describe premenstrual tension syndrome

1. MAGDY ABDELRAHMAN MOHAMED
2015
PREMENSTRUAL
TENTION
SYNDROMES

2. PMS is a group of physical, mood-related, and behavioral
changes that occur in a regular, cyclic relationship to
the luteal phase of the menstrual cycle and interfere
with some aspect of the patient’s life
PMDD identifies women with PMS who have more severe
emotional symptoms (such as anger, irritability, and
depression) that may require more extensive therapy
Definition

3. Severe (PMDD)
Moderate (PMS)
Mild (PMS)
None
Spectrum of Premenstrual Syndromes
Premenstrual
Syndrome
Severity
Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C
Gambone, Calvin J Hobel. Chapter 36 (387).

4. Premenstrual symptoms
Commonly seen in most of the females
Physiological
Not much distressful
No treatment or intervention generally sought

5. Premenstrual Syndrome (PMS)
Severe than commonly experienced
physiological symptoms
Around 40% of females experience this cluster
of various symptoms
However, impairment in daily functioning is
less as compared to PMDD

6. Premenstrual Dysphoric Disorder
(PMDD)
Severe form of PMS
Around 3% to 8% females experience it
Impairment in functioning:
Work, Social interaction, Academics and even
Daily Routine

7. Hippocrates (460-377 B.C.)
Described a group of conditions
that occurred prior to the onset of
menses,
in which women might develop
suicidal ideation and other severe
symptoms

8. Frank (in 1931)
Described 15 women experiencing
severe premenstrual symptoms
and coined the term ‘Premenstrual
Tension Syndrome
Green and Dalton (in 1953)
coined the term ‘Premenstrual
Syndrome’

9. PMDD is a relatively a new concept!

10. 1987
Diagnostic and Statistical Manual of Mental
Disorders (DSM) -III-R included criteria for Late
Luteal Phase Dysphoric Disorder.
1994
In DSM-IV the name has been changed to
Premenstrual Dysphoric Disorder
Included as a Depressive Disorder Not
Otherwise Specified.

11. October 1998,
A panel of experts evaluated the evidence
then available, and a consensus was reached
that PMDD was a distinct clinical entity
A review by a group of experts "reached the consensus that
PMDD is a distinct entity with clinical and biological profiles
dissimilar to those seen with other disorders"
(Endicott et al. J Womens Health Gend Based Med
1999;8:663-679).

12. A distinct clinical presentation with characteristic
symptoms
Cyclical course linked to the menstrual cycle
Unique physical symptoms such as bloating and
breast tenderness
Cessation of symptoms during pregnancy and after
menopause
Rapid response to selective serotonin reuptake
inhibitors (SSRIs)—in contrast to the slower onset in
major depressive disorder
Normal hypothalamic-pituitary-adrenal axis
functioning—in contrast to major depression

13. November 1999,
US FDA Neuropharmacology Advisory
Committee supported this concept

14. PMS/PMDD: Symptoms
Somatic Symptoms
 Breast tenderness
 Abdominal bloating – most common, occurs in 90%
 Headache
 Swelling of extremities
 Weight gain

15. Affective Symptoms
 Depression
 Angry outbursts
 Irritability
 Anxiety
 Confusion
 Social withdrawal
 Decreased concentration
 Sleep disturbance
 Appetite change/food cravings
PMS/PMDD: Symptoms

16. PMS/PMDD: Symptoms
Sample: Daily Symptoms
Calendar
Diagnostic tool used
to assist the patient
with recording her
premenstrual symptoms
diary
Endicott and Harrison 2006. 5.Endicott, J., & Harrison, W. Daily Record
of Severity of Problems Calendar.

17. Symptoms absent, the week after
the onset of menses (Follicular
Phase)
Symptoms subside few days
after the onset of menses
Symptoms present in the last
week of Luteal Phase

18.  Patient reports 1 affective symptom and somatic symptom(s)
during the luteal phase before menses
 Symptoms relieved within 4 days of onset of menses, without
recurrence until at least cycle day 13
 Symptoms occur in 2 consecutive menstrual cycles
 Patient suffers from identifiable dysfunction in social or
economic performance
PMS: Diagnosis

19. DSM-IV Criteria
 Symptoms interfere with usual functioning and relationships
 Symptoms are not an exacerbation of another disorder
 Symptoms resolve at onset of menses
 Premenstrual timing is confirmed by menstrual calendar in 2
consecutive cycles
PMDD: Diagnosis

20. DSM-IV Criteria
 At least 5 of 11 premenstrual symptoms
 At least 1 of the following:
 Depressed mood
 Marked anxiety
 Marked affective lability
 Marked irritability
 Other possible symptoms
 Decreased interest in regular activities
 Difficulty concentrating
 Lethargy/fatigue
 Appetite change/food cravings
 Sleep disturbance
 Feelings of being overwhelmed
 Physical symptoms (bloating, weight gain, breast tenderness, edema)
PMDD: Diagnosis

21. Differential Diagnosis
Premenstrual Syndrome.
Premenstrual exacerbation of current mental
disorder.
Premenstrual exacerbation of general medical
condition such as epilepsy, asthma or
endocrine disorders.

22. Aetiology ???
Ovarian hormones (sex steroids)
Serotonin
Other neurotransmitter
Beta endorphins
Aldosterone
Prolactin
Ions and minerals

23. Ovaries
Limbic system
Prefrontal cortex
Hippocampus
Hypothalamus
Pituitary
?Kidney

24. What data has to say?
premenstrual syndrome is probably the result
of a complex interaction between ovarian
steroids and central neurotransmitters
(N Engl J Med 1998;338:256-257)

25. Regular hormones levels
No consistent difference in blood and urine
level of estrogen and progesterone in women
with PMDD compared to those without
disorder.

26. Why hormones involved?
If the fluctuation of hormones is somehow
stopped, the premenstrual symptoms
improve!

27. GnRH agonists improves PMS
Supporting studies
Freeman EW, Sondheitjer SH, Rickets K.
Gonadotropin-releasing hormone agonist in treatment of premenstrual
symptoms with and without ongoing dysphorics:
a controlled study. Psychopharmacol Bull. 1997;33:303-309
Hammarback S, Backstrom T.
Induced anovulation as treatment of premenstrual tension syndrome:
a double-blind cross-over study with GnRH-agonist versus placebo.
Acta Obstet Gynecol Scand. 1988;67:159-166.

28. Allopregnanolone-
a metabolite of progesterone
Summary of various reviews and studies
Allopregnanolone levels are high in PMDD
Increase in allopregnanolone in response to
stress occur in PMDD
Allopregnanolone to progesterone ratio is higher
in PMDD following an oral progesterone dose
(Klatzkin et al. Psychoneuroendocrinology 2006;31:1208-1219)

29. Neurotransmitters
Retrospective evidence of Serotonin involvement- as the
symptoms improves with SSRIs
Serotonin
Increase allopregnanolone synthesis.
Increase sensitivity to neurosteroids.
SSRIs
The effect is unrelated to the serotonin uptake inhibiting
property of these drugs.

30. Genetic susceptibility
A preliminary study suggested that genetic
variation in the estrogen receptor alpha
gene is associated with increased risk for PMDD;
leading the authors to speculate that there might
be a "genetic susceptibility to affective
dysregulation induced by normal levels of
gonadal steroids"
(Huo et al. Biol Psychiatry 2007;62:925-933).

31. TREATMENT
OPTIONS

32. Nutritional approaches
More studies for PMS; so ?? For severe
symptoms of PMDD.
Limitations:
Poor study design, Vague definition of
PMS, High placebo response
(review by Bendich. J Am Coll Nutr 2000;19:3-12)

33. General nutritional recommendation
Limit intake of alcohol, caffeine, salt, tobacco, and
refined sugars
Increase complex carbohydrate and protein
intake
Avoid overeating and weight gain
Consider frequent small meals

34. Pyridoxine (vitamin B6)
Despite the limitation of study designs.
100 mg/day benefits in premenstrual
symptoms.
by Wyatt et al.
(BMJ 1999;318:1375-1381)

35. Calcium
A large double blind placebo-controlled multi-
center trial available
1200 mg daily
Effective in reducing PMS symptoms

36. Magnesium
Few placebo-controlled trials availabe
200 mg daily
Improves fluid retention problem

37. Evening primrose oil
little value even in PMS
(Budeiri et al. Control Clin Trials 1996;17:60-68).

38. Herbs
Female Balance
(a product widely sold on internet, containing
unspecified amount of 16 herbs- as an effective, natural, gentle
way for treating PMS)
No scientific support
Hypericum perforatum (St. John’s Wart)
Uncontrolled study available (small sample of 19
women)
well designed controlled study needed
(Stevinson and Ernst. BJOG 2000;107:870-876)

39.  SSRIs
 Can be taken throughout the cycle or during the luteal phase
of the cycle
 Fluoxetine 20-60 mg qd
PMDD: Treatment (Medical)

40.  Anti-depressants
 SSRI’s (Fluoxetine)
 Spironolactone - bloating
 Bromocriptine – mastalgia
 Ovulation suppression
 GnRH agonists (e.g. Lupron)
 Danazol
 OCPs
(Medical Treatment)

41.  Oophorectomy
 Not generally recommended
 Irreversible
 Reserved for severely affected patients who only respond to
GnRH agonists
PMS/PMDD: Treatment (Surgical)

42. Summary
 PMDD identifies women with PMS who have more severe
emotional symptoms that may require intensive therapy.
 The physiologic mechanism that results in the occurrence of PMS
and PMDD is not well understood.
 The diagnosis of PMS and PMDD is based on documentation of the
relationship of the patient’s symptoms to the luteal phase.
 DSM-IV criteria are used to establish the diagnosis of PMDD.
 In addition to lifestyle changes, behavioral therapies, and dietary
supplementation, some pharmacologic agents have been shown to
have symptom relief.