PMS and PMDD: Clinical Approaches Kathleen McIntyreSeltman, MD

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PMS and PMDD Clinical ApproachesKathleen
McIntyre-Seltman, MD
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Learning Objectives

• As a result of this presentation the participant
  will be able to
• Describe PMS and PMDD
• Counsel patients about lifestyle management
• Counsel patients about the risks and benefits of
  medical management

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In the Past

• hysteria mad behavior because the womb was
  wandering in search of a baby, resolved with
  onset of menstruation
• Premenstrual tension 1930s
• Premenstrual syndrome K. Dalton 1960s
• PMDD 1990s DSM IV 1994

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Premenstrual Dysphoric Disorder DMS-IV American
Psychiatric Association 1994

• At least 5 sx, with at least 1 of the first 4 sx
• Most cycles in last year
• Occur week before menses, remit first few days of
  menses, absent in post menstrual week
• Confirmed by prospective daily ratings in at
  least 2 cycles

• Sx must interfere with work, school, social
  activies, relationships
• Sx NOT due to exacerbation of other psych disorder

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Premenstrual Dysphoric DisorderDMS-IV American
Psychiatric Association 1994

• At least 1 of these

• Along with any of these

• Depressed mood or hopelessness
• Anxiety or tension
• Affective lability
• Irritability or anger

• Decreased interest in activities
• Difficulty concentrating
• Lack of energy
• Change in appetite
• Change in sleep patterns
• Feeling out of control or overwhelmed
• Physical sx breast pain, bloating, headache

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Premenstrual Syndrome

• Any of these sx - but less severe
• Interfere with school, work, social activities,
  relationships but not as much
• Timing - same

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(No Transcript)
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Premenstrual Dysfunction
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Etiology

• Balance of estrogen to progesterone relative low
  levels of progesterone
• Impact of catecholestrogens or other
  hormone-bound neurotransmitters
• Effect of hormone shifts on endogenous opiods
• Effect of hormones on serotonergic receptors
• Increased sensitivity to subtle neurotransmitter
  alterations modulated by hormones
• ?

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Political Issues

• PMDD used as legal defense for murder, other
  crimes
• Feminist perspective
• Medicalization of normal changes
• Medicalization of learned / cultural expectations
• Labeling behaviors such as anger, assertiveness
  as abnormal, reinforcing passive, nice, serene
  as normal feminine behavior
• Labeling women with psych disorder
• Excuse to limit womens professional achievement
• Excuse for relationship issues

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Differential Diagnosis

• Other Medical Concerns

• Psychiatric Disorders

• Major depressive disorder
• Anxiety / panic attack
• Bipolar disorder
• Personality disorder
• PTSD
• schizophrenia

• Substance abuse
• Hypothyroidism
• Migraine
• Hypoglycemia
• Other endocrine or metabolic disorders

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Evaluation

• Rule out medical / psych disorders
• History and physical exam, including pelvic
• TSH
• glucose if indicated, drug testing, other
  metabolic assessment as indicated
• Occasionally assessment of ovulation
• Psychiatric evaluation if indicated
• Symptom Calendar
• Prospective for at least 2 menstrual cycles
• Nature ,severity , and timing of sx

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Management

• Identify the problem and its cyclic nature
• Defer big decisions, confrontations etc if
  feasible
• Exercise
• Diet frequent small meals, high carbs
• Sleep hygiene
• Limitation of caffeine
• Limitation of substance use (alcohol especially)

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Management

• Vitamens B6, D, E
• Minerals calcium and magnesium
• Herbs
• Chasteberry
• Dong qai

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Cognitive Behavioral Therapy
Hunter M et al J Psychosomatic ObGyn 23193
2002 Randomized trial 433 women screened, 108
enrolled Daily fluoxetine vs cognitive behavioral
therapy
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Pyridoxine B6meta analysis Wyatt K et al BMJ
3181375 1999

• 25 trials, 9 suitable for meta-analysis
• 940 women
• Overall OR 1.57 (1.40-1.77)
• Doses 50 500 mg daily
• No dose response effect
• No difference daily or luteal phase only

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Calcium
Sulak ObGyn 89179 Calcium carbonate 2 pills
twice a day (1200 mg elemental Ca) Tums E-X
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Chasteberry

• Meta-analysis
• CAM 5246 2008

• Summary of Evidence
• AFP 72821 2005

• Good efficacy for cyclic breast pain
• Moderate evidence for effficy for other PMS sx
• Side effects nausea, GI distress, headache,
  fatigue, dizziness infrequent and mild

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Management - Pharmacologic

• Inhibit cycles
• OCP
• GnRH agonists
• Neurotransmitter modulation
• SSRIs
• GABA

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SSRIs
Steiner M et al. N Engl J Med 19953321529-1534
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Response to Fluoxetine in women with PMDD
Steiner M et al. N Engl J Med 19953321529-1534
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SSRIs2008 Meta-analysis

• 29 studies, 2964 women
• SSRIs are effective for PMS
• 53 improvement
• OR 0.38 (0.22 0.66)
• SSRIs are effective for PMDD
• 51 improvement
• OR 0.40 (0.30 0.53)

Shah N et al Ob/Gyn 1d111175 2008
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SSRIs2008 Meta-analysis

• Intermittent dosing less effective than
  continuous dosing regimens
• OR 0.55 vs 0R 0.28
• No difference among fluoxetine, paroxetine,
  sertraline, citalopram

Shah N et al Ob/Gyn 1d111175 2008
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Alprazolam

• Small number randomized trials
• Decrease in sx used in luteal phase
• 50 (vs 30 placebo) JAMA 1995 274-51
• 1/3 for tension, anxiety
• 2/3 for irritability, out of control
• vs placebo ObGyn 1994 84379

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OCP

• Generally more effective than placebo (50-60 vs
  30 )
• Most studies with drosperinone (Yasmin / Yaz)
• Other OCP also effective but less studies

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OCP Meta-analysis
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ProgesteroneMeta-analysis Wyatt k BMJ 3223776
2001
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Practical Clinical Management

• History and physical, r/o other etiologies
• Assess severity of impairment
• Prospective symptom charting is important
• Can begin lifestyle management during charting

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Practical Clinical Management

• If behavioral measures not enough
• OCP
• with drosperinone
• Consider extended cycle
• SSRI
• Continuous
• Luteal phase only
• If still symptomatic
• Consider GnRH agonist

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Practical Clinical Management
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Appendix - doses