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L1 Gynecology D. Huda Adnan
Premenstrual Syndrome
Premenstrual Syndrome
Modern Definition
Distressing physical, psychological and behavioral symptoms significantly cause significant
impairment 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
2
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 behavioral therapy.
2. Conventional therapy: e.g. evening primrose oil, calcium, vit. D, multivitamins, magnesium,
.etc. of no evidence based support.
3. Medical therapy, either hormonal or non-hormonal.
• Hormonal include
a. Combined oral contraceptive pills.
b. Percutaneous estradiol + cyclical progesterone intrauterine progesterone 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:
1. Failed medical treatment.
2. Long-term GnRh agonist is required.
3. Presence of other gynecological condition indicate surgery.
*endometrial ablation or hysterectomy alone is not indicated.
*oophorectomy alone is not recommended.
Hormone replacement therapy after surgery
Following hysterectomy, estrogen only can be used (avoid progesterone because associated with
PMS symptoms).
Considerations should be given to replace testosterone.
Mubark A. Wilkins