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

The cyclic recurrence during the luteal
 phase of the menstrual cycle of a
 combination of distressing physical,...
Epidemiology

Women
Up to 75% of women of reproductive age
 will suffer from PMS
1-10% will suffer total debilitating
 ...
Most common symptoms...

Headaches           Cramps
Depression          Acne
Moodiness           Weight Gain
Bloati...
A_C_D_H Classification
(Abraham’s)

A--                 C--
  Anxiety             Cravings
   Nervous tension      Hea...
A_C_D_H Classification
(Abraham’s)

D--               H--
  Depression        Water-related
   Forgetfulness      symp...
ETIOLOGY??


Who knows?
Multifactorial
Each woman‟s etiology may be different!!
The goal of therapy is to start „simpl...
Hormones!
Occurs just prior to menses(1-2 weeks)
Estrogen or progesterone deficient?
  For some you may see a decrease ...
B6 & Magnesium

B6 deficiency impairs the liver‟s ability to process
 estrogen, resulting in fluid retention, weight
 gai...
Serotonin

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




Abnormal metabolism
Diet

Saturated fats will increase “bad”
 prostaglandin levels producing uterine
 discomfort, bloating & mood swings
Sug...
Diagnosis

Symptom Diary/Log
Blood test?
Treatment


Diet & Exercise
Eat „real‟ food! Eliminate „junk‟ food
 (caffeine, soda, alcohol, processed foods,
 sugar)
...
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...
Evening Primrose Oil

gamma-Linoleic acid is a precursor for
 prostaglandin E1
breast symptoms, bloating, weight gain,
 ...
Hormones

Progesterone &/or estrogen
Chaste tree berry - stimulates
 progesterone production ( 10drops in
 water qAM fro...
Hormones

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

HCTZ
Spironolactone
  Ease symptoms of bloating, edema, and
   breast fullness
Antidepressants/NSAIDS

Prozac
Lithium
Valium
Others?

GnRH
Bromocriptine
PMDD

Most of the same symptoms as PMS
 except…debilitating!
Core symptoms:
  Markedly depressed mood, feelings of hope...
PMDD Additional Symptoms

Decreased interest in usual activities
Subjective sense of difficulty in
 concentrating
Letha...
PMDD Additional
Symptoms

Other Physical Symptoms:
  Breast tenderness or swelling
  Headaches
  Joint or muscle pain
...
DSM-IV Criteria

1-year duration of symptoms (occur
 luteal/remit follicular)
5 (or more) of the 11 specified PMS
 sympt...
DSM-IV Criteria cont’d

 Marked anger & irritability
 Seriously interferes with work, social
  activities, relationships...
PMDD is a severe form of PMS




Primarily mood                  Primarily physical
  symptoms                         sym...
Comorbidity

PMDD is associated with a high rate of
 comorbidity, in particular with major
 depression, anxiety, and othe...
Treatment

Surgical oophorectomy
  Eliminates ovulation
  Effective for severe cases of PMDD
Nonpharmalogical
  High ...
Hormones

Estrogen or Natural progesterone
  Widely used for the treatment of PMS
  There is no clear evidence in favor...
DIURETICS
   Effective for somatic but not mood symptoms
   Useful as augmentation therapy
PSYCHOTROPIC DRUGS
   Anxi...
Premenstrual Syndrome
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Premenstrual Syndrome

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Cause to Care about Premenstrual Difficulties

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  • Very thorough and excellent presentation on PMS and PMDD, though I didn't see where it mentions calcium and magnesium. Also, the current consensus is that Evening Primrose Oil is no better than placebo for PMS. Glad you emphasized diet. We have our own version of healthy eating for PMS and PMDD here: http://www.pmscomfort.com/pms-diet/
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Premenstrual Syndrome

  1. 1. Anna Mae Smith, PA-C Lock Haven University Physician Assistant Program
  2. 2. 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.
  3. 3. 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
  4. 4. Most common symptoms... Headaches Cramps Depression Acne Moodiness Weight Gain Bloating Swelling Fatigue Constipation Breast tenderness Allergies Fluid retention Joint Pain Backache
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. Serotonin Produced from tryptophan(AA) Decreased production may interfere with sleep patterns, menstrual cycles & carbohydrate metabolism
  11. 11. Normal metabolism Abnormal metabolism
  12. 12. 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
  13. 13. Diagnosis Symptom Diary/Log Blood test?
  14. 14. Treatment Diet & Exercise Eat „real‟ food! Eliminate „junk‟ food (caffeine, soda, alcohol, processed foods, sugar) Carbohydrates will raise serotonin levels, instinctively crave sugars, chocolates
  15. 15. 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
  16. 16. Evening Primrose Oil gamma-Linoleic acid is a precursor for prostaglandin E1 breast symptoms, bloating, weight gain, and edema
  17. 17. 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
  18. 18. Hormones OCP‟s Excellent hormone control Careful…some can make psych symptoms worse!
  19. 19. Diuretics HCTZ Spironolactone Ease symptoms of bloating, edema, and breast fullness
  20. 20. Antidepressants/NSAIDS Prozac Lithium Valium
  21. 21. Others? GnRH Bromocriptine
  22. 22. 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
  23. 23. 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
  24. 24. PMDD Additional Symptoms Other Physical Symptoms: Breast tenderness or swelling Headaches Joint or muscle pain “Bloating” sensation Weight gain
  25. 25. 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
  26. 26. 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
  27. 27. PMDD is a severe form of PMS Primarily mood Primarily physical symptoms symptoms
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. DIURETICS Effective for somatic but not mood symptoms Useful as augmentation therapy PSYCHOTROPIC DRUGS Anxiolytics TCAs SSRIs Sarafem

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