Premenstrual syndrome

Premenstrual syndrome

1. Premenstrual syndrome
Prof Aboubakr Elnashar
Benha university Hospital



Aboubakr Elnashar

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.

Aboubakr Elnashar

3. Prevalence
In the general population
15% of women are asymptomatic,
50% have mild PMS symptoms.
30% moderate
5-10% severe.

Aboubakr Elnashar

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
Aboubakr Elnashar

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.
Aboubakr Elnashar

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.

Aboubakr Elnashar

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. Aboubakr Elnashar

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.

Aboubakr Elnashar

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.
Aboubakr Elnashar

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.

Aboubakr Elnashar

11. 3. Exercise
Moderate regular aerobic exercise promoting
cardiovascular work: beneficial

4. Stress reduction
Relaxtion techniques, yoga.
Meditation, breathing techniques
encouragement of healthier lifestyle

5. Cognitive behavioural therapy
long-term benefit.

Aboubakr Elnashar

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.
Aboubakr Elnashar

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.
Aboubakr Elnashar

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.
Aboubakr Elnashar

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.
Aboubakr Elnashar

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.

Aboubakr Elnashar

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}

Aboubakr Elnashar

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 .


Aboubakr Elnashar

19. Thank you
Aboubakr Elnashar