1. Premenstrual Syndrome
Krishna B. Singh, MD
Department of Obstetrics & Gynecology
LSU Health Sciences Center
Shreveport, LA

2. PMS: Topics Covered Historical review Incidence Clinical features
Diagnosis
Management
Summary

3. PMS: Learning Objectives
Be able to understand that...
PMS is a common clinical condition
Multiple clinical symptoms/mood changes
Few hormonal, biochemical changes
Many theories of pathogenesis
Many treatment options available

4. PMS: Literature Review
First described by Robert Frank (1931) as PMT in 15 cases
Katharina Dalton (1953) popularized the term PMS and reported 86 cases
New developments (JAMA: 1992)
Websites for support groups

5. Definitions of Premenstrual Syndrome
Recurrence of symptoms premenstrually with complete absence of symptoms after menstruation (Dalton 1984)
Other Definitions: National Institutes of Mental Health; American Psychiatric Association

6. Incidence of Premenstrual Syndrome
The incidence varies 40-97%
About 5% women in US have severe PMS
50% may have moderate PMS

7. PMS: Problems In Focus Absentees from work: ~ 5 billion dollars (1969)
Association with intellectual impairment
Increased numbers of crimes and violent acts
Increased admissions in psychiatric hospitals

8. PMS: Known Risk Factors
Genetic factors: Monozygous twins affected
Adolescent daughters and natural mothers
Positive correlation with high parity, history of toxemia of pregnancy, post-partum blues, alcohol abuse and working outside the home
Not correlated with marital status, educational level, race or culture

9. PMS: Clinical Features Reported
More than 150 signs and symptoms
Cluster analysis used for sub-types of PMS
Neuroendocrine disorder; pathogenesis poorly understood: neuropsychological components include symptoms - A type PMS; B type PMS
Both components present C, D and E types- These require consultations

10. Theories of Premenstrual Syndrome
PMS considered a global and multifactorial neuroendocrine disorder
Brain and limbic system control the hypothalamus-pituitary-ovarian axis that are needed for reproductive cycle initiation and maintenance; may be mood changes
PMS is a disorder of multiple theories

11. Possible Causes of PMS
Beta-endorphin deficiency: lower plasma levels during the luteal phase
Serotonin (5HT) deficiency: Platelet uptake and blood levels decreased during the luteal phase
Progesterone withdrawal rather than deficiency; receptors may be abnormal

12. PMS: More Theories... Carbohydrate metabolism and GTT
Protein and amino acid metabolism
Prostaglandins and prostanoids
Sodium, potassium, Ca++ metabolism
Vitamins: A, B6 and E
Minerals: zinc and copper

13. PMS: Differential Diagnosis
Laboratory tests remain controversial
Baseline values: CBC, morning
Baseline serum PRL, TSH, morning
Cervical swab for wet mount, KOH prep

14. Diagnosing Premenstrual Syndrome
Daily diary, assessment charts, other ancillary methods are helpful aids to clinical diagnosis
The time and timing of the symptoms are more important than severity of symptoms
History and physical examination with selected laboratory and hormonal tests during several visits are essential components

15. PMS: Things To Remember
Rule out psychological conditions which may require referral to psychiatrists and counselors
Beware of misdiagnosis “on the fly”
Consider the family and friends connection
Supportive and educational measures have strong placebo effects (up to 40%)

16. PMS: Management Issues
Principal components: confirm diagnosis and identify category; identify and manage concurrent illness; identify and manage social and family triggers; identify and manage patient needs
There are numerous options for management but no curative treatments

17. PMS: Treatment Options
General measures: diet, exercise, relaxation
Avoid megadose vitamins and OTC drugs
Contraception: DMPA 150 mgm/3 months
Hormones: Micronized or P4 suppository ( mgm/d); Parlodel, Danazol as needed
Drugs: Alprazolam (Xanax 0.25 mg/tid); Fluoxetine (Prozac 20-60mg/d); Buspirone (BuSpar 5 mg/tid)

18. Treatment Summary of PMS
Hormonal: progesterone, GnRHa
Non-hormonal: antidepressants, diet
Supportive and cognitive...
Support groups; Websites portals
Educational materials available

19. PMS: Things To Remember
Patients who fail to respond probably do not have PMS or allied condition
About 80% PMS patients will have remission of symptoms for more than a few months
About 50% PMS patients may respond to a combined psychiatric and endocrine intervention

20. What This Means...
PMS is a common disorder in the reproductive age group of women; these women generally have regular menstrual cycles
PMS has many facets of clinical presentation
PMS can be successfully managed and treated