1. Premenstrual
Syndrome
Dr. Sharda Jain
Dr Jyoti Agarwal

2. "Management of Premenstrual Tension (PMT)"
PMT (Premenstrual Tension) or PMDD
(Premenstrual Dysphoric Disorder) is common
problem.
Its impact on women's lives, family life in big way
emphasizing the need for effective management.

3. Premenstrual Syndrome- क्या
है
1.Distressing psychological problem:-
with over 200 physical, and/or behaviural
symptoms.
2.Occurrence during the luteal phase of
the menstrual cycle (or cyclically after
hysterectomy with ovarian conservation).
3.Significant regression of symptoms with
onset of or during the period.

4. Prevalence of PMS
In the general population  study at PGIMER Very common
• Only 15% of women are asymptomatic,
• 50% have mild PMS symptoms.
• 30% moderate
• 5-10% severe.

5. Etiology
1. Cyclical ovarian activity the central component (ovarian
'trigger', such as ovulation, may initiate a cascade of
events).
2. Central: increased responsiveness to a combination of
steroids, chemical messengers
3. Psychological sensitivity

6. Diagnosis
• Most women self-diagnose it
• History :- can suggest a diagnosis of PMS
• Symptom record :- can establish its true nature.
• Symptom charts :- PRACTICE Guidelines of
Premenstrual
Syndrome.
• Moderate/severe PMS
1.disruption of work and interpersonal
relationships
2.interference with normal activities.

7. • Diagnostic criteria for premenstrual dysphoric disorder:
equivalent to severe PMS,but need psychiatrist in the
loop to manage severe form.
• It is important to exclude organic disease and significant
psychiatric illness.
• Perimenopausal women may have increasing
premenstrual symptoms as well as menopausal
symptoms.

8. Criteria for premenstrual dysphoric
disorder
At least 5 symptoms present for most of the late luteal phase
with remission within a few days of onset of menses and absence
of symptoms in the week post menses.
At least: one symptom must be from the following first four.
1. Marked depressed mood, feeling of hopelessness, or Self
deprecation .
2. Marked anxiety; tension (being 'on edge).
3. Marked affective lability(e.g. feeling suddenly sad or tearful).
4. Persistent and marked anger/irritability/increased conflicts.

9. 5. Decreased interest in usual activities ( friends, hobbies).
6. Subjective sense of difficulty in concentrating.
7. Lethargy. Easy fatigability lack of energy.
8. Marked Change in appetite, overeating. or specific food
cravings.
9. Hypersomnia or insomnia.
10. Subjective sense of being overwhelmed or out of control.
11. Other physical symptoms, such as breast tenderness or
swelling, headaches; Joint or muscle pain, a sense of 'bloating';

10. Diagnosis -PMS
Clinical diagnosis of PMS requires that the symptoms are confirmed
by prospective recording (that is recorded as they occur) for at least
two menstrual cycles and that they cause substantial distress or
impairment to daily life.

11. Non-Hormonal Management
Non-hormonal options are often considered as the first-line
treatment for PMT.
The following are non-hormonal approaches:
 Lifestyle Modifications
 Dietary Changes
 Stress Reduction Techniques
 Exercise

12. Dietary Changes
Dietary changes can help manage PMT:
 Reducing salt and sugar intake & High fat diet
 Increasing consumption of fibre , fruits, vegetables, and
whole grains
 Calcium - effective
 Magnesium effective
 and Vitamin D supplementation

13. Stress Reduction Techniques
Various stress reduction techniques:
* Mindfulness and meditation
* Yoga
* Deep breathing exercises
* Biofeedback

14. Exercise
Benefits of regular exercise are immence in managing
PMT: moderate Exercise / Aerobic
* Reduces mood swings
* Enhances overall well-being
* Improves sleep quality

15. Hormonal Management
Introduce hormonal options for PMT
management.
These treatments are considered when non-
hormonal approaches are insufficient or not
tolerated.

16. Hormonal Options
Following hormonal treatment options:
 Progesterone
 Oral Contraceptive Pills (OCPs)
 GnRH Analogues
 Selective Serotonin Reuptake Inhibitors (SSRIs)

17. Progesterone
Progesterone may be used to manage PMT.
No potential benefits.

18. Oral Contraceptive Pills (OCPs)
 OCPs can help manage PMT.
 Useful in some women regulate hormonal fluctuations.
 Yasmin /YAZ are good with least side effects.
 Continuos therapy is better
 New pill are demand with withdral bleeding after 90 days

19. OESTRGEN PATCHES + PROGESTERONE
WELL ESTABLISHED & ACCEPTED

20. GnRH Analogues
Use of GnRH analogues in PMT management is seen in severe cases.
They suppress ovulation and hormonal fluctuations.
ADD BACK THERAPY
USED FOR 6 MONTHS  ,BMD EVERY 2 YRS FOR BONE RESERVE

21. Selective Serotonin Reuptake
Inhibitors (SSRIs)
 The use of SSRIs as an First line treatment option for PMT management.
 Their mechanism of action in managing mood-related symptoms.

22. Selective Serotonin Receptor
Inhibitors (SSRI)
First-line treatment of PMS with predominantly emotional symptom
SSRIs were found to be effective for reducing the overall symptoms
of PMS and also for reducing specific types of symptoms
(psychological, physical and functional symptoms, and irritability)

23. Agent Dosing
Paroxetine (CR) Starting dose: 12.5 mg/day
Up to 25 mg/day
Continuous or intermittent
Fluoxetine (Sarafem) Starting dose: 20 mg/day
0 Up to 60 mg/day
Continuous or intermittent
Sertraline Starting dose: 50 mg/day
Up to 150 mg/day continuous
0 50 mg/day to 100 mg/day intermittent
FDA-Approved SSRIs

24. Luteal Phase and Symptom Onset Dosing
Luteal Phase Dosing
• Start SSRI at day 14 of
a 28-day
• cycle Take SSRI during
last 2 weeks of cycle
only
• Stop when menses
begin
Symptom Onset Dosing
• Dose when symptoms
begin and as long as
they last
• Cycles must be regular
Continuous Dosing
• Take SSRI during
whole month
• One meta-analysis
showed slightly
better response

25. DANAZOLE
DEFINITE BENEFIT
MASCULINISING SIDE EFFECTS +
SO USED IN LUTEAL PHASE ONLY

26. Combination Therapies
 Please note a combination of hormonal and non-
hormonal approaches may be used for severe PMT
cases.
 Experts have their rationale and benefits.

27. SURGERY
BSO
HYSTERCTOMY + BSO
VERY rare SEVERE CASE
GnRH a test is test of cure

28. Alternative Tt
Homeopathy -90%
MIND BODY THERAPY
AROMA THERAPY
REFLEXOLOGY

29. Prognosis -PMS
Symptoms of PMS can mostly recur after
stopping the treatment, except after
oophorectomy and menopause

30. Complications- PMS
• Untreated PMS are likely to affect sexual life, thereby leading to a
higher level of sexual distress, which can, in turn, lead to
relationship problems and more psychological issues.
• There is also evidence that relates the PMS to increased suicidal risk
in hormone-sensitive females

31. Monitoring and Follow-Up
Emphasize the importance of monitoring and follow-
up appointments to assess treatment effectiveness
and adjust as needed.
Patient & family must be counselled

32. Conclusion
The management of PMT  ALL GYNAECOLOGIST MUST KNOW.
PMS is underestimated -80% suffer frm it.
Symtoms Diary tobe used for 2 months minimum to plan Tt
We Encourage personalized treatment plans.
Lifestyle changes ,diet ,exercise & complimentary therapy to be
planned & offered simultaneously with Medical Treatment
COCP & SSRI ARE MAIN STAY OF TREAMENT
GnRH a & SUGICAL Tt is last resort for very severe cases .

33. Questions and Discussion