Download PMS, PMDD, Dysmenorrhea 4-1-11

Premenstrual Syndrome and
Premenstrual Dysphoric Disorder
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series
Objectives for PMS and PMDD
 Identify the criteria for making the diagnosis of
Premenstrual Syndrome (PMS) and Premenstrual
Dysphoric Disorder (PMDD)
 List treatment options for PMS and PMDD
Definition
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
Incidence
 PMS symptoms - 75%- 85% of women
 Severe/debilitating PMS - 5-10% of women
 PMDD - 3-5% of women
Spectrum of Premenstrual Syndromes
Severe (PMDD)
Premenstrual
Syndrome
Severity
Moderate (PMS)
Mild (PMS)
None
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).
PMS/PMDD: Symptoms
Somatic Symptoms
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Breast tenderness
Abdominal bloating – most common, occurs in 90%
Headache
Swelling of extremities
Weight gain
PMS/PMDD: Symptoms
Affective Symptoms
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Depression
Angry outbursts
Irritability
Anxiety
Confusion
Social withdrawal
Decreased concentration
Sleep disturbance
Appetite change/food cravings
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.
PMS: Diagnosis
 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
PMDD: Diagnosis
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
DSM-IV Criteria
 At least 5 of 11 premenstrual symptoms
 At least 1 of the following:
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Depressed mood
Marked anxiety
Marked affective lability
Marked irritability
 Other possible symptoms
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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)
PMS/PMDD: Differential Diagnosis
Rule out other diseases:
 Psychological disorders
 Depression, Bipolar disorders, Personality disorders, Anxiety
 Gynecologic disorders
 Dysmenorrhea, Endometriosis, Pelvic Inflammatory Disease, Perimenopause
 Endocrine disorders
 Thyroid disease, Adrenal disorders, True hypoglycemia
 GI conditions
 Inflammatory bowel disease, Irritable bowel syndrome
 Drug or substance abuse
 Chronic fatigue states
PMS/PMDD: Treatment (Conservative)
 Supportive therapy
 Lifestyle changes
 Frequent exercise
 Nutritional supplements
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Magnesium sulfate 360 mg/d
Calcium 1200 mg/d
Vitamin E 400 IU/d
Vitamin B6 100 mg/d
PMS: Treatment (Medical)
 NSAIDs
 Anti-depressants
 SSRI’s (Fluoxetine or Sertraline)
 Buspirone
 Spironolactone - bloating
 Bromocriptine or Danocrine – mastalgia
 Ovulation suppression
 GnRH agonists (e.g. Lupron)
 Danazol
 OCPs
PMDD: Treatment (Medical)
 SSRIs
 Can be taken throughout the cycle or during the luteal phase
of the cycle
 Fluoxetine 20-60 mg qd
 Sertraline 50-150 mg qd
PMS/PMDD: Treatment (Surgical)
 Oophorectomy
 Not generally recommended
 Irreversible
 Reserved for severely affected patients who only respond to
GnRH agonists
Bottom Line Concepts
 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.
 As an overall clinical approach, treatments should be employed in
increasing orders of complexity.
References and Resources
 APGO Medical Student Educational Objectives, 9th edition, (2009),
Educational Topic 49 (p104-105).
 Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010),
Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William
NP Herbert, Douglas W Laube, Roger P Smith. Chapter 39 (p347-352).
 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 (p386-388).
Dysmenorrhea
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series
Objectives for Dysmenorrhea
 Define dysmenorrhea and distinguish primary and
secondary dysmenorrhea
 Describe the pathophysiology and identify the etiologies
of dysmenorrhea
 Discuss the steps in the evaluation and management
options for dysmenorrhea
Definition
Painful menstruation that prevents a woman from
performing normal activities
 Primary dysmenorrhea – no readily identifiable cause
 Secondary dysmenorrhea – identifiable organic cause
Primary Dysmenorrhea: Pathophysiology
 Caused by excess prostoglandin F2α (PGF2α ) and PGE2
produced from shedding endometrium
 Prostoglandins are potent smooth-muscle stimulants that
cause uterine contractions and ischemia
 Prostoglandin F2α causes contractions in smooth muscle
elsewhere in the body, resulting in nausea, vomiting, and
diarrhea
Primary Dysmenorrhea: Symptoms
 Pain
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Onset within 2 years of menarche
Begins a few hours before or just after onset of menses
Lasts 48 – 72 hours
Described as “cramp-like”
Strongest over lower-abdomen
Radiates to back or inner thighs
 Associated symptoms
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Nausea and vomiting
Fatigue
Diarrhea
Lower backache
Headache
Primary Dysmenorrhea: Treatment
 Reassurance and explanation
 Medical
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NSAIDs
Hormonal contraceptives (e.g. OCPs, IUD, Vaginal rings, Patches)
Progestins (e.g. Medroxyprogesterone acetate)
Tocolytics (e.g. Salbutamol)
Analgesics
 Other Measures
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Transcutaneous nerve stimulation
Acupuncture
Psychotherapy
Hypnotherapy
Secondary Dysmenorrhea: Pathophysiology
 Depends on underlying (secondary) cause and in most cases
is not well understood
 Causes of secondary dysmenorrhea:
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Endometriosis
Pelvic inflammation
Adenomyosis
Fibroid tumors (benign, malignant)
Ovarian cysts (e.g. endometriosis, luteal cysts)
Pelvic congestion
Secondary Dysmenorrhea: Symptoms
 Pain
 Develops in older women (30’s to 40’s)
 Not limited to menses
 Associated symptoms
 Dyspareunia
 Infertility
 Abnormal uterine bleeding
Secondary Dysmenorrhea: Symptoms
Condition
Signs and Symptoms
Endometriosis
Pain extends to premenstrual and postmenstrual phase
Deep dyspareunia
Tender pelvic nodules (e.g. uterosacral ligaments)
Onset in 20’s – 30’s
Pelvic inflammation
Pain initially menstrual, with each cycle extends into premenstrual phase
Intermenstrual bleeding
Pelvic tenderness
Fever, chills, malaise
Adenomyosis,
Pain + menorrhagia
Uterus symmetrically enlarged, mildly tender, “boggy”
Uterine fibroids
Pain + menorrhagia
Firm, irregularly enlarged uterus
Ovarian cysts
Mid-cycle, unilateral pain
Pelvic congestion
Dull, ill-defined pelvic ache
Pain worse premenstrually and relieved by menses
History of sexual problems
Secondary Dysmenorrhea: Treatment
 Management consists of treatment of the underlying disease
 Treatment used for primary dysmenorrhea often helpful
Bottom Line Concepts
 Primary and secondary dysmenorrhea are a source of recurrent
disability for a significant number of women in their early reproductive
years.
 Primary dysmenorrhea is caused by excess prostoglandin produced by
the shedding endometrium.
 Secondary dysmenorrhea is due to organic pelvic disease, including;
endometriosis, PID, adenomyosis, uterine fibroids, and pelvic
congestion.
 Primary dysmenorrhea presents within 2 years of menarche, where as
secondary dysmenorrhea more often presents in older women.
 For patient’s with dysmenorrhea, the physical exam is directed at
uncovering possible causes of secondary dysmenorrhea.
 Treatment of secondary dysmenorrhea should be directed at the
underlying condition.
References and Resources
 APGO Medical Student Educational Objectives, 9th edition, (2009),
Educational Topic 46 (p98-99).
 Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010),
Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William
NP Herbert, Douglas W Laube, Roger P Smith. Chapter 30 (p277-279).
 Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and
Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone,
Calvin J Hobel. Chapter 21 (p256-259).