premenstrual syndrome green top guideline 2017

1. Management of
Premenstrual
Syndrome
Green-top Guideline, 2017
Prof. Aboubakr
Elnashar
Benha university hospital,
Egypt
ABOUBAKR ELNASHAR

2. Contents
1.Definition
2.Classification
3.Prevalence
4.Aetiology
5.Diagnosis
6.Treatment
conclusion
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3. 1. DEFINITION
PMS encompasses a vast array of
psychological symptoms
depression, anxiety, irritability, loss of confidence
and mood swings.
physical symptoms
bloatedness and mastalgia.
Diagnosis depend on:
Timing
rather than the types of symptoms
luteal phase of the menstrual cycle.
Degree
significant impairment to the individual
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4. 2. CLASSIFICATION (ISPMD CONSENSUS)
1. Core premenstrual disorders (PMDs)
Most common
Symptoms must be severe enough to
affect daily functioning or
interfere with work, school performance or
interpersonal relationships
Nonspecific
Recur in ovulatory cycles.
During the luteal phase and abate as menstruation
begins, which is then followed by a symptom-free
week.
Some individuals will have
predominantly psychological,
predominantly somatic or
mixture of symptoms
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6. 2. Variant’ PMDs
do not meet the criteria for core PMDs.
1. Premenstrual exacerbation of an underlying
disorder’
 such as diabetes, depression, epilepsy, asthma
and migraine.
 experience symptoms relevant to their disorder
throughout the menstrual cycle.
2. Non-ovulatory PMDs’
ovarian activity without ovulation
poorly understood {lack of evidence}
follicular activity of the ovary can instigate
symptoms.
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7. 3. Progestogen-induced PMDs
caused by exogenous progestogens present in
HRT and COC.
This reintroduces symptoms to women who
may be particularly sensitive to progestogens.
Although progestogen-only contraceptives may
introduce symptoms, as they are noncyclical they
are not included within variant PMDs and are
considered adverse effects(probably with similar
mechanisms) of continuous progestogen therapy.
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8. 4. PMDs with absent menstruation’
include women who still have a functioning ovarian
cycle, but for reasons such as hysterectomy,
endometrial ablation or LNG-IUS they do not
menstruate.
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9. Premenstrual dysphoric disorder (PMDD)
(American Psychiatric Association)
 requires fulfilment of strict criteria
 5 out of 11 stipulated symptoms, one of which
must include mood.
The symptoms must
strictly occur in the luteal phase
 severe enough to disrupt daily functioning.
These restrictive criteria may
exclude women with a narrow range of severe
symptoms who should receive treatment.
Care
not to label women with psychiatric or somatic
disorders that do not appear to be influenced by
the menstrual cycle as having PMS.ABOUBAKR ELNASHAR

10. 3. PREVALENCE
4 in 10 women (40%)
of these 5–8% suffer from severe PMS.
6-week symptom diary
24% prevalence of premenstrual symptoms.
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11. 4. AETIOLOGY
uncertain
2 theories
1. Some women are ‘sensitive’ to progesterone and
progestogens
{serum concentrations of estrogen or progesterone
are the same in those with or without PMS}
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12. 2. Neurotransmitters serotonin and Ɣ-aminobutyric
acid (GABA).
 Serotonin receptors are responsive to estrogen
and progesterone, and selective serotonin
reuptake inhibitors (SSRIs) are proven to
reduce PMS symptoms.
 GABA levels are modulated by the metabolite
of progesterone, allopregnanolone
 in women with PMS the allopregnanolone
levels appear to be reduced.
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13. 5. DIAGNOSIS
1. Symptoms
 should be recorded prospectively, over 2 cycles
 using a symptom diary
 {retrospective recall of symptoms is unreliable}.
 symptom diary should be completed by the patient
prior to commencing treatment.
2. GnRHa
 may be used for 3 months for a definitive diagnosis
if the completed symptom diary alone is inconclusive.
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14. Daily Record of Severity of Problems (DRSP)
most widely used
Simple
provide a reliable and reproducible record of
symptoms
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17. 6. MANAGEMENT
Who can treat?
1. Gynaecologist when
1. simple measures (e.g. COCs,vitamin B6, SSRIs)
failed
2. severity of the PMS justifies gynaecological
intervention.
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18. 2. Multidisciplinary team
Women with severe PMS
1. general practitioner
2. general gynaecologist
3. gynaecologist with a special interest in PMS
4. mental health professional (psychiatrist, clinical
psychologist or counsellor)
5. dietician.
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19.  Lines of treatment
I. Complementary therapies
II. Cognitive behavioural therapy
III. Hormonal
IV. Non hormonal
V. Hysterectomy and bilateral oophorectomy
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20. I. Complementary therapies
conflicting evidence
It is important to evaluate evidence carefully for PMS
as there is a 36–43% placebo response
An integrated holistic approach should be used
particularly important when hormonal therapy is
contraindicated.
Interactions with conventional medicines should be
considered.
St John’s Wort :
should not be used concurrently with SSRIs
and can render low dose COCs ineffective.
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24. Unsaturated fatty acids
as contained in evening primrose oil
improve menstrual symptoms compared with
placebo at both 1 g/day and 2 g/day dosages.
Calcium
alleviated both physical and psychological symptoms
vit B6 and Vitex
Contradictory: advice could not be given for either.
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25. II. Cognitive behavioural therapy (CBT) and other
psychological counselling
In severe PMS, CBT should be considered. A
If CBT proves successful: avoid pharmacotherapy
and potential adverse effects.
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26. III. Hormonal
1. Drospirenone-containing COCs
 effective and should be considered as a first-
line pharmaceutical intervention. B
{antimineralocorticoid and antiandrogenic
progestogen}
Despite COC to suppress ovulation, studies initially
illustrated no benefit in the treatment of PMS.
{ progestogens in second-generation pills
(levonorgestrel or norethisterone) regenerating PMS-
type symptoms}.
Cochrane review: drospirenone-containing COC
used for 3 months did reduce the severity of
symptoms for those with PMDD
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27. COC continuously rather than cyclically.
168-day extended regimen (of drospirenone 3 mg
and ethinylestradiol 30 micrograms):
 significant decrease in premenstrual-type
symptoms compared with a standard 21/7-day
regimen
364 day: mood, headache and pelvic pain scores
improved when compared with a 21/7-day
regimen.
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28. 2. Percutaneous estradiol combined with cyclical progestogens
effective for the management of physical and psychological
symptoms of severe PMS. A
the lowest possible dose of progesterone or progestogen is
recommended to minimise progestogenic adverse effects. A
a cyclical 10–12 day course of oral or vaginal progesterone or
long-term progestogen with the LNG-IUS 52 mg should be
used for the prevention of endometrial hyperplasia.
When using a short duration of progestogen therapy, or in
cases where only low doses are tolerated, there should be a
low threshold for investigating unscheduled bleeding.
The lowest dose for the shortest time should limit unwanted
progestogenic effects, and therefore an oral dose (micronised
progesterone 100 mg or norethisterone 2.5 mg) for days 17–
28 of each calendar month should be sufficient.
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29. insufficient data to advise on the long-term effects on breast
and endometrial tissue.
Due to the uncertainty of the long-term effects of opposed
estradiol therapy, treatment of women with PMS should be on
an individual basis, taking into account the risks and benefits.
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30. 3. Danazol
200 mg twice daily
effective in the luteal phase for breast symptoms
potential irreversible virilising effects. A
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31. 4. GnRH analogues
highly effective in treating severe PMS. A
not recommended routinely unless they are
being used to aid diagnosis or
treat particularly severe cases.
{effects on BMD}
{suppress ovarian steroid production}: drastic
improvement or complete cessation of symptoms
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32. Treating for more than 6 months
add-back hormone therapy. A
continuous combined HRT or
tibolone A
advice regarding the effects of exercise, diet and
smoking on BMD.
measurement of BMD (dual-energy X-ray
absorptiometry [DEXA]) every year.
Treatment should be stopped if bone density
declines significantly.
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33. When the diagnosis of PMS is unclear from 2 months’
prospective DRSP charting,
GnRH analogues can be used to establish and/or
support a diagnosis of PMS.
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34. Treating PMS with progesterone or progestogens is
not appropriate. A
No evidence to support the use of the LNG-IUS 52 mg
alone to treat PMS symptoms.
Its role should be confined to opposing the action of
estrogen therapy on the endometrium.
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35. IV. Non-hormonal medical
1. SSRIs
 one of the first-line pharmaceutical options in
severe PMS. A
 either luteal or continuous dosing B
{Women with PMS have low concentrations of
serotonin within their platelets and this varies
throughout the menstrual cycle}.
Mode of action of SSRIs
both estrogen and progesterone have the ability to
regulate the number of serotonin receptors,
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36. should be discontinued gradually over a few weeks
{avoid withdrawal symptoms}, if given on a continuous
basis.
withdrawal symptoms
Gastrointestinal disturbances, headache, anxiety,
dizziness, paraesthesia, sleep disturbances,
fatigue, influenza-like symptoms and sweating
Adverse effects
nausea, insomnia, somnolence, fatigue and
reduction in libido.
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37. Efficacy may be improved and adverse effects
minimised by
luteal-phase regimens with the newer agents. A
Citalopram
Escitalopram.
Sertraline 25 or 50 mg
in the luteal phase for two cycles
followed by one cycle of continuous dosing and
ending with symptom-onset dosing for the final
cycle.
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38. Should discontinued prior to and during pregnancy.
{PMS symptoms will abate during pregnancy}
Women with PMS who become pregnant while taking
an SSRI/SNRI
possible, although unproven, association with
congenital malformations.
extremely small when compared to the general
population.
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39. 2. Spironolactone
can be used to treat physical symptoms. C
improvement in both mood and physical symptoms
 Spironolactone 100 mg
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40. V. hysterectomy and bilateral oophorectomy
Indications:
1. women with severe PMS
2. when medical management has failed
3. long-term GnRH analogue treatment is required
4. other gynaecological conditions indicate
surgery.
surgery should not be contemplated without
preoperative use of GnRH analogues as a test of
cure and to ensure that HRT is tolerated.
Important in
women younger than 45 years of age
PMS alone.
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41. Permanent form of ovulation suppression:
removes the ovarian cycle completely
removes the endometrium: allowing the use of
estrogen replacement without the need for
progestogen.
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42. After surgery:
 HRT, particularly if they are younger than 45 y
estrogen-only replacement
The avoidance of progestogen prevents
reintroduction of PMS-type adverse effects.
Consideration to replacing testosterone
{ovaries are a major production source (50%) and
deficiency could result in distressing low libido
(hypoactive sexual desire disorder).}
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43. Endometrial ablation and hysterectomy with
conservation of the ovaries
not recommended.
Bilateral oophorectomy alone
without removal of the uterus
necessitate the use of a progestogen as part of any
subsequent HRT regimen: risk of reintroduction of
PMS-like symptoms (progestogen-induced PMD).
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44. Conclusion
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