I PREMENSTRUAL SYNDROME ^561
Premenstrual syndrome (PMS) is the cyclic recurrence of symptoms that occur in the luteal phase of the menstrual cycle, are variable in intensity and effect on daily life, and cease shortly after the onset of menstruation.
Emotional and physical changes occur premenstrually in up to 85% of women of reproductive age, although the vast majority of patients with these symptoms do not have PMS. It is estimated that 20-40% of these women regard their emotional and physical changes as difficult, and a smaller proportion report a significant effect on work, lifestyle, or relationships. Severe PMS that interferes with daily life affects approximately 3-5% of reproductive-aged women and is classified by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders as premenstrual dysphoric disorder (PMDD) (see also “Premenstrual Dysphoric Disorder” later in this section).The etiology of PMS remains ill defined. Levels of estrogen and progesterone are normal in women with PMS, although there may be an underlying neurobiologic vulnerability to normal fluctuations of one or more of these hormones. Stress does not appear to be a major risk factor for PMS.
Evaluation and Diagnosis
Diagnosis of PMS depends on the exclusion of other medical and psychiatric disorders and the demonstration, with a patient-completed prospective calendar, of true cyclicity of symptoms severe enough to impair the woman’s life. The diagnostic criteria for PMS are outlined in Box 4-2. These symptoms should be documented prospectively in two or three calendar months.
Clinicians should be able to rule out disease processes and psychiatric problems through a careful history, physical examination, and laboratory testing as indicated. Laboratory testing is only rarely needed; for example, a thyroid function test might be ordered if hypothyroidism is suspected.
Menstrual magnification or exacerbation of other medical or psychologic disorders (including migraines, asthma, depression, or an anxiety disorder) should be considered in the differential diagnosis and ruled out before PMS or PMDD is diagnosed.Box 4-2. Diagnostic Criteria for Premenstrual Syndrome ^
Premenstrual syndrome can be diagnosed if the patient reports at least one of the following affective and somatic symptoms during the 5 days before menses in each of the three prior menstrual cycles:[*****]
Affective
• Depression
• Angry outbursts
• Irritability
• Anxiety
• Confusion
• Social withdrawal
Somatic
• Breast tenderness or swelling
• Abdominal bloating
• Headache
• Joint or muscle pain
• Weight gain
• Swelling of extremities
Management
As an overall clinical approach, treatments should be used in increasing order of complexity. In most cases, therapy options should be considered in the following order:
Step 1. Supportive therapy, including a complex carbohydrate diet, aerobic exercise, nutrition supplements (eg, calcium), and spironolactone
Step 2. Administration of selective serotonin reuptake inhibitors; for women who do not respond, an anxiolytic agent can be considered to alleviate specific symptoms
Step 3. Hormonal ovulation suppression with oral contraceptives or gonadotropin-releasing hormone agonists
Lifestyle changes, including diet and aerobic exercise, should be recommended first. For additional supportive therapy, calcium supplements have been shown to be effective in the treatment of women with PMS. Magnesium, vitamin B6, and vitamin E may have minimal effectiveness. The bulk of scientific evidence does not support the usefulness of natural progesterone or primrose oil in the treatment of patients with PMS. Spironolactone is the only diuretic that has been shown to be of benefit in PMS. Oral contraceptive pills that contain drospirenone, an analog of spironolactone, may help treat premenstrual symptoms, although studies have not conclusively demonstrated benefit over other oral contraceptive pills.
Drug therapy should be considered for women with severe symptoms or symptoms resistant to supportive interventions. Several available drugs have been found to be effective for PMS and can be prescribed. Selective serotonin reuptake inhibitors are the initial drugs of choice, and any of the following may be used:
• Fluoxetine (It usually is administered in the morning to reduce insomnia. This drug is the most studied of the selective serotonin reuptake inhibitors.)
• Sertraline
• Paroxetine
• Citalopram
• Other antidepressants
— Clomipramine
— Venlafaxine
Clinicians should follow adult dosage guidance and should be aware that because some of these medications are available as extended-release formulations, dose and frequency may vary. Although continuous administration and luteal-phase administration are effective, one meta-analysis found continuous administration to be slightly more effective. Likelihood of patient adherence, however, can help guide the regimen. Treatment with the anxiolytic alprazolam is effective in some patients who are not relieved by other interventions, but its adverse effects limit its use as first- line therapy.
Oral contraceptives may improve physical symptoms of PMS, but their effectiveness in relieving mood symptoms has not been as promising. Gonadotropin-releasing hormone agonists and surgical oophorectomy have been shown to be effective in treating women with PMS. However, the adverse effects of hypoestrogenism limit their usefulness in most patients.
Premenstrual Dysphoric Disorder ^607
Premenstrual dysphoric disorder is defined by the American Psychiatric Association as the cyclic recurrence of severe, sometimes disabling changes in affect—such as mood lability, irritability, dysphoria, and anxiety—that occur in the luteal phase of a woman’s menstrual cycle and subside around, or shortly after, the onset of menses. These symptoms may be accompanied by the common physical and behavioral symptoms of PMS (Box 4-2).
The Diagnostic and Statistical Manual of Mental Disordersy diagnostic criteria for PMDD are shown in Box 4-3. Although many of the symptoms of PMS and PMDD may be similar, the primary distinction is that although the symptoms of PMS may be uncomfortable, the symptoms of PMDD are severe enough to interfere with a woman’s ability to function, comparable with other mental disorders, such as a major depressive episode or generalized anxiety disorder. Treatments for PMDD may be similar to treatments for depression (see also the “Depression” section in Part 3).Box 4-3. Diagnostic Criteria for Premenstrual Dysphoric Disorder <
A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses.
B. One (or more) of the following symptoms must be present:
1. Marked affective lability (eg, mood swings; feeling suddenly sad or tearful or increased sensitivity to rejection).
2. Marked irritability or anger or increased interpersonal conflicts.
3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
4. Marked anxiety, tension, feelings of being keyed up, on edge, or both.
C. One (or more) of the following symptoms must additionally be present, to reach a totally of five symptoms when combined with symptoms from Criterion B above.
1. Decreased interest in usual activities (eg, work, school, friends, hobbies).
2. Subjective difficulty in concentration.
3. Lethargy, easy fatigability, or marked lack of energy.
4. Marked change in appetite, overeating, or specific food cravings.
5. Hypersomnia or insomnia.
6. A sense of being overwhelmed or out of control.
7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain.
Note: The symptoms in Criteria A-C must have been met for most menstrual cycles that occurred in the preceding year.
D. The symptoms are associated with clinically significant distress or interferences with work, school, usual social activities, or relationships with others (eg, avoidance of social activities; decreased productivity and efficiency at work, school, or home).
E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).
(continued)
Box 4-3. Diagnostic Criteria for Premenstrual Dysphoric Disorder (continued)
F. Criteria A should be confirmed by prospective daily ratings during at least two symptomatic cycles. (Note: The diagnosis may be made provisionally prior to this confirmation.)
G. The symptoms are not attributable to the physiologic effects of a substance (eg, a drug of abuse, a medication, or other treatment) or another medical condition (eg, hyperthyroidism).
Reprinted with permission from the American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Washington, DC: APA. Copyright 2013 American Psychiatric Association. All rights reserved.
Bibliography
American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Washington, DC: APA; 2013.
Jarvis CI, Lynch AM, Morin AK. Management strategies for premenstrual syndrome/ premenstrual dysphoric disorder. Ann Pharmacother 2008;42:967-78. [PubMed]
Lopez LM, Kaptein AA, Helmerhorst FM. Oral contraceptives containing drospirenone for premenstrual syndrome. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD006586. DOI: 10.1002∕14651858.CD006586.pub4. [PubMed] [Full Text]
Marjoribanks J, Brown J, O'Brien PMS, Wyatt K. Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD001396. DOI: 10.1002∕14651858.CD001396.pub3.
[PubMed] [Full Text]Mortola JF, Girton L, Yen SS. Depressive episodes in premenstrual syndrome. Am J Obstet Gynecol 1989;161:1682-7. [PubMed]
Shah NR, Jones JB, Aperi J, Shemtov R, Karne A, Borenstein J. Selective serotonin reuptake inhibitors for premenstrual syndrome and premenstrual dysphoric disorder: a meta-analysis. Obstet Gynecol 2008;111:1175-82. [PubMed] [Obstetrics & Gynecology]
Yonkers KA, O'Brien PM, Eriksson E. Premenstrual syndrome. Lancet 2008;371: 1200-10. [PubMed] [Full Text]
Resources
American College of Obstetricians and Gynecologists. Premenstrual syndrome. Patient Education Pamphlet AP057. Washington, DC: American College of Obstetricians and Gynecologists; 2010.
Department of Health and Human Services, Office on Women's Health. Menstruation, menopause, and mental health. Available at: http://www.women- shealth.gov/mental-health/menstruation-menopause. Retrieved April 10, 2014.
Department of Health and Human Services, Office on Women's Health. Premenstrual syndrome (PMS) fact sheet. Available at: http://www.womenshealth.gov/publica- tions/our-publications/fact-sheet/premenstrual-syndrome.html. Retrieved April 10, 2014.