The Good the Bad and The The Good the Bad and The UglyUgly

Complications of Menstruation& PMS

Jennifer McDonald DO

Premenstrual SyndromePremenstrual Syndrome

• 80% women experience one symptom (functioning not impaired)

• 20-40% moderate symptoms (two to five symptoms)

• 2-9% severe symptoms (PMDD)

What is it??

Symptoms ??Symptoms ??

Somatic

Behavioral

EtiologyEtiology

• Multifactorial• Hypersensitivity of the individual to

changes in gonadal activity• External stressors

• Neurotransmitter alterations• GABA

• Serotonin• Renin-angiotensin-aldosterone system (RAAS)

Neurotransmitters Neurotransmitters and and

NeurohormonalNeurohormonalSystems*Systems*

Genetic Genetic PredispositionPredisposition VulnerabilityVulnerability Increased SensitivityIncreased Sensitivity

to Changes in to Changes in Gonadal HormonesGonadal Hormones

InteractInteractwithwith

Gonadal Gonadal HormonesHormones

and Metabolitesand Metabolites

Altered Altered Responses toResponses toChanges in Changes in

Gonadal Hormone Gonadal Hormone LevelsLevels

PremenstrualPremenstrualSymptomsSymptoms

*Serotonin, renin-angiotensin-aldosterone system, -aminobutyric acid (GABA), and cholecystokinin.

Halbreich U. Psychoneuroendocrinology. 2003;28(Suppl 3):55-99.

DiagnosisDiagnosis

• Luteal phase symptoms• Symptom free interval of 7 days in the

first half of the cycle• 2 consecutive cycles

50% women who believe they have severe PMS do not have a luteal phase pattern when

menstrual cycle diaries are reviewed

Copy placed on IQWebAlso visit

MyMonthlyCycles.com

Treatment Options

Dietary Changes Exercise

Stress Management

Chaste berry extract

Calcium 1200 mg/day

Magnesium 200-400 mg/day

L-Tryptophan 6g/d from ovulation to

menses

No Proven BenefitNo Proven Benefit

• Reducing caffeine intake• Reducing salt intake

• Vitamin E• Vitamin B6

• Evening primrose oil

Evidence is anecdotal and not supported in randomized clinical trials

Pharmacologic TherapyPharmacologic Therapy

• SSRIs Luteal phase dosing

Daily dosing

• Sprironolactone• Oral contraceptives

• Ovulation suppression (worst case scenario)

DysmenorrheaDysmenorrhea

Painful menstruatio

n

Primaryvs.

Secondary

14-26% adolescents miss school because of pain

Primary DysmenorrheaPrimary Dysmenorrhea

• Symptoms begin shortly after menarche• Usually regular cycles

• Pain associated with ovulatory cycles

• Prostaglandins (PGE2 & PGF2) implicated as the inducing agents

• Uterine contractions cause ischemia which in turn causes pain

Treatment options ??

Secondary DysmenorrheaSecondary Dysmenorrhea

• Association with pelvic pathology

Differential ??

Big on DefinitionsBig on Definitions

• Menorrhagia• Metrorrhagia

• Hypomenorrhea• Metrorrhagia

• Polymenorrhea• Menometrorrhagia• Oligomenorrhea

• Cryptomenorrhea

Dysfunctional Uterine BleedingDysfunctional Uterine Bleeding

• Exclusion of pathologic causes• Extremes of reproductive age

• Treatment depends on age group

Which group would be the most concerning?

Adolescents? Young women? Premenopausal?

History & Evaluation of History & Evaluation of Female ComplaintsFemale Complaints

• Menstrual history

• Reproductive history

• General medical history

• Family history

What would be important to know ??

EvaluationEvaluation

• History• Physical exam

• Endometrial biopsy• Hysteroscopy

• D&C (dilation & curettage)

HysteroscopyHysteroscopy

• 3 mm hysteroscope

• Saline or CO2

• Panoramic view of uterus

• Visualization of polyps, intramural fibroids, scar tissue

Endometrial Ablations

• Conservative treatment for menorrhagia

• Thermal energy applied directly to uterine lining

• Majority of women amenorrheic after

treatment

• Other ablation techniques

Thermachoice (water balloon)

Freezing (HER option)

Hot water (Hydrothermablator)

Postmenopausal BleedingPostmenopausal Bleeding

Cancer until proven otherwise