PREMENSTRUAL SYNDROME

Ozgul Muneyyirci-Delale

Premenstrual Syndrome

Premenstrual Syndrome (PMS) is defined as “the cyclic recurrence in the luteal phase of the menstrual cycle of a combination of distressing physical, psychological, and/or behavioral changes of sufficient severity to result in deterioration of interpersonal relationships and/or interference with normal activities. Nearly 200 symptoms have been associated with this definition and it is the clustering of these signs and symptoms that is the hallmark of PMS.

Catamenial

The term “catamenial” is derived from the Greek and signifies around menses. In general an instance where a single recognized medical condition presented in the premenstruum was referred to as a catamenial disorder while a cluster of symptoms was referred to as PMS.

Premenstrual Magnification

Many patients with psychiatric disorders also complain of worsening of their symptoms around the premenstrual phase, called “premenstrual magnification” (PMM).

PMS

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.

Concordance Rate

The concordance rate (if both twins have PMS) was found to be significantly higher in monozygous twins (93%) than dizygous twins (44%) and in non-twin control women (31%).

Common Symptoms of PMS

Women with PMS

Symptom Showing Symptoms (%)

BehavioralFatigue 92Irritability 91

Labile mood with alternating sadness and anger 81Depression 80Oversensitivity 69Crying spells 65Social withdrawal 65Forgetfulness 56Difficulty concentrating 47

Common Symptoms of PMS(Continued)

PhysicalAbdominal bloating 90Breast tenderness 85Acne 71Appetite changes and food cravings 70Swelling of the extremities 67Headache 60Gastrointestinal upset 48

Differences Between PMS and PMDD

Diagnostic criteria Tenth Revision ofthe InternationalClassification ofDisease (ICD-10)

Diagnostic andStatistical Manualof MentalDisorders, 4th ed.(DSM-IV)

Providers usingthese criteria

Obstetrician/gynecologists, primarycare physicians

Psychiatrists, othermental health careproviders

Number ofsymptomsrequired

One 5 of 11 symptoms

Differences Between PMS and PMDD(Continued)

Functionalimpairment

Prospectivecharting ofsymptoms

Not required

Not required

Interference withsocial or rolefunctioningrequired

Prospectivedaily charting ofsymptomsrequired for twocycles

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).

Patterns of PMS(Continued)

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.

Differential Diagnosis

Psychiatric disorders Major depression Dysthymia Generalized anxiety Panic disorder Bipolar illness (mood

irritability) Other

Medical disorders Anemia Autoimmune disorders Hypothyroidism Diabetes Seizure disorders Endometriosis Chronic fatigue

syndrome Collagen vascular

disease

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

Diagnosis of PMS

PMSA. Does not meet DSM-IV

criteria but does meet ICD-10 criteria for PMS

B. Symptoms occur only in the luteal phase, peak shortly before menses, and cease with menstrual flow or soon after

C. Presence of one or more of the following symptoms

Mild psychological discomfort

Bloating and weight gain Breast tenderness Swelling of hands and

feet Aches and pains Poor concentration Sleep disturbance Change in appetite

PMDD (DMS-IV Criteria)

A. At least five of the symptoms below, with at least one being a core symptom, are present a week before menses and remit a few days after onset of menses:

Depressed mood or dysphoria (core symptom)

Anxiety or tension (core symptom) Affective lability (core symptom) Irritability (core symptom) Decreased interest in usual activities

PMDD (DMS-IV Criteria)(Continued)

Concentration difficulties Marked lack of energy Marked change in appetite, overeating, or

food cravings Hypersomnia or insomnia Feeling overwhelmed Other physical symptoms (e.g., breast

tenderness, bloating, headache, joint or muscle pain)

PMDD (DMS-IV Criteria)(Continued)

B. Symptoms must interfere with work, school, usual activities, or relationships

C. Symptoms must not merely be an exacerbation of

D. Criteria A, B and C must be confirmed by prospective daily ratings for at least two cycles

See Attached Menstrual Symptom Diary

Treatment of PMS

Oral contraceptives Vitamin B6

Bromocriptine Monoamine oxidase inhibitors Synthetic progestational agents Spironolactone Massage therapy Chiropractic therapy Calcium

Treatment of PMS(Continued)

Primrose oil Prostaglandin synthesis inhibitors Medical and surgical oophorectomy Alprazolam (Xanax) Naltrexone: opiate antagonist Fluxetine (Prozac)

With a placebo response rate in patients with PMS ranging between 20% and 50%, it is essential that double-blind, randomized trials be conducted to assess therapeutic effectiveness.