Premenstrual Syndromes : PMS and PMDD - Rutuja :: The site ...

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Clinical evaluation and management
Andrea J Rapkin and Judy Mikacich
INTRODUCTION
The clinical approach to evaluation and management
of premenstrual syndrome (PMS) or premenstrual dysphoric
disorder (PMDD) involves taking an accurate
history, prospective daily symptom monitoring to
establish the diagnosis, patient-specific initial medical
or psychological therapy, and adequate follow-up with
appropriate alterations in the treatment plan. A typical
patient can present with premenstrual irritability, mood
swings, anxiety and/or depression, and physical symptoms
that may include breast tenderness, bloating,
fatigue, appetite, and sleep alterations, or difficulty
concentrating; these conditions result in significant
overall interference with daily activities or social interactions.
As the symptoms are not unique in their nature
but only in their timing, the diagnosis should be made
only after the patient completes daily recording of bothersome
symptoms for 2–3 consecutive months. However,
a detailed psychiatric interview by an appropriately
trained professional may rule out underlying affective
disorder. This may be a useful compromise when only
retrospective information is available. 1 Various medical
and affective disorders included in the differential diagnosis
must be excluded. Current management strategies
include education and self-care, calcium supplementation,
and the choice of a number of psychotropic agents
that augment serotonin, administered either throughout
the cycle or during the luteal phase alone. Pharmacological
options include selective serotonin reuptake
inhibitors (SSRIs), serotonin/norepinephrine reuptake
inhibitors (SNRIs), serotonergic tricyclic antidepressants,
or hormonal approaches that prevent ovulation,
such as some oral contraceptives, gonadotropin-releasing
hormone agonists (GnRH agonists), danazol, and highdose
estrogen. Psychological approaches, including
cognitive/behavioral and relaxation therapy, may also
be effective. The treatment plan should be designed
according to the patient’s specific symptoms, past pharmacological
treatment experiences, and other current
and past health and contraceptive needs.
CLINICAL EVALUATION
Diagnostic criteria
One of the limitations in establishing the diagnosis of a
premenstrual disorder is the lack of universally accepted
diagnostic criteria. Factors generic to the diagnosis
of PMS and PMDD are that (1) the somatic, affective,
and/or behavioral symptoms only occur in ovulatory
women and that (2) the symptoms must recur cyclically
in the luteal phase of the menstrual cycle and resolve by
the end of menses, leaving a symptom-free interval in
the late follicular phase, before ovulation.
The American College of Obstetricians and Gynecologists
(ACOG) published a practice bulletin on PMS
containing diagnostic criteria. 2 According to these criteria,
the diagnosis of PMS requires that a woman must
have one or more of the affective or somatic symptoms
listed in Table 17.1.
The PMS criteria additionally specify that the symptoms
must occur during the 5 days before menses in
each of three prior menstrual cycles, with relief by day
4 of menses. This cyclic pattern must be confirmed in at
least two consecutive months of prospective symptom
charting. The symptoms must be bothersome, with the
woman experiencing dysfunction in social and/or occupational
spheres. These recurring symptoms must be
present in the absence of pharmacological therapy,
including hormones, or use of alcohol or drugs. Other
psychiatric and medical disorders must have been
excluded as a potential cause of the symptoms. 3,4