1. Diagnosis & Treatment of PMS
19 October 2011
Lizzie Eley

2. Diagnosis
Symptoms that may suggest diagnosis

3. Diagnosis- Symptoms Physical and psychological, second half of the
menstrual cycle (luteal phase), interfering with
the woman's life
Abdominal bloating- 90% of PMS,
Breast tenderness & headaches >50% of PMS
30% to 95% of menstruating women PMS symptoms
Symptom free interval in the follicular phase (relieved within 4 days of onset of menses and without recurrence until at least cycle day 12).

4. Differential Diagnoses...........
What do you want to exclude?
Would you do any investigations?

5. Cause unknown, normal concentrations of serum oestrogen and progesterone? abnormal response to hormone changes
U&E’s, FBC, TSH
if cycles irregular <25 or > 36/7
FSH, LH, prolactin
women >40 yrs, consider perimenopause
Screen for underlying depression

6. Treatments
Do you know of any?
medical, alternative

7. Treatments Efficacy SSRI’s(unlicenced) (Alprazolam- anxiolytic)
(Agents that suppress ovulation: GnRH agonists &Danazol)
Possible efficacy
Oral contraceptives
Vitamin supplements
No Evidence of Efficacy
Progesterone
Diuretic
Dietary restrictions
Exercise

8. SSRI’s- Systematic reviews
Fluoxetine 20 mg/day - 60 to 75%
Sertraline mg/day, Paroxetine mg/day, Citalopram mg/day
Venlafaxine mg/day (Selective Serotonin & Noradrenaline re-uptake inhibitor) more effective than placebo
Luteal phase therapy — start on day 14, discontinue at onset of menses. Effective, less expensive, fewer side effects, but may need higher doses & ? smaller effect
Others–TCA’s, MAOI’s & lithium not effective

9. Possible Efficacy Oral Contraceptive Yasmin Progestagen = drospirenone
4/7 pill-free interval, instead of 7/7
more effective than placebo for symptom relief in women with severe PMS (PMDD)
2 placebo controlled trials & 1 meta analysis

10. Agnus castus fruit extract The chasteberry tree
Vitex agnus castus
Native Mediterranean plant , history of use in folk medicine for women
Effects pituitary function, antagonizes prolactin and has progesterone-like effects. May stimulate (LH) and inhibit (FSH)
Placebo-controlled trial of 170 women
- significant decrease in irritability, anger, headache, and breast fullness
-No differences in adverse events
-herbal preparations are not regulated

11. Vitamin supplements and diet
Variable data quality
vitamin B6 up to 100 mg/day
calcium 600 mg bd
magnesium mg tds
Complex carbohydrate-rich beverage – increases the availability of the amino acid, tryptophan - this is actively transported into the CNS & is the rate limiting step in serotonin synthesis

12. INEFFECTIVE THERAPIES
Progesterone —no more effective than placebo in most studies and systematic reviews
Dietary and vitamin supplements
-evening primrose oil, essential free fatty acids, and ginkgo biloba extract

13. Any Questions???