Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are defined as physical and emotional symptoms that occur before menstruation. Common symptoms include mood swings, irritability, breast tenderness, and bloating. While mild PMS affects most women of reproductive age, 3-8% meet criteria for PMDD characterized by severe impairment. Hormonal fluctuations are thought to trigger symptoms, though etiology is still under investigation. Treatment options range from lifestyle changes and supplements for mild PMS to SSRIs, contraceptives, CBT, and GnRH agonists for more severe forms. Differential diagnosis considers other conditions with cyclic symptoms.
Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are defined as physical and emotional symptoms that occur before menstruation. Common symptoms include mood swings, irritability, breast tenderness, and bloating. While mild PMS affects most women of reproductive age, 3-8% meet criteria for PMDD characterized by severe impairment. Hormonal fluctuations are thought to trigger symptoms, though etiology is still under investigation. Treatment options range from lifestyle changes and supplements for mild PMS to SSRIs, contraceptives, CBT, and GnRH agonists for more severe forms. Differential diagnosis considers other conditions with cyclic symptoms.
Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are defined as physical and emotional symptoms that occur before menstruation. Common symptoms include mood swings, irritability, breast tenderness, and bloating. While mild PMS affects most women of reproductive age, 3-8% meet criteria for PMDD characterized by severe impairment. Hormonal fluctuations are thought to trigger symptoms, though etiology is still under investigation. Treatment options range from lifestyle changes and supplements for mild PMS to SSRIs, contraceptives, CBT, and GnRH agonists for more severe forms. Differential diagnosis considers other conditions with cyclic symptoms.
SYNDROME EMINE ZEYNEP YILMAZ, MD, ASSISTANT PROFESSOR
MEDIPOL UNIVERSITY HEALTH CARE
PRACTICE & RESEARCH CENTER ESENLER HOSPITAL DEFINITION
• Most women of reproductive age experience one or
more mild emotional or physical symptoms for one to two days before the onset of menses. These symptoms (such as breast soreness and bloating) are mild, do not cause severe distress or functional impairment, and are not considered to represent premenstrual syndrome (PMS) • In contrast, clinically significant PMS is defined by the American College of Obstetricians and Gynecologists (ACOG) as at least one symptom associated with "economic or social dysfunction" that occurs during the five days before the onset of menses and is present in at least three consecutive menstrual cycles. • Premenstrual dysphoric disorder (PMDD) is the most severe form. PMS • Nearly 300 different symptoms have been reported and typically include both psychiatric and physical complaints. • For most women, these are self-limited. However, approximately 15 percent report moderate-to-severe complaints that cause some impairment or require special consideration • Current estimates are that 3 to 8 percent of menstruating women meet the strict criteria for PMDD SYMPTOMS Most common symptoms — More than 150 physical, behavioral, emotional, and cognitive symptoms have been ascribed to PMS in the literature. However, the number of symptoms seen in the vast majority of patients is much more limited. ●The most common affective or behavioral symptom of PMS is mood swings. Other frequent nonphysical behavioral symptoms include irritability, anxiety/tension, sad or depressed mood, increased appetite/food cravings, sensitivity to rejection, and diminished interest in activities. ●The most common physical manifestations of PMS are abdominal bloating and an extreme sense of fatigue. Other common symptoms include breast tenderness, headaches, hot flashes, and dizziness. ETIOLOGY • Still under investigation, PMDD is thought to spring from genetic factors, psychosocial factors (particularly stress), and an altered sensitivity to the normal hormonal fluctuations that influence CNS functioning. • Because of the timing of symptoms, current thinking is that hormonal fluctuation is the key trigger. DIAGNOSTIC CRITERIA for PMDD DIFFERENTIAL DIAGNOSIS • Mood and anxiety disorders • Menopausal transition — Unlike PMS symptoms, which occur during ovulatory cycles, menopausal mood symptoms typically begin when menstrual cycles become irregular/anovulatory. • Thyroid disorders • Substance abuse — It has been suggested that women with PMS consume more alcohol than controls, independent of cycle phase, and that women with a family history of alcoholism experience more anxiety premenstrually. However, a firm link between alcoholism and PMS has never been established. • Other — A variety of medical disorders (eg, migraine; chronic fatigue syndrome [CFS] also known as myalgic encephalomyelitis/chronic fatigue syndrome [ME/CFS]; irritable bowel syndrome) are exacerbated just prior to or during menses. However, the symptoms expressed are not those typical of PMS, and the timing is not usually confined to the luteal phase. PMS • Women without menstruation — The diagnosis of premenstrual disorders is more challenging, but still possible, in women with normal ovarian function and ovulation in the absence of menstruation. These women experience the typical cyclic symptoms of PMS/PMDD but cannot use menses as a reference point for their symptoms. Examples include: • ●Women who have undergone hysterectomy (with ovarian conservation) or an endometrial ablation, which results in amenorrhea in approximately 35 to 40 percent. • ●Women using a LNG-IUD (for contraception or heavy menstrual bleeding). Amenorrhea typically develops after six months of use, but ovulation persists in approximately 75 percent of women. TREATMENT –MILD PMS • Exercise and relaxation techniques • A number of vitamins and dietary supplements, including primrose oil, vitamin B6, vitamin E, calcium, and magnesium, have been studied as therapeutic agents for PMS; however, evidence that any of these is more effective than placebo, which has a 30 percent response rate, is inconsistent • Vitex agnus castus, John’s wort • Meditation, quality of sleep, decreased caffein, alcohol and salt intake TREATMENT – CONTRACEPTION OR NOT? • Selective serotonin reuptake inhibitors — Because of their proven efficacy and safety profile, SSRIs for women with premenstrual symptoms that include socioeconomic dysfunction is first choice. • Clinical trials and systematic reviews of SSRIs for PMS and PMDD conclude that these medications are effective. • We typically start sertraline, citalopram, escitalopram or fluoxetine as these are extensively studied. Paroxetine is also effective but is more likely to be associated with weight gain. • A beneficial effect can be expected in the first cycle. If response is suboptimal, the dose can be increased in the subsequent cycle. SSRI therapy appears to be more effective for mood symptoms than somatic symptoms. There are no strong predictors of response to SSRIs in women with PMDD. TREATMENT – CONTRACEPTION OR NOT? • Combined estrogen-progestin contraception — For women with moderate to severe nondepressive symptoms who are interested in hormonal contraception, we suggest treatment with a COC. This is the simplest way to suppress the hypothalamic-pituitary-ovarian axis and ovulation. We prefer monophasic pills, as multiphasic preparations can worsen mood symptoms • Cognitive behavioral therapy — Cognitive behavioral therapy (CBT) may provide some benefit for women with PMDD. A meta-analysis of five randomized trials observed a reduction in symptoms of anxiety and depression with CBT compared to other interventions. • GnRH agonists — In women with severe symptoms who have not responded to or cannot tolerate SSRIs or COCs, we suggest gonadotropin-releasing hormone (GnRH) agonist therapy with low-dose estrogen-progesterone "add back" therapy as the next step.However, GnRH agonists should not be considered until the patient has first tried multiple SSRIs and a COC with a shortened pill-free interval or continuous administration. • Acupuncture • Surgery