Chapter 73 Premenstrual Syndrome and Premenstrual Dysphoric Disorder
Clinical Case Problem 1 A 23-Year-Old Woman with Cyclic Physical and Affective Symptoms
Select the best answer to the following questions
1. What is the most likely diagnosis in this patient?
2. Which of the following is not a necessary Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criterion for diagnosis of this condition?
3. What is the main characteristic that differentiates this condition from major depression?
4. What is the main characteristic that differentiates this condition from premenstrual syndrome (PMS)?
5. Which of the following is a reliable aid in the diagnosis of this condition?
6. Which of the following statements comparing PMS and PMDD is (are) true?
7. Which of the following is true regarding hormone levels in patients with PMS or PMDD?
8. Which of the following pharmacologic treatments has demonstrated the best evidence (level 1a) to support its effectiveness for the treatment of PMDD?
9. Which of the following vitamins or minerals has demonstrated the best evidence (level 1b) to support its effectiveness for the treatment of PMDD?
10. Which of the following nonpharmacologic therapies have demonstrated the best evidence (level 1c) to support their effectiveness for the treatment of PMS and PMDD?
Answers
1. e.The patient’s presentation is most consistent with PMDD, a cyclic disorder of reproductive-age women characterized by a wide variety of severe emotional and physical symptoms that consistently occur during the luteal phase of the menstrual cycle. PMDD is a diagnosis of exclusion. Although the patient may have symptoms consistent with an affective disorder (anxiety, depression, and panic), the cyclic onset and remission of her symptoms in relation to her menstrual cycle are classic for PMDD. Dysmenorrhea is a condition characterized by pelvic pain that occurs just after the onset of menses and peaks with heaviest flow. This patient’s symptoms precede the onset of menses and remit during menses.
2. c.The following are DSM-IV diagnostic criteria for PMDD: (1) symptoms must be present most of the time during the last week of the luteal phase, (2) symptoms must remit a few days after the onset of the follicular phase (menses), (3) symptoms must be absent in the week after menses, (4) symptoms must occur in most menstrual cycles during the past year, (5) symptoms must interfere with function, and (6) symptoms must not be an exacerbation of an existing disorder.
3. d.The affective symptoms of PMDD can be indistinguishable from those of major depression. The recurrent onset and remission of these symptoms in relation to the menstrual cycle help distinguish PMDD from major depression.
4. b.Like PMDD, PMS is characterized by the cyclic recurrence of psychological and physical symptoms during the late luteal phase of the menstrual cycle. The variety of potential symptoms for both of these conditions is similar, and they generally begin between the ages of 25 and 35 years. Women who have more severe affective symptoms are classified as having PMDD. Both PMS and PMDD symptoms improve rapidly after the onset of menses.
5. a.PMS and PMDD can be diagnosed only after a variety of physical and psychiatric disorders have been excluded. PMS and PMDD are best distinguished from other conditions by the consistent occurrence of function-impairing symptoms only during the luteal phase of the menstrual cycle. This can be confirmed best by having the patient complete a prospective daily symptom rating form for at least two consecutive cycles. Although sensitivity to sex hormones may play a role in both of these conditions, patients with PMS and PMDD have normal estradiol, progesterone, FSH, LH, and other hormone levels. SSRIs often improve the symptoms of PMS and PMDD, although there is also a significantly high placebo effect in treatment of these conditions. SSRIs also alleviate the symptoms of several other similar conditions (depression, anxiety, and panic), so the response to their empirical use is nondiagnostic.
6. b.PMS and PMDD have in common a variety of psychological and physical symptoms that interfere with normal function. PMS (20% to 40%) is a significantly more common condition than PMDD (2% to 10%) in menstruating women. As many as 85% of menstruating women report having one or more premenstrual symptoms. Menopause usually results in cessation of these conditions.
7. e.There is no consensus regarding the etiology of either PMS or PMDD. Patients with these conditions usually have normal hormone levels. However, they appear to have an abnormal response to normal female sex hormone fluctuations.
8. a.Although numerous treatment strategies are available, few have been evaluated adequately in randomized controlled trials (RCTs). Even the results of RCTs can be difficult to apply because of the significant variability of inclusion criteria and outcome measures and the high response rate to placebo (25% to 50%). However, the systematic review of many of these RCTs has yielded some evidence-based recommendations.
There is clear evidence that SSRIs can significantly improve the symptoms of severe PMS and PMDD (evidence level 1a). Fluoxetine and sertraline are the most extensively studied for the treatment of PMS and PMDD, but all SSRIs appear to be effective. SSRIs can be administered daily or only during the luteal phase. However, there are no definitive recommendations regarding how long to continue treatment because symptoms tend to return on discontinuation.
Nonsteroidal antiinflammatory drugs (NSAIDs) can be helpful for symptoms of abdominal pain and headaches. Aldactone has been shown to relieve symptoms of fluid retention.
Estrogen and progesterone/progestin-containing products, administered by different routes (intravaginally, rectally, orally, and transdermally), have been widely prescribed for the management of PMS and PMDD. However, none has been shown to be consistently effective and actually may exacerbate symptoms in some patients. Low-dose estrogen therapy may improve some physical symptoms, but it does not appear to have a positive effect on mood symptoms. The efficacy of estrogen therapy is limited by the need for progestin/progesterone opposition, which commonly exacerbates PMS and PMDD symptoms; however, it is required to prevent endometrial hyperplasia or carcinoma.
Gonadotropin-releasing hormone (GnRH) agonists (e.g., leuprolide) and androgens (e.g., danazol) are somewhat effective in alleviating the physical and behavioral symptoms of PMS and PMDD. However, their short- and long-term side effect profiles limit their use.
The Food and Drug Administration approved the oral contraceptive Yaz (3 mg drospirenone/30 mcg ethinyl estradiol) for the treatment of the physical and emotional symptoms of PMDD, in women who choose to use an oral contraceptive as their method of contraception, on the basis of results of two RCTs. Drospirenone exhibits antimineralocorticoid and antiandrogenic properties unlike any other available progestin oral contraceptives. Although Yaz has been shown to be effective for the treatment of symptoms of PMDD, it has not been evaluated for the treatment of PMS. The effectiveness of Yaz for the treatment of symptoms of PMDD has not been evaluated for more than three menstrual cycles in clinical trials. Prescribing information for Yaz is available at http://berlex.bayerhealthcare.com.
9. b.There is good evidence that calcium is effective for the treatment of PMS and PMDD (evidence level 1b). A large, well-conducted RCT demonstrated that 1200 mg/day of calcium carbonate administered for three consecutive menstrual cycles resulted in significant symptom improvement in 48% of women with PMS compared with 30% of women treated with placebo. Although there is evidence suggesting that vitamin B6 may improve PMS and PMDD symptoms, most of the RCTs were of poor quality. Magnesium has been shown to have minimal benefit only in alleviating PMS-related bloating. Studies of vitamin A do not support its use for PMS or PMDD. The result of one RCT suggests that vitamin E, administered at 400 IU/day during the luteal phase, may improve both affective and somatic symptoms (especially mastalgia) in women with PMS. However, larger, better quality studies are needed.
10. c.Two herbal therapies, chasteberry and evening primrose oil, may be effective in alleviating breast tenderness in patients with PMS and PMDD (evidence level 1c). The other options either have been shown to be ineffective (dong quai) or lack sufficient data to support their use. Some even have potential severe side effects, such as kava kava (liver damage), blue cohosh (peripheral vascular constriction), and St. John’s wort (decreased oral contraceptive pill efficacy). One should also keep in mind the following: (1) none of the therapies listed is approved by the Food and Drug Administration for PMS or PMDD, (2) their safety in pregnancy and lactation has not been established, and (3) the manufacturing standards for herbal products are not uniform. Recommended nonpharmacologic interventions for patients with PMS and PMDD include the following: (1) patient education about the biologic basis and prevalence of the condition, (2) keeping a daily symptom diary, (3) adequate rest and structured sleep schedule, (4) sodium and caffeine restriction, and (5) aerobic exercise.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
