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• Definition
• Incidence
• Pathogenesis
• Common Complaint
• Subjective Data
• Signs & Symptoms
• Differential Diagnosis
• Plan
• Follow Up
• Pharmacological Therapy
• Handouts

625.4 Pemenstrual tension syndromes

Definition:

Psychoneuroendrocrine disorder with a constellation of symptoms that occur in the luteal phase, beginning particularly day 18-21 and interferes with a woman’s life. This is followed by a symptom free period. American Psychiatric Association diagnosis is called luteal phase dysphoric disorder.

Incidence:

Virtually every menstruating woman will experience some symptoms, sometimes. Twenty percent will have symptoms serious enough to interfere with their lives. Occurs more often in 30’s and 40’s than earlier.

Pathogenesis:

Presumably hormonal; perhaps there is a genetic sensitivity to fluctuations of the neurotransmitters.

APA Criteria for Luteal Phase Dysphoric Disorder

1. Symptoms are temporally related to the menstrual cycle, beginning during the last week of the luteal phase and remitting after the onset of menses.
2. The diagnosis requires at least 5 of the following and one of the symptoms must be either one of the first four:
   1. Affective labile, e.g., sudden onset of being sad, tearful, irritable, or angry (mood swings).
   2. Persistent and marked anger or irritability.
   3. Marked anxiety or tension.
   4. Markedly depressed mood, feelings of hopelessness.
   5. Decreased interest in usual activities
   6. Easy fatigability or marked lack of energy
   7. Subjective sense of difficulty in concentrating
   8. Hypersomnia or insomnia
   9. Physical symptoms such as breast tenderness, headaches, edema, abdominal bloating, joint or muscle pain, weight gain.
3. The symptoms interfere with work or usual activities or relationships.
4. The symptoms are not an exacerbation of another psychiatric disorder.

Common Complaints:

"I’ve got PMS!! I’m so miserable!!"

Subjective Data:

Obtain a complete menstrual history

Menarche, frequency, duration and regularity of periods.

Ask about premenstrual symptoms that are physical, social, behavioral, emotional.

Ask particularly about the timing of the symptoms. When do the symptoms begin and end in relationship to the menstrual period? Has the patient kept a calendar of symptoms?

Ask about symptoms of dysmenorrhea. Some women confuse menstrual cramps and PMS.

Type of contraception.

Obstetric history

Type of treatment of symptoms and efficacy of treatment.

Amount and type of exercise. Women with PMS often get little exercise.

Signs & Symptoms: Physical Exam Diagnostic Tests

Differential Diagnoses:

Premenstrual syndrome

Major depression

Dysmenorrhea

Substance abuse

Perimenopausal symptoms

Sexual dysfunction

Fibromyalgia

Rarely major medical problems, but hypothyroidism, hyperthyroidism, anemia, autoimmune disorders must be kept in mind.

Not to be Missed:

A suicidal or homicidal patient

Eating disorder

Systemic disease such as systemic lupus erythematosis

Plan:

Symptomatic treatments. Some treatments help some women, other treatments help others.

Diet.

• Six small meals a day to even out glucose load.,
• Avoid caffeine to decrease irritability and facilitate sleep.
• Avoid simple sugars and eat complex carbohydrates to provide a slow steady source of energy.
• Avoid salt to decease edema.

Increase exercise, preferably aerobic. Exercise every day by walking, swimming, stretching.

Try stress reduction activities such as imagery or Yoga

Join a support or counseling group.

Avoid or stop smoking.

Get adequate sleep and rest.

Pharmacological Therapy:

Diruetics The purpose is to decrease edema peripherally and, perhaps, centrally

Anti-depressants: The purpose is to decrease depression, anxiety and improve mood.

(fluoxitine, sertraline, ). Usually a small dose on a continual basis or during the premenstrual or symptomatic period.

Antinxiety drugs: The purpose is to decrease anxiety.

Buspirone 5-10 mg bid or tid in the luteal phase.

Miscellaneous drugs:

Minerals: Magnesium 300-500 mg per day; Calcium 1000 mg per day

Vitamins: B6 50 mg BID; multiple vitamin 1 per day.

Herbs

Follow Up:

Every 3 to 4 months to assess therapy or alter therapy.

Primary Points:

Consult physician if symptoms are severe of not relieved by first line measures.

Education and encouragement are therapeutic. Acknowledge reality of symptoms.

Individual Considerations:

PARTNERS: Encourage patient to have partner come to a visit. Partner education and support.

References:

Johnson, C. A. (1996).Premenstrual syndrome. In Johnson, C. A., Johnson, B. E., Murray, J. L. and Apgar, B. S. Women’s Health Handbook, St. Louis: CV Mosby.

Peters, S. (1997). The puzzle of premenstrual syndrome Putting the pieces together. Advance for Nurse Practitioners. 5(10), 41-42,44,79.

Speroff, L.,Glass, R. H. and Case, N. G. (1994) Clinical Gynecologic Endocrinology and Infertility. (5 th Ed), Philadelphia: Williams & Wilkins.

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