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Uploaded byDrisya Nidhin
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Pms

Premenstrual syndrome (PMS) and menopause are conditions that affect women. PMS involves cyclic symptoms like mood changes that occur in the week before a woman's period. It is caused by changes in estrogen and progesterone levels. Treatment may include lifestyle changes, antidepressants, or hormonal birth control. Menopause is when periods stop permanently due to low estrogen levels. It causes symptoms like hot flashes and vaginal dryness. Hormone replacement therapy can relieve symptoms but also has risks, so non-hormonal options are also used.

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Mrs.DRISYA.V.R. 2nd Year MSc Nursing PREMENSTRUAL SYNDROME (PMS)
• Premenstrual syndrome (PMS) is a psychoneuro endocrine disorder of unknown aetiology, often noticed just prior to menstruation. • There is cyclic appearance of a large number of symptoms during the last 7-10 days of the menstrual cycle.
It should fulfill the following criteria (ACOG): • Not related to any organic lesion. • Regularly occurs during the luteal phase of each ovulatory menstrual cycle. • Symptoms must be severe enough to disturb the life style of the woman or she requires medical help. • Symptom-free period during rest of the cycle. • When these symptoms disrupt daily functioning they are grouped under the name premenstrual dysphoric disorder (PMDD).
Pathophysiology The exact cause is not known but the following hypotheses are postulated: 1. Alteration in the level of oestrogen and progesterone starting from the midluteal phase. Either there is altered oestrogen: progesterone ratio or diminished progesterone level. 2. Neuroendocrine factors : Serotonin Endorphins γ-aminobutyric acid (GABA)
3.Psychological and psychosocial factors may be involved to produce behavioural changes. 4.Others These are thyrotrophin releasing hormone (TRH) prolactin, renin, aldosterone, prostaglandins and others.
Clinical features : • PMS is more common in women aged 30-45. • It may be related to childbirth or a disturbing life event.
TREATMENT • Life style modification and congnitive behaviour therapy are important steps. • General 1.Nonpharmacological: • (a) Assurance, Yoga, Stress management, Diet manipulation, • (b) Avoidance of salt, caffeine and alcohol specially in second half of cycle improves the symptoms.
2.Nonhormonal: • a. Tranquilizers or antidepressant drugs, may be of help logically. • b. Pyridoxine -100 mg twice daily • c. Diuretics in the second half of the cycle - Frusemide 20 mg daily for consecutive 5 days • d. Anxiolytic agents - Alprazolam (0.25 mg, Bd) • e. Spironolactone — It is given in the luteal phase (25-200 mg/day). It improves the symptoms of PMDD.
f. Selective Serotonin Reuptake Inhibitors (SSRI) and Noradrenaline Reuptake Inhibitors (SNRI) are found to be very effective. • Fluoxetine -A single oral dose of 20 mg was • Other drugs used are : Sertraline (50 mg/day) and Venlafaxine.
• 3.Hormones : a.Oral contraceptive pills • The idea is to suppress ovulation and to maintain an uniform hormonal milieu. • The therapy is to be continued for 3-6 cycles.
• b. Progesterone Levonorgestrel intrauterine system (IUS) • d. Bromocriptine — 2.5 mg daily or twice daily
• 4.Suppression of ovarian cycle — Suppression of the endogenous ovarian cycle can be achieved by : a. Danazol 200 mg daily is to be adjusted so as to produce amenorrhoea. Barrier method of contraception should be advised during the treatment.
b. GnRH analogues • Goserelin (Zoladex): 3.6 mg is given subcutaneously at every 4 weeks. • Leuprorelin acetate (Prostap): 3.75 mg is given by SC or IM at every 4 weeks. • Triptorelin (Decapeptyl): 3 mg is given IM every four weeks.
5.Oophorectomy
MENOPAUSE • It is the permanent cessation of menstruation at the end of reproductive life due to loss of ovarian follicular activity. • The clinical diagnosis is confirmed following stoppage of menstruation for 12 consecutive months without any other pathology.
• Pre menopause • Post menopause • Peri menopause / climacteric
Endocrinology Depletion of ovarian follicles impaired folliculogenesis diminished oestradiol production increase in FSH and LH anovulation/ oligo ovulation.
• Oestrogens – oestrone and oestradiol • Androgen – androstenedione and testosterone • Progesterone • Gonadotrophins
Organ changes • Ovaries – shrink in size,become wrinkled and white. Abundance of stromal cells. • Fallopian tubes –atrophy.cilia disappear, plicae less prominent, muscle coat becomes thinner • Uterus – smaller, endometrium thin, scanty cervical secretions • Vagina – narrow, thin vaginal epithelium, flattened rugae, alkaline pH.
• Vulva – atrophy, flattened labia, scantier pubic hair, narrow introitus. • Breast- fat is reabsorbed, atrophic glands, decrease in size of nipples, becomes flat and pendulous • Bladder and urethra – changes same as vagina, thin epithelium, more prone to damage and infection, dysuria, frequency, stress incontinence
• Loss of muscle tone – pelvic relaxation, uterine descent • Bone metabolism- osteoporosis • Cardiovascular – high risk for CVD
Menopausal symptoms • Vasomotor symptoms o Hot flush o Palpitation o Fatigue o Weakness o Disturbed sleep
• Genital and urinary system o Dyspareunia o Frequency o Urgency o Stress incontinence
• Vagina o Dyspareunia o Vaginal infections o Dryness o Pruritis o Leucorrhoea o UTI
• Sexual dysfunction • Skin and hair o Thinning, loss of elasticity and wrinkling of skin o Purse string wrinkling around mouth o Crow feet wrinkling around eyes
• Psychological changes o Anxiety o Headache o Insomnia o Irritability o Dysphagia o Depression, dementia, mood swings
• Osteoporosis and fracture
Diagnosis • Cessation of menstruation for consecutive 12 months during climacteric • appearance of menopausal symptoms hot flush and night sweats • Vaginal cytology – features of low oestrogen • Serum oestradiol - <20 pg/ml • Serum FSH and LH :>40 mIU/ml
TREATMENT • Non-hormonal 1. Nutritious diet 2. Supplementary calcium 3. Exercise 4. Vitamin D 400-800 IU/day 5. Cessation of smoking and alcohol 6. Biphosphonates – etidronate , alendronate
7. Fluoride – 1 mg/kg 8. Calcitonin – nasal spray or SC 9. Selective oestrogen receptor modulators 10. Clonidine 11. Thiazides 12. Paroxetine 13. Gabapentine 14. Phytooestrogens 15. Soy protein
HRT • Indications  Relief of menopausal symptoms Prevention of osteoporosis To maintain the quality of life in menopausal years
• Benefits Improvement of vasomotor symptoms Improvement in urogenital atrophy Increase in bone mineral density Decreased risk in vertebral and hip fractures Reduction in colorectal cancer Possibly cardio protection
• Risks Endometrial cancer Breast cancer Venous thromboembolic disease CHD Lipid metabolism Dementia, alzheimers
Contra indications  Undiagnosed genital tract bleeding  Oestrogen dependent neoplasm in the body  History of venous thromboembolism  Active liver disease  Gall bladder disease
Preparations used • Oestrogens – conjugated oeastogen (0.625 – 1.25 mg/day), micronised oestardiol( 1 – 2 mg/day) • Progestins – medroxyprogesterone acetate (2.5 -5 mg/day), micronised progesterone (100 – 300 mg/day), dydrogesterone ( 5 – 10 mg/day)
• Oral oestrogen regime – conjugated equine oestrogen 0.3 mg or 0.625 mg daily • Oestrogen and cyclic progestin - with intact uterus, oestrogen contineusly for 25 days and progestin is added for last 12 – 14 days
• Continuous oestrogen and progestin therapy o Subdermal implants o Percutaneous oestrogen gel o Transdermal patch o Vaginal cream o Progestins o Tibolone
• Monitor a. Physical examination including pelvic examination b. BP c. Breast examination and mammography d. Cervical cytology e. Pelvic USG
Pms