Premenstrual Syndrome Krishna B. Singh, MD Department of Obstetrics & Gynecology LSU Health Sciences...
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Transcript of Premenstrual Syndrome Krishna B. Singh, MD Department of Obstetrics & Gynecology LSU Health Sciences...
Premenstrual Syndrome
Krishna B. Singh, MDDepartment of Obstetrics &
GynecologyLSU Health Sciences CenterShreveport, LA
PMS: Topics Covered
Historical review Incidence Clinical features Diagnosis Management Summary
PMS: Learning Objectives
Be able to understand that... PMS is a common clinical condition Multiple clinical symptoms/mood
changes Few hormonal, biochemical changes Many theories of pathogenesis Many treatment options available
PMS: Literature Review
First described by Robert Frank (1931) as PMT in 15 cases
Katharina Dalton (1953) popularized the term PMS and reported 86 cases
New developments (JAMA: 1992) Websites for support groups
Definitions of Premenstrual Syndrome
Recurrence of symptoms premenstrually with complete absence of symptoms after menstruation (Dalton 1984)
Other Definitions: National Institutes of Mental Health; American Psychiatric Association
Incidence of Premenstrual Syndrome
The incidence varies 40-97% About 5% women in US have severe PMS 50% may have moderate PMS
PMS: Problems In Focus
Absentees from work: ~ 5 billion dollars (1969)
Association with intellectual impairment Increased numbers of crimes and violent
acts Increased admissions in psychiatric
hospitals
PMS: Known Risk Factors
Genetic factors: Monozygous twins affected Adolescent daughters and natural mothers Positive correlation with high parity, history
of toxemia of pregnancy, post-partum blues, alcohol abuse and working outside the home
Not correlated with marital status, educational level, race or culture
PMS: Clinical Features Reported
More than 150 signs and symptoms Cluster analysis used for sub-types of PMS Neuroendocrine disorder; pathogenesis
poorly understood: neuropsychological components include symptoms - A type PMS; B type PMS
Both components present C, D and E types- These require consultations
Theories of Premenstrual Syndrome
PMS considered a global and multifactorial neuroendocrine disorder
Brain and limbic system control the hypothalamus-pituitary-ovarian axis that are needed for reproductive cycle initiation and maintenance; may be mood changes
PMS is a disorder of multiple theories
Possible Causes of PMS
Beta-endorphin deficiency: lower plasma levels during the luteal phase
Serotonin (5HT) deficiency: Platelet uptake and blood levels decreased during the luteal phase
Progesterone withdrawal rather than deficiency; receptors may be abnormal
PMS: More Theories...
Carbohydrate metabolism and GTT Protein and amino acid metabolism Prostaglandins and prostanoids Sodium, potassium, Ca++ metabolism Vitamins: A, B6 and E Minerals: zinc and copper
PMS: Differential Diagnosis
Laboratory tests remain controversial Baseline values: CBC, Chem-20 @
morning Baseline serum PRL, TSH, SHBG @
morning Cervical swab for wet mount, KOH prep
Diagnosing Premenstrual Syndrome
Daily diary, assessment charts, other ancillary methods are helpful aids to clinical diagnosis
The time and timing of the symptoms are more important than severity of symptoms
History and physical examination with selected laboratory and hormonal tests during several visits are essential components
PMS: Things To Remember
Rule out psychological conditions which may require referral to psychiatrists and counselors
Beware of misdiagnosis “on the fly” Consider the family and friends
connection Supportive and educational measures
have strong placebo effects (up to 40%)
PMS: Management Issues
Principal components: confirm diagnosis and identify category; identify and manage concurrent illness; identify and manage social and family triggers; identify and manage patient needs
There are numerous options for management but no curative treatments
PMS: Treatment Options
General measures: diet, exercise, relaxation Avoid megadose vitamins and OTC drugs Contraception: DMPA 150 mgm/3 months Hormones: Micronized or P4 suppository
(400-600 mgm/d); Parlodel, Danazol as needed
Drugs: Alprazolam (Xanax 0.25 mg/tid); Fluoxetine (Prozac 20-60mg/d); Buspirone (BuSpar 5 mg/tid)
Treatment Summary of PMS
Hormonal: progesterone, GnRHa Non-hormonal: antidepressants, diet Supportive and cognitive... Support groups; Websites portals Educational materials available
PMS: Things To Remember
Patients who fail to respond probably do not have PMS or allied condition
About 80% PMS patients will have remission of symptoms for more than a few months
About 50% PMS patients may respond to a combined psychiatric and endocrine intervention
What This Means...
PMS is a common disorder in the reproductive age group of women; these women generally have regular menstrual cycles
PMS has many facets of clinical presentation PMS can be successfully managed and
treated