8th Edition APGO Objectives for Medical Students

1. 8th Edition APGO Objectives for Medical Students Premenstrual Syndrome and Premenstrual Dysphoric Disorder

2. Rationale Premenstrual syndrome involves physical and emotional discomfort and may affect interpersonal relationships. Effective management of this condition requires an understanding of symptoms and diagnostic methods.

3. Objectives The student will be able to cite: • Definition of premenstrual syndrome • Theories of etiology • Methods of diagnosis • Management strategies

4. Definition Group of physical/behavioral symptoms occurring in second 1/2 (luteal phase) of menstrual cycle and interfering with lifestyle • Cyclic, unprovoked, uncontrollable mood changes and somatic symptoms occurring within 5 days of onset of menses which have adverse effects on job or family • Occurs in greater than 2 consecutive cycles • Relief within 4 days of menses onset • Psychiatric diagnostic designation: luteal phase dysphoric disorder

5. Incidence • Moderate to severe - 20-40% • Debilitating disease/symptoms - 2.5-5% • Generally age 30-40 yr.

6. Etiology • Not known; personality traits and stress not factors • Some theories - disturbances in central neurotransmitter regulation • Decreased serotonin activity (central deficiency) • β-Endorphins • Role of GABA system • B6 deficiency

7. Symptoms Anxiety • Mood changes/lability • Irritability • Impatience • Listlessness/fatigue

8. Symptoms Depression • Confused • Cry easily • Social withdrawal • Insomnia

9. Symptoms Water retention • Swelling • Weight gain • Abdominal bloating • Breast tenderness

10. Symptoms Cognition • Forgetfulness • Difficulty concentrating

11. Symptoms Pain • Cramps • Backache • Breast pain/tenderness

12. Symptoms Hypoglycemia-like symptoms • Craving for sweets • Headache • Voracious appetite • Fatigue • Decreased coordination

13. Diagnosis • History (must be consistent with ovulation) • Symptom calendarﾐ20-30% increase in luteal score symptoms over 2 mo.

14. Diagnosis Rule out other diseases • Depression • Bipolar disorders • Substance abuse • Personality disorder • Chronic fatigue syndrome • Thyroid disease • Irritable bowel syndrome • True hypoglycemia

15. Treatment Aimed at relieving symptoms, as cause unknown Conservative • Self help strategies • Nutritional changes • Frequent, small meals • Avoid sweets, caffeine • Magnesium sulfate 360 mg/d • Evening primrose oil • High-protein diet, B6 • Exercise - milder symptoms

16. Treatment Aimed at relieving symptoms, as cause unknown Medical • Mood/other symptom relief • Naproxyn (prostaglandin inhibitor) • Mefenamic Salt restriction for water retention • Spironolactone for water retention • Transdermal estrogen • Bromocriptine for breast symptoms • Anti-anxiety drugs • Fluoxetine (Prozac) appears most promising as first-line medication • Alprazolam (Xanax)

17. Treatment Aimed at relieving symptoms, as cause unknown Medical • Ovulation suppression • Oral contraceptives • Depomedroxyprogesterone acetate (DMPA) • Gonadotropin-releasing hormone (GnRH) agonists

18. Treatment Aimed at relieving symptoms, as cause unknown Surgical • Oophorectomy not generally recommended • Possibly indicated if symptoms respond to GnRH agonists or danazol

19. Clinical Case Premenstrual Syndrome and Premenstrual Dysphoria Disorder

20. Patient presentation GS, a 37-year-old married woman, comes to your office for an “annual checkup.” She has recently moved to town, and all her previous medical care was in a different city. She has not seen a gynecologist for 2 years and states that she wants to establish a relationship with a physician in her new surroundings.

21. Patient presentation The patient is a gravida 3, para 3. She has regular periods, although they have gotten somewhat longer in the past year or so. She is currently not sexually active and is taking no medications or supplements. Past history reveals that she underwent an appendectomy as a child and has had two diagnostic laparoscopies for pelvic pain, with the most recent done 3 years ago. She has no pain at the present time, has no medical conditions and is not allergic to any medications.

22. Patient presentation Her family history reveals that her mother suffered from depression. Her 40-year-old sister was recently diagnosed with breast cancer. Upon review of systems, she describes occasional constipation and diarrhea. She has recently had difficulty sleeping and feels that she gets tired more easily than she should. Upon further questioning, she reveals that she has difficulty falling asleep, often because she is thinking about what has happened during the day and/or what may be coming up the next day. The patient and her three children have recently moved to town, while her husband has remained in their previous city to fulfill his job obligation. This domestic separation has been going on for approximately 6 months.

23. Patient presentation On physical examination, all findings are normal. The patient did appear to be a bit nervous and startled easily as you entered the room. On further questioning, the patient thinks that her jitteriness and sleeplessness have led to increased irritability with the children. She worries a great deal, particularly about her domestic situation and being separated from her husband. She has difficulty concentrating at her job (she works as a bank teller) and also feels that her memory is failing her, as she loses her keys or misplaces items at home from time to time. Further questioning also reveals that the patient has observed no pattern indicating that the symptoms occur only during the luteal phase. You also note that at the time of the examination, when she presents with nervousness, GS is in the follicular phase of her cycle.

24. Patient presentation She saw a physician assistant in a primary care practice regarding these symptoms. He told her that he believes she has PMS. The patient does believe that her symptoms may get worse at different times of the month, but she has never been able to keep track of them long enough to know whether there is a specific cyclic pattern to these problems. General lab tests were performed and were normal. Under the assumption that it is PMS, he recommended a series of treatments, all of which have been unsuccessful, i.e. birth control pills, progesterone suppositories, vitamin B6 supplementation, diuretics and nonsteroidal anti-inflammatory drugs, specifically Ibuprofen and Naproxen Sodium. She has taken all of these medications and has also tried to get more exercise and “eat right.” She believes that the combination of being separated from her husband, moving to a new town, and the stress of doing her job accurately has overwhelmed her. She does not understand why the PMS has not improved and asks whether a hysterectomy might be the solution.

25. Treatment Because the physical examination, thyroid function tests, electrolytes, liver function test and a complete blood count are normal, you are confident that the patient does not have any underlying medical conditions. You suggest to the patient that she may have an anxiety disorder, perhaps generalized anxiety disorder. You initially start her on Alprazolam, 0.25 mg, three times a day and suggest that she monitor her symptoms and return in one week.

26. Treatment The patient returns in one week and reports significant improvement in her sleep patterns, as well as her mental functioning. She feels much calmer. You reassure the patient that there is no underlying medical problem and that she is not “going crazy,” but appears only to have an anxiety disorder that can be treated successfully. You explain to her that life stressors can exacerbate her underlying anxiety disorder.

27. Treatment You also recommend that she avoid caffeine and alcohol. Although she feels better, the patient wishes to discontinue the medication to see if her lifestyle changes might make a difference. She returns 1 month later, and her symptoms have returned. You then initiate therapy with Buspirone, 10 mg, three times a day, and explain to her that it will take 2 to 3 weeks for this medication to take effect. You also explain that it does not have any sedating qualities and will not be habit forming. The patient returns 3 months later, at which time she is functioning well and is quite comfortable with the current dosage of Buspirone.

28. Teaching points • Differentiating PMS from anxiety may depend on prospective documentation of symptoms. Without the documentation or with a history that is unclear, making a firm diagnosis of PMS/PMDD may be difficult. Alternatively, if symptoms are compatible with anxiety, this should be a primary consideration. • An empathetic, sensitive approach to the patient’s concerns is needed. Understanding the environment in which these patients find themselves is often helpful in making the diagnosis. • May women who believe they have PMS actually have a different condition. To some patients, PMS is a more acceptable diagnosis. This is certainly more commonly seen in an ob-gyn office than in the office of a mental health care professional. • Initial management with a benzodiazepine will provide an earlier response potential. The use of buspirone, with its benefits of not being sedating and not being habit forming, might be useful for long-term management.