Premenstrual Syndrome

Premenstrual Syndrome Pathophysiology, Definition of the Disease, and Treatment Options

Dr. Huda Adnan

Premenstrual Syndrome Modern Definition

Distressing physical, psychological and behavioural symptoms significantiy cuase significant impairement to the individual, not caused by organic disease, which regularly recur during the luteal phase of the menstrual cycle and which significantly regress or disappear during the remainder of the cycle.

PMDD Definition (DSM IV - Diagnostic and Statistical Manual of Mental Diseases) (4th edn. American Psychiatric Association, 1994)
Five or more of the following present premenstrually (one must be a core* symptom): Markedly depressed mood * Marked anxiety/tension* Marked affective lability Marked anger/irritability* Decreased interest in usual activities* Difficulty concentrating Lethargy/fatigue Appetite change/food cravings Sleep disturbance Feeling overwhelmed Physical symptoms (e.g. breast tenderness, bloating) Diagnosis Symptoms in most menstrual cycles during the last year (retrospective confirmation) and in at least two cycles (symptoms diary) as prospective confirmation Occur in the last week prior to period ,GnRh analogue may be used for 3 months for Dx.

Premenstrual Syndrome Prevelence and Aetiology

Overall 40% Sever cases 5-8% No convincing evidence for any of the postulated biological or psychological mechanisms May be multiple aetiologies ( increase progesteron,decrease serotonin and GABA neurotransmitter) Ovarian function appears to play an essential role in the genesis of symptoms.

Management

1) Cognitive behavioural therapy.2) Convinentional therapy : e.g evenening primirose oil, calcium, vit. D, multivitamines, magnesium,….etc, of no evidence based support.3) Medical therapy, either hormonal and non hormonal. hormonal include a)combined oral contraceptive pills. b)percutaneous estradiol + cyclical progesteron intrauterine progesteron device.

c)danazol. d)GnRh agonist or GnRh agonist + addback therapy (estrogen). Non hormonal include SSRI or spironolacton. 4) surgical management in form of hysterectomy and bilateral salpingoophorectomy. *should be preceded by GnRh agonist to confirm the diagnosis.

Indications of surgical management: Failed medical treatement. Long term GnRh agonist is required. Presence of other gynaecological condition indicate surgery. *endometerial ablation or hysterectomy alone is not indicated . *oophorectomy alone is not recommended.



Hormone replacement theapy after surgery Following hysterectomy, estrogen only can be used ( avoid progesteron because associated with PMS symptoms). Considerations should be given to replace testosteron.