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.

1. Mrs.DRISYA.V.R.
2nd Year MSc Nursing
PREMENSTRUAL SYNDROME
(PMS)

2. • 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.

3. 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).

4. 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)

5. 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.

6. Clinical features :
• PMS is more common in women aged 30-45.
• It may be related to childbirth or a disturbing
life event.

9. 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.

10. 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.

11. 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.

12. • 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.

13. • b. Progesterone
Levonorgestrel intrauterine system (IUS)
• d. Bromocriptine — 2.5 mg daily or twice
daily

14. • 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.

15. 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.

16. 5.Oophorectomy

17. 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.

18. • Pre menopause
• Post menopause
• Peri menopause / climacteric

19. Endocrinology
Depletion of ovarian follicles impaired
folliculogenesis diminished oestradiol
production increase in FSH and LH
anovulation/ oligo ovulation.

20. • Oestrogens – oestrone and oestradiol
• Androgen – androstenedione and
testosterone
• Progesterone
• Gonadotrophins

21. 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.

22. • 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

23. • Loss of muscle tone – pelvic relaxation,
uterine descent
• Bone metabolism- osteoporosis
• Cardiovascular – high risk for CVD

24. Menopausal symptoms
• Vasomotor symptoms
o Hot flush
o Palpitation
o Fatigue
o Weakness
o Disturbed sleep

25. • Genital and urinary system
o Dyspareunia
o Frequency
o Urgency
o Stress incontinence

26. • Vagina
o Dyspareunia
o Vaginal infections
o Dryness
o Pruritis
o Leucorrhoea
o UTI

27. • 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

29. • Psychological changes
o Anxiety
o Headache
o Insomnia
o Irritability
o Dysphagia
o Depression, dementia, mood swings

30. • Osteoporosis and fracture

31. 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

32. 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

33. 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

34. HRT
• Indications
 Relief of menopausal symptoms
Prevention of osteoporosis
To maintain the quality of life in menopausal
years

35. • 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

36. • Risks
Endometrial cancer
Breast cancer
Venous thromboembolic disease
CHD
Lipid metabolism
Dementia, alzheimers

37. Contra indications
 Undiagnosed genital tract bleeding
 Oestrogen dependent neoplasm in the body
 History of venous thromboembolism
 Active liver disease
 Gall bladder disease

38. 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)

39. • 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

40. • Continuous oestrogen and progestin therapy
o Subdermal implants
o Percutaneous oestrogen gel
o Transdermal patch
o Vaginal cream
o Progestins
o Tibolone

41. • Monitor
a. Physical examination including pelvic
examination
b. BP
c. Breast examination and mammography
d. Cervical cytology
e. Pelvic USG