Premenstrual syndrome

1. Premenstrual SyndromePremenstrual Syndrome
Dr J RomainDr J Romain

2. DefinitionDefinition
The occurrence of cyclical somatic, The occurrence of cyclical somatic,
psychological and emotional symptoms psychological and emotional symptoms
that occur in the luteal, (premenstrual) that occur in the luteal, (premenstrual)
phase of the menstrual cycle and resolve phase of the menstrual cycle and resolve
by the time menstruation ceases.by the time menstruation ceases.
(although in secondary PMS the symptoms (although in secondary PMS the symptoms
do not totally disappear)do not totally disappear)

3. PrevalencePrevalence
Occurs in almost all women of Occurs in almost all women of
reproductive agereproductive age
Particularly affects women in the third Particularly affects women in the third
decade of lifedecade of life
5% of women experience severe 5% of women experience severe
symptoms and may seek helpsymptoms and may seek help

4. AetiologyAetiology
Essentially unknownEssentially unknown
May represent an exaggerated response May represent an exaggerated response
to the physiological levels of ovarian to the physiological levels of ovarian
hormones through the cyclehormones through the cycle
Low serotonin levels may also play a roleLow serotonin levels may also play a role
Commonly precipitated by stress and Commonly precipitated by stress and
tensiontension

5. SymptomsSymptoms
Mood- irritability, tearfulness, depression, Mood- irritability, tearfulness, depression,
hostilityhostility
Cognitive function- poor concentration, Cognitive function- poor concentration,
forgetfulness and confusionforgetfulness and confusion
Somatic manifestations- bloating, Somatic manifestations- bloating,
mastalgia, headaches, appetite and sleep mastalgia, headaches, appetite and sleep
disturbancedisturbance
Behavioural change- social withdrawl, Behavioural change- social withdrawl,
inability to copeinability to cope

7. SymptomsSymptoms
Often helpful to use a ‘premenstrual Often helpful to use a ‘premenstrual
symptom questionnaire’ to assess severity symptom questionnaire’ to assess severity
of symptoms of symptoms
Based on a scoring system of 0-3 for each Based on a scoring system of 0-3 for each
symptom depending on severitysymptom depending on severity
Quality of life questionnaires assess Quality of life questionnaires assess
degree to which woman’s life is disrupteddegree to which woman’s life is disrupted

8. DiagnosisDiagnosis
Good history and symptom chartingGood history and symptom charting
Cycle charts- clearly differentiate cyclical Cycle charts- clearly differentiate cyclical
symptoms from those with continuous symptoms from those with continuous
symptoms i.e. endogenous depression, symptoms i.e. endogenous depression,
hypothyroidism, anaemiahypothyroidism, anaemia
In ambiguous cases a therapeutic 3-month In ambiguous cases a therapeutic 3-month
trial of GNRH analogue is used which trial of GNRH analogue is used which
suppress’s ovulation. If remains suppress’s ovulation. If remains
symptomatic-not PMSsymptomatic-not PMS

10. ManagementManagement
List of therapies extensive as unknown aetiologyList of therapies extensive as unknown aetiology
Start with basic approachesStart with basic approaches
- explore situations which may cause undue - explore situations which may cause undue
stress and tension, counselling usefulstress and tension, counselling useful
- exercise may reduce stress due to enhancing - exercise may reduce stress due to enhancing
endorphinsendorphins
- caffeine withdrawl, encourage vitamins and - caffeine withdrawl, encourage vitamins and
mineralsminerals
- circadian modification involves sleep - circadian modification involves sleep
deprivation for 1 night in luteal phase- influence deprivation for 1 night in luteal phase- influence
melatonin secretionmelatonin secretion

11. ManagementManagement
Oil of evening primrose, vitamin B6, Oil of evening primrose, vitamin B6,
calcium, magnesium, zinc supplementscalcium, magnesium, zinc supplements
Hormonal medication- ovulation Hormonal medication- ovulation
suppressionsuppression
–OCP or depot OCP or depot
–Danazol, not commonly usedDanazol, not commonly used
–Oestrogen implant or high-dose patchOestrogen implant or high-dose patch
–GnRH analogueGnRH analogue

12. ManagementManagement
Non hormonal medicationNon hormonal medication
- diuretics if true water retention- diuretics if true water retention
- SSRI’s beneficial (fluoxetine)- SSRI’s beneficial (fluoxetine)
- NSAID’s to relieve pain- NSAID’s to relieve pain
In extreme cases bilateral oophorectomy. In extreme cases bilateral oophorectomy.
Proven benefit from ovarian suppression Proven benefit from ovarian suppression
must be confirmed firstmust be confirmed first

13. Assessment of any Assessment of any
form of therapy is form of therapy is
particularly difficult particularly difficult
because of a 70-80% because of a 70-80%
placebo responseplacebo response

14. ThankyouThankyou