Psychological and physical disorders of the menstrual cycle

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Chapter 29 Psychological and physical disorders of the menstrual cycle

CHAPTER CONTENTS

Mood and physical symptoms in the menstrual cycle 229
Premenstrual syndrome 229

Premenstrual syndrome (premenstrual dysphoric disorder) 229
Functional bowel disease 230

Irritable bowel syndrome 230
Chronic pelvic pain 230
Dysmenorrhoea 232

Primary dysmenorrhoea 232
Secondary dysmenorrhoea 233
Eating and exercise disorders 233
Psychological symptoms after hysterectomy and oophorectomy 233

Hysterectomy 234
Oophorectomy 234

MOOD AND PHYSICAL SYMPTOMS IN THE MENSTRUAL CYCLE

In the proliferative phase of the menstrual cycle few problems occur. Some women experience lower abdominal pain, which is unilateral and occurs at the time of ovulation. The pain is usually not severe and lasts for 12 hours or less. The condition is called mittelschmerz. It indicates that ovulation has occurred, but investigations show no intra-abdominal pathology. If mittelschmerz is recurrent and distressing, relief can be obtained if the woman takes a hormonal contraceptive.

Most women in the reproductive years experience some psychological (negative mood) or physical symptoms in the luteal phase of the menstrual cycle. The symptoms vary in character and tend to become worse as menstruation approaches. They do not occur in every cycle, and may vary in intensity in different cycles. A few women have severe mood and physical symptoms; a diagnosis of premenstrual syndrome (PMS) or premenstrual dysphoric disorder is made in these cases.

PREMENSTRUAL SYNDROME

Premenstrual syndrome (premenstrual dysphoric disorder)

In 5–15% of women, who are usually aged in their late 20s or early 30s (range 20–40), the negative mood and physical changes occurring in the luteal phase are sufficiently severe to affect day-to-day living and social and personal relationships, particularly with partners and children, most or all months. With the onset of menstruation, or during it, the symptoms disappear. During the postmenstrual period, for at least a week the woman feels well, sometimes euphoric, but with – or soon after – ovulation the symptoms reappear.

The symptoms vary in character and in severity in different menstrual cycles, but there is always a symptom-free interval of at least 1 week. The mood changes tend to cluster together and are described as irritable, depressive, anxious and tense, with mood swings and feelings of being out of control, fatigued and lacking motivation. Different women will describe slightly different symptoms as the most problematic. This may depend on the woman’s country of birth and her current lifestyle and stresses. The same symptoms can be reported by women taking oral contraception just before and during the pill-free week; the symptoms are usually mild.

Diagnosis of PMS

The diagnosis of PMS is made after evaluating the periodicity of the physical and mood symptoms, ascertaining that there is a symptom-free period after menstruation, and ensuring that the symptoms cannot be explained by some other illness. Other illnesses can be exacerbated during the luteal phase of the menstrual cycle, and this can lead to inaccuracies in the diagnosis. The suspected diagnosis should be confirmed by asking the woman to complete a daily record of symptoms over three menstrual cycles (Fig. 29.1). As well as establishing a firm diagnosis, the value of the daily record is that the woman develops an insight into her symptoms and is encouraged by the fact that the medical practitioner has an interest in her problems.

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Fig. 29.1 Menstrual history diary.

Aetiology of PMS

The aetiology of PMS is unknown (Box 29.1). It is reported to be more severe if the woman is under stress. There may be a genetic component, but the current theory is that PMS is multifactorial. One underlying abnormality may be a fluctuation in the levels of oestradiol in the luteal phase, which may cause the symptoms directly or by decreasing brain serotonin activity. A problem in accepting this theory is that no consistent fluctuations have been detected with daily monitoring. PMS does not occur if the ovaries are absent.

Box 29.1 PMS summary

What is PMS? Negative mood and physical symptoms commencing after ovulation and resolving during the luteal phase of the menstrual cycle. There must be at least 7 days free of symptoms each month and the symptoms must be of sufficient severity to affect the woman’s lifestyle
Aetiology Unknown
Prevalence All women have cyclical changes in symptoms; 5–15% of women in their 20s and 30s have moderate to severe symptoms
Diagnosis By history and examination, daily diary, and excluding other causes for the symptoms
Symptoms
Mood: irritability, depression, sadness, fatigue, labile mood, anxious, tense
Physical symptoms: breast swelling and soreness, abdominal swelling and discomfort, headache and backache and increased appetite

Management
Taking a very good medical and psychosocial history and discussing management with the woman
Psychological: cognitive behavioural therapy to help the woman understand her symptoms and make changes to reduce stress and the factors exacerbating her symptoms. Keeping a daily diary to help understand the symptoms and their changing severity each month assists both diagnosis and management
Hormonal: oral contraception or continuous low-dose oestrogen and progestogen
Other medication: SSRIs, lowest dose available continuously or during luteal phase
Surgical: removal of the ovaries is of theoretical interest only

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