premenstrual syndrome (PMS); premenstrual dysphoric disorder (PMDD)

Introduction

Variable constellation of physical & emotional symptoms that are most severe during the week prior to the menstrual period & occasionally 1-2 days after.

Epidemiology

• high dietary intake of thiamine & riboflavin reduces incidence of new-onset PMS

Pathology

• involvement of GABA &/or serotonin

Clinical manifestations

• bloating
• headache
• bowel changes
• breast pain & tenderness (mastodynia)
• backache
• anxiety
• irritability
• mood swings
• depression

Diagnostic criteria

• at least 1 primary symptom
  • mood swings
  • irritability or anger
  • feelings of hopelessness or depressed mood
  • anxiety
• at least 5 symptoms in total, including
  • appetite changes
  • decreased interest in usual activities
  • fatigue
  • difficulty concentrating
  • feelings of loss of control
  • sleep disturbance
  • physical symptoms presumptively collectively counts as 1 symptom
    • breast tenderness, weight gain, bloating, myalgia).

Management

• symptom-oriented
• pre-treatment daily diary of symptoms & menses for at least 2 months
• avoidance of caffeine
• spironolactone 100 mg/day for bloating (take for 2 weeks before menses
• NSAIDs for severe cramps
• bromocryptine for mastodynia
• oral contraceptives to suppress ovulation
  • may increase risk of stroke in patients with migraine
• danazol to induce endometrial atrophy & attenuate migraine
• gonadotropin-releasing hormone agonists
  • severe cases
  • complete suppression of gonadal function
  • gonadorelin
  • leuprolide
  • estrogen replacement to avoid bone loss if > 6 months of therapy
• mood disorders (premenstrual dysphoric disorder)
  • benzodiazepines for anxiety disorder
    • alprazolam (Xanax)
  • selective serotonin re-uptake inhibitors (SSRI) 1st line
    • fluoxetine (Prozac)
      • 10-20* mg PO QD starting 14 days prior to expected menses, continuing through 1st full days of bleeding, or
      • Prozac weekly 7 & 14 days prior to menses
    • sertraline (Zoloft)
      • 50-150 mg QD
      • intermittent dosing 7 & 14 days prior to menses
      • start 50 mg; increase to 100 mg after 3 doses
      • intermittent dosing starting 14 days prior to menses & continuing until day 2 of next cycle
      • large placebo effect (still 1st line)
• calcium 1200 mg/day may help with pain, cramping & mood changes; may take a few months for benefit
• magnesium 200-400 mg/day may help with headache, fluid retention & mood changes
• vitamin E 400 IU/day
• vitamin B6 100 mg QD
• complex carbohydrates improve mood & reduce food cravings
• aerobic exercise can help with fluid retention
• 'natural' or pharmaceutical progesterone of NO benefit

* 20 mg of fluoxetine improves both physical & mood symptoms

More general terms

• gynecologic disease
• syndrome
• mood disorder