Diseases » Basilar artery migraine

Premenstrual Syndrome (PMS)

Premenstrual Syndrome (PMS): Excerpt from The 5-Minute Pediatric Consult

Ann B. Bruner, MD

Premenstrual Syndrome - BASICS

Premenstrual Syndrome - description

• Premenstrual syndrome (PMS), also called luteal phase disorder, is a disorder characterized by psychologic and physical symptoms that occur cyclically and consistently during the second half (luteal phase) of the menstrual cycle, negatively impact a woman’s usual activities of daily living, and remit after the onset of menstruation.
• PMS is diagnosed through prospective symptom charting with symptoms present beginning at approximately day 13 of the cycle and resolving within 4 days of menses for 2 consecutive cycles.
  • At least one of the following symptoms must occur within 5 days of onset of menses: Breast tenderness, bloating/weight gain, headache, swelling of hands/feet, aches/pains, mood symptoms (depression, anger, irritability, anxiety, social withdrawal), poor concentration, sleep disturbance, or change in appetite.
• Premenstrual dysphoric disorder (PMDD) is the extreme variant of PMS; defined in DSM-IV-TR as severe psychologic symptoms causing significant dysfunctions, which are not an exacerbation of symptoms of a chronic condition and are confirmed through prospective daily ratings of 3 consecutive cycles.
• Criteria for PMDD: At least 5 symptoms among the following must be present during most of the luteal phase, with at least 1 of the symptoms being among the 1st 4:
  • Depressed mood: Feeling sad, hopeless, or self-deprecating
  • Anxiety or tension: Feeling tense, anxious, or “on edge”
  • Affective lability: Fluctuating emotions interspersed with frequent tearfulness
  • Irritability or anger: Increased interpersonal conflicts
  • Decreased interest in usual activities, which may be associated with withdrawal from social relationships
  • Difficulty concentrating
  • Feeling fatigued, lethargic, or lacking in energy
  • Marked changes in appetite, which may be associated with binge eating or craving certain foods
  • Hypersomnia or insomnia
  • A subjective feeling of being overwhelmed or out of control
  • Physical symptoms such as breast tenderness/swelling, headaches, bloating or weight gain, arthralgias, or myalgias

Premenstrual Syndrome - epidemiology

Premenstrual Syndrome - prevalence

• 40–75% of women experience some PMS symptoms at some time
• 15–30% of women report recurrent symptoms suggestive of PMS
• 2–5% of women have symptoms that interfere with their usual activities (PMDD)
• 14–88% of adolescent girls have moderate to severe PMS

Premenstrual Syndrome - risk factors

Premenstrual Syndrome - genetics

Genetic factors may play a role in the development of PMS/PMDD: Twin studies show a 93% concordance rate in monozygotic twins, with only a 44% rate in dizygotic twins.

Premenstrual Syndrome - pathophysiology

• Occurrence of symptoms is related to ovarian function/ovulation:
  • PMS does not occur before menarche, during pregnancy, or after menopause.
  • PMS can occur after hysterectomy, but not after bilateral oophorectomy.
• Research suggests altered cyclic interactions between sex hormones and neurotransmitters (in particular, relationships between sex hormones, prostaglandins, and serotonin): γ-Aminobutyric acid (GABA) and opioid neurotransmitter systems have also been studied, along with trace elements, vitamins, and minerals.
• Women with PMS do not have abnormal serum concentrations of estrogen or progesterone or hormonal imbalance; research suggests that women with PMS have abnormal responses to normal variations in sex hormones.

Premenstrual Syndrome - etiology

Etiology unknown, but presumed to be multifactorial

Premenstrual Syndrome - DIAGNOSIS

Premenstrual Syndrome - signs & symptoms

Many women report that their PMS symptoms are not taken seriously.

Premenstrual Syndrome - history

• Complete medical history, including use of medications or illicit substances, cigarettes, dietary evaluation
• Gynecologic history: Age at onset of pubertal development, menstrual pattern, sexual activity, contraceptive use, dysmenorrhea
• Psychiatric history: Mental health disorders, medications
• Family history: Mental health and substance use/abuse
• Psychosocial history: Living situation, school/vocational activities and goals, hobbies, peers
• Complete review of systems including both physical symptoms (fatigue, breast tenderness/swelling, bloating, edema, weight gain, headache, arthralgias, myalgias, pelvic discomfort, changes in bowel habit, reduced coordination) and emotional/psychologic symptoms (depression, mood lability, irritability, tension, anxiety, tearfulness, restlessness, reduced concentration, fatigue, altered libido, altered appetite/eating habits, altered sleep)
• Chronologic review to determine if symptoms are recurrent with most menstrual cycles, isolated to luteal phase of cycle, and remit with onset of menses

Premenstrual Syndrome - physical exam

There are no specific physical findings of PMS.

• Enlarged thyroid gland: May suggest hypothyroidism and need to evaluate for thyroid disease
• Virilization (hirsutism, clitoromegaly): May suggest hyperandrogenism and need to evaluate for adrenal disease, including Cushing syndrome, or other hormonal disorders such as polycystic ovarian syndrome
• Pallor: May suggest anemia
• Orthostatic hypotension: May suggest neurally mediated hypotension

Premenstrual Syndrome - tests

PAF (Premenstrual Assessment Form), PRISM (Prospective Record of Severity of Menstruation), or COPE (Calendar of Premenstrual Experiences): Prospective symptom calendars can help establish diagnosis and provide information about symptom patterns (recurrence and relation to menses).

Premenstrual Syndrome - lab

• CBC: Rule out anemia.
• Thyroid-stimulating hormone (TSH) assay:

  Rule out thyroid disease.

Premenstrual Syndrome - differencial diagnosis

• Psychiatric:
  • Mood disorder, including major depression, dysthymia, bipolar illness, postpartum depression, anxiety disorder
  • Substance abuse
  • Physical, sexual, or emotional abuse
  • Somatization disorder
  • Eating disorder
• Endocrinologic:
  • Thyroid disease
  • Cushing disease
  • Diabetes mellitus
• ∑Gynecologic:
  • Dysmenorrhea (primary or secondary)
  • Pregnancy
  • Endometriosis
  • Hormonal contraceptive use
  • Perimenopause
• Immunologic/Hematologic:
  • Anemia
  • Fibromyalgia
  • Systemic lupus erythematosus (SLE)
  • Chronic fatigue syndrome
• Neurologic:
  • Migraine headache
  • Neurally mediated hypotension

Premenstrual Syndrome - TREATMENT

Premenstrual Syndrome - general measures

• Treatment goals include reducing both symptom frequencies and severities and the impact of symptoms on patients’ activities.
• Patient education, counseling, and reassurance may be all that is needed for women with milder symptoms.
• Many pharmacologic and nonpharmacologic modalities have not been formally evaluated.

Premenstrual Syndrome - diet

• Research supports reducing caffeine and alcohol intake and suggests that reductions in salt and refined sugars may also be beneficial.
• Meta-analyses of research to date have shown that some supplements are beneficial in reducing symptom frequencies and severities, including calcium carbonate (1,200 mg/d), pyridoxine/vitamin BMany herbal therapies in use, including evening primrose oil, chaste berry, black cohosh, ginkgo, and St. John’s wort: There is no strong evidence to support their use in PMS.

Premenstrual Syndrome - activity

• Increasing physical activity, ensuring adequate and regular sleep, and maintaining a healthy diet are important 1st steps.
• Mind/Body therapies are frequently used including individual psychotherapy, relaxation techniques, guided imagery, yoga, massage, biofeedback, and group therapy; to date, there is no strong evidence to support their use in PMS.

Premenstrual Syndrome - medication

Premenstrual Syndrome - first line

Many menstrually associated symptoms can be managed with nonsteroidal anti-inflammatory drugs (NSAIDs):

• NSAIDs (e.g., naproxen sodium 275–550 mg b.i.d.) relieve the majority of physical symptoms–premenstrual/menstrual cramping, headaches, and myalgias/arthralgias.
• Side effects include gastrointestinal upset and renal dysfunction.

Premenstrual Syndrome - second line

SSRIs are 1st line for PMDD and severe PMS, especially those with predominantly psychologic symptoms. SSRIs have been shown to improve mood, decrease irritability, ameliorate physical symptoms such as bloating and breast tenderness, and improve psychosocial function. Both continuous and intermittent (during luteal phase) dosing can be used, and symptom amelioration can occur during the 1st cycle of treatment. Intermittent use includes administration during the last 14 days of the menstrual cycle or treatment begun at expected date of symptom onset:

• Fluoxetine (20–60 mg/d), sertraline (50–150 mg/d), paroxetine (10–30 mg/d), and citalopram (5–20 mg/d) are some of the most commonly used SSRIs for PMS/PMDD; side effects include gastrointestinal upset, insomnia, tremor/agitation, fatigue, dry mouth, and sexual dysfunction. SSRIs recently received a US FDA black box warning concerning an increased risk of suicidality among depressed children and adolescents; the warning was for the treatment of depression, not PMS/PMDD.
• Hormonal contraceptives (i.e., low-dose oral contraceptive pills, contraceptive patch) suppress ovulation, which may ameliorate hormonally mediated symptoms such as breast swelling/tenderness and bloating, but may exacerbate mood symptoms.
• Spironolactone (50 mg b.i.d.) is effective for breast tenderness and bloating; potassium levels must be monitored, and spironolactone is contraindicated in patients with abnormal renal function.

Premenstrual Syndrome - FOLLOW UP

• Frequent follow-up and the use of prospective menstrual/symptom calendars are important.
• After the diagnosis of PMS is established, and after recommending appropriate lifestyle changes (and possibly NSAIDs), the patient should be re-evaluated after 3 months. If there has not been substantial improvement, secondary pharmacologic therapies (SSRIs) may need to be considered. When SSRIs are prescribed as first-line therapy for patients with more severe PMS or PMDD, response to SSRIs and any adverse reactions should be assessed at follow-up and dosage adjusted as needed.

Premenstrual Syndrome - disposition

Premenstrual Syndrome - issues for referral

A gynecologist/reproductive endocrinologist can assist in the management of severe PMS/PMDD: Other pharmacologic agents that are used include gonadotropin-releasing hormone (GnRH) analogues, danazol, estrogen implants, and androgens.

Premenstrual Syndrome - complications

Psychologic morbidity includes difficulty with interpersonal relationships (family and friends) and school absence/failure.

Premenstrual Syndrome - bibliography

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 2000.
1. Claman F, Miller T. Premenstrual syndrome and premenstrual dysphoric disorder in adolescence. J Pediatr Health Care. 2006;29:1–12.
2. Cronje WH, Studd JWW. Premenstrual syndrome and premenstrual dysphoric disorder. Prim Care. 2002;29:1–12.
3. Dickerson LM, Mazyck PJ, Hunter MH. Premenstrual syndrome. Am Fam Phys. 2003;67:1743–1752.
4. Girman A, Lee R, Kligler B. An integrative approach to premenstrual syndrome. Clin J Women Health. 2002;2:116–127.
5. Halbreich U, Bornestein J, Pearlstein T, et al. The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). Psychoneuroendocrinology. 2003;28(suppl 3):1–23.
6. Halbreich U. The etiology, biology, and evolving pathology of premenstrual syndromes. Psychoneuroendocrinology. 2003;28(suppl 3):55–99.
7. Steiner M, Pearlstein T, Cohen L, et al. Expert guidelines for the treatment of severe PMS, PMDD, and comorbidities: The role of SSRIs. J Womens Health (Larchmt). 2006;1:57–69.

Premenstrual Syndrome - CODES

Premenstrual Syndrome - icd9

625.4 Premenstrual syndrome

Premenstrual Syndrome - FAQ

• Q: Can adolescent girls have PMS and PMDD?
• A: The incidence of PMS and PMDD in adolescents is not well established. Although ≤50% of cycles are anovulatory during the 1st 1–2 years after menarche, younger patients experience many PMS symptoms, and menstrual problems are some of the most common reasons for school absence. Most experts believe that PMS/PMDD will not develop until a regular ovulatory pattern is established, ~2–3 years after menarche.
• Q: Is family history important?
• A: Genetic factors may play a role in the development of PMS/PMDD; twin studies show a 93% concordance rate in monozygotic twins, with only a 44% rate in dizygotic twins.
• Q: Are there any common comorbidities?
• A: The symptoms of PMS/PMDD are also seen with depression, anxiety, and other mood disorders. Psychiatric symptomatology can fluctuate, and symptoms may change in relation to the menstrual cycle. Careful and thorough history taking and prospective symptom diaries can help differentiate PMS/PMDD from another mental health disorder.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

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More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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