1. Premenstrual Syndrome Dr Patel GP VTS

2. Aims To make an accurate diagnosis of premenstrual syndrome (PMS) To make an accurate diagnosis of premenstrual syndrome (PMS) To provide appropriate advice to women with PMS To provide appropriate advice to women with PMS To offer options for treatment that are appropriate for initiation in primary care To offer options for treatment that are appropriate for initiation in primary care To refer the woman when primary care treatment is not adequate To refer the woman when primary care treatment is not adequate

3. Premenstrual Syndrome Modern Definition ‘Distressing physical, psychological and behavioural symptoms, not caused by organic disease, which regularly recur during the same phase of the menstrual (ovarian) cycle and which significantly regress or disappear during the remainder of the cycle’ Magos & Studd (1984) Magos & Studd (1984)

4. What is Premenstrual Syndrome (PMS) distressing physical, behavioural, and psychological symptoms distressing physical, behavioural, and psychological symptoms Regularly occur in the luteal phase of the menstrual cycle Regularly occur in the luteal phase of the menstrual cycle Significantly improved or resolved by the end of menstruation. Significantly improved or resolved by the end of menstruation. Mild PMS  Mild PMS  –symptoms do not interfere with the woman's personal, social, and professional life. Moderate PMS  Moderate PMS  –symptoms interfere with the woman's personal, social, and professional life. Daily functioning is possible, although maybe not to the usual level. Severe PMS  Severe PMS  –the woman withdraws from social and professional activities and cannot function normally. –If symptoms are predominantly emotional and behavioural, this is sometimes referred to as premenstrual dysphoric disorder

5. Common Symptoms More than 100 different symptoms of PMS have been recorded, but the most common are listed below. More than 100 different symptoms of PMS have been recorded, but the most common are listed below.

6. Physical symptoms Fluid retention and feeling bloated Fluid retention and feeling bloated Pain and discomfort in your abdomen Pain and discomfort in your abdomen Headaches Headaches Changes to your skin and hair Changes to your skin and hair Backache Backache Muscle and joint pain Muscle and joint pain Breast tenderness Breast tenderness Insomnia (trouble sleeping) Insomnia (trouble sleeping) Dizziness Dizziness Tiredness Tiredness Nausea Nausea Weight gain (up to 1kg) Weight gain (up to 1kg)

7. Psychological symptoms Mood swings Mood swings Feeling upset or emotional Feeling upset or emotional Feeling irritable or angry Feeling irritable or angry Depressed mood Depressed mood Crying and tearfulness Crying and tearfulness Anxiety Anxiety Difficulty concentrating Difficulty concentrating Confusion and forgetfulness Confusion and forgetfulness Restlessness Restlessness Decreased self-esteem Decreased self-esteem

8. Behavioural symptoms Loss of interest in sex Loss of interest in sex Appetite changes or food cravings Appetite changes or food cravings Any chronic (long-term) illnesses, such as asthma or migraine, may get worse. Any chronic (long-term) illnesses, such as asthma or migraine, may get worse.

9. Premenstrual Dysphoric Disorder The symptoms of PMDD are similar to those of PMS, but more exaggerated. The symptoms of PMDD are similar to those of PMS, but more exaggerated. a small percentage of women have symptoms that are severe enough to stop them living their normal lives. a small percentage of women have symptoms that are severe enough to stop them living their normal lives. They can include: They can include: feelings of hopelessness feelings of hopelessness persistent sadness or depression persistent sadness or depression extreme anger and anxiety extreme anger and anxiety decreased interest in usual activities decreased interest in usual activities sleeping much more or less than usual sleeping much more or less than usual very low self-esteem very low self-esteem extreme tension and irritability extreme tension and irritability PMDD can be particularly difficult to deal with because it can have a negative effect on your daily life and relationships. PMDD can be particularly difficult to deal with because it can have a negative effect on your daily life and relationships.

10. What causes it ? The exact cause of premenstrual syndrome (PMS) is uncertain, but because it does not occur before puberty, in pregnancy, or after the menopause, cyclical ovarian activity is thought to contribute [RCOG, 2007]. The exact cause of premenstrual syndrome (PMS) is uncertain, but because it does not occur before puberty, in pregnancy, or after the menopause, cyclical ovarian activity is thought to contribute [RCOG, 2007].RCOG, 2007RCOG, 2007

11. Suggested theory Hormone changes Hormone changes Chemical changes Chemical changes Weight and exercise Weight and exercise Stress Stress Diet Diet

12. How common ? Mild PMS is experienced by many women. Mild PMS is experienced by many women. Around 5% of women have severe premenstrual symptoms [RCOG, 2007]. Around 5% of women have severe premenstrual symptoms [RCOG, 2007].RCOG, 2007RCOG, 2007 In the UK, only about a fifth of women experiencing PMS symptoms seek medical help. However, up to 13% of working women with PMS symptoms take time off during the year because of PMS [MeReC, 2003]. In the UK, only about a fifth of women experiencing PMS symptoms seek medical help. However, up to 13% of working women with PMS symptoms take time off during the year because of PMS [MeReC, 2003].MeReC, 2003MeReC, 2003

13. Risk Factors Common in women whose mothers also experienced PMS symptoms (70%) Common in women whose mothers also experienced PMS symptoms (70%) Monozygotic twins  93% concordance rate Monozygotic twins  93% concordance rate Dizygotic twins  44%[Bhatia and Bhatia, 2002]. Dizygotic twins  44%[Bhatia and Bhatia, 2002].Bhatia and Bhatia, 2002Bhatia and Bhatia, 2002 More common in women who are obese, do not exercise, and who have a lower level of academic achievement [RCOG, 2007]. More common in women who are obese, do not exercise, and who have a lower level of academic achievement [RCOG, 2007].RCOG, 2007RCOG, 2007 Women using hormonal contraception are less likely to experience PMS [RCOG, 2007]. Women using hormonal contraception are less likely to experience PMS [RCOG, 2007].RCOG, 2007RCOG, 2007

14. Diagnosis of PMS Diagnosis  Clinical Diagnosis  Clinical Difficulty in diagnosis often occurs because PMS can present with a large number of symptoms which are common to a range of conditions [Rapkin and Mikacich, 2008]. Difficulty in diagnosis often occurs because PMS can present with a large number of symptoms which are common to a range of conditions [Rapkin and Mikacich, 2008].Rapkin and Mikacich, 2008Rapkin and Mikacich, 2008 Ask the woman to record a daily symptom diary for two or three cycles [MeReC, 2003]. Ask the woman to record a daily symptom diary for two or three cycles [MeReC, 2003].MeReC, 2003MeReC, 2003 Investigations are not usually helpful in making the diagnosis. Investigations are not usually helpful in making the diagnosis.

15. Conditions to exclude Depression Depression Anxiety and panic disorders Anxiety and panic disorders Hypothyroidism Hypothyroidism Anaemia Anaemia Dysmenorrhoea Dysmenorrhoea Irritable bowel syndrome Irritable bowel syndrome Interstitial cystitis Interstitial cystitis Endometriosis Endometriosis Chronic fatigue syndrome Chronic fatigue syndrome Fibromyalgia Fibromyalgia Systemic lupus erythematosus Systemic lupus erythematosus

16. Managment Management should be tailored according to the severity and type of symptoms, and the woman's preferences and any desire to become pregnant. Management should be tailored according to the severity and type of symptoms, and the woman's preferences and any desire to become pregnant. Mild symptoms Mild symptoms Mild symptoms Mild symptoms Offer lifestyle advice. Offer lifestyle advice. Regular, frequent (2–3 hourly), small balanced meals rich in complex carbohydrates. Regular, frequent (2–3 hourly), small balanced meals rich in complex carbohydrates. Regular exercise. Regular exercise. Smoking cessation. Smoking cessation. Alcohol restriction. Alcohol restriction. Regular sleep. Regular sleep. Stress reduction. Stress reduction.

17. Management Moderate PMS Moderate PMS Moderate PMS Moderate PMS Offer lifestyle advice and consider: Offer lifestyle advice and consider: A new-generation combined oral contraceptive A new-generation combined oral contraceptive UNLICENSED  if used solely to treat PMS symptoms UNLICENSED  if used solely to treat PMS symptoms Can be used cyclically or continuously Can be used cyclically or continuously But the first-line choice of COC is not clear. But the first-line choice of COC is not clear. –More evidence to support : the use of drospirenone-containing COCs (for example Yasmin®) than other preparations the use of drospirenone-containing COCs (for example Yasmin®) than other preparations desogestrel (for example Marvelon®) desogestrel (for example Marvelon®) norgestimate (for example Cilest®) or gestodene (for example Femodene®), may also be effective, especially if they have been used before and have been found to be of benefit. norgestimate (for example Cilest®) or gestodene (for example Femodene®), may also be effective, especially if they have been used before and have been found to be of benefit. –Inform the woman that it is not possible to predict whether her PMS symptoms will respond. Paracetamol or a nonsteroidal anti-inflammatory drug - if the predominant problem is pain Paracetamol or a nonsteroidal anti-inflammatory drug - if the predominant problem is pain Cognitive behavioural therapy (CBT; referral is likely to be required) if it is thought the woman would benefit from psychological intervention. Cognitive behavioural therapy (CBT; referral is likely to be required) if it is thought the woman would benefit from psychological intervention.

18. Management Severe PMS Severe PMS Severe PMS Severe PMS Offer lifestyle advice and consider: Offer lifestyle advice and consider: The treatment options outlined above for moderate PMS The treatment options outlined above for moderate PMS A selective serotonin reuptake inhibitor (SSRI) A selective serotonin reuptake inhibitor (SSRI) –Unlicensed use –Do not prescribe an SSRI  doubt about the diagnosis, < 18 yrs without advice a specialist –taken either continuously or just during the luteal phase (for example days 15–28 of the menstrual cycle, depending on its length). –initial trial of 3 months' treatment  benefit  continue 6 months to 1 year. –Monitor the woman's response to treatment closely, including asking about any thoughts of self-harm.

19. Managment 12 yrs onwards 12 yrs onwards 1 st line : Lifestyle advice : 1 st line : Lifestyle advice : –The following things may help to ease PMS. –Eat regular, frequent, small balanced meals rich in complex carbohydrates. –Take regular exercise. –Stop smoking. –Don't drink too much alcohol. –Get regular sleep.

20. 12yrs + Paracetamol Paracetamol NSAIDs NSAIDs Mefanemic acid 500mg tds Mefanemic acid 500mg tds

21. Combined Oral Contraception Age from 13 to 50 years: Age from 13 to 50 years: COCs monophasic: COCs monophasic: –EE 30-35mcg with drospirenone or norgestimate eg : Yasmin: drospirenone 3mg + ethinylestradiol 30mcg Yasmin: drospirenone 3mg + ethinylestradiol 30mcg Cilest: norgestimate 250mcg + ethinylestradiol 35mcg Cilest: norgestimate 250mcg + ethinylestradiol 35mcg –EE 30mcg with gestodene or desogestrel Femodene: gestodene 75mcg + ethinylestradiol 30mcg Femodene: gestodene 75mcg + ethinylestradiol 30mcg

22. Selective Serotonin Receptor Inhibitors 18yrs + : 18yrs + : Fluoxetine 20mg od, Sertraline 50mg od, paroxetine 20mg od, citalopram 20mg od Fluoxetine 20mg od, Sertraline 50mg od, paroxetine 20mg od, citalopram 20mg od Luteal phase selective serotonin reuptake inhibitors (SSRIs) Luteal phase selective serotonin reuptake inhibitors (SSRIs) Fluoxetine, citalopram: 20mg each morning on days 15-28 of cycle Fluoxetine, citalopram: 20mg each morning on days 15-28 of cycle

23. When should I refer a woman with premenstrual syndrome? Refer the woman to a psychiatrist if there is marked underlying psychopathology in addition to premenstrual syndrome (PMS). Refer the woman to a psychiatrist if there is marked underlying psychopathology in addition to premenstrual syndrome (PMS). Consider referral to a clinic with a specific interest in PMS (or a general gynaecology clinic if this is not available) if the symptoms are severe and appropriate primary care measures have been explored but have failed. Consider referral to a clinic with a specific interest in PMS (or a general gynaecology clinic if this is not available) if the symptoms are severe and appropriate primary care measures have been explored but have failed.

24. Evidence on treatments not recommended in primary care Progesterone or progestogens used alone Progesterone or progestogens used alone Antidepressants other than SSRIs Antidepressants other than SSRIs Transdermal oestradiol Transdermal oestradiol Diuretics Diuretics Vitamin B6 (pyridoxine) Vitamin B6 (pyridoxine) Calcium and vitamin D Calcium and vitamin D Magnesium Magnesium Evening primrose oil Evening primrose oil Agnus castus (chaste tree) Agnus castus (chaste tree) Alprazolam Alprazolam Gonadotrophin releasing hormone analogues eg Danazol Gonadotrophin releasing hormone analogues eg Danazol Hysterectomy and bilateral salpingo-oophorectomy may be considered under certain circumstances in secondary care for women with severe PMS. Hysterectomy and bilateral salpingo-oophorectomy may be considered under certain circumstances in secondary care for women with severe PMS.