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

152 THE PREMENSTRUAL SYNDROMES
for a period of 2 months. Some type of severity rating
must be a part of these charts, such as using a scale
ranging from ‘0’ for no symptoms to ‘4’ for severe
symptoms, for example, and noting those that interfere
with functioning. Various validated diaries will be discussed
below.
The woman should then evaluate the impact of
various lifestyle approaches during the recording of her
symptoms. In order to minimize the her disappointment
with the prospect of leaving the office without
specific therapy, the following points should be made:
1. The diagnosis usually requires prospective monitoring
to rule out affective disorders that would
require daily, not luteal, therapy with specific psychotropics,
as opposed to hormonal agents.
2. Treatment options will be better tailored to her
symptom type and timing and to her other gynecological
needs, such as treatment of dysmenorrhea
or contraception.
3. Lifestyle change, stress reduction, and daily charting
may be effective treatment.
4. Treatment is usually necessary for most of the
reproductive years and thus the approach using the
lowest dose of a pharmacological agent specific for
the natural symptom duration and severity, and
providing the best side-effect profile is preferable.
The second visit consists primarily of reviewing the
symptom diary, establishing a diagnosis of a premenstrual
disorder and choosing the optimal treatment
approach. Dividing a woman’s symptom ratings into
the premenstrual, menstrual, and postmenstrual phases
will determine if a temporal relationship exists between
symptoms and menses.
Daily Rating Forms
There is a lack of agreement on the practicality of daily
prospective symptom rating due to the amount of time
required and delay in therapeutic interventions while
symptoms are recorded. Some consider that an interview
by an appropriately trained psychiatrist could
suffice to exclude an underlying psychiatric disorder
and could replace daily symptom recording. However,
this is not universally accepted (particularly for research)
and is contrary to the guidance in DSM-IV. Daily
symptom diaries can also be therapeutic, increasing
patient involvement and adherence to management
strategies and allowing for the individualization of
treatment. When the woman is unable to provide
prospective data, the spouse/partner can keep a calendar
of premenstrual observations to establish the type,
severity, and pattern of symptoms. One must recognize
the limitations of self-reported retrospective measures.
Biases include sociocultural, environmental, and patient
and family expectations. Patients may forget to fill out
the calendar daily and use recall to complete the missed
days. The use of an electronic, voice-activated device
that allows the patient to record daily while blinding
prior entries may assist in obtaining more accurate
information. 12
Some clinicians may prefer to use a visually graphic
evaluative tool. A visual analog scale (VAS) requires the
patient to rate specific symptoms on a line, 100 mm in
length. The anchor lines at the left- and right-hand ends
of the scale represent ‘0,’ or no symptoms, and ‘100,’
extreme symptoms. The VAS was recently revised to
more nearly reflect the DSM-IV-TR criteria for PMDD;
it includes the four core symptoms (irritability, tension,
depressed mood, and mood lability) and seven symptom
clusters (decreased interest in usual activities, difficulty
concentrating, lack of energy, appetite change, change
in sleep, feeling out of control, and somatic symptoms). 1
The days most appropriate for calculating the follicular
and luteal score in a clinical setting are cycle days 7
through 11 for the follicular score and days 16 through
22 for the late luteal score. 13
The Calendar of Premenstrual Experiences (COPE)
is a daily diary that includes 22 symptoms commonly
reported by women with PMS. 14 The symptoms are
rated on a four-point scale, ranging from ‘0’ for no
symptoms to ‘3,’ which indicates that the symptoms are
severe and the woman is unable to perform normal
activities. PMS is diagnosed when the total of the
points for the luteal phase (i.e. the last 7 days of the
cycle) is at least 30% greater than the sum of points for
the follicular phase of the cycle (i.e. days 3 through 9 of
the cycle).
The Daily Record of Severity of Problems (DRSP) is
a daily diary that has been developed for use in the
diagnosis of PMDD. 15 The 11 symptoms included in
the DSM-IV-TR diagnostic criteria for PMDD are
described in 21 separate items. In addition, the DRSP
includes three symptom-related areas of functional
impairment that are necessary for the diagnosis of
PMDD. Women are also instructed to list the days of
bleeding. Symptoms are rated on a scale ranging from
1 � not at all to 6 � extreme. The individual and
summary scores in the DRSP have high reliability and
tend to be sensitive to treatment differences.
Severe PMS and PMDD can be difficult to differentiate
from the premenstrual exacerbation of a medical or
psychiatric disorder. At present, a diagnosis of PMDD
specifically requires the exclusion of any psychiatric
disorder that might explain the symptoms. 5 In screening
for psychiatric disorders, it is especially important
to determine any past or current episodes of depressive,