PMS

• Overview:

  • Premenstrual syndrome (PMS) describes the psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle
  • Affects most women
  • Symptoms resolve once menstruation begins
  • Symptoms are not present before menarche, during pregnancy or after menopause
• Pathophysiology:

  • Thought to be caused by fluctuation in oestrogen and progesterone - increased sensitivity to progesterone
  • Or interaction between hormones and the neurotransmitters serotonin and GABA
• Symptoms:

  • Low mood
  • Anxiety
  • Mood swings
  • Irritability
  • Bloating
  • Fatigue
  • Headaches
  • Breast pain
  • Cognitive impairment
  • Clumsiness
  • Reduced libido
• Symptoms can occur in the absence of menstruation after a hysterectomy, endometrial ablation or on the Mirena coil, as the ovaries continue to function and the hormonal cycle continues. They can also occur in response to the combined contraceptive pill or cyclical hormone replacement therapy containing progesterone, and this is described as progesterone-induced premenstrual disorder.
• When features are severe and have a significant effect on quality of life, this is called premenstrual dysphoric disorder.
• Diagnosis:

  • Symptom diary spanning 2 menstrual cycles e.g. Daily Record of Severity of Problems (DRSP)
  • Should demonstrate cyclical symptoms that occur just before, and resolve after the onset of menstruation
  • A specialist can make a definitive diagnosis by administering a GnRH analogues to halt the menstrual cycle
• First line management:

  • Complementary/conservative - exercise, CBT, vitamin B6
  • Hormonal - combined new generation pill (continuous better than cyclically)
  • Non hormonal - continuous or luteal phase (day 15-28) low dose SSRIs e.g. citalopram
• Combined contraceptives:

  • New combined contraceptives containing drospirenone (antimineralocorticoid and antiandrogenic progestogen)
  • Yasmin
  • Beneficial if women require contraception
  • Continuous is better than cyclical
• SSRIs:

  • Fluoxetine
  • Citalopram
  • Sertraline
  • Warn about side effects - nausea, sweating, loss of libido and insomnia
  • Don't abruptly stop
• Second line management:

  • Hormonal - Estradiol patches + micronised progesterone (orally or vaginally - can use LNG-IUS)
  • Non hormonal - higher dose SSRI continuously or luteal phase
• Spironolactone can be used to treat symptoms of mood and weight gain

  • Diuretic
  • Also has progestogenic and anti-androgenic actions
• Third line management:

  • Hormonal - GnRH analogues +/- add back HRT (especially if under 45 - reduce risk of osteoporosis) - continuous combined oestrogen and progesterone
• GnRH:

  • Provides continuous serum levels of GnRH and thus overrides the pulsatility of endogenous GnRH
  • Induces downregulation of GnRH receptors so release of LH and FSH are suppressed - which leads to suppression of production of gonadal oestrogen
• 4th line management:

  • Surgical +/- HRT
  • Hysterectomy and bilateral salpingo-oophorectomy
  • Only for selected cases - severe PMS with failure of medical management or requirement of long term GnRH analogues
  • HRT advised in those under 45 years - risk of osteoporosis
  • Consider testosterone
• For a diagnosis of PMDD one of the following must be present:

  • Marked affective lability e.g. mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection
  • Marked irritability or anger or increased interpersonal conflicts
  • Markedly depressed mood, feelings of hopelessness, or suicidal thoughts
  • Marked anxiety, tension and/or feelings of being on edge