Gynecology: Premenstrual Syndrome (PMS)

Guest · **posting in usmle forum about Obstetrics & Gynecology**

I. General. Constellation of physical, emotional, or behavioral symptoms occurring during the second half of the menstrual cycle (luteal phase, 7 to 10 days before menses), with resolution of symptoms soon after flow begins. There must be a symptom-free interval of at least one week during the first half (follicular phase) of the menstrual cycle. PMS affects 90% of women minimally and 10% severely. It affects primarily those in late 20s to early 30s without racial, socioeconomic, or other demographic predilection. Hysterectomized patients can still experience PMS if at least one ovary is present.

II. Diagnosis is clinical.

III. Variability in symptoms can be wide. PMS may be diagnosed even if all criteria for Premenstrual Dysphoric Disorder are not met. Additional symptoms such as flatulence, constipation, diarrhea, sore throat, palpitations, urinary symptoms, dizziness, and others may be present.

IV. Symptom calendar is helpful in documenting cyclicity and in monitoring response to therapy.

V. Causes
A. Hormonal and chemical. Theories abound. Probably a neurotransmitter imbalance induced by the normal hormonal cycle.

B. Biopsychosocial. Expectations, beliefs, personality, coping style, sexual experiences, partner responses, social supports, etc. all play a role.

VI. Treatment
A. Validation. The symptoms are not "all in her head." Consider support groups.

B. Regular aerobic exercise helps both mood and somatic symptoms.

C. Psychological therapy. Stress management, relaxation therapy, and supportive psychotherapy.

D. Diet. Limit salt (fluid retention), caffeine (breast tenderness), alcohol and fat. Increase complex carbohydrates and fiber. Consider vitamin B6 50 mg PO TID, keeping in mind risk of peripheral neuropathy.

E. Medications.
1. Breast symptoms may respond to bromocriptine 2.5mg QHS or danazol 200mg/day or BID.

2. Antidepressants. SSRIs (fluoxetine, sertraline, etc.) may be titrated to effect. Clomipramine is also effective, 25-75 mg QD. Use only during the luteal phase if possible, all month if necessary. Has been shown to be effective in controlling symptom severity in multiple placebo-controlled clinical trials.

3. Anti-anxiety medication such as buspirone 5-10 mg PO TID is useful where anxiety predominates. Benzodiazepines have also been used but are addictive and should be used very cautiously.

4. Calcium. 1000-1200 mg daily (divide BID) or magnesium 400 IU PO QD during the luteal phase have both been shown to be effective in placebo-controlled trials.

5. Diuretics. Spironolactone 25 mg TID-QID during luteal phase (12 days before menses). Best for those with weight gain, bloating, and edema.

6. Prostaglandin inhibitors. Ibuprofen 400 to 800 mg TID, naproxen 500 mg PO BID, or mefenamic acid 500 mg TID 10 days before period through day 2 of menses. Have been shown to reduce the intensity of both the physical and emotional symptoms.

7. Cycle suppression with oral contraceptives or Depo-Provera. Rarely, GnRH agonists are used.

8. Progesterone. Oral 100-400 mg PO BID. Vaginal or rectal suppository 200 to 400 mg/day during luteal phase. Medroxyprogesterone acetate 10-20 mg PO QD is another possibility.