Premenstrual syndrome

Premenstrual Syndrome (PMS)

Table of content

1. Definition

2. Classification

3. Incidence

4. Aetiology

5. Diagnosis

6. Management

7. Treatment Algorithm

8. Reference

Definitions

PMS encompasses a vast array of psychological symptoms such as depression, anxiety, irritability, loss of confidence and mood swings during the luteal phase of menstruation. Physical symptoms include typical bloatedness and mastalgia.
Timing rather than types of symptoms and degree of impact on daily activity supports a diagnosis of PMS

Classification

Core Premenstrual disorder

• To differentiate physiological menstrual symptoms from PMS, it must be demonstrated that symptoms cause significant impairment to the individual during the luteal phase of the menstrual cycle
• They must abate as menstruation begins, which is then followed by a symptom free week

Variant PMDs do not meet the criteria for core PMDs- Variant premenstrual disorders fall into 4 subtypes.

1.Premenstrual exacerbation of an underlying disorder-such as diabetes, depression, epilepsy, asthma and migraine. These patients will experience symptoms relevant to their disorder throughout the menstrual cycle.

2. Non-Ovulatory PMDs-Occur in the presence of ovarian activity without ovulation

3. Progesterone-induced PMDs-Caused by exogenous progestogens in hormone replacement therapy (HRT) and the combined oral Contraceptive pill COCP
4. PMDs with absent menstruation-occurs in women with a functional ovarian cycle but absent menstruation due to previous hysterectomy, endometrial ablation or the levonorgestrel-releasing intrauterine system.

Incidence

• 40% of women experience PMDs
•  5-8% experience severe PMD

Aetiology-2 theories

• Increase sensitivity to progesterone
• Disturbances in serotonin and GABA

Diagnosis

• Prospective symptom diary for 2 cycles (Before any treatment)
• Trial of GnRH analogue e.g. Prostap/Zoladex
•  General Practitioner to refer to Gynaecologist if first line of treatment fails\

Management

•  There is conflicting evidence regarding complementary therapies
• If administering estradiol add progesterone to prevent endometrial hyperplasia e.g. cyclical 10-12 days course per oral/per vagina or Mirena
•  There is insufficient evidence of long-term effect of oestrogen on breast and endometrium
•  Spironolactone 100mg has been shown to be effective in managing both mood and physical symptoms
•  Danazol 200mg twice daily in the luteal phase is effective but has potential irreversible virilising effect
• Danazol taken during pregnancy is known to cause cliteromegaly, labial fusion and urogenital sinus abnormalities in female foetuses. Patients should therefore use other contraception if being treated with danazol
•  You must question/ doubt the diagnosis of PMS if GnRH analogue is ineffective
• If GnRH analogue is administered for more than 6months add HRT e.g. Tibolone. It should only be used if cases of severe PMS or to aid diagnosis of PMS
• Women on long-term treatment of GnRH analogue should have measurement of Bone Mineral Density (ideally by dual-energy X-ray absorptiometry [DEXA]) every year. Treatment should be stopped if bone density declines significantly
•  Perform surgery Hysterectomy+ Salpingoophorectomy only as last resort after ensuring response to GNRH analogue and HRT

Treatment Algorithm

1st line Exercise, Cognitive behavioural therapy, vitamin B6
Combined new generation pill (cyclical or continuously)
Continuous or luteal phase (day15-28) low dose SSRI e.g. Citalopram 10mg

2nd line Estradiol patches 100mcg + Micronised progesterone 100-200mg (day 17-28), orally or vaginally) or LNG IUS 52mg
Higher dose SSRI continuously or luteal phase e.g. citalopram 20-40mg

3rd line GNRH analogue+ add back HRT (Continuous combined oestrogen + progesterone (e.g. 50–100 micrograms estradiol patches or 2–4 doses of estradiol gel combined with micronized progesterone 100 mg/day] or tibolone 2.5mg

4th line Surgical treatment +/- HRT

Reference

• RCOG green top guideline no 48 February 2017