Cause to Care about Premenstrual Difficulties

1. Anna Mae Smith, PA-C
Lock Haven University
Physician Assistant Program

3. Defined
The cyclic recurrence during the luteal
phase of the menstrual cycle of a
combination of distressing physical,
psychologic, or behavioral changes that
interfere with family, social, or work-
related activities.

4. Epidemiology
Women
Up to 75% of women of reproductive age
will suffer from PMS
1-10% will suffer total debilitating
symptoms! PMDD (Premenstrual
Dysphoric Disorder)
90% of women suffer at least from one of
the ~150 symptoms of PMS

5. Most common symptoms...
Headaches Cramps
Depression Acne
Moodiness Weight Gain
Bloating Swelling
Fatigue Constipation
Breast tenderness Allergies
Fluid retention Joint Pain
Backache

6. A_C_D_H Classification
(Abraham’s)
A-- C--
Anxiety Cravings
Nervous tension Headache
Mood swings Craving for sweets
Irritability Increase appetite
Anxiety Heart pounding
Fatigue
Dizziness or faintness

7. A_C_D_H Classification
(Abraham’s)
D-- H--
Depression Water-related
Forgetfulness symptoms
Crying Weight gain
Confusion Swelling of extremities
Insomnia Breast tenderness
Abdominal bloating

8. ETIOLOGY??
Who knows?
Multifactorial
Each woman‟s etiology may be different!!
The goal of therapy is to start „simple‟ &
progress to the more complex treatments

9. Hormones!
Occurs just prior to menses(1-2 weeks)
Estrogen or progesterone deficient?
For some you may see a decrease in
progesterone level & an increase in estrogen
and the opposite is also true

10. B6 & Magnesium
B6 deficiency impairs the liver‟s ability to process
estrogen, resulting in fluid retention, weight
gain, & breast tenderness
Also affects serotonin levels & melatonin levels
Need B6 for magnesium to function
properly…together they convert EFA‟s to
prostaglandins

11. Serotonin
Produced from tryptophan(AA)
Decreased production may interfere with
sleep patterns, menstrual cycles &
carbohydrate metabolism

12. Normal metabolism
Abnormal metabolism

13. Diet
Saturated fats will increase “bad”
prostaglandin levels producing uterine
discomfort, bloating & mood swings
Sugar & caffeine deplete all the B
vitamins & some minerals
Caffeine causes breast tenderness
Alcohol interferes with the liver‟s ability to
process estrogen

14. Diagnosis
Symptom Diary/Log
Blood test?

15. Treatment
Diet & Exercise
Eat „real‟ food! Eliminate „junk‟ food
(caffeine, soda, alcohol, processed foods,
sugar)
Carbohydrates will raise serotonin levels,
instinctively crave sugars, chocolates

16. Vitamins
Vitamin E 400IU a day
B6 100-300 mg a day
Zinc 10-20mg a day
Vit.C 500-2,000mg
Evening primrose oil (3-6gms taken with meals),
borage, flax seed(1 tablespoon in salad), &
pumpkin seed contain an EFA that is converted
to the “good” prostaglandin

17. Evening Primrose Oil
gamma-Linoleic acid is a precursor for
prostaglandin E1
breast symptoms, bloating, weight gain,
and edema

18. Hormones
Progesterone &/or estrogen
Chaste tree berry - stimulates
progesterone production ( 10drops in
water qAM from midcycle until menses)
Black cohosh - phytoestrogens (not with
heavy menses or pregnancy)
Dong Quai - phytoestrogens - calms
hormones, good for cramps

19. Hormones
OCP‟s
Excellent hormone control
Careful…some can make psych symptoms
worse!

20. Diuretics
HCTZ
Spironolactone
Ease symptoms of bloating, edema, and
breast fullness

21. Antidepressants/NSAIDS
Prozac
Lithium
Valium

22. Others?
GnRH
Bromocriptine

23. PMDD
Most of the same symptoms as PMS
except…debilitating!
Core symptoms:
Markedly depressed mood, feelings of hopelessness,
or self-depreciating thoughts
Marked anxiety, tension, feelings of being “keyed up”
or “on edge”
Marked affected labiality (eg, tearfulness)
Persistent, marked anger, irritability, or increased
interpersonal conflicts

24. PMDD Additional Symptoms
Decreased interest in usual activities
Subjective sense of difficulty in
concentrating
Lethargy, tiredness, lack of energy
Marked change in appetite, overeating,
food cravings
Subjective sense of being overwhelmed or
out of control

25. PMDD Additional
Symptoms
Other Physical Symptoms:
Breast tenderness or swelling
Headaches
Joint or muscle pain
“Bloating” sensation
Weight gain

26. DSM-IV Criteria
1-year duration of symptoms (occur
luteal/remit follicular)
5 (or more) of the 11 specified PMS
symptoms with at least one of the
following:
Marked depressed mood, hopelessness
Marked anxiety, tension
Marked affective labiality

27. DSM-IV Criteria cont’d
Marked anger & irritability
Seriously interferes with work, social
activities, relationships
Not an exacerbation of another disorder
Confirmed by prospective daily ratings during
at least 2 consecutive symptomatic cycles

28. PMDD is a severe form of PMS
Primarily mood Primarily physical
symptoms symptoms

29. Comorbidity
PMDD is associated with a high rate of
comorbidity, in particular with major
depression, anxiety, and other mood
disorders
Comorbid disorders may be exacerbated
by PMDD and may make the diagnosis of
PMDD more difficult

30. Treatment
Surgical oophorectomy
Eliminates ovulation
Effective for severe cases of PMDD
Nonpharmalogical
High protein/low refined sugar diet
Reduce/eliminate caffeine, alcohol, and tobacco
Only effective against milder PMS symptoms
Can be useful adjuncts to pharmacotherapies for
PMDD

31. Hormones
Estrogen or Natural progesterone
Widely used for the treatment of PMS
There is no clear evidence in favor of
progesterone &estrogen in treating PMDD
OVULATION SUPPRESSORS
GnRH agonists
Risk of osteoporosis & CAD
Danazol (gonadotropin release inhibitor)
Effective for severe breast pain

32. DIURETICS
Effective for somatic but not mood symptoms
Useful as augmentation therapy
PSYCHOTROPIC DRUGS
Anxiolytics
TCAs
SSRIs
Sarafem