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

to try self-help strategies that are widely recommended
for PMS to determine whether a non-medical approach
is helpful. 52
Diagnostic procedures
There are no laboratory tests or physical findings that
indicate a diagnosis of PMS. Laboratory tests should
not be routinely performed for this diagnosis, although
laboratory tests that indicate or confirm other possible
disorders are useful if suggested by the individual woman’s
symptom presentation or medical findings. A gynecological
examination is not mandatory, but may be important
for ruling out other disorders. Patients may consider
a pelvic examination unnecessarily intrusive, particularly
in the absence of physical symptoms. Menstrual
cycles that are irregular or outside the normal range are
an indication for further gynecological evaluation.
Specific information on functional impairment is helpful
for determining the impact of the symptoms. A medical
history with emphasis on reproductive events, other
physical disorders that might account for the symptoms,
mood disorders, and family history of PMS and
mood disorders should be obtained.
Premenstrual exacerbations and
comorbidities
Other disorders need to be identified if present. Primary
dysmenorrhea is often confused or included with PMS
but is a distinct diagnosis. Dysmenorrhea is characterized
by pelvic pain or backache that may occur for several
days but typically peaks on the first day of the menstrual
flow. Primary dysmenorrhea is linked to prostaglandins
originating in secretory endometrium and is relieved by
prostaglandin inhibitors in the great majority of dysmenorrheic
women. Pelvic pain, backache, or complaints
of dyspareunia may also signal endometriosis, particularly
in women who previously had pain-free menses for
an extended period of time. Symptoms of endometriosis
can be present throughout the month and are not
limited to the luteal phase, although women can also
have extensive endometriosis with little or no pain.
Migraine is associated with ovulatory cycles, as indicated
by its onset at menarche (10.7%), attacks in the time
around menses (60% of cases), and disappearance
during pregnancy (67% of cases), and may be a modulator
of PMS. 53,54 Menstrually related migraine attacks
appear longer and less responsive to the treatments
than non-menstrual attacks and consequently may
require different treatment considerations. 55
Many women who seek treatment for PMS have a
depression or anxiety disorder that is exacerbated premenstrually.
56,57 The extent of premenstrual exacerbation
CLINICAL PRESENTATION AND COURSE OF PMS 59
is suggested in the large STAR-D study of major depressive
disorder, where 64% of the premenopausal women
not taking oral contraceptives reported premenstrual
worsening of their depression. 58 The mood symptoms
that are predominant in PMS include depression,
anxiety, tension, and irritability, but these symptoms
are ongoing in mood and anxiety disorders and are not
limited to the luteal phase of the menstrual cycle. One
approach to differentiating PMS and mood disorders is
to evaluate the patient at least once in the postmenstrual
phase of the cycle when premenstrual symptoms
have remitted. Clinically significant mood or
anxiety symptoms in the postmenstrual phase strongly
suggest a psychiatric or other medical diagnosis.
There are numerous other conditions whose symptoms
may be confused with PMS or may be exacerbated
premenstrually. Physical conditions such as uterine
fibroids, endometriosis, adenomyosis, chronic pelvic
pain, ovarian cysts, pelvic inflammatory disease, seizure
disorders, thyroid disorders, asthma, allergies, diabetes,
hepatic dysfunction, lupus, anemia, chronic fatique syndrome,
fibromyalgia, and infections may worsen premenstrually.
Other psychiatric conditions that may be
comorbid or exacerbated premenstrually include substance
abuse, eating disorders, and schizophrenia. It
can be difficult to determine whether the symptoms
are an exacerbation of a comorbid condition or PMS
symptoms (that occur only in the luteal phase) superimposed
on another condition. In either case, the usual
recommendation is to treat the underlying condition
first, then assess the response to treatment and possibly
increase the dose premenstrually and/or add medication
for the symptoms that arise in the premenstrual
phase.
SUMMARY
Guidelines and criteria for diagnosis of PMS have
advanced in the past decade. Appropriate diagnosis has
become increasingly important as effective treatments
have been identified for PMS, and the majority of patients
can obtain relief from their symptoms. However, it is still
difficult for primary care clinicians to evaluate a disorder
that is linked with hundreds of possible symptoms, lacks
widely accepted criteria, and depends upon the patient’s
maintaining daily reports of the symptoms for several
months. A greater consensus on the diagnostic criteria
for PMS is needed, together with an empirical demonstration
that the criteria appropriately diagnose women
who seek treatment for PMS. Further studies of the utility
of well-designed retrospective reports of the symptom
complaints that can be administered at the office visit
are also needed. Continued advances in the diagnosis of