PMS
Premenstrual syndrome
What is PMS?
Premenstrual syndrome (PMS) is a condition characterized by psychological,
physical, and behavioural symptoms occurring in the luteal phase of the
normal menstrual cycle (that is, the time between ovulation and onset of
menstruation)
Symptoms:
Nearly all women have some premenstrual symptoms. Each woman’s symptoms
are different, but the most common include:
• mood swings
• feeling depressed, irritable or bad-tempered
• feeling upset, anxious or emotional
• tiredness or having trouble sleeping
• headaches
• changes in appetite and food cravings
• feeling clumsy
• fluid retention and feeling bloated
• changes to skin or hair
• sore or tender breasts.
Risk Factors:
● The strongest risk factor for premenstrual syndrome (PMS) is the presence
of ovulatory menstrual cycles. This is supported by the absence of PMS
prior to puberty, during pregnancy, and after the menopause.
● Other possible risk factors include:
○ Family history of PMS — monozygotic twin studies suggest a possible
genetic component to PMS; however, no genes have been identified
○ Mood disorders — PMS or premenstrual dysphoric disorder (PMDD)
may be a precursor to major depression, or follow a diagnosis of
depression
○ Cigarette smoking.
○ Alcohol intake, although further studies are needed to determine
whether there is a threshold of alcohol intake under which the harmful
effect on PMS is non-existent
○ Sexual abuse and/or trauma.
○ Weight gain
○ Stress
Symptoms can vary from month to month, although they tend to
form a pattern over time. Between 2 and 4 in 100 women get PMS
that is severe enough to prevent them from getting on with their
daily lives.
A very small number of women get an even more intense form of PMS
known as premenstrual dysphoric disorder (PMDD). If PMDD is
suspected, you should involve mental health team. (Has at least five
out of 11 distinct psychological premenstrual symptoms, one of which must
include mood)
Prognosis:
Women with PMS tend to be affected throughout their reproductive
lives, although symptoms remit during pregnancy.
Pathophysiology:
- One theory suggests that some women are sensitive to progesterone and
progestogens.
- Second theory involves the effects of oestrogen and progesterone on
various neurotransmitters, including serotonin and gamma-aminobutyric
acid (GABA).
How to diagnose PMS?
Purely based on history.
● The timing of symptoms in relation to the menstrual cycle. If
appropriate, also ask about the presence of symptoms before,
during, and after pregnancy.
● The severity of the symptoms and the degree of impact on daily
activity. In particular, ask about the effect of symptoms on the
woman's work, school, family life, and interpersonal relationships.
● If the woman has pelvic pain or abdominal swelling, perform a full physical
examination, including an abdominal and pelvic examination, to rule out any
other underlying cause of their symptoms.
How to diagnose PMS?
Ask the woman to record a daily severity of problems diary for two
or three cycles, and review the woman with the diary.
(DRSP has a negative predictive value of more than 80 percent)
When clinically reviewing women for PMS, symptoms should be
recorded prospectively, overtwo cycles using a symptom diary, as
retrospective recall of symptoms is unreliable.
Advice for patients:
If you are getting symptoms, you should write them down
in a diary for at least two menstrual cycles in a row.
BJOG 2017
Management of
Premenstrual
SyndromeGreen-top
Guideline No. 48February
2017
How to diagnose PMS?
Diagnose PMS if the symptom diary shows prominence of symptoms
during the luteal phase of the menstrual cycle, which resolve with
the onset of menses or soon after, followed by a symptom-free
week.
● Symptoms should be severe enough to affect daily functioning
or interfere with the woman's work, school, performance, or
interpersonal relationships.
How to diagnose PMS?
● If cyclical symptoms are not found, exclude other conditions
that could explain the symptoms, such as depression,
hypothyroidism, anaemia, irritable bowel syndrome, and
endometriosis.
At what stage of treatment should the
patients be referred to a gynaecologist?
- If the completed symptom diary alone is inconclusive,, refer the woman
to secondary care. (Symptom diaries can sometimes be confusing and/or inconclusive,
especially in women with variant PMDs.)
- Referral to a gynaecologist should be considered when simple measures
(e.g. combined oral contraceptives [COCs], vitamin B6, selective
serotonin reuptake inhibitors [SSRIs]) have been explored and failed and
when the severity of the PMS justifies gynaecological intervention.
Variant PMDs (premenstrual disorders):
● Premenstrual exacerbation of an underlying disorder
● Non-ovulatory PMDs
● Progestogen-induced PMD
● PMDs with absent menstruation
Management
Management of PMS should be tailored to the severity and type of
symptoms, the woman's treatment preferences, and any desire to
become pregnant.
1. Offer lifestyle advice
2. If the predominant symptom is pain (for example headache or
generalized aches and pains), prescribe a simple analgesics.
3. Offer advice on the use of complementary treatments and/or
dietary supplements
- Supplementation with 1,200 mg of calcium per day improves
PMS symptoms.
- Supplementation with 50 to 100 mg of vitamin B6 per day may
improve PMS symptoms.
Management
4. Provide patient information on PMS
5. For women with moderate PMS symptoms, consider prescribing
a new-generation combined oral contraceptive (COC).
- (When treating women with PMS, drospirenone-containing
COCs may represent effective treatment for PMS and should
be considered as a first-line pharmaceutical intervention).
- (Continuous COC is more effective than using them cyclically).
6. When treating women with severe PMS, CBT should be
considered routinely as a treatment option.
What is the role for progesterone and
progestogen preparations in treating PMS?
There is good evidence to suggest that treating PMS with
progesterone or progestogens is not appropriate.
There is no evidence to support the use of the LNG-IUS 52 mg
alone to treat PMS symptoms. Its role should be confined to
opposing the action of estrogen therapy on the endometrium.
Therefore, women with PMS wanting mirena coils for
contraception should also be offered estrogen.
Management
7. For women with severe PMS, SSRIs should be considered one of the first-line
pharmaceutical management options.
- When treating women with PMS, either luteal or continuous dosing with SSRIs
can be recommended. Efficacy may be improved and adverse effects
minimised by the use of luteal-phase regimens with the newer agents.
- Give an initial trial of 3 months' treatment; if there is benefit, continue
treatment for 6 months to 1 year.
- Paroxetine (Paxil) should be avoided for PMS treatment because of its increased
risk for congenital abnormalities when taken in the first trimester of pregnancy.
- Review the woman after 2 months to assess the effectiveness of the treatment.
- Women should be provided with pre pregnancy counselling at every opportunity.
They should be informed that PMS symptoms will abate during pregnancy and
SSRIs should therefore be discontinued prior to and during pregnancy.
SSRIs and Doses:
- Fluoxetine 20 mg a day
- Sertraline 50 mg to 100 mg a day
- Citalopram 20 mg a day
- Escitalopram 20 mg a day
- Paroxetine 20 mg a day.
Management
Refer to gynae if not responding to any treatments or
reconsider diagnosis.
Trial of spironolactone or Danazol to treat physical symptoms.
OR
Hysterectomy and bilateral oophorectomy.
References:
https://www.rcog.org.uk/media/mcreb5ix/pi-managing-premenstrual-syndrome-pm
s.pdf
https://www.aafp.org/pubs/afp/issues/2011/1015/p918.html
https://cks.nice.org.uk/topics/premenstrual-syndrome/
Would anyone like to share any insights from
their experience?
