Premenstrual syndrome
Recurrence of the psychological or somatic symptom or both occur specifically during the luteal phase of menstrual cycle and resolve in the follicular phase , at least by the end of the menstruation ( one week free ).It occur most of the women, 80% of regularly ovulating women experience some degree of physical & psychological premenstrual symptoms, in 5% or less, these symptoms are so severe that they seriously interfere with daily functioning or personal relationships.
Common symptoms reported by patients include :
Depression , insomnia , irritability, anxiety, tension, feeling out of control ( psychological symptoms). Bloating ( sense of abdominal swelling ) , headache , mastalagia ( breast swelling and tenderness), odema & weight gain (physical symptoms).
There is no objective tests to assist in the diagnosis, so the diagnostic criteria for PMS:
-symptoms seriously interfere with usual functioning & relationships.
- premenstrual timing is confirmed by menstrual calendar in 2 consecutive cycles.
- symptoms resolve after onset of menses.
- symptoms are not an exacerbation of another disorder.
At least 5 premenstrual symptoms :
Depressed mood
Marked anxiety
Marked affective lability
Marked irritability
Other possible symptoms ;( decreased interest in regular activities, fatigue, appetite change, sleep change, headache, bloating, breast swelling& tenderness) .
GnRH agonist may be used in diagnosis of the premenstrual syndrome .( it suppress the ovarian cycle & then resolve the symptoms ) .
Aetiology: the cause of PMS is uncertain .
Multifactorial ( genetic, envirmental, psychological), the cyclic progesterone produced in luteal phase is responsible on the symptoms in women who are unusually sensitive to the normal level of progesterone,( increase sensitivity to progesterone related to dys regulation of the serotonin metabolism )
Estrogen has effect on neurotransmitter ( increase serotonin receptor & synthesis which play role in regulation mood, sleep, sexual activity.
Treatment :
First line: life style modifications ( exercise, stress reduction, dietary change)
Combined oral contraceptive pills ( ideally continuous)
Selective serotonin reuptake inhibitors : fluoxetine 20 mg daily ( continuous or luteal phase)
Second line:
Esterdiol patches + oral progesterone (dydrogesterone) or levonorgestel IUCD
SSRIs ( 40 mg continous or luteal phase)
Third line
GnRH analogues + addback HRT ( tibolone)
Fourth line
Total abdominal hysterectomy and bilateral oopherectomy + HRT .
Dysmenorrhoea: painful menstruation, may be primary ( no identifiable cause) , secondary ( associated with pelvic pathology). It is commonest problem 50% of women (10% interfere with daily activity).
Primary dysmenorrheal: occurs during ovulatory cycles & usually appears within 6-12 months of the menarche. The etiology of it has been attributed to uterine contraction with ischemia & production of prostoglandins.
hypercontractility( increase amplitude, frequency of uterine contraction) lead to decrease endometrial blood flow (ischemia) with colicky pain.
During menstruation , prostoglandins are realeased as a consequence of endometrial cell lysis. So menstrual fluid from women with this disorder have higher than normal levels of PGs especially PGF2 & PGE2 which produce the discomfort & other associated symptoms such as nausea, vomiting, headache.
Sign & symptom:
Pain begins a few hours before or just after the onset of menstruation & usually lasts 48-72 hours, cramp - like & is usually strongest over the lower abdomen & may radiate to the back or inner thighs .this pain associated with other symptoms ( nausea, vomiting diarrhea, fatigue, lower backache, headache) .
Pelvic examination findings are normal.
Treatment:
Life style change: low fat diet, exercise may improve symptoms by improving pelvic blood flow.
Medical measures: NSAIDs( ibuprofen, mefenamic acid, naproxen.
Hormonal contraceptive: oral COCP ,hormone releasing IUCDs. High dose continuous daily progestogens( medroxy progesterone acetate or dydrogesterone). Resistant cases may respond to tocolytic agents( sulbutamol, nifedipine).
Nonpharmacologic: psychotherapy ,hypnotherapy, transcutanous electrical stimulation, heat patches.
Surgical:presacral neurectomy & uterosacral ligment section.
Secondary dysmenorrhea :it isnot limited to the menses & can occur before as well as after the menses. It is less related to the first day of flow , develops in older women ( 30-40) & is usually associated with other symptoms such as dyspareunia, inferitility, abnormal uterine bleeding.
Causes :
-endometriosis & adenomyosis : pain extends to premenstrual or postmenstrual phase or may be continuous, deep dyspareunia, premenstrual bleeding .
- PID : initially pain may be menstrual, but with each cycle it extend to premenstrual phase, intermenstrual bleeding, pelvic tenderness.
- fibroid
- IUCD
- pelvic congestion: dull, ill defined pelvic ache, worse premenstrual , relieved by menses .
- cervical stenosis & haematometra .
Treatment :
Treat the underlying cause. The treatments used for primary dysmenorrheal are often helpful .