Premenstrual Syndrome

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Chapter 41 Premenstrual Syndrome

INTRODUCTION

Description: Premenstrual syndrome (PMS) involves physical and emotional symptoms characterized by their relationship to menses. Symptoms are confined to a period of not more than 14 days before the onset of menstrual flow with complete resolution at, or soon after, the end of menstrual flow.
Prevalence: Reproductive (25% to 85%; 5% to 10% affect lifestyle, 2% to 5% meet strict criteria).
Predominant Age: Reproductive; most commonly 30s and 40s.
Genetics: Family tendency, but no confirmed genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: The physiologic foundations of PMS, premenstrual dysphoric disorder (PMDD), and premenstrual magnification (PMM) have yet to be established. The most promising research into a cause of PMS has been in the areas of β-endorphins and serotonin.
Risk Factors: None known.

CLINICAL CHARACTERISTICS

Signs and Symptoms

Physical or emotional symptoms confined to a period of not more than 14 days before the onset of menstrual flow with complete resolution at, or soon after, the end of menstrual flow. More than 150 different signs and symptoms have been described under the rubric of PMS. (The character of the symptoms is not important—only the timing of their appearance. Symptoms that are present at all times but worsen before menses or those that appear at irregular intervals do not meet the criteria for PMS; they should be classified as premenstrual magnification.)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Breast disorders
• Chronic fatigue states
• Drug and substance abuse
• Endocrinologic disorders
• Family, marital, and social stress
• Gastrointestinal conditions
• Gynecologic disorders
• Idiopathic edema
• Psychiatric and psychologic disorders

Associated Conditions: Bipolar disorders, sleep disorders, chronic pain states, and somatization.

Workup and Evaluation

Laboratory: Complete blood count, liver enzyme studies, endocrine studies (androgens, follicle-stimulating hormone [FSH]/luteinizing hormone [LH], glucose tolerance test, prolactin, thyroid function studies [highly sensitive thyroid-stimulating hormone, thyronine, thyrotropin-releasing hormone stimulation]), all to rule out other conditions.
Imaging: No imaging indicated.
Special Tests: Prospective menstrual calendar or other diary for a 3-month period to establish the diagnosis.
Diagnostic Procedures: History, physical examination, prospective menstrual calendar or diary. Research has shown that up to 80% of patients who present with self-diagnosed “PMS” fail to meet strict criteria for this diagnosis. Most are found to have other conditions ranging from mood disorders to irritable bowel syndrome or endometriosis. This observation makes it imperative that no therapy be instituted until the diagnosis can be firmly established.

Pathologic Findings

None.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Lifestyle changes (aerobic exercise [20 to 45 minutes, three times weekly], smoking cessation, stress reduction), dietary changes and supplementation (adequate protein and complex carbohydrates; avoidance of alcohol, caffeine, and simple sugars; eating frequent small meals and plenty of fresh fruits and vegetables; reduction of dietary fat to <15%; salt restriction; increased dietary or supplemental fiber; 1000 mg calcium daily; magnesium 200 mg daily during luteal phase; vitamin B6 50 to 200 mg daily; vitamin E 150 to 300 IU daily) all have been advocated but with few data to support the recommendations.
Specific Measures: Generally based on specific symptoms. A favorable response should be expected for 80% of patients with PMS and 50% of those with premenstrual magnification.
Diet: See previous.
Activity: Aerobic exercise (20 to 45 minutes, three times weekly).
Patient Education: Reassurance; American College of Obstetricians and Gynecologists Patient Education Pamphlets AP057 (Premenstrual Syndrome), AP106 (Depression).

Drug(s) of Choice

Hydrochlorothiazide 25 to 50 mg daily, luteal phase (for fluid retention).
Alprazolam 0.25 mg three to four times daily or atenolol 25 mg two to three times daily (for agitation and anxiety).
Buspirone 5 mg three times daily or fluoxetine 20 mg daily (in the morning) for mood swings.
Third-generation oral contraceptives (e.g., desogestrelcontaining).
Danazol sodium 200 mg daily, luteal phase or continuous gonadotropin-releasing hormone (GnRH) agonists (depot leuprolide 3.75 mg IM monthly for a maximum of 6 months or nafarelin acetate nasal spray, 200 microgram twice daily for a maximum of 6 months).

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Contraindications: See individual agents.
Precautions: See individual agents.

FOLLOW-UP

Patient Monitoring: Normal health maintenance.
Prevention/Avoidance: General stress reduction appears to blunt the cyclic symptoms experienced.
Possible Complications: Social withdrawal or isolation, work or family disruption. The rate of suicide increases during the luteal phase.
Expected Outcome: Symptoms can generally be resolved through the process of diagnosis, providing insight and control to the patient, and pharmacologic intervention.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy. Patients with a history of PMS may have exaggerated response to the hormonal changes associated with pregnancy.
ICD-9-CM Codes: 625.4.

REFERENCES

Level I

Facchinetti F, Borella P, Sances G, et al. Oral magnesium successfully relieves premenstrual mood changes. Obstet Gynecol. 1991;78:177.

Goodale IL, Domar AD, Benson H. Alleviation of premenstrual syndrome symptoms with the relaxation response. Obstet Gynecol. 1990;75:649.

London RS, Murphy L, Kitlowski KE, Reynolds MA. Efficacy of alpha-tocopherol in the treatment of the premenstrual syndrome. J Reprod Med. 1987;32:400.

Schmidt PJ, Nieman LK, Danaceau MA, et al. Differential behavioral effects of gonadal steroids in women with and in those without premenstrual syndrome. N Engl J Med. 1998;338:209.

Steiner M, Steinberg S, Stewart D, et al. Fluoxetine in the treatment of premenstrual dysphoria. Canadian Fluoxetine/Premenstrual Dysphoria Collaborative Study Group. N Engl J Med. 1995;332:1529.

Thys-Jacobs, Starkey P, Bernstein D, Tian J. Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Premenstrual Syndrome Study Group. Am J Obstet Gynecol. 1998;179:444.

Yonkers KA, Halbreich U, Freeman E, et al. Symptomatic improvement of premenstrual dysphoric disorder with sertraline treatment. A randomized controlled trial. Sertraline Premenstrual Dysphoric Collaborative Study Group. JAMA. 1997;278:983.

Level II

Ford O, Lethaby A, Mol B, Roberts H. Progesterone for premenstrual syndrome. Cochrane Database Syst Rev. 4, 2006. CD003415

Freeman E, Rickels K, Sondheimer S, Scharlop B. Diagnostic classifications from daily symptom ratings of women who seek treatment for premenstrual symptoms. Am J Gynecol Health. 1987;1:17.

Garris PD, Sokol MS, Kelly K, et al. Leuprolide acetate treatment of catamenial pneumothorax. Fertil Steril. 1994;61:173.

Kornstein SG, Pearlstein TB, Fayyad R, et al. Low-dose sertraline in the treatment of moderate-to-severe premenstrual syndrome: efficacy of 3 dosing strategies. J Clin Psychiatr. 2006;67:1624.

Krasnik C, Montori VM, Guyatt GH, et alMedically Unexplained Syndromes Study Group. The effect of bright light therapy on depression associated with premenstrual dysphoric disorder. Am J Obstet Gynecol. 2005;193:658.

Level III

American College of Obstetricians and Gynecologists. Premenstrual syndrome. ACOG Practice Bulletin 15. Washington, DC: ACOG, 2000.

Braverman PK. Premenstrual syndrome and premenstrual dysphoric disorder. J Pediatr Adolesc Gynecol. 2007;20:3.

Claman F, Miller T. Premenstrual syndrome and premenstrual dysphoric disorder in adolescence. J Pediatr Health Care. 2006;20:329.

Futterman LA, Rapkin AJ. Diagnosis of premenstrual disorders. J Reprod Med. 2006;51:349.

Kroll R, Rapkin AJ. Treatment of premenstrual disorders. J Reprod Med. 2006;51:359.

Lentz GM. Primary and secondary dysmenorrhea, premenstrual syndrome, and premenstrual dysphoric disorder. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:906.

Moline ML. Pharmacologic strategies for managing premenstrual syndrome. Clin Pharm. 1993;12:181.

Plouffe LJr, Trott EA. Premenstrual syndrome: new concepts and recent therapeutic breakthroughs. Postgrad Obstet Gynecol. 1995;15:1.

Rubinow DR. The premenstrual syndrome: new views. JAMA. 1992;268:1908.

Winer SA, Rapkin AJ. Premenstrual disorders: prevalence, etiology and impact. J Reprod Med. 2006;51:339.

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