So today I'd like to talk to you about molimina, premenstrual syndrome
and premenstrual dysphoric disorder.
These are three different clinical scenarios
that will be helpful in you taking your step two.
So during the reproductive years,
a lot of women about 80-90% of menstruating women
will experience some symptoms.
They’ll have breast pain, bloating, acne, or constipation,
that will forewarn them of an impending menstruation.
This is called molimina.
This is a normal natural process that happens prior to your period,
and it can alert women that their period is coming.
Premenstrual syndrome, however, is a bit different.
It encompasses a wide range of severity with more than
100 physical and psychological symptoms reported.
Over 60% of women report some swelling or bloating.
And some women have cyclical breast pain
and about 22% of those women express moderate to extreme discomfort.
30%-40% of women are sufficiently bothered
to ask their health care provider about how to relieve symptoms.
Usually these symptoms with PMS appear the week before menstruation
and resolve within one week of the onset of menses.
This is different though than premenstrual dysphoric disorder,
which is abbreviated PMDD.
This diagnosis should be reserved for a more severe constellation of symptoms.
And they are mostly psychiatric.
These symptoms can lead to periodic interference with the day-to-day activities
and interpersonal relationships that the patient may experience.
PMDD has a 3%-5% incidence during their reproductive years.
There are different causes for PMS and PMDD.
We think that it could be ovarian fluctuation, ovarian steroid fluctuation.
It could be a lack of CNS neurotransmitters.
It could be a genetic predisposition,
or it could be the suicidal and social expectations place on a woman.
There is a distinct diagnostic criteria for PMDD.
Recall that these diagnoses is mostly a psychiatric diagnosis.
So the diagnosis is based on a, the timing of symptoms.
In the majority of menstrual cycles,
at least 5 symptoms must be present in the final week before the onset of menses.
And they then start to improve after the onset of menses.
The symptoms that one can experience
with PMDD include marked lability,
marked irritability, depression and anxiety.
However, you can also experience decrease interest
in your usual daily activities and that can also lead to fatigue,
difficulty concentrating and change in your whole appetite.
It can also lead to sleep abnormalities and feeling overwhelmed or out of control.
Breast tenderness, swelling, joint pain;
also make up this constellation of symptoms.
The symptoms are usually severe enough
that they interfere with the daily activities that the woman may experience.
However, the most important thing with PMDD
is that we not forget to consider other psychiatric disorders
and you can actually have a presentation of PMDD at the same time that you have
co-occurring psychiatric and mental disorders.
The confirmation of the disorder is made by
criterion A, should be confirmed by a prospective daily rating
during two symptomatic cycles.
And we must not forget that you have to exclude other medical explanations.
So the diagnostic criteria for PMDD include
a daily listing of symptoms, rating of symptoms
throughout the month that are severe.
Timing of symptoms that lead in relationship rather to menstruation.
And rating the baseline symptoms during the follicular phase
which is the first half of the menstrual cycle.
Clinically we sometime use a tool called PRISM Menstrual Calendar.
And PRISM stands for Perspective Record of Impact and Severity of Menstrual symptoms.
It’s a menstrual calendar that allows the woman to record their symptoms accurately.
In actual practice, we don't use this,
however it’s something good to know for your exam.
There are some laboratory test that we typically send
on a woman who is experiencing these symptoms.
TSH or thyroid-stimulating hormone,
is a test that we would use to make sure the woman
doesn't have hypothyroidism or hyperthyroidism.
In terms of management of PMDD,
the first thing we wanna do is encourage healthy communication strategies,
so that during times of irritability and anger,
the patient can communicate effectively with the people around her.
We also counsel patients that improving their diet
during this time can help with their overall symptoms, especially bloating.
So we encourage them
to eliminate salt, sugar, processed food that would encourage more bloating.
Exercise is a really good treatment strategy
and that it helps relieve stress which can also
exacerbate the symptoms that a woman might be suffering from.
However, if those management strategies do not work,
medical options are an alternative.
Medical ovarian suppression with oral contraceptive pills
has been shown to be very effective
and usually those pills are prescribed continuously.
Another medication is Danazol.
Danazol is an androgenic medication that causes
oily skin, male pattern hair growth, and breast atrophy.
So most women don’t desire these symptoms.
Another method of ovarian suppression are GnRH agonists.
GnRH agonists shut down the hypothalamic, pituitary-ovarian access
and cause vasomotor symptoms such as
hot flashes or hot flushes as they are known medically
and they can also lead to bone loss.
Another proven strategy to treat PMDD are luteal phase SSRIs.
Selective serotonin reuptake inhibitors, which increase serotonin levels.
So in your checklist, remember to take accurate and thorough gynecologic history.
Rule out other psychiatric disorders and rule out other medical causes.
Ask the patient to keep a menstrual calendar if you're having trouble making the diagnosis.