PMS / PMDD
Symptoms
Impairs function, symptoms remit with menses or shortly after
Affective - Depression, irritability, anxiety
Somatic - Breast pain, bloating swelling, headache
150 ascribed symptoms to PMS
References:
Rx PMS / PMDD - UTD
PMS - Jean Hailles / Medical Observer
PMS / PMDD Webinar - Jean Hailles Dr. Worley / Jean Haiiiles Endocrinologist = Most useful
IAPMD - IAPMD International Association of Premenstrual Disorders
PMDD
Premenstrual dysphoric disorder (PMDD) is more severe
5 to 10% of women of reproductive age
Symptom-free in the follicular phase
Diagnosis requires a 2-month daily diary
Needs 1 of depression, irritability, anxiety, affect lability
Needs 5 total including decreased interest, difficulty concentrating, fatigue, feeling out of control, insomnia, change in appetite, breast tenderness, breast swelling
Interfere with activities
Ddx
Premenstrual exacerbation of existing disorder (PME) e.g. depression
Cause
Normal hormone levels but different brain response
Progesterone sensitivity
Allopregnanolone metabolites of progesterone
Acts on GABA receptors
Menstrual migraine symptoms are triggered by the premenstrual decline in oestradiol
Increased inflammatory markers IL4, IL10
Natural history
Begin any time after menarche
Usually by the early 20s
Continue throughout life
Risk factors
Genetic factors - runs in families
Early childhood trauma
Exam
Normal
Investigations
Normal
Management as per Up To Date
MILD
Exercise and relaxation techniques
Vitex agnus castus (chasteberry)
Herbal supplement
Better than placebo for mild PMS
Others
No consistent evidence greater than placebo for Primrose oil, Vitamin B6, Vitamin E, Calcium, Magnesium
MODERATE TO SEVERE
SSRI
Most evidence of Sertraline, Citalopram, Escitalopram, Fluoxetine, Venlafaxine, Clomipramine
Can do continuous daily, luteal phase (starts day 14 and ends on menses), symptom onset therapy (also ends on menses)
60-70% of women with PMDD respond
COCP
Drospirenone-containing COCP with shortened pill-free interval e,g, 4 days
3mg drospirenone / 20mcg ethinyl estradiol e.g Yaz
If no improvement after 3 months increase to 30mcg ethinyl estradiol e.g. Yasmin
If no improvement trial continuous treatment (no pill-free days)
CBT
Reduces symptom intensity and distress
Management as per Medical Observer Article
According to Jean Hailles / Medical Observer Article
First line treatment
CBT
Exercise
Vitex agnus castus
Calcium
Vitamin B6
COCP with drospirenone
Continue or luteal phase (days 15 to 28) low dose SSRI
Second line treatment
Oestradiol patches 100mcg plus micronised progesterone 100mg vaginally or 200mg orally from days 15 to 28 of cycle
Higher dose SSRIs
Third line
GnRH analogues plus add-back menopause HRT (continuous combined oestrogen plus progesterone)
Fourth Line
Surgical treatment +/- menopause hormone therapy
Hysterectomy
Management as per Jean Hailles Webinar Dr Worsley
SSRI
60 to 70% effective
Fluoxetine has the lowest number of side effects
Start with 10mg
Can start at the onset of symptoms, or from day 14
A small study shows Fluoxetine stops Progesterone > Allopregnanolone
Half-life 7 days, less likely for withdrawal symptoms
Stop ovulation
COCP works well for some women but contains progesterone
Guidelines state Yaz
Dr. Worley doesn’t use Yaz
Problems are increased DVT risk and increase in anxiety on it
Zoely is an option
Non-pharmacology
Vitex agnus castus
One RCT, funded by people that sell Vitex
Mixed evidence for Vitamin B6
Ensure dose <100mg
High dose magnesium 900mg for menstrual migraine
Calcium
Some evidence
600mg twice a daily
Lifestyle management
Physical activity increases endorphins but only helps if done throughout the cycle
Doesn’t matter what type of exercise
Stress reduction
Psychological strategies
Diary management
Plan activities around your cycle, avoid stressful event at the time of period
Delegation
Chores, tasks to family
Sleep
Sleep hygiene, and insomnia is common
Avoid alcohol
Smoking cessation
Avoid illicit drugs
Case study 1
28 yo with PMDD
Not responding Fluoxetine or Sertraline
Has Mirena in situ
Answer 1
SSRI dose?
Daily vs cyclical
Trial other SSRI, SNRI
Consider Psychiatrist
Transdermal oestrogen
Moderate dose 50mcg
High dose 100mcg with often suppresses ovulation
Case study 2
Severe PMDD
First and second-line treatments fail
When to use chemical or surgical menopause?
Answer 2
Look at history very carefully
Try everything else first including transdermal oestrogen
Treat contributing factors
Migraine, Endo, Iron deficiency, Thyroid
Check for Coeliac, B12, other causes
Read the chemical / surgical menopause section of IAPMD
Ensure psycho-social support in place
Work out the aim of therapy? bridge to menopause
Usually add back HRT / MHT
Understand consequences
Low BMD
Case study 3
30yo mother, 2 x daughters, PMDD
Thoughts of intrusive self-harm 1 week prior to period
Mood drops quickly
Very heavy menstrual bleeding
Answer 3
Psychiatrist
Check Ferritin
Mirena + Transdermal oestrogen
Case study 4
46yo female, anxiety exactly 4 days before her period, improves after she finishes her period, has kept a diary
Best management for PMS morphing into perimenopause/menopause
Answer 4
PMS PMDD is often worse in the 40s
HRT / MHT
Femoston 2/10 or transdermal oestrogen + Mirena
SSRI
Case study 5
Perimenopausal cognition and mood changes in women with a history of worrsening mood of hormone contraceptives in the past
Answer 5
Usually SE to Progestin
Femoston, Tibolone, low dose OCP
E2 + Prometrium
