Premenstrual syndrome

From Ganfyd

Introduction

The terms premenstrual tension and premenstrual syndrome describe the emotional or physical symptoms associated with the hormone changes in the premenstrual phase of the menstrual cycle. This is normal but in less than 10% the symptoms impair function. In these cases the patient may meet the criteria for the conditions of:

• Severe premenstrual syndrome (PMS)
• Premenstrual dysphoric disorder (PMDD)

Aetiology

Mammalian oestrous is associated with changes in female behavior associated with the oestrogen peak before ovulation with increased sexual receptivity and decreased aggression. In the human (ape) menstrual cycle no symptoms occur in anovulatory cycles, consistent with gonadal steroids being critical. However there is no absolute relationship with progesterone or oestradiol and the severe syndromes appear to result from an abnormal response that can be related to genetics, BMI, stress and trauma. Other physiology such as circadian rhythm and hormones such as thyroxine may fluctuate more in affected women confirming complex neurohormonal interactions. Sex hormone receptors are abundant in the calls of the hypothalamus and amygdala. Serotonin modulates sex-steroid related behaviour in other mammals and the GABA A receptor interacts with some progesterones^[1].

Assessment

• Evaluate against objective criteria
• Document cyclic relationship eg with Daily record od severity of problems
• Exclude other pathologies
  • Hypothyroidism
  • Anxiety disorder
  • Depression

Treatment

Use of progesterone plessaries is placebo treatment !

• Hormone therapy^[2]
  • Progesterone therapy in luetal phase is not evidenced based
  • Oestrogen and intermittent progesterone
  • Long-acting GnRH agonists work but produce menopausal symptoms so:
    • Combination with oestrogen and intermittent progesterone
    • Continuous tibolone
  • Drosperinone-ethinyl oestradiol^[3]
• SSRIs are generally regarded as first choice for severe mood disorders^[4]. They are not licensed for this indication in Europe for complex reasons which include diagnostic criteria issues and potential for use in mild PMS.
  • Response rates twice that of placebo
  • Citalopram^[5], escitalopram, fluoxetine^[6] all proven
  • Intermittent therapy from midcycle to menses feasible as rapid response in mood disorder
  • Continuous treatment more effective with somatic symptoms
• Clomipramine (has SSRI properties)^[7]
• Venlafaxine^[8]
• Other psychotrophics with evidence (second line)
  • Buspirone^[9]
• Cognitive behavioural therapy^[10]
• Pyridoxine^[11]
• Calcium salts^[12]
• Agnus castus^[13]
• Treatments for specific symptoms
  • Alprazolam - perhaps as add-on with severe insomnia/anxiety but care^[14]
  • Spironolactone with breast tenderness or bloating
• The following are of unknown effectiveness (trials inconsistent or very small numbers)
  • Diet with complex carbohydrates
  • Exercise
  • Mefenamic acid^[15]
  • Naproxen
  • Naltrexone
  • Magnesium salts
  • Saffron^[16]
  • St John's wort^[17]
  • Light therapy^[18]
  • Ginkgo^[19]
  • Pollen extract^[20]
• The following are unlikely to be benefical:
  • Evening primrose oil^[21]
  • Diet restricting sugar or with frequent small meals
  • Progesterone alone
  • Bromocriptine^[22]

External link

• Management of premenstrual syndrome RCOG Green-top Guideline No. 48 2007

References