2. Definition
1.Distressing psychological, physical, and/or behaviural symptoms.
2.Occurrence during the luteal phase of the menstrual cycle (or cyclically after hysterectomy with ovarian conservation).
3.Significant regression of symptoms with onset of or during the period.
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3. Prevalence
In the general population 15% of women are asymptomatic, 50% have mild PMS symptoms. 30% moderate 5-10% severe.
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4. Etiology 1. Cyclical ovarian activity the central component (ovarian 'trigger', such as ovulation, may initiate a cascade of events). 2. Central increased responsiveness to a combination of steroids, chemical messengers (E2/serotonin, progesterone/GABA) 3. Psychological sensitivity
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5. Diagnosis
Most women self-diagnose.
History can suggest a diagnosis of PMS
Symptom record can establish its true nature.
Symptom charts National Association of Premenstrual Syndrome.
Moderate/severe PMS
1.disruption of work and interpersonal relationships
2.interference with normal activities.
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6. DSM-IV diagnostic criteria for premenstrual dysphoric disorder: equivalent to severe PMS,
It is important to exclude organic disease and significant psychiatric illness.
Perimenopausal women may have increasing premenstrual symptoms as well as menopausal symptoms.
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7. DSM.IV criteria for premenstrual dysphoric disorder
At least 5 symptoms present for most of the late luteal phase with remission within a few days of onset of menses and absence of symptoms in the week post menses.
At least: one symptom must be from the following first four.
1.Marked depressed mood, feeling of hopelessness, or Self deprecation .
2.Marked anxiety; tension (being 'on edge).
3.Marked affective lability(e.g. feeling suddenly sad or tearful).
4.Persistent and marked anger/irritability/increased conflicts.
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8. 5. Decreased interest in usual acetivities (school, friends, hobbies).
6. Subjective sense of difficulty in concentrating.
7. Lethargy. Easy fatigability lack of energy.
8, Marked Change in appetite, overeating. or specific food cravings.
9. Hypersomnia or insomnia.
10. Subjective sense of being overwhelmed or out of control.
11. Other physical symptoms, such as breast tenderness or swelling, headaches; Joint or muscle pain, a sense of 'bloating'; weight gain.
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9. Management I. Self-help techniques 1. Dietary alteration less fat, sugar. salt, caffeine. and alcohol, frequent starchy meals more fibre, fruit, and vegetables 4-hourly small snacks.
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10. 2. Dietary supplements
•Vitamin B6: possible benefit
•Vitamin E.: promising.
•Calcium: (1200-1600mg) some improvement
•Magnesium; most beneficial for premenstrual anxiety.
•Evening primrose oil of value for mastalgia only.
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12. II. Hormonal
Progesterone and progestogens no benefit of progesterone pessaries, suppostories, depot injections, or oral formulations.
Ovulation suppression agents 1. COCP:
•useful for some women.
•Some women have PMS type progestaienic side effects or symptoms during the pill-free interval
•Yasmin contains drospirenone with a better side effect profile
•Newer pills with a 2-4.day break or with no pill-free interval may be more therapeutic.
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13. 2. Danazol
•benefit for PMS
•Side effects: significant masculinizing
•Treatment in luteal phase only is effective for breast tenderness. 3. Oestrogen:
•well established and accepted treatment.
•Estradiol patch: 100 micrograms twice weekly with a progestogen (cyclical basis).
•Implants: unsuitable for those who may wish to conceive.
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14. 4. GnRH analogues ± addback HRT:
•proven benefit for moderate to severe PMS
•6mths treatment only due to bone loss.
•addback tibolone (fewer side effects and bone loss).
•'GnRH test' useful for those considering hysterectomy and BSO for severe symptoms.
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15. III. Non-hormonal 1. SSRlsl seleetive noradrenalin reuptake inhibitors:
•benefit for continuous and luteal phase only treatment.
•Side effects may be problematic, but are reduced by luteal phase only dosing. 2. Antidepressants: tricyclics and anxiolytics have benefits for selected patients.
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16. IV. Surgery
•benefit of removal of the ovarian trigger with the uterus {avoid the need for combined HRT}
• definitive treatment for severe PMS.
•GnRH test' is performed to ensure that a benefit will be realized andlor another indication for hysterectomy is present.
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17. V. Complementary and alternative therapies 1. Acupuncture: positive data for dysmenorrhoea. 2. Phytoestrogens: possible benefit for PMS symptoms 3. Herbal remedies: benefit of Vitex agnus castus (20mg od) St John's wort {its action as an SSRI}
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18. 4. Homeopathy: improvement in 90%. 5. Mind-body: Aromatherapy Reflexology photic stimulation magnotherapy may show some benefit, but data are sparse. Progesterone and wild yam: no benefit .
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