Premenstrual Syndrome and Premenstrual Dysphoric Disorder UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series.

Premenstrual Syndrome and Premenstrual Dysphoric Disorder

UNC School of MedicineObstetrics and Gynecology Clerkship

Case Based Seminar Series

Objectives for PMS and PMDD

Identify the criteria for making the diagnosis of Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD)

List treatment options for PMS and PMDD

PMS is a group of physical, mood-related, and behavioral changes that occur in a regular, cyclic relationship to the luteal phase of the menstrual cycle and interfere with some aspect of the patient’s life

PMDD identifies women with PMS who have more severe emotional symptoms (such as anger, irritability, and depression) that may require more extensive therapy

Definition

PMS symptoms - 75%- 85% of women Severe/debilitating PMS - 5-10% of women PMDD - 3-5% of women

Incidence

Severe (PMDD)

Moderate (PMS)

Mild (PMS)

None

Spectrum of Premenstrual Syndromes

PremenstrualSyndromeSeverity

Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 36 (387).

Somatic Symptoms Breast tenderness Abdominal bloating – most common, occurs in 90% Headache Swelling of extremities Weight gain

PMS/PMDD: Symptoms

Affective Symptoms Depression Angry outbursts Irritability Anxiety Confusion Social withdrawal Decreased concentration Sleep disturbance Appetite change/food cravings

PMS/PMDD: Symptoms

PMS/PMDD: Symptoms

Sample: Daily Symptoms Calendar

Diagnostic tool used to assist the patientwith recording her

premenstrual symptoms diary

Endicott and Harrison 2006. 5.Endicott, J., & Harrison, W. Daily Record of Severity of Problems Calendar.

Patient reports 1 affective symptom and somatic symptom(s) during the luteal phase before menses

Symptoms relieved within 4 days of onset of menses, without recurrence until at least cycle day 13

Symptoms occur in 2 consecutive menstrual cycles Patient suffers from identifiable dysfunction in social or

economic performance

PMS: Diagnosis

DSM-IV Criteria Symptoms interfere with usual functioning and relationships Symptoms are not an exacerbation of another disorder Symptoms resolve at onset of menses Premenstrual timing is confirmed by menstrual calendar in 2

consecutive cycles

PMDD: Diagnosis

DSM-IV Criteria At least 5 of 11 premenstrual symptoms

At least 1 of the following: Depressed mood Marked anxiety Marked affective lability Marked irritability

Other possible symptoms Decreased interest in regular activities Difficulty concentrating Lethargy/fatigue Appetite change/food cravings Sleep disturbance Feelings of being overwhelmed Physical symptoms (bloating, weight gain, breast tenderness, edema)

PMDD: Diagnosis

Rule out other diseases: Psychological disorders

Depression, Bipolar disorders, Personality disorders, Anxiety

Gynecologic disorders Dysmenorrhea, Endometriosis, Pelvic Inflammatory Disease, Perimenopause

Endocrine disorders Thyroid disease, Adrenal disorders, True hypoglycemia

GI conditions Inflammatory bowel disease, Irritable bowel syndrome

Drug or substance abuse Chronic fatigue states

PMS/PMDD: Differential Diagnosis

Supportive therapy Lifestyle changes

Frequent exercise Nutritional supplements

Magnesium sulfate 360 mg/d Calcium 1200 mg/d Vitamin E 400 IU/d Vitamin B6 100 mg/d

PMS/PMDD: Treatment (Conservative)

NSAIDs Anti-depressants

SSRI’s (Fluoxetine or Sertraline) Buspirone

Spironolactone - bloating Bromocriptine or Danocrine – mastalgia Ovulation suppression

GnRH agonists (e.g. Lupron) Danazol OCPs

PMS: Treatment (Medical)

SSRIs Can be taken throughout the cycle or during the luteal phase

of the cycle Fluoxetine 20-60 mg qd Sertraline 50-150 mg qd

PMDD: Treatment (Medical)

Oophorectomy Not generally recommended

Irreversible Reserved for severely affected patients who only respond to

GnRH agonists

PMS/PMDD: Treatment (Surgical)

Bottom Line Concepts PMDD identifies women with PMS who have more severe emotional

symptoms that may require intensive therapy.

The physiologic mechanism that results in the occurrence of PMS and PMDD is not well understood.

The diagnosis of PMS and PMDD is based on documentation of the relationship of the patient’s symptoms to the luteal phase.

DSM-IV criteria are used to establish the diagnosis of PMDD.

In addition to lifestyle changes, behavioral therapies, and dietary supplementation, some pharmacologic agents have been shown to have symptom relief.

As an overall clinical approach, treatments should be employed in increasing orders of complexity.

References and Resources

APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 49 (p104-105).

Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 39 (p347-352).

Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 36 (p386-388).

DysmenorrheaUNC School of Medicine

Obstetrics and Gynecology ClerkshipCase Based Seminar Series

Objectives for Dysmenorrhea

Define dysmenorrhea and distinguish primary and secondary dysmenorrhea

Describe the pathophysiology and identify the etiologies of dysmenorrhea

Discuss the steps in the evaluation and management options for dysmenorrhea

Painful menstruation that prevents a woman from performing normal activities Primary dysmenorrhea – no readily identifiable cause Secondary dysmenorrhea – identifiable organic cause

Definition

Caused by excess prostoglandin F2α (PGF2α ) and PGE2 produced from shedding endometrium

Prostoglandins are potent smooth-muscle stimulants that cause uterine contractions and ischemia

Prostoglandin F2α causes contractions in smooth muscle elsewhere in the body, resulting in nausea, vomiting, and diarrhea

Primary Dysmenorrhea: Pathophysiology

Pain Onset within 2 years of menarche Begins a few hours before or just after onset of menses Lasts 48 – 72 hours Described as “cramp-like” Strongest over lower-abdomen Radiates to back or inner thighs

Associated symptoms Nausea and vomiting Fatigue Diarrhea Lower backache Headache

Primary Dysmenorrhea: Symptoms

Reassurance and explanation Medical

NSAIDs Hormonal contraceptives (e.g. OCPs, IUD, Vaginal rings, Patches) Progestins (e.g. Medroxyprogesterone acetate) Tocolytics (e.g. Salbutamol) Analgesics

Other Measures Transcutaneous nerve stimulation Acupuncture Psychotherapy Hypnotherapy

Primary Dysmenorrhea: Treatment

Depends on underlying (secondary) cause and in most cases is not well understood

Causes of secondary dysmenorrhea: Endometriosis Pelvic inflammation Adenomyosis Fibroid tumors (benign, malignant) Ovarian cysts (e.g. endometriosis, luteal cysts) Pelvic congestion

Secondary Dysmenorrhea: Pathophysiology

Pain Develops in older women (30’s to 40’s) Not limited to menses

Associated symptoms Dyspareunia Infertility Abnormal uterine bleeding

Secondary Dysmenorrhea: Symptoms

Secondary Dysmenorrhea: Symptoms

Condition Signs and Symptoms

Endometriosis Pain extends to premenstrual and postmenstrual phaseDeep dyspareuniaTender pelvic nodules (e.g. uterosacral ligaments)Onset in 20’s – 30’s

Pelvic inflammation Pain initially menstrual, with each cycle extends into premenstrual phaseIntermenstrual bleedingPelvic tendernessFever, chills, malaise

Adenomyosis, Pain + menorrhagiaUterus symmetrically enlarged, mildly tender, “boggy”

Uterine fibroids Pain + menorrhagiaFirm, irregularly enlarged uterus

Ovarian cysts Mid-cycle, unilateral pain

Pelvic congestion Dull, ill-defined pelvic achePain worse premenstrually and relieved by mensesHistory of sexual problems

Management consists of treatment of the underlying disease

Treatment used for primary dysmenorrhea often helpful

Secondary Dysmenorrhea: Treatment

Bottom Line Concepts Primary and secondary dysmenorrhea are a source of recurrent

disability for a significant number of women in their early reproductive years.

Primary dysmenorrhea is caused by excess prostoglandin produced by the shedding endometrium.

Secondary dysmenorrhea is due to organic pelvic disease, including; endometriosis, PID, adenomyosis, uterine fibroids, and pelvic congestion.

Primary dysmenorrhea presents within 2 years of menarche, where as secondary dysmenorrhea more often presents in older women.

For patient’s with dysmenorrhea, the physical exam is directed at uncovering possible causes of secondary dysmenorrhea.

Treatment of secondary dysmenorrhea should be directed at the underlying condition.

References and Resources

APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 46 (p98-99).

Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 30 (p277-279).

Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 21 (p256-259).