Areesha Arshad

1^st Year MBBS, Islamabad Medical and Dental College, Islamabad, Pakistan

Key points:

• Definition and significance of PMS
• Epidemiology
• Pathophysiology
• Symptoms
• Evaluation
• Treatment/Management
• Prognosis and complications
• Deterrence and patient education

Definition and significance:

A woman of reproductive age experiences menstruation sometimes referred to as menses or the menstrual cycle. Women may have a range of cyclical and recurring symptoms related to their menstrual cycle that may interfere with their daily activities. Premenstrual disorders (PMDs) are defined as any set of symptoms a woman experiences before her menstrual cycle. They are classified into two groups by the International Society for Premenstrual Disorders: variant PMDs, which have more complex features such as premenstrual exacerbation, PMD with anovulation, PMD with absent menstruation, and progestogen- induced PMDs, and core PMDs, which are typical, pure, or reference disorders associated with spontaneous ovulatory menstrual cycles.¹

Core PMDs include premenstrual dysphoric disorder (PMDD) and premenstrual syndrome (PMS). During the luteal phase just before menstruation, a variety of physical and mental symptoms known as PMS recur often and go away a few days into the menstrual cycle. This is regarded as the fundamental description of PMS. Various categories make use of more specific criteria. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and the American Congress of Obstetricians and Gynecologists (ACOG) emphasis on the management of symptoms and treatments to identify PMS/PMDD in a more clinically significant way.¹

Epidemiology:

Based on well-established research, 90% of women who are fertile experience premenstrual symptoms ranging from moderate to severe. Of these, between 20% and 40% have PMS, while between 2% and 8% have PMDD. In a similar vein, it seems that the prevalence of PMDD varies by ethnic group and culture. The incidence of PMDD is 2.4% in a national sample of Korean women, 3.3% in a population of Bulgarians, 7.7% among Jordanian female university students, and 17.6% among young adult women in southern Brazil. Female university students are affected the most by PMS, and it adversely affects their life and academic performance. This geographical difference in the prevalence of PMS may be attributed to disparities in genetic, dietary, and lifestyle factors among young adult females and may be attributable to various community-adopted practices before and during menstruation.

Pathophysiology:

Premenstrual syndrome has a complicated, ambiguous, and poorly understood pathogenesis. Progesterone is thought to affect neurotransmitters such as gamma-aminobutyric acid (GABA), opioids, serotonin, and catecholamines, which may have an impact on PMS. This condition may potentially be caused by a preexisting serotonin deficit with enhanced progesterone sensitivity. PMS is associated with increased prolactin levels or sensitivity to the effects of prolactin, abnormalities in the hypothalamic-pituitary-adrenal (HPA) axis function, insulin resistance, deficits in specific nutrients, including electrolytes, and hereditary factors.³

Symptoms:

Premenstrual syndrome symptoms can be minor, moderate, or severe. Changes in appetite, weight gain, headaches, back, low back, and stomach discomfort, as well as swelling and tenderness in the breasts, nausea, constipation, anxiety, restlessness, irritability, aggression, and mood swings are some of the symptoms that may accompany these conditions. Affective symptoms might last anywhere from a few days to two weeks. Usually, symptoms start to worsen a week before menstruation starts and peak two days before.⁴

Evaluation:

It is necessary to rule out several other physical and psychological conditions in order to diagnose PMS and PMDD. The presence of three elemental criteria — symptoms being consistent with PMS, persistent symptom occurrence exclusively during the luteal phase of the menstrual cycle, and detrimental effects on the patient's function and lifestyle—confirms the diagnosis. Patients should be urged to record their premenstrual symptoms for a continuous month to check for cycle-to-cycle fluctuation.⁵

Obtaining results for follicle-stimulating hormone (FSH), estradiol (E2), thyroid-stimulating hormone (TSH), prolactin, cortisol, and thyroid problems, as well as ruling out hyperprolactinemia might potentially be part of the first workup for diagnosis.

Management:

The main intention to treat PMS is symptom relief and to reduce its effects on daily routine activities. Premenstrual syndrome was traditionally treated with pharmacotherapy, however recent studies have indicated that combination therapy provides greater advantages. Premenstrual symptoms have been successfully treated by combining pharmacotherapies (such as NSAIDs, SSRIs, anxiolytic agents, gonadotropin-releasing hormone (GnRH) agonists, spironolactone, and oral contraceptive pills) with nonpharmacological therapies, primarily cognitive and behavioural therapies, exercises, massage therapy, light therapy, and dietay and nutritional modifications.⁶

Regular exercise, avoiding stressful situations, and upholding sound sleeping practices—particularly in the lead-up to menstruation—are examples of lifestyle adjustments.

The goal of cognitive-behavioural therapy (CBT) is to address disruptive, unresolved ideas, actions, and emotions. CBT assists in identifying these habits and in creating coping mechanisms to enhance day-to-day functioning. The only herbal remedy that has been proven to regulate mood swings and irritation associated with PMS is the fruit extract Vitex agnus- castus. PMDD symptoms have been shown to improve in recent trials using combination oral contraceptives that include 3. mg of drospirenone and 0.02 mg of ethinyl estradiol. When treating PMS with mostly emotional symptoms, selective serotonin receptor inhibitors (SSRIs) might be utilized as the first line of therapy.⁷

Prognosis:

Symptoms of PMS can mostly recur after stopping the treatment, except after oophorectomy and menopause.⁸

Complications:

Untreated PMS is likely to have an impact on one's sexual life and raise one's level of sexual anguish, which can then result in relationship problems and other psychiatric disorders. Additionally, there is proof linking PMS to a higher risk of suicide in hormone- sensitive women.⁹

Deterrence and Patient Education:

Premenstrual syndrome is a prevalent issue among females of child-bearing age. Providing the patient with accurate and adequate insights regarding her condition, reproductive health and lending an empathetic ear is important. The involvement of the partner in understanding the problem also assists the patient in seeking help at home or seeking treatment with the health care provider. Informing family members and significant others about supportive actions that lessen PMS symptoms is equally vital. Couple-based cognitive behavioral therapy (CBT) therapies significantly improve behavioral coping. Since PMS is a frequent issue, it is crucial to provide widespread information about its diagnosis and successful treatment via radio, TV, and internet channels.¹⁰

References