Premenstrual Syndrome

Krishna B. Singh, MDDepartment of Obstetrics &

GynecologyLSU Health Sciences CenterShreveport, LA

PMS: Topics Covered

Historical review Incidence Clinical features Diagnosis Management Summary

PMS: Learning Objectives

Be able to understand that... PMS is a common clinical condition Multiple clinical symptoms/mood

changes Few hormonal, biochemical changes Many theories of pathogenesis Many treatment options available

PMS: Literature Review

First described by Robert Frank (1931) as PMT in 15 cases

Katharina Dalton (1953) popularized the term PMS and reported 86 cases

New developments (JAMA: 1992) Websites for support groups

Definitions of Premenstrual Syndrome

Recurrence of symptoms premenstrually with complete absence of symptoms after menstruation (Dalton 1984)

Other Definitions: National Institutes of Mental Health; American Psychiatric Association

Incidence of Premenstrual Syndrome

The incidence varies 40-97% About 5% women in US have severe PMS 50% may have moderate PMS

PMS: Problems In Focus

Absentees from work: ~ 5 billion dollars (1969)

Association with intellectual impairment Increased numbers of crimes and violent

acts Increased admissions in psychiatric

hospitals

PMS: Known Risk Factors

Genetic factors: Monozygous twins affected Adolescent daughters and natural mothers Positive correlation with high parity, history

of toxemia of pregnancy, post-partum blues, alcohol abuse and working outside the home

Not correlated with marital status, educational level, race or culture

PMS: Clinical Features Reported

More than 150 signs and symptoms Cluster analysis used for sub-types of PMS Neuroendocrine disorder; pathogenesis

poorly understood: neuropsychological components include symptoms - A type PMS; B type PMS

Both components present C, D and E types- These require consultations

Theories of Premenstrual Syndrome

PMS considered a global and multifactorial neuroendocrine disorder

Brain and limbic system control the hypothalamus-pituitary-ovarian axis that are needed for reproductive cycle initiation and maintenance; may be mood changes

PMS is a disorder of multiple theories

Possible Causes of PMS

Beta-endorphin deficiency: lower plasma levels during the luteal phase

Serotonin (5HT) deficiency: Platelet uptake and blood levels decreased during the luteal phase

Progesterone withdrawal rather than deficiency; receptors may be abnormal

PMS: More Theories...

Carbohydrate metabolism and GTT Protein and amino acid metabolism Prostaglandins and prostanoids Sodium, potassium, Ca++ metabolism Vitamins: A, B6 and E Minerals: zinc and copper

PMS: Differential Diagnosis

Laboratory tests remain controversial Baseline values: CBC, Chem-20 @

morning Baseline serum PRL, TSH, SHBG @

morning Cervical swab for wet mount, KOH prep

Diagnosing Premenstrual Syndrome

Daily diary, assessment charts, other ancillary methods are helpful aids to clinical diagnosis

The time and timing of the symptoms are more important than severity of symptoms

History and physical examination with selected laboratory and hormonal tests during several visits are essential components

PMS: Things To Remember

Rule out psychological conditions which may require referral to psychiatrists and counselors

Beware of misdiagnosis “on the fly” Consider the family and friends

connection Supportive and educational measures

have strong placebo effects (up to 40%)

PMS: Management Issues

Principal components: confirm diagnosis and identify category; identify and manage concurrent illness; identify and manage social and family triggers; identify and manage patient needs

There are numerous options for management but no curative treatments

PMS: Treatment Options

General measures: diet, exercise, relaxation Avoid megadose vitamins and OTC drugs Contraception: DMPA 150 mgm/3 months Hormones: Micronized or P4 suppository

(400-600 mgm/d); Parlodel, Danazol as needed

Drugs: Alprazolam (Xanax 0.25 mg/tid); Fluoxetine (Prozac 20-60mg/d); Buspirone (BuSpar 5 mg/tid)

Treatment Summary of PMS

Hormonal: progesterone, GnRHa Non-hormonal: antidepressants, diet Supportive and cognitive... Support groups; Websites portals Educational materials available

PMS: Things To Remember

Patients who fail to respond probably do not have PMS or allied condition

About 80% PMS patients will have remission of symptoms for more than a few months

About 50% PMS patients may respond to a combined psychiatric and endocrine intervention

What This Means...

PMS is a common disorder in the reproductive age group of women; these women generally have regular menstrual cycles

PMS has many facets of clinical presentation PMS can be successfully managed and

treated