This document discusses premenstrual changes (PMCs), also known as premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). PMCs are common cyclic affective disorders affecting young and middle-aged women, characterized by mood and physical symptoms in the luteal phase prior to menstruation. Mild symptoms affect 30-80% of women, while severe symptoms affect 3-5%. The exact causes are unclear but likely involve serotonin and hormonal fluctuations. Diagnosis involves tracking symptoms over at least two cycles to identify cyclic patterns. Treatment options range from lifestyle modifications to pharmacotherapy depending on symptom severity.
Premenstrual Syndrome – Recent Guidelines
Premenstrual Syndrome & Premenstrual Dysphoric Disorder
Incidence
80% of women have atleast one physical or psychiatric symptom during luteal phase
PMS -12-15%
PMDD – 1.3-5.3%
Premenstrual Syndrome – Recent Guidelines
Premenstrual Syndrome & Premenstrual Dysphoric Disorder
Incidence
80% of women have atleast one physical or psychiatric symptom during luteal phase
PMS -12-15%
PMDD – 1.3-5.3%
Menstrual cycle irregularities can have many different causes. For some women, use of birth control pills can help regulate menstrual cycles. However, some menstrual irregularities can't be prevented. Regular pelvic exams can help ensure that problems affecting your reproductive organs are diagnosed as soon as possible.
Topic of presentation: Amenorrhea. Content includes: Introduction, Etiology, signs and symptoms, classification, diagnosis and management with treatment. How it can be prevented. Both the types: Primary and secondary are discussed.
There is general inconsistency in the nomenclature used to describe abnormal uterine bleeding (AUB) classification system for AUB, which has been approved by the International Federation of Gynecology and Obstetrics (FIGO) Executive Board as a FIGO PALM-COEIN classification system.
AMENORRHEA
Ludmila Barbakadze
Ivane Javakhishvili Tbilisi State University Assistant Professor Medical Doctor at Archil Khomassuridze Institute of Reproductology ,Tbilisi , Georgia.
Menopause is the time in a woman's life when her period stops. It usually occurs naturally, most often after age 45. Menopause happens because the woman's ovaries stop producing the hormones estrogen and progesterone. A woman has reached menopause when she has not had a period for one year.
Urinary incontinence is defined as any involuntary or uncontrolled loss of urine sufficient to cause a social or hygienic problem.
Urge urinary or “urge”—incontinence is the involuntary leakage accompanied or immediately preceded by a perceived strong imminent need to void
Menstrual cycle irregularities can have many different causes. For some women, use of birth control pills can help regulate menstrual cycles. However, some menstrual irregularities can't be prevented. Regular pelvic exams can help ensure that problems affecting your reproductive organs are diagnosed as soon as possible.
Topic of presentation: Amenorrhea. Content includes: Introduction, Etiology, signs and symptoms, classification, diagnosis and management with treatment. How it can be prevented. Both the types: Primary and secondary are discussed.
There is general inconsistency in the nomenclature used to describe abnormal uterine bleeding (AUB) classification system for AUB, which has been approved by the International Federation of Gynecology and Obstetrics (FIGO) Executive Board as a FIGO PALM-COEIN classification system.
AMENORRHEA
Ludmila Barbakadze
Ivane Javakhishvili Tbilisi State University Assistant Professor Medical Doctor at Archil Khomassuridze Institute of Reproductology ,Tbilisi , Georgia.
Menopause is the time in a woman's life when her period stops. It usually occurs naturally, most often after age 45. Menopause happens because the woman's ovaries stop producing the hormones estrogen and progesterone. A woman has reached menopause when she has not had a period for one year.
Urinary incontinence is defined as any involuntary or uncontrolled loss of urine sufficient to cause a social or hygienic problem.
Urge urinary or “urge”—incontinence is the involuntary leakage accompanied or immediately preceded by a perceived strong imminent need to void
Työllistämisehdon soveltaminen julkisissa hankinnoissa on markkinapohjainen ohjauskeino, jota kunnat ja valtio voivat hyödyntää yhteiskunnallisten tavoitteiden saavuttamiseksi. Työtä julkisilla hankinnoilla -esite kertoo miksi työllistää julkisten hankintojen avulla ja miten soveltaa työllistämisehtoa käytännön esimerkkien avulla.
Natalie Thrutle educates on the critical issue of lead poisoning in developing countries.
Critical care means different things to different people. In the context of lead poisoning, you may or may not think of developing countries such as Nigeria.
The response to the Zamfara state, lead poisoning outbreak, in Northern Nigeria, is unprecedented and requires a nuanced interpretation of ‘critical care’.
In 2010, 400 children died from lead encephalopathy in the largest lead poisoning outbreak ever recorded, affecting more than 5000 children in Zamfara.
The outbreak is ongoing. Children were presenting with intractable seizure and coma, not responsive to treatment for malaria and meningitis. 50% of these children were dying.
Environmental poisoning was considered early on, due to the high levels of artisanal gold mining in the area. This increase in mining was a major economic boom to a remote and rural population much in need.
MSF had never dealt with a lead poisoning outbreak before… neither had the Nigerian government. No one had ever dealt with a lead poisoning outbreak in the world before. It had never been seen.
Initially there were three main aims. Chelation, remediation, and safer mining practices.
Whilst chelation worked, it would have been futile without an effort to clean the environment (remediation). This in turn was futile without considering safer mining practices. The solution to the problem required by in and input from all parties. Herein lay the challenge.
Parallels with the Ebola outbreak in Guinea can be drawn. In this instance there were attacks on both healthcare workers and quarantine facilities. Zamfara did not see such extreme reactions although there was certainly a feeling of animosity and resistance coming from the mining community.
In this talk, Natalie highlights the successes and the ongoing challenges of facing this issue head on. Progress has been made, and challenges still exist.
For more like this, head to our podcast page. #CodaPodcast
Automotive Systems course (Module 06) - Power Transmission Systems in road ve...Mário Alves
This presentation provides and overview of the most important power transmission systems, the ones that permit to transmit power to the wheels in any vehicle, maximizing engine power and torque. We organize the presentation according to the main components of any power transmission system: gear boxes, clutches and differentials.
Automotive Systems course (Module 09) - Ignition Systems for Internal Combus...Mário Alves
This presentation is dedicated to ignition systems for Internal Combustion Engines (ICE). The Ignition System is paramount for every car, motorcycle, truck or bus that runs an ICE based on gasoline, alcohol or Liquefied Petroleum Gas (LPG). It controls the timings when the spark plugs are fired, therefore igniting the air-fuel mixture in the combustion chamber. The Ignition System is one of the major players in what concerns the performance of the engine in terms of output power, pollutant emissions and fuel consumption.
Lugansk State Medical University (LSMU) is attested according to the highest (the fourth) Level of accreditation. Lugansk State Medical University ranks third among Medical Universities in Ukraine & the higher medical schools and university of the 4th accreditation level according to the last ranking list of the Ministry of Health of Ukraine.The University activities conform with The Constitution of Ukraine, Ukrainian legislation, acts issued by the President and the Cabinet of Ministers of Ukraine, Decrees of the Health Department and Education Department of Ukraine, the University Rules .
"Management of Premenstrual Tension (PMT)"
PMT (Premenstrual Tension) or PMDD (Premenstrual Dysphoric Disorder) is common problem.
Its impact on women's lives, family life in big way emphasizing the need for effective management.
National Prize of Applied Sciences nominee Dr. Jorge Lolas Talhami and his research on “cyclical hysterotoxemia”. Featuring: Dr. Enrique Vazquez-Vera - MD, FACOG; Dr. Jorge Lolas Talhami; Amanda Parodi; and Yusnaiberth Rivero De Detraux.
Content presented by Dr. Enrique Vazquez-Vera - MD, FACOG at the 2015 NAPMDD National Conference 8/9/2015.
View the session video at: http://napmdd.org/denver2015nc/session-03.html
Become a member of NAPMDD at:
http://napmdd.org/join
Mood disorders:major depressive and bipolar disorderNandu Krishna J
a basic description about mood disorders mainly MDD and bipolar disorder. Can be made useful in presentations and theory exams. Subject was imbibed from different presentations and DSM IV manual. Thanks for viewing.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
2. • PMCs (Premenstrual Changes) are a budding
issue having both the psychiatry and
gynecology-related symptoms with adverse
social consequences.
3. • PMCs (Premenstrual Changes) are a common
cyclic affective disorder of young and middle-
aged occuring in the luteal phase.
• PMCs range from mild mood fluctuations,
called Premenstrual Syndrome (PMS) to
severe mental and physical disturbances,
called Premenstrual Dysphoric Disorder
(PMDD).
• The exact aetiology of PMCs is largely under-
explored.
• Its diagnosis and management are often
difficult.
4. Incidence
• Premenstrual syndrome and premenstrual
dysphoric disorder are diagnoses of exclusion;
therefore, alternative explanations for symptoms
must be considered before either diagnosis is
made
• Milder symptoms are believed to occur in about
30% to 80% of reproductive-age women, while
severe symptoms are estimated to occur in 3%
to 5% of menstruating women.
6. • Cerebral serotonin neurotransmitter system (5-HTs) is
an important component, involved in a large number
of psychiatric illnesses where the affect is disturbed.
• PMDD is another extreme reflection of the affective
disturbances. Therefore, it is interesting to note
whether 5-HTs play any role in the development of
PMCs. Studies have shown that post-synaptic
serotonergic response possibly is disturbed during the
late-luteal-premenstrual phase of the MC or even
throughout the cycle in those who have severe
vulnerability trait
• Though the gonadal hormone (oestrogen and
progesterone)-induced modulation of 5-HTs is a
known fact at the backdrop of schizophrenia
• , in PMCs, differential effects in the cerebral 5-HTs
due to differential hormonal changes in the MC
7. Diagnosis
• Screening of patients could easily be done
by asking the patients to maintain regular
menstrual diary for at least two
consecutive cycles to note the target
symptoms.
8.
9. Diagnostic Criteria for
Premenstrual Syndrome
• National Institute of Mental Health
• A 30% increase in the intensity of symptoms of premenstrual
syndrome (measured using a standardized instrument) from
cycle days 5 to 10 as compared with the six-day interval before
the onset of menses and Documentation of these changes in a
daily symptom diary for at least two consecutive cycles
• University of California at San Diego
• At least one of the following affective and somatic symptoms
during the five days before menses in each of the three
previous cycles:
– Affective symptoms: depression, angry outbursts, irritability, anxiety,
confusion, social withdrawal
– Somatic symptoms: breast tenderness, abdominal bloating, headache,
swelling of extremities
– Symptoms relieved from days 4 through 13 of the menstrual cycle
10.
11. Common Symptoms of PMS
Women with PMS
Symptom Showing Symptoms (%)
Behavioral
Fatigue 92
Irritability 91
Labile mood with alternating
sadness and anger 81
Depression 80
Oversensitivity 69
Crying spells 65
Social withdrawal 65
Forgetfulness 56
Difficulty concentrating 47
12. Common Symptoms of PMS
(Continued)
Physical
Abdominal bloating 90
Breast tenderness 85
Acne 71
Appetite changes and
food cravings 70
Swelling of the extremities 67
Headache 60
Gastrointestinal upset 48
13. Differences Between PMS and PMDD
Functional
impairment
Prospective
charting of
symptoms
Not required
Not required
Interference with
social or role
functioning
required
Prospective
daily charting of
symptoms
required for two
cycles
Diagnostic criteria Tenth Revision of
the International
Classification of
Disease (ICD-10)
Diagnostic and
Statistical Manual
of Mental
Disorders, 4th
ed.
(DSM-IV)
Providers using
these criteria
Obstetrician/gynec
ologists, primary
care physicians
Psychiatrists, other
mental health care
providers
Number of
symptoms
required
One 5 of 11 symptoms
14. Patterns of PMS
• Premenstrual symptoms can begin at ovulation
with gradual worsening of symptoms during the
luteal phase (pattern 1).
• PMS can begin during the second week of the
luteal phase (pattern 2).
• Some women experience a brief, time-limited
episode of symptoms at ovulation, followed by
symptom-free days and a recurrence of
premenstrual symptoms late in the luteal phase
(pattern 3).
• The most severely affected women have
symptoms that at ovulation worsen across the
luteal phase and remit only after menses cease
(pattern 4). These women describe having only
one week a month that is symptom-free.
16. Differential Diagnosis
(Continued(
Premenstrual
exacerbation
• Of psychiatric disorders
• Of seizure disorders
• Of endocrine disorders
• Of cancer
• Of systemic lupus
erythematosus
• Of anemia
• Of endometriosis
Psychosocial spectrum
• Past history of sexual
abuse
• Past, present, or current
domestic violence
17. Management protocol
• Management of PMCs is often extremely
difficult
• Patients qualified for PMCs could be rated
for the symptoms severity under the three-
point scale:
mild, moderate and severe.
• According to the symptom rating, the
guidelines for the management of PMCs
could be adopted as follows
18. • A. Life style modification including
counseling or behavioral psychotherapy
for coping up with the symptoms when the
symptoms are mild, and
• B. Pharmacotherapy when the symptoms,
although mild, are not been tackled by
simple life style modification or counseling
and psychotherapy or the symptoms are
moderate to severe and incapacitating.
19. Strategies to cope up PMCs by
modifying life styles:
• Doctors often prescribe/advice the followings for
their patients with mild PMCs as the first-line of
management:
• Prohibition for caffeine, refined sugars, and
crude salt intake,
• Avoiding alcohol and related beverages
• Regular exercise, especially isotonic
• Increase carbohydrate intake in the diet , and
• Cognitive-behavioral psychotherapy, if required
20. • Though the role of these are quite under
tested, the reasons for such age-old
prescriptions are probably continuing due
to the other benefits and safety
• . If these are found to be ineffective or
inadequate, or the symptoms are severe,
pharmacotherapy remains the mainstay of
the treatment
21. Strategies for opting for the
pharamacological agents
• Vitamins and minerals as dietary
supplements,
• Psychopharmacologiucal drugs, and
• Hormonal agents:
• Vitamins and minerals
24. Progesterone
• The role of Progesterone in the treatment of PMS probably
arose from the theory that the syndrome is caused from a lack
of progesterone which was popular back in the 1950s up until
the 1980s.
• Treatment with high doses of "natural" progesterone vaginally
became popular in the 1970s after the publication of a large
number of case reports in the lay press,
• none of which had any true control groups. Since then, several
randomised-controlled trials have failed to show any benefit
from topical or oral micronized progesterone over placebo
Topical progesterone preparations are also expensive. Given
the lack of efficacy and the expense of the product,
Progesterone can not be recommended as a treatment of PMS.
25. Pyridoxine vitamin B(6)
• Pyridoxine or vitamin B6 is the most widely
used supplement used to treat PMS.
• It has been proposed that vitamin B6 may help
to correct a "deficiency" in the hypothalamic
pituitary axis. Vitamin B6 is a cofactor in the
synthesis of tryptophan and tyrosine, which are
the precursors of serotonin and dopamine
respectively. Theoretically, low levels of vitamin
B6 may lead to high levels of prolactin which in
turn could underlay the edema and
psychological symptoms associated with PMS.
26. • it would appear that there is very limited
evidencve to support the generalized use of
vitamin B6 for the treatment of PMS.
• Vitamin B6 can also cause significant toxicity
and unpleasant side effects. It can produce a
progressive sensory ataxia taken at doses as
low as 500 mg. a day and can also cause a
number of gastrointestinal side effects,
particularly nausea.
• Consequently, given the lack of clear scientific
evidence for its effectiveness, and the
associated risks of treatment, vitamin B6 can
not generally be recommended as a treatment
for PMS.
27. Bromocriptine
• Another theory that was popular in the 1970s
was that PMS was caused by increased levels
of, or an increased sensitivity to, Prolactin.
• Bromocriptine is expensive and has a number
of side effects. Consequently its use can not be
recommended for the general treatment of PMS
• One exception is severe cyclical mastalgia for
which Bromocriptine may be effective.
28. Combination Oral contraceptives
• Combination oral contraceptives are also
widely used to treat PMS. Despite their
popularity,
• Consequently, the lack of scientific evidence for
their effectiveness along with the associated
expense and potential risks,
• OCPs can not be recommended for the
treatment of PMS
30. Diet
• Dietary recommendations are commonly
recommended to help alleviate the physical and
psychological symptoms of PMS.
• The most common dietary recommendations
are to restrict sugar
and increase the consumption of complex
carbohydrates.during the latter half of their
cycle may help alleviate some of the
psychological symptoms of PMS
31. Aerobic exercise
• Women who have PMS are often
encouraged to increase their activity
level. It has been hypothesised that
exercise; particularly aerobic
varieties increase endorphin levels,
which in turn improves mood
• , it would seem reasonable to
recommend an aerobic exercise
program to alleviate PMS symptoms
32. Psychological approaches
• various psychological approaches including
instruction on
relaxation techniques,
cognitive behavioural strategies
and information giving may all help relieve
PMS symptoms.
33. Magnesium
• Studies have found that women who suffer from PMS
have lower levels of erythrocyte and monocellular
magnesium during their menstrual cycles than women
who do not have PMS.
• Accordingly, magnesium supplementation has been
used as a potential therapy.
• It reported less fluid retention .Menstrual cramps,
irritability and fatigue, but They did not have any
improvement in mood, cramping or food cravings
• Magnesium is considered safe at doses up to 483
mg. per day in healthy adults. It must be used with
caution, however, in people with significant heart and
renal disease
34. Evening Primrose Oil
• Evening Primrose Oil is used extensively to
alleviate PMS symptoms. EPO contains two
essential fatty acids: linoleic and gamma
linoleic acids. It has been hypothesised that
women with PMS are deficient in gamma
linoleic acid which is necessary for
prostaglandin
• EPO may be of some benefit to those women
with cyclical mastalgia but is probably of limited
if any benefit to women who have significant
mood and cognitive symptoms
35. Vitamin E
• Vitamin E has been used to treat PMS and
general breast tenderness. There have been
only a few studies that have addressed this
issue.
36. Spironolactone
• Diuretics have been used to treat the fluid
retention associated with PMS for over 50
years.
• Despite their wide spread use, there is no
evidence that the thiazide diuretics are of any
benefit. These medications are also associated
with significant side effects including
hypokalemia, secondary aldosteronism and
cyclical edema. Consequently they can not be
recommended for the treatment of PMS.
37. Non Steroidal Anti-inflammatories
• There is some evidence that NSAIDS given
during the luteal phase does help relieve the
physical and affective symptoms of PMS.
Mefenamic acid (500 mg. T.I.D.), Naproxen
when administered during the luteal phase of
the cycle.
38. Ovulation Suppression
• The use of Danazol and Gonadotrophin Releasing Hormone
Agonists to suppress ovulation have been shown to reduce the
symptoms of PMS.
• The significant side effects associated with these treatments
however, makes them generally unacceptable for use in
Primary Care..
• It is important to appreciate that the synthetic hormones vary in
their chemical composition and effects from each other and the
natural products. Consequently differences in chemical
compositions, even relatively subtle ones, may underly the
differences in response to various hormonal treatments
including hormonal regimes that have been found to be
effective and the OCPs and natural progesterone which have
not been found to be effective
40. Calcium
• findings provide good evidence for the
effectiveness of calcium carbonate as a
treatment for PMS.
• Calcium is also relatively inexpensive and plays
an important role in the prevention of
osteoporosis, therefore it is recommended for
the treatment of PMS.
41. Selective Serotonin Reuptake Inhibitors
• PMS has been linked with dysfunctional serotonin metabolism
and there is experimental evidence that hormonal fluctuations
do affect central serotonin levels
• strongly support the effectiveness of SSRIs in the treatment of
PMS. Interestingly,
• It was found no difference in the effectiveness of continuous
compared to intermittent therapy during the luteal phase.
• The doses used for PMS also tend to be lower than that used
for depression.
• Consequently the incidence of side effects tend to be lower as
well The use of the SSRIs is not with out its drawbacks. A host
of side effects have been reported including headache,
nervousness, insomnia, drowsiness, fatigue, sexual dysfunction
and gastrointestinal complaints.
• The SSRIs are also relatively expensive
• Nonetheless given their proven efficacy, they are
recommended, particularly for women with severe affective
symptoms for whom other measures have not been effective.
42. • The ACOG recommends SSRIs as initial drug therapy
in women with severe PMS and PMDD. [Evidence
level C, expert/consensus guidelines]
• Common side effects of SSRIs include insomnia,
drowsiness, fatigue, nausea, nervousness, headache,
mild tremor, and sexual dysfunction.
• Use of the lowest effective dosage can minimize side
effects. Morning dosing can minimize insomnia.
• In general, 20 mg of fluoxetine or 50 mg of sertraline
taken in the morning is best tolerated and sufficient to
improve symptoms.
• Benefit has also been demonstrated for the
continuous administration of citalopram (Celexa).
• alleviating physical and behavioral symptoms, with
similar efficacy for continuous and intermittent
43. SSRIs Dos
age
Recemmendations for
use
Side
effects
Fluoxetine
(Sarafem(
10to
20
mg
per
day
First-choice agents for the
treatment of PMDD; at
present, only fluoxetine is
labeled for this indication.
Clearly effective in
alleviating behavioral and
physical symptoms of
PMS and PMDD
For intermittent therapy,
administer during luteal
phase (days before
menses(.
Insomnia,
drowsiness,
fatigue,
nausea,
nervousnes
s,
headache,
mild tremor,
sexual
dysfunction
Sertraline
(Zoloft(
50to
150
mg
per
day
Paroxetine
(Paxil(
10to
30
mg
per
day
44. NATURAL THERAPIES
• Following is a description of some of the
more commonly used herbal preparations
used to treat PMS. Our current knowledge
about these substances is largely based
on pharmacological and descriptive data,
which significantly limits our ability to draw
conclusions about their effectiveness and
long term safety.
45. Black Cohosh
• This herbal remedy is derived from the rhizome and root of the plant. Its
action is related to the binding of estrogens receptors and suppression of
leutinizing hormone although it is not thought to increase the risk for
endometrial and breast cancers. It has been rated as "possibly effective" for
the treatment of pre-menstrual discomfort. It is likely safe when taken in low
doses (0.3 to 2 mg. T.I.D.) for less than six months.
• Black Cohosh also contains Salicylic acid and consequently should not be
taken by people who should avoid aspirin or who are at risk of bleeding.
Similarly, it should be avoided in women in whom estrogen is
contraindicated. Overdose of Black Cohosh can cause nausea, vomiting,
dizziness, visual disturbance, and decreased heart and respiration rates
Borage Seed oil
• Borage seed oil contains 26% gamma linoleic acid and is used as a
replacement for evening primrose oil. It is "likely safe" if used orally as
directed. Gamma linoleic acid can prolong bleeding time and therefore
should be used with caution in people at risk of serious bleeding including
those who are taking other medications and herbal products that can
prolong bleeding times.
46. Dandelion
• Dandelion is used for a variety of medicinal purposes. It has been shown to
have mild diuretic and anti-inflammatory properties in animal studies. It has
been rated as "possibly effective" for promoting diuresis and may be of
some benefit in treating the fluid retention associated with PMS.
• Theoretically dandelion can have hypoglycemic effects and therefore should
be used with caution in individuals taking diabetic medications
• . Individuals who have environmental allergies to members of the Asteracae
family, which includes ragweed, chrysanthemums, marigolds and daisies,
should also avoid this herb
Dong Quai
• Dong Quai is a commonly used herb used for a variety of gynecological
symptoms including PMS. It contains a number of different constituents,
which are thought to have vasodilating, antispasmodic, and anti platelet
activities.
• Dong Quai does have carcinogenic and mutagenic properties and can
cause severe photodermatits especially when used in large amounts.
• It is rated as "possibly unsafe" by the Natural Medicine Comprehensive
Database.
• It may also interact with several medications and other herbal remedies
48. • How do we organise the above information into
a practical concise set of guidelines for Family
Physicians?
• The following recommendations are based on
interpretation of the strength of evidence for
effectiveness of the various therapies, as well as
the potential costs, adverse effects and long
term risks involved.
• The nature of the symptoms was also taken into
account. Johnson describes a similar but not
identical approach in her very comprehensive
review article on the subject
49.
50. Summary of Management Guidelines
• All women with PMS or PMDD
• Nonpharmacologic treatment: education, supportive therapy, rest, exercise,
dietary modifications
• Symptom diary to identify times to implement treatment and to monitor
improvement of symptoms
• Treatment of specific physical symptoms
• Bloating: spironolactone (Aldactone)
• Headaches: nonprescription analgesic such as acetaminophen, ibuprofen,
or naproxen sodium (Anaprox; also, nonprescription Aleve)
• Fatigue and insomnia: instruction on good sleep hygiene and caffeine
restriction
• Breast tenderness: vitamin E, evening primrose oil, luteal-phase
spironolactone, or danazol (Danocrine)
• Treatment of psychologic symptoms
• For symptoms of PMDD, continuous or intermittent therapy with an SSRI
• Treatment failure
• Hormonal therapy to manipulate menstrual cycle