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Premenstrual Disorders. Premenstrual Syndrome / Premenstrual Dysphoric Disorders Folake V Falaki PGY 3 Emory Family Medicine November 19, 2009. Different Faces of Premenstrual Disorders. Table Of Content. Introduction Etiology Differential diagnosis Diagnosis Management Conclusion

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premenstrual disorders

Premenstrual Disorders

Premenstrual Syndrome / Premenstrual Dysphoric Disorders

Folake V Falaki


Emory Family Medicine

November 19, 2009

table of content
Table Of Content
  • Introduction
  • Etiology
  • Differential diagnosis
  • Diagnosis
  • Management
  • Conclusion
  • References
clinical scenario
Clinical Scenario
  • A 30 yo old AAF female presents with symptoms of anxiety, sadness , unexplained crying spells which has been occurring for 6 months. Symptoms usually occur few days before the onset of her periods and improve by day 3 of her menses . She also noticed severe bloating , abdominal pain and back pain during these periods. She has had difficulty caring for her 2 young children due to intense fatigue and lack of energy. She also lacks interest in her daily activities and stays in bed all day

She works as a cashier and she has used up her sick leave for the year. She is concerned that she might loose her job . A friend told her about some herbal supplements which she tried, but this did not help. She denies any history of depression and she is not on any medication .

Lab tests: CBC, CMP, TSH, UDS and Urinalysis are all WNL

  • Premenstrual syndrome (PMS) is a group of physical and behavioral symptoms that occur in a cyclic pattern during the luteal phase of the menstrual cycle.
  • Premenstrual dysphoric disorder (PMDD) is a severe form of PMS
  • Millions of women in their reproductive years have recurrent emotional, physical and social symptoms during their menstrual cycle. It Affects up to 80 % of women.
  • PMS affects 20-30 % of women while PMDD occurs in about 2-10 % of these women.
  • Symptoms usually start between ages 25-35 years

References 1, 2, 3

premenstrual dysphoric disorder dsm iv criteria
Premenstrual Dysphoric DisorderDSM –IV Criteria


  • Documentation of physical and behavioral symptoms present for most of the preceding year
  • 5 or more symptoms of the listed must be present .
  • At least 1 of the symptoms must be any of the first 4 symptoms.
  • Symptoms occurs in the luteal phase of the cycle, improve in the first few days of menstrual flow and resolves in post menstrual week.

Reference 4

premenstrual dysphoric disorder dsm iv criteria8
At least one symptom

Depressed mood, hopelessness and self deprecating thoughts

Intense feeling of anxiety, tension and edged up

Marked affective lability

Persistent anger or irritability or increased self conflict

Reference 4

With any of these symptoms

Decreased interest in daily activities

Difficulty with concentration

Lethargy, lack of energy, easy fatigability

Marked change in appetite

Hypersomnia or insomnia

Feeling overwhelmed or out of control

Physical symptoms: Breast pain, headaches, Joint and muscle pain, bloating

Premenstrual Dysphoric DisorderDSM –IV Criteria
premenstrual dysphoric disorder dsm iv criteria9
Premenstrual Dysphoric DisorderDSM –IV Criteria
  • B.Symptoms significantly interferes with work, School, daily social activities and relationships.
  • C. Symptoms are not due to an exacerbation of another psychological disorders.
  • D. The above criteria must be confirmed by prospective daily ratings in at least two consecutive symptomatic cycles.

Reference 4

premenstrual syndrome
Premenstrual Syndrome
  • Any of the above symptoms , but less severe.
  • Same timing
  • Most common physical manifestation are abdominal bloating and extreme sense of fatigue which occurs in 90 % of women with PMS; breast tenderness and headaches occur in 50%.
  • Minimally Interferes with work, school, social activities and relationship

Reference 3

common symptoms of premenstrual syndrome
Common Symptoms Of Premenstrual Syndrome
  • Behavioral symptoms: fatigue, insomnia, dizziness, changes in sexual interest, food cravings or overeating
  • Psychologic symptoms: irritability, anger, depressed mood, crying and tearfulness, anxiety, tension, mood swings, lack of concentration, confusion, forgetfulness, restlessness, loneliness, decreased self-esteem, tension
  • Physical symptoms: headaches, breast tenderness and swelling, back pain, abdominal pain and bloating, weight gain, swelling of extremities, water retention, nausea, muscle and joint pain

References 1, 2

premenstrual disorders etiology
Premenstrual DisordersEtiology
  • Cause is unknown!
  • Interactions of ovarian hormones with neurotransmitters – Alterations of serotoninergic and GABAnergic activity in the brain.
  • Imbalance between Estrogen and Progesterone levels
  • Serotonin deficiency
  • Effects of hormone shift on endogenous opiods
  • Biologic, physiologic, environmental and social factors all seems to be contributory
  • Genetic factors seems to play a role.

References 1, 2, 3

premenstrual disorders differential diagnosis
Affective disorders

( depression, anxiety, panic attacks, personality disorders, dysthymia)

Anorexia/ Bulimia



References 1,2

Metabolic disorders ( Diabetes mellitus, Hypothyroidism)



Oral contraceptive pill use


Substance abuse



Premenstrual DisordersDifferential Diagnosis
premenstrual disorders diagnosis
Premenstrual DisordersDiagnosis
  • Exclude medical, physical and psychiatric problems
  • TSH, Drug screening, Blood glucose level etc.
  • Keep symptoms calendar.

- At least two consecutive menstrual cycles

- Nature, and timing

  • Exclude simple Menstrual symptoms like breast tenderness and bloating, not affecting daily activities.
premenstrual disorders diagnosis15
Premenstrual DisordersDiagnosis

Adapted from AFP Journal, April 15,2003

premenstrual disorders diagnosis16
Premenstrual DisordersDiagnosis

Adapted from AFP journal, April 15,2003

premenstrual disorders management
Premenstrual DisordersManagement
  • Goals of treatment

- Reduction or elimination of symptoms

- Improvement in social and occupational functioning.

References 1,2

premenstrual disorders management18
Premenstrual DisordersManagement
  • Lifestyle Changes or Conservative treatment:

- Aerobic exercise

- Dietary changes; Frequent small meals, High complex carb., low salt

- Reduce caffeine intake

- Reduce substance abuse e.g. alcohol

- Sleep Hygiene

- Smoking cessation

  • Nutritional Supplements:

- Vitamin B6 (100mg/day) and Vitamin E (600iu/day) May have some efficacy6

- Calcium carbonate ( 1,200- 1,600mg/day) placebo-controlled trial showed 48% reduction of sx in 466 women with PMS7

References 6, 7

premenstrual disorders management19
Premenstrual DisordersManagement
  • Nutritional Supplements:

- Magnesium ( up to 500mg/day)


  • Herbal Therapies:

- Evening primrose oil

- Chaste tree berry

* May improve breast tenderness

* Not FDA approved for this purpose

* Safety data lacking

premenstrual disorders management20
Premenstrual DisordersManagement
  • Nonpharmacologic treatments:

- Cognitive behavioral therapy

- Anger management

- Stress reduction and management

- Education

- Light therapy

- Therapy

- Support groups

References 1,2, 8

premenstrual disorders management21
Premenstrual DisordersManagement
  • Pharmacologic Treatments:
  • Neurotransmitter modulation:

-Selective serotonin reuptake inhibitors (SSRI’s)

- GABA receptor modulators

  • Menstrual Cycle inhibition :

- GnRH agonists


premenstrual disorders management22
Premenstrual DisordersManagement

Adapted from AFP journal, October 1, 2002

premenstrual disorders management23
Premenstrual DisordersManagement

Adapted from AFP journal October 1, 2002

premenstrual disorders management24
Premenstrual DisordersManagement

Adapted from AFP journal October 1, 2002

premenstrual disorders management25
Premenstrual DisordersManagement
  • ACOG recommends the serotoninergic antidepressants as the first-line treatment of choice for severe PMS and PMDD. (Evidence level C)
  • The US FDA approved use of fluoxetine and sertraline for women with PMDD
effect of fluoxetine in women with pmdd
Effect of Fluoxetine In Women With PMDD

Steiner M et al. N Engl J Med 1995;332:1529-1534

premenstrual disorders management27
Premenstrual Disorders Management

Adapted from AFP journal, October 1, 2002

premenstrual disorders conclusion
Premenstrual DisordersConclusion
  • PMS and PMDD affects women in the reproductive age group
  • PMS and PMDD can be treated.
  • All women with PMS or PMDD should be offered nonpharmacological treatment first.
  • Symptoms diary to help monitor symptoms are recommended
  • SSRI is the first choice for pharmacological treatment.
premenstrual disorders references
Premenstrual DisordersReferences
  • Bhatia, SC, Bhatia SK. Diagnosis and treatment of premenstrual disorder. American Family Physician Journal.2002 oct.1, 66(7) :1239-48
  • Dickerson ,L Mazyck P, Hunter M. Premenstrual syndrome. American Family Physician. 2003 April 15,67(8): 1743-52
  • Casper R, Yonkers K. Epidemiology and pathogenesis of premenstrual syndrome and premenstrual dysphoric disorder. UpToDate. 2009 May
  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental disorders. 4th ed. Washington DC: APA,1994:717-8
premenstrual disorders references30
Premenstrual DisordersReferences
  • Steiner M , Steinberg S, Stewart D et al . New England Journal of Medicine. 1995 june;332:1529-1534
  • Wyatt K, Dimmock P ,Jones Pet al. Efficacy of Vitamin B6 in the treatment of premenstrual syndrome. BMJ 1999;318:1375-81
  • Ward M, Holliman T. Calcium treatment for premenstrual syndrome. Ann pharmacother 1999;33:1356-8
  • Mclntyre- Seltman K. PMS and PMDD: Clinical Approaches. 2009 Nov; ppt.