PREMENSTRUAL SYNDROME (PMS)

PREMENSTRUAL SYNDROME (PMS) - Daphne J. Karel, MD
BASICS
DESCRIPTION
• Premenstrual syndrome is defined as a symptom complex severe enough to interfere with everyday life and occurring cyclically during the luteal phase of menses.
• The American Psychiatric Association's DSM-MD IV revised diagnosis is premenstrual dysphoric disorder when the dominant symptoms are emotional.
• System(s) Affected: Endocrine/Metabolic, Nervous, Reproductive
• Synonyms: Premenstrual dysphoric disorder, PMDD
GENERAL PREVENTION
Calcium with vitamin D (1,000-2,000mg elemental calcium) (1)[C]
EPIDEMIOLOGY
• Predominant age: Child-bearing years, increasing with age
• Predominant sex: Females only
Prevalence
Almost all women have some symptoms before menses (this is not premenstrual syndrome); ~5% have actual PMS.
RISK FACTORS
• High caffeine intake
• Stress may precipitate condition.
• Increasing age
• History of depression
• Tobacco use
• Family history
Genetics
Unknown; probably familial incidence
ETIOLOGY
Unknown; altered response to progesterone metabolites and serotonin are current theories.

DIAGNOSIS
SIGNS AND SYMPTOMS
• Physiologic symptoms
- Abdominal bloating/pain
- Edema
- Weight gain
- Mastalgia/breast swelling
- Fatigue
- Headache
- Sleep disturbance
- Tension/muscle aches
- Food cravings
• Psychologic/behavioral changes
- Depressed mood/dysphoria
- Mood swings/irritability
- Anxiety
- Sense of loss of control/poor coping
- Poor concentration
History
Symptoms start in the week prior to menses, and the remainder of the month is symptom free.
Physical Exam
Unremarkable
TESTS
Lab
None, unless history indicates need to rule out other diagnosis.
Diagnostic Procedures/Surgery
• Prospective patient log of symptoms completed over a minimum of 2 months and showing luteal phase exacerbation of symptoms. (2)[A] Can include any of the following
- Self diary (dates of menses and symptoms)
- Standardized questionnaire completed throughout the follicular and luteal phases
 COPE (Callender of Premenstrual Experiences)
 PRISM (Prospective Record of the Impact and Severity of Menstruation)
 VAS (Visual Analogue Scales)
DIFFERENTIAL DIAGNOSIS
• Diseases with symptom overlap
- Thyroid disease
- Adrenal disorders
- Perimenopause
• Menstrual exacerbations of chronic illness
- Asthma
- Allergies
- Seizure disorder
- Migraines
- Irritable bowel syndrome
- Chronic fatigue syndrome
• Psychiatric disorders
- Affective mood disorders
- Panic disorder
- Generalized anxiety disorder
TREATMENT
STABILIZATION
Outpatient
GENERAL MEASURES
• Increase daily exercise. (2)[C]
• Eat regular, balanced meals.
• Stop smoking.
• Get regular sleep.
• Use stress-reduction techniques.
• Try cognitive behavioral therapy.
• Join a support group.
• Try light-based therapy.
Diet
Low-salt; low-caffeine; low-fat; frequent, small meals high in complex carbohydrates (2)[B]
Activity
• No restrictions
• Exercise is recommended.
SPECIAL THERAPY
Complementary and Alternative Medicine
• Cognitive behavioral therapy (6 months of treatment provides improvement and maintenance of symptoms) (3)[B]
• Calcium with vitamin D (1,000-1,2000mg elemental calcium) (2)[B]
• Omega-3-fatty acids (2)[A]
• Agnus castus (Chaste tree) extract (1 tablet daily for 3 cycles) improved subjective symptoms.
• Vitamin E (400 IU for 5 days around menstrual period) for 2 cycles significantly reduced dysmenorrhea, analgesic need, and estimated blood loss. [B]
• Insufficient evidence to recommend black cohosh, dong quai, primrose oil, progestins, red clover, and soy extract.
MEDICATION (DRUGS)
• No cure. Therapy is targeted at symptom control.
• Control of total symptom complex (physical and behavioral)
- Selective serotonin reuptake inhibitors (SSRIs) with continuous or luteal phase dosing (4)[A]
 Fluoxetine (Prozac, Sarafem)
 Sertraline (Zoloft)
 Escitalopram (Lexapro)
 Citalopram (Celexa)
 Venlafaxine (Effexor) (serotonin-norepinephrine reuptake inhibitor)
- Some nutritional supplements may be minimally beneficial with little to no risk (2)[B]
 Vitamin B6 in modest doses (50 mg PO b.i.d; may be toxic in higher doses)
 Magnesium 200-400 mg daily
 Calcium with vitamin D (1,000-1,200 mg elemental calcium)
- Drospirenone-containing oral contraceptives (2,5)[B]
- Gonadotropin-releasing hormone (GnRH) agonists with or without hormone replacement (2)[B]
• Targeted symptom improvement
- Cramping and pain: NSAIDs
- Fluid retention: Spironolactone
- Breast tenderness: Bromocriptine 2.5 mg t.i.d.
- Depression: All non-SSRI antidepressants
- Anxiety: Anxiolytics (buspirone, alprazolam)
• Contraindications: Refer to manufacturer's profile of each drug.
• Precautions
- Effects of long-term hormonal treatment remain unknown.
- Refer to manufacturer's profile of each drug.
• Significant possible interactions: Refer to manufacturer's profile of each drug.
First Line
• Lifestyle modification, calcium and vitamin E supplement (2)[C]
• Cognitive behavioral therapy (3)[B]
• Targeted symptom control
Second Line
• SSRIs (4)[A]
• GnRH agonists (2)[B]
• Surgical intervention (2)[B]
SURGERY
Bilateral oophorectomy provides relief in a limited subset of patients. Surgery may be offered to patients who fail 1st-line therapy and have a significant response to GnRH agonists over 3 months.
FOLLOW-UP
PROGNOSIS
• Many patients can have their symptoms adequately controlled. PMS disappears at menopause.
• PMS sometimes continues after hysterectomy.
PATIENT MONITORING
Provide general support and further patient education.
REFERENCES
1. Bertone-Johnson ER. Arch Intern Med. 2005;165(11):1246-1252.
2. Practice Bulletin. The American College of Obstetricians and Gynecologists. Management of premenstrual syndrome. Clinical Management Guidelines No. 15, April 2000.
3. Hunter MS, Ussher JM, Browne SJ, et al. A randomized comparison of psychological (cognitive behavior therapy), medical (fluoxetine) and combined treatment for women with premenstrual dysphoric disorder. J Psychosom Obstet Gynaecol. 2002;23:193-199.
4. Wyatt KM, Dimmock PW, O'Brien PM. Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database Sys Rev. 2002;(4):CD001396.
5. Yonkers KA. Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder. Obstet Gynecol. 2005;106(3):492-501.
6. Ziaei S, Zakeri M, Kazemnejad A. A randomized controlled trial of vitamin E in the treatment of primary dysmenorrheal. Br J Obstet Gynecol. 2005;112:466-469.
MISCELLANEOUS
See also: Mastalgia