Premenstrual Syndrome and Premenstrual Dysphoric Disorder

1
Premenstrual Syndrome and Premenstrual Dysphoric
Disorder

• UNC School of Medicine
• Obstetrics and Gynecology Clerkship
• Case Based Seminar Series

2
Objectives for PMS and PMDD

• Identify the criteria for making the diagnosis of
  Premenstrual Syndrome (PMS) and Premenstrual
  Dysphoric Disorder (PMDD)
• List treatment options for PMS and PMDD

3
Definition

• PMS is a group of physical, mood-related, and
  behavioral changes that occur in a regular,
  cyclic relationship to the luteal phase of the
  menstrual cycle and interfere with some aspect of
  the patients life
• PMDD identifies women with PMS who have more
  severe emotional symptoms (such as anger,
  irritability, and depression) that may require
  more extensive therapy

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Incidence

• PMS symptoms - 75- 85 of women
• Severe/debilitating PMS - 5-10 of women
• PMDD - 3-5 of women

5
Spectrum of Premenstrual Syndromes
Severe (PMDD)
Moderate (PMS)
Mild (PMS)
None
Premenstrual Syndrome Severity
Hacker Moore Hacker and Moore's Essentials of
Obstetrics and Gynecology, 5th edition (2009),
Neville F Hacker, Joseph C Gambone, Calvin J
Hobel. Chapter 36 (387).
6
PMS/PMDD Symptoms

• Somatic Symptoms
• Breast tenderness
• Abdominal bloating most common, occurs in 90
• Headache
• Swelling of extremities
• Weight gain

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PMS/PMDD Symptoms

• Affective Symptoms
• Depression
• Angry outbursts
• Irritability
• Anxiety
• Confusion
• Social withdrawal
• Decreased concentration
• Sleep disturbance
• Appetite change/food cravings

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PMS/PMDD Symptoms
Sample Daily Symptoms Calendar Diagnostic tool
used to assist the patient with recording her
premenstrual symptoms diary
Endicott and Harrison 2006. 5.Endicott, J.,
Harrison, W. Daily Record of Severity of Problems
Calendar.
9
PMS Diagnosis

• Patient reports 1 affective symptom and somatic
  symptom(s) during the luteal phase before menses
• Symptoms relieved within 4 days of onset of
  menses, without recurrence until at least cycle
  day 13
• Symptoms occur in 2 consecutive menstrual cycles
• Patient suffers from identifiable dysfunction in
  social or economic performance

10
PMDD Diagnosis

• DSM-IV Criteria
• Symptoms interfere with usual functioning and
  relationships
• Symptoms are not an exacerbation of another
  disorder
• Symptoms resolve at onset of menses
• Premenstrual timing is confirmed by menstrual
  calendar in 2 consecutive cycles

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PMDD Diagnosis

• DSM-IV Criteria
• At least 5 of 11 premenstrual symptoms
• At least 1 of the following
• Depressed mood
• Marked anxiety
• Marked affective lability
• Marked irritability
• Other possible symptoms
• Decreased interest in regular activities
• Difficulty concentrating
• Lethargy/fatigue
• Appetite change/food cravings
• Sleep disturbance
• Feelings of being overwhelmed
• Physical symptoms (bloating, weight gain, breast
  tenderness, edema)

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PMS/PMDD Differential Diagnosis

• Rule out other diseases
• Psychological disorders
• Depression, Bipolar disorders, Personality
  disorders, Anxiety
• Gynecologic disorders
• Dysmenorrhea, Endometriosis, Pelvic Inflammatory
  Disease, Perimenopause
• Endocrine disorders
• Thyroid disease, Adrenal disorders, True
  hypoglycemia
• GI conditions
• Inflammatory bowel disease, Irritable bowel
  syndrome
• Drug or substance abuse
• Chronic fatigue states

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PMS/PMDD Treatment (Conservative)

• Supportive therapy
• Lifestyle changes
• Frequent exercise
• Nutritional supplements
• Magnesium sulfate 360 mg/d
• Calcium 1200 mg/d
• Vitamin E 400 IU/d
• Vitamin B6 100 mg/d

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PMS Treatment (Medical)

• NSAIDs
• Anti-depressants
• SSRIs (Fluoxetine or Sertraline)
• Buspirone
• Spironolactone - bloating
• Bromocriptine or Danocrine mastalgia
• Ovulation suppression
• GnRH agonists (e.g. Lupron)
• Danazol
• OCPs

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PMDD Treatment (Medical)

• SSRIs
• Can be taken throughout the cycle or during the
  luteal phase of the cycle
• Fluoxetine 20-60 mg qd
• Sertraline 50-150 mg qd

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PMS/PMDD Treatment (Surgical)

• Oophorectomy
• Not generally recommended
• Irreversible
• Reserved for severely affected patients who only
  respond to GnRH agonists

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Bottom Line Concepts

• PMDD identifies women with PMS who have more
  severe emotional symptoms that may require
  intensive therapy.
• The physiologic mechanism that results in the
  occurrence of PMS and PMDD is not well
  understood.
• The diagnosis of PMS and PMDD is based on
  documentation of the relationship of the
  patients symptoms to the luteal phase.
• DSM-IV criteria are used to establish the
  diagnosis of PMDD.
• In addition to lifestyle changes, behavioral
  therapies, and dietary supplementation, some
  pharmacologic agents have been shown to have
  symptom relief.
• As an overall clinical approach, treatments
  should be employed in increasing orders of
  complexity.

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References and Resources

• APGO Medical Student Educational Objectives, 9th
  edition, (2009), Educational Topic 49 (p104-105).
• Beckman Ling Obstetrics and Gynecology, 6th
  edition, (2010), Charles RB Beckmann, Frank W
  Ling, Barabara M Barzansky, William NP Herbert,
  Douglas W Laube, Roger P Smith. Chapter 39
  (p347-352).
• Hacker Moore Hacker and Moore's Essentials of
  Obstetrics and Gynecology, 5th edition (2009),
  Neville F Hacker, Joseph C Gambone, Calvin J
  Hobel. Chapter 36 (p386-388).

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Dysmenorrhea

• UNC School of Medicine
• Obstetrics and Gynecology Clerkship
• Case Based Seminar Series

20
Objectives for Dysmenorrhea

• Define dysmenorrhea and distinguish primary and
  secondary dysmenorrhea
• Describe the pathophysiology and identify the
  etiologies of dysmenorrhea
• Discuss the steps in the evaluation and
  management options for dysmenorrhea

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Definition

• Painful menstruation that prevents a woman from
  performing normal activities
• Primary dysmenorrhea no readily identifiable
  cause
• Secondary dysmenorrhea identifiable organic
  cause

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Primary Dysmenorrhea Pathophysiology

• Caused by excess prostoglandin F2a (PGF2a ) and
  PGE2 produced from shedding endometrium
• Prostoglandins are potent smooth-muscle
  stimulants that cause uterine contractions and
  ischemia
• Prostoglandin F2a causes contractions in smooth
  muscle elsewhere in the body, resulting in
  nausea, vomiting, and diarrhea

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Primary Dysmenorrhea Symptoms

• Pain
• Onset within 2 years of menarche
• Begins a few hours before or just after onset of
  menses
• Lasts 48 72 hours
• Described as cramp-like
• Strongest over lower-abdomen
• Radiates to back or inner thighs
• Associated symptoms
• Nausea and vomiting
• Fatigue
• Diarrhea
• Lower backache
• Headache

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Primary Dysmenorrhea Treatment

• Reassurance and explanation
• Medical
• NSAIDs
• Hormonal contraceptives (e.g. OCPs, IUD, Vaginal
  rings, Patches)
• Progestins (e.g. Medroxyprogesterone acetate)
• Tocolytics (e.g. Salbutamol)
• Analgesics
• Other Measures
• Transcutaneous nerve stimulation
• Acupuncture
• Psychotherapy
• Hypnotherapy

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Secondary Dysmenorrhea Pathophysiology

• Depends on underlying (secondary) cause and in
  most cases is not well understood
• Causes of secondary dysmenorrhea
• Endometriosis
• Pelvic inflammation
• Adenomyosis
• Fibroid tumors (benign, malignant)
• Ovarian cysts (e.g. endometriosis, luteal cysts)
• Pelvic congestion

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Secondary Dysmenorrhea Symptoms

• Pain
• Develops in older women (30s to 40s)
• Not limited to menses
• Associated symptoms
• Dyspareunia
• Infertility
• Abnormal uterine bleeding

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Secondary Dysmenorrhea Symptoms
Condition Signs and Symptoms
Endometriosis Pain extends to premenstrual and postmenstrual phase Deep dyspareunia Tender pelvic nodules (e.g. uterosacral ligaments) Onset in 20s 30s
Pelvic inflammation Pain initially menstrual, with each cycle extends into premenstrual phase Intermenstrual bleeding Pelvic tenderness Fever, chills, malaise
Adenomyosis, Pain menorrhagia Uterus symmetrically enlarged, mildly tender, boggy
Uterine fibroids Pain menorrhagia Firm, irregularly enlarged uterus
Ovarian cysts Mid-cycle, unilateral pain
Pelvic congestion Dull, ill-defined pelvic ache Pain worse premenstrually and relieved by menses History of sexual problems
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Secondary Dysmenorrhea Treatment

• Management consists of treatment of the
  underlying disease
• Treatment used for primary dysmenorrhea often
  helpful

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Bottom Line Concepts

• Primary and secondary dysmenorrhea are a source
  of recurrent disability for a significant number
  of women in their early reproductive years.
• Primary dysmenorrhea is caused by excess
  prostoglandin produced by the shedding
  endometrium.
• Secondary dysmenorrhea is due to organic pelvic
  disease, including endometriosis, PID,
  adenomyosis, uterine fibroids, and pelvic
  congestion.
• Primary dysmenorrhea presents within 2 years of
  menarche, where as secondary dysmenorrhea more
  often presents in older women.
• For patients with dysmenorrhea, the physical
  exam is directed at uncovering possible causes of
  secondary dysmenorrhea.
• Treatment of secondary dysmenorrhea should be
  directed at the underlying condition.

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References and Resources

• APGO Medical Student Educational Objectives, 9th
  edition, (2009), Educational Topic 46 (p98-99).
• Beckman Ling Obstetrics and Gynecology, 6th
  edition, (2010), Charles RB Beckmann, Frank W
  Ling, Barabara M Barzansky, William NP Herbert,
  Douglas W Laube, Roger P Smith. Chapter 30
  (p277-279).
• Hacker Moore Hacker and Moore's Essentials of
  Obstetrics and Gynecology, 5th edition (2009),
  Neville F Hacker, Joseph C Gambone, Calvin J
  Hobel. Chapter 21 (p256-259).