Malady Wise

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PMS / PMDD

Maladywise

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:

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