Download 8th Edition APGO Objectives for Medical Students

8th Edition APGO Objectives
for Medical Students
Premenstrual
Syndrome and
Premenstrual
Dysphoric Disorder
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.
Objectives
The student will be able to cite:
 Definition of premenstrual syndrome
 Theories of etiology
 Methods of diagnosis
 Management strategies
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
Incidence
Moderate to severe - 20-40%
 Debilitating disease/symptoms - 2.5-5%
 Generally age 30-40 yr.

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
Symptoms
Anxiety
 Mood changes/lability
 Irritability
 Impatience
 Listlessness/fatigue
Symptoms
Depression
 Confused
 Cry easily
 Social withdrawal
 Insomnia
Symptoms
Water retention
 Swelling
 Weight gain
 Abdominal bloating
 Breast tenderness
Symptoms
Cognition
 Forgetfulness
 Difficulty concentrating
Symptoms
Pain
 Cramps
 Backache
 Breast pain/tenderness
Symptoms
Hypoglycemia-like symptoms
 Craving for sweets
 Headache
 Voracious appetite
 Fatigue
 Decreased coordination
Diagnosis
History (must be consistent with
ovulation)
 Symptom calendarﾐ20-30% increase in
luteal score symptoms over 2 mo.

Diagnosis
Rule out other diseases

Depression

Bipolar disorders

Substance abuse

Personality disorder

Chronic fatigue syndrome

Thyroid disease

Irritable bowel syndrome

True hypoglycemia
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
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)
Treatment
Aimed at relieving symptoms, as cause unknown
Medical

Ovulation suppression
 Oral contraceptives
 Depomedroxyprogesterone acetate (DMPA)
 Gonadotropin-releasing hormone (GnRH)
agonists
Treatment
Aimed at relieving symptoms, as cause unknown
Surgical


Oophorectomy not generally recommended
Possibly indicated if symptoms respond to
GnRH agonists or danazol
Clinical Case
Premenstrual
Syndrome and
Premenstrual
Dysphoria Disorder
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.
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.
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.
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.
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.
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.
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.
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.
Teaching points
1.
2.
3.
4.
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.