraesthesia); 70% response rate
• Ovulation suppression
• COCPs (e.g. 3rd generation COCP containing anti-androgenic and anti-mineralocorticoid agent dro-spire-none such as Yasmin); benefit of
contraception, shorten menses by reducing placebo pill to 4d, if persistent symptoms then consider continuous COCP (e.g. 90mcg levo-nor-gestrel
and ethinyl-estradiol 20mcg); VTE risk with drospirenone.
• Danazol; androgenic steroid (19-nortestosterone derivative with progestin like effects); suppress pituitary gonadotrophin release and ovarian
enzymes; adverse effects include androgenic virilising s/effects (hirsuitism, acne, weight gain)
• GnRH anologues with low dose combined HRT; continuous GnRH suppresses pituitary gonadotrophin release; adverse effects of hypoestrogenism
(e.g. VMS, osteopaenia/osteoporosis). Good response rate.
• Surgical
• Oopherectomy +- hysterectomy; in severe cases or PMDD, if child-bearing complete, good response to GnRH analogues with add-
back therapy