Premenstrual Syndrome Krishna B. Singh, MD Department of Obstetrics & Gynecology LSU Health Sciences Center Shreveport, LA

PMS: Topics Covered Historical review Incidence Clinical features Diagnosis Management Summary

PMS: Learning Objectives Be able to understand that... PMS is a common clinical condition Multiple clinical symptoms/mood changes Few hormonal, biochemical changes Many theories of pathogenesis Many treatment options available

PMS: Literature Review First described by Robert Frank (1931) as PMT in 15 cases Katharina Dalton (1953) popularized the term PMS and reported 86 cases New developments (JAMA: 1992) Websites for support groups

Definitions of Premenstrual Syndrome Recurrence of symptoms premenstrually with complete absence of symptoms after menstruation (Dalton 1984) Other Definitions: National Institutes of Mental Health; American Psychiatric Association

Incidence of Premenstrual Syndrome The incidence varies 40-97% About 5% women in US have severe PMS 50% may have moderate PMS

PMS: Problems In Focus Absentees from work: ~ 5 billion dollars (1969) Association with intellectual impairment Increased numbers of crimes and violent acts Increased admissions in psychiatric hospitals

PMS: Known Risk Factors Genetic factors: Monozygous twins affected Adolescent daughters and natural mothers Positive correlation with high parity, history of toxemia of pregnancy, post-partum blues, alcohol abuse and working outside the home Not correlated with marital status, educational level, race or culture

PMS: Clinical Features Reported More than 150 signs and symptoms Cluster analysis used for sub-types of PMS Neuroendocrine disorder; pathogenesis poorly understood: neuropsychological components include symptoms - A type PMS; B type PMS Both components present C, D and E types- These require consultations

Theories of Premenstrual Syndrome PMS considered a global and multifactorial neuroendocrine disorder Brain and limbic system control the hypothalamus-pituitary-ovarian axis that are needed for reproductive cycle initiation and maintenance; may be mood changes PMS is a disorder of multiple theories

Possible Causes of PMS Beta-endorphin deficiency: lower plasma levels during the luteal phase Serotonin (5HT) deficiency: Platelet uptake and blood levels decreased during the luteal phase Progesterone withdrawal rather than deficiency; receptors may be abnormal

PMS: More Theories... Carbohydrate metabolism and GTT Protein and amino acid metabolism Prostaglandins and prostanoids Sodium, potassium, Ca++ metabolism Vitamins: A, B6 and E Minerals: zinc and copper

PMS: Differential Diagnosis Laboratory tests remain controversial Baseline values: CBC, Chem-20 @ morning Baseline serum PRL, TSH, SHBG @ morning Cervical swab for wet mount, KOH prep

Diagnosing Premenstrual Syndrome Daily diary, assessment charts, other ancillary methods are helpful aids to clinical diagnosis The time and timing of the symptoms are more important than severity of symptoms History and physical examination with selected laboratory and hormonal tests during several visits are essential components

PMS: Things To Remember Rule out psychological conditions which may require referral to psychiatrists and counselors Beware of misdiagnosis “on the fly” Consider the family and friends connection Supportive and educational measures have strong placebo effects (up to 40%)

PMS: Management Issues Principal components: confirm diagnosis and identify category; identify and manage concurrent illness; identify and manage social and family triggers; identify and manage patient needs There are numerous options for management but no curative treatments

PMS: Treatment Options General measures: diet, exercise, relaxation Avoid megadose vitamins and OTC drugs Contraception: DMPA 150 mgm/3 months Hormones: Micronized or P4 suppository (400-600 mgm/d); Parlodel, Danazol as needed Drugs: Alprazolam (Xanax 0.25 mg/tid); Fluoxetine (Prozac 20-60mg/d); Buspirone (BuSpar 5 mg/tid)

Treatment Summary of PMS Hormonal: progesterone, GnRHa Non-hormonal: antidepressants, diet Supportive and cognitive... Support groups; Websites portals Educational materials available

PMS: Things To Remember Patients who fail to respond probably do not have PMS or allied condition About 80% PMS patients will have remission of symptoms for more than a few months About 50% PMS patients may respond to a combined psychiatric and endocrine intervention

What This Means... PMS is a common disorder in the reproductive age group of women; these women generally have regular menstrual cycles PMS has many facets of clinical presentation PMS can be successfully managed and treated