PREMENSTRUAL SYNDROME PMS

PREMENSTRUAL SYNDROME (PMS)

Many women experience physical and emotional symptoms 7-14 days before onset of menses that drop slowly on 3^rd to 4^th day of menses. These symptoms affect their normal life and go month to month, thus describe under the term "premenstrual syndrome" (PMS). The symptoms appear at luteal phase, i.e. on start of ovulation (14 or 15 day of 28-days cycle but vary among every woman).

The symptoms mostly start on adolescent or 14 year age (at that time called menstrual pain or primary dysmenorrhoea) until menopause. PMS develop in late 20 to 40 year of age or few years before menopause.

The most severe PMS, affecting daily activities and relationships, is "Premenstrual Dysphoric Disorder" (PMDD). The severity of symptoms, affecting the quality of life, help us to differentiate PMS and PMDD. Sometimes the mental symptoms of PMDD are too severe.

OVERVIEW

·         PMS have symptoms of breast swelling, pain, abdominal bloating, and headache, temporary weight gain, depression, irritability, anxiety and food cravings.

·         There is no test for diagnosis but symptoms may help. Daily symptoms dairy for at least two months is helpful in diagnosis.

·         Hot water bag on abdomen relieve pain.

·         Calcium, magnesium, vitamin B6 supplements are good in PMS.

·         OTC medicine like ibuprofen, acetaminophen, naproxen and mefenamic acid etc are helpful in reducing pain and other physical symptoms but should take before onset of menses. OTC medicines should be taken after getting advice by pharmacist and general practitioner (GP).

·         Hyoscine hydrobromide (buscopan) is most effective for lower abdominal pain.

·         Prescribed medicines should be taken after getting prescribed by doctor.

·         Doctor should know about OTC medicines using by patient before prescribing.

·         Good lifestyle are also helpful in relieving PMS, as regular exercise; reduce caffeine, salt and sugar; cease smoking and alcohol intake; reduce stress; healthy nutrients.

POPULARITY

Surveys have shown that 90% of women suffer from PMS, out of them only 5^th seek medical help. These studies are free of racial and ethnic differences. But most women are over 30 year of age.

CAUSES

The exact cause is unknown---- but different thoughts are,

It may be due to

ü  Imbalance between estrogen and progesterone.

ü  Transient water retention in different body tissues due to estrogen action.

ü  Excess of aldosterone and antidiuretic hormone.

Recently, it is believe that it is due to:

ü  Interaction between ovarian steroids and serotonin in brain.

RISK FACTORS

·         Advancing age, i.e. greater than 30 year

·         Genetic factors

·         Hereditary, i.e. mothers with PMS

In case of PMDD, traumatic events like

·         Physical threat

·         Childhood abuse

·         Severe accidents

SYMPTOMS

Symptoms range from mild to severe especially mood symptoms.

v  Physical Symptoms include

·         Swelling

·         Breast fullness

·         Acnes

·         Headache

·         Abdominal bloating (Pain in lower part of abdomen)

·         Temporary weight gain

v  Behavioral Symptoms include

·         Sleep disturbances

·         Food craving

·         Poor concentration

·         Lack of interest in activities

·         Social withdrawal

v  Mood Symptoms include

·         Irritability

·         Mood swings

·         Anxiety/ tension

·         Depression

·         Feeling out of control

Symptoms of PMDD are severe, and more psychological than physical. These include:

·         Depression

·         Anxiety

·         Lack of interest in activities

·         Low self-esteem

·         Irritability

·         Fear of death

·         Sleepiness

If women with PMS also have asthma, epilepsy or dermatological disorders these disorders are worsen by PMS.

PMS symptoms confuses with mental health disorder like depression and anxiety.

Patient with PMDD may also involve in suicidal attempt.

Following points help to differentiate PMS from Primary Dysmenorrhoea (PD)

ü  Absence of behavioral and mood symptoms in PD.

ü  Difference in timing of symptoms relating to onset of menses.

DIAGNOSIS

No specific physical findings and laboratory tests are required.

American College of Obstetricians and Gynecologists (ACOG) diagnostic criteria for PMS suggest:

ü  Diagnosis made in presence of one affective and one somatic symptom in three past menstrual cycles during 5 day before onset of menses.

ü  The symptoms must be present in two consecutive cycles recorded.

ü  The symptoms must adversely affect the social relationships and work activities.

The diagnostic criterion for PMS has three essential characteristics:

ü  Symptoms must occur 5 days before onset of menses and resolve few days of menstruation.

ü  Symptoms are consistent from atleast two menstrual cycles and better diagnosed by other physical or psychological symptoms.

ü  Symptoms are severe to act social and work-related activities.

Every woman with PMS must keep "daily dairy" for at least two consecutive months to observe the severity of symptoms. The dairy is the baseline to assess the severe symptom and once therapy selected, it help to access patient response.

TREATMENT

SELF-CARE AT HOME

·         Keep daily dairy of all symptoms for at least two months.

·         Reduce stress.

·         Exercise for at least 30 minutes daily including walking, swimming and aerobics. Yoga is helpful for mental relaxations. Too much exercise result in the menstrual irregularity.

·         Reduce salt and sugar in daily diet.

·         Eliminate red meat from diet.

·         Stop caffeine intake 2-3 days before symptoms. Reduce daily intake of caffeinated beverages (coffee, tea, cola, and hot chocolate) to one serving a day. If you are taking eight servings daily, reduce it to four servings daily on next week, then to two servings daily on next week and then one serving daily on further week.

·         Stop alcohol intake as it reduce the vitamin B and minerals. Alcohol is toxic to liver and reduces its ability to metabolize hormones.

·         Smoking cessation.

·         Supportive bra is helpful if breast swells.

·         Hot water bag on abdomen relief abdominal bloating.

OVER-THE-COUNTER (OTC) MEDICATION

Calcium

Calcium 1200mg, given as 600mg two times a day, for three menstrual cycles decrease physical and emotional symptoms as abdominal distention, fatigue, headache, food craving and pain.

Calcium is safe and provides prevention for osteoporosis.

Magnesium

Magnesium is mast effective for pain in PMS as compared to other medication. Its dose range from 200 to 360 mg daily.

Pyridoxine (Vitamin B6)

Vitamin B6 is mast effective for depression symptom in dose of 50-100mg daily. But its long-term use is not advised.

NSAIDs

NSAIDs are used to relieve physical symptoms of PMS as headache, joint pain, etc but not effect behavioral and mood symptoms. These medicine are given before the menses but stop on start of menstrual bleeding.

·         Naproxen 500mg initially then 250mg every 6-8 hour as required.

·         Mefenamic acid orally three times a day reduces physical symptoms but not breast pain.

·         Other NSAIDs include ibuprofen, acetaminophen etc.

Diuretic

Diuretics are used to remove water from the body. During PMS increase sodium level in the body result in the increase water retention, resulting in swelling of breast (breast tenderness) and abdomen (abdominal bloating). Spirnolactone 100mg daily orally before menses when symptoms start is effective in reducing breast tenderness and abdominal bloating.

PRESCRIPTION MEDICATION

Selective Serotonin REUPTAKE INHIBITORS (SSRIs)

SSRIs are effective in reducing irritability, depression mood, psychological function and physical symptoms of PMDD or severe PMS like bloating, breast tenderness and food craving.

Medications include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluoxamine (Luvox), paroxetine (Paxil), paroxetine controlled release (Paxil CR), sertraline (Zoloft)

Psychotropic Agents

Psychotropic Agents are beneficial in relieving psychological and physical symptoms. These include

ANTIDEPRESSANT:

·         Nefazodone with brand name Serzone

·         Venlafaxine with brand name Effexor

BENZODIAZEPINES: Alprazolam with brand name Xanax, reserved for those unresponsive to other therapies.

Combination Oral Contraceptives

A low dose combination oral contraceptive, ehinyl estradiol (20µg) and 3mg drospirenone with 4 days hormone free interval, is effective in treatment of emotional and physical symptoms.

Oral contraceptives, progestin medroxyprogestrone (PMPA), will reduce breast pain and abdominal cramping.

Hormone Therapy

Treatment with Gn-RH agonists is used for physical and psychological symptoms of PMS.

Danazol, 200mg two times a day, result in greater symptoms relief. But it is limited to those who have failed other therapy.

COGNITIVE BEHAVIORAL THERAPY

It is supported therapy given to patient of PMS for psychological symptoms.

SURGERY

OOPHORECTOMY—removal of ovaries, as ovaries remove there is no production of eggs, estrogen and progesterone and thus no menstrual bleeding. Oophorectomy result in menopause. Progestin-estrogen Hormone Replacement Therapy (HRT) is required for prevention of uterine cancer if only ovaries are removed.

HYSTERECTOMY—removal of uterus, after removal of ovaries, is helpful to prevent uterine cancer. Estrogen Replacement Therapy (ERT) is required for prevention of osteoporosis.

PREVENTION

Lifestyle Modifications

·         Regular exercise, as it increase brain chemical (endorphins) that lessen the pain.

·         Reduce stress with relaxation and sleep. Sleep for at least seven hours.

·         Quit smoking and alcohol intake.

·         Vitamin E 400 IU daily, magnesium 400mg daily, and evening primrose oil 500mg three times daily are important supplements in PMS. Vitamin B6 in a dosage of 100 to 500 mg taken after breakfast is a good supplement.

Healthy Diet

·         Reduce amount of caffeine, salt and sugar in your diet.

·         Bad eating habits should change to good habit slowly or step-by-step.

·         Diet in childhood affect the early menstrual cycle.

·         Following diet are helpful in preventing PMS:

v  Vegetables: leafy greens, beets, beans, cabbage, broccoli, cauliflower, Brussels sprouts, carrots, garlic, onions, radishes, squash, yams, turnips and peas.

v  Whole grains: brown rice, millet, oatmeal, barley, rye, and wheat (unless you are allergic to it).

v  Seeds and nuts: almonds, walnuts, or peanuts, pumpkin, sunflower or sesame seeds.

v  Fruit: apples, berries, and pears.

v  Oils: olive, sesame, canola, and safflower.

v  Meats: poultry and fish.

By:

Salma Nuzhat

2006-gwc-537

University College of Pharmacy

University of The Punjab, Lahore