1. The Good the Bad and The Ugly Complications of Menstruation & PMS Jennifer McDonald DO

3. Premenstrual 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??

4. Symptoms ?? Somatic Behavioral

5. Etiology Multifactorial Hypersensitivity of the individual to changes in gonadal activity External stressors Neurotransmitter alterations GABA Serotonin Renin-angiotensin-aldosterone system (RAAS)

6. NeurotransmittersandNeurohormonalSystems* GeneticPredispositionVulnerability Increased Sensitivity to Changes in to Changes in Gonadal Hormones Interactwith GonadalHormones and Metabolites Altered Responses to Changes in Gonadal Hormone Levels PremenstrualSymptoms *Serotonin, renin-angiotensin-aldosterone system,  -aminobutyric acid (GABA), and cholecystokinin. Halbreich U. Psychoneuroendocrinology. 2003;28(Suppl 3):55-99.

7. Diagnosis 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

9. Copy placed on IQWeb Also visit MyMonthlyCycles.com

10. Treatment Options Dietary ChangesExercise Stress Management Chaste berry extract Calcium 1200 mg/day Magnesium 200-400 mg/day L-Tryptophan 6g/d from ovulation to menses

11. No 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

12. Pharmacologic Therapy SSRIs Luteal phase dosing Daily dosing Sprironolactone Oral contraceptives Ovulation suppression (worst case scenario)

13. Dysmenorrhea Painful menstruation Primary vs. Secondary 14-26% adolescents miss school because of pain

14. Primary Dysmenorrhea Symptoms begin shortly after menarche Usually regular cycles Pain associated with ovulatory cycles Prostaglandins (PGE 2 & PGF 2 ) implicated as the inducing agents Uterine contractions cause ischemia which in turn causes pain Treatment options ??

15. Secondary Dysmenorrhea Association with pelvic pathology Differential ??

16. Big on Definitions Menorrhagia Metrorrhagia Hypomenorrhea Metrorrhagia Polymenorrhea Menometrorrhagia Oligomenorrhea Cryptomenorrhea

17. Dysfunctional 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?

18. History & Evaluation of Female Complaints Menstrual history Reproductive history General medical history Family history What would be important to know ??

19. Evaluation History Physical exam Endometrial biopsy Hysteroscopy D&C (dilation & curettage)

20. Hysteroscopy 3 mm hysteroscope Saline or CO2 Panoramic view of uterus Visualization of polyps, intramural fibroids, scar tissue

21. 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)

22. Postmenopausal Bleeding Cancer until proven otherwise