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PREMENSTRUAL SYNDROME

 

PREMENSTRUAL SYNDROME

PMS is characterized by recurring symptoms that appear anywhere from 2 - 14 days before menstruation, usually disappearing after menstruation begins.  A symptom-free time follows with the onset of menstruation.  Up to 40% of women will experience PMS, but a smaller percentage will have severe, debilitating symptoms.

PMS symptoms affect women both emotionally and physically. While symptoms vary from woman to woman, the most common ones include: 

Irritability          Hostility           Forgetfulness        Abdominal bloating       Muscle spasms

Anxiety             Depression       Clumsiness           Headache                    Craving sweets,

Tension            Crying spells     Fluid Retention      Weight gain                 Increased appetite

Mood swings    Confusion         Backache             Swelling of joints          Fatigue

Dizziness          Fainting            Panic attacks         Migraine                     Seizures

Cold sores        Boils                Asthma attacks      Allergies                     Sinus problems

Acne          Craving carbohydrates, alcohol, and/or chocolate       Breast tenderness/swelling   

Any patient with an anxiety or depressive disorder can have PMS with symptoms that increase in severity, markedly and consistently during the premenstrual phase. 

Premenstrual Dysphoric Disorder or PMDD is a severe form of PMS found in 10% of women.  It largely involves depression, anxiety, or other psychiatric symptoms that really interfere with everyday functioning. 

The most important tool for sorting out the correct diagnosis is to chart symptoms in a diary for at least 2 menstrual cycles.  Also, visualizing the type, severity and timing of symptoms may make them seem more manageable and give a sense of control.  What you think is PMS could be a serious case of depression with premenstrual exacerbations.  You would want to treat the correct disorder.

There are many postulated theories for the cause of PMS. Possible explanations have included: progesterone deficiency, nutritional factors, hypoglycemia, retention of fluids, vitamin/mineral deficiency, excess prolactin, stress, psychosomatic causes, chronic yeast infections, Serotonin deficiency, and endorphin fluctuations.  Studies of PMS have failed to show unequivocally, an association between PMS and age, other demographic variables, dietary and exercise factors, stress, menstrual cycle characteristics, or personality characteristics.  Genetic factors may also contribute to PMS.

There have been multiple studies which have failed to show differences in gonadal steroid hormone levels in women with PMS (Estrogen, Progesterone).  The factors more likely to be involved include neurotransmitters such as Norepinephrine and Serotonin.  Rapkin (1992) reviewed the literature concerning the influence of gonadal steroids on serotonin and the role of serotonin in determining depression, anxiety, aggression, and social behavior.  Other controlled studies of women with PMS reported reduced luteal whole-blood serotonin, and reduced luteal serotonin platelet uptake.   What all of this means is that in the second half of the menstrual cycle, approximately 2 wks before the onset of bleeding, a decreased functioning of a brain chemical called serotonin may start to occur. Treatment with serotonergic antidepressants may now be considered the first line drug treatment for PMS, owing to their impressive success, and tolerability. 

Certain blood tests may be ordered to rule out other medical problems which may mimic PMS, such as hypothyroidism, elevated prolactin, diabetes, or anemia.

Psychological/psychiatric counseling may be recommended.  We have counselors in the office that will help you.  Behavior modification may be helpful for such things as carbohydrate binging.

Mild or moderate PMS symptoms may be reduced with a program of education, good nutrition, and aerobic exercise.  Be sure your diet includes 1000 mg of calcium per day.  (J. Clin Endocr. Metab. 80; 2227-32; 1995). Your diet may also need rearranging.  Due to the neuro-chemical (brain) imbalances, you may use carbohydrate binges to raise your mood levels. This translates to fast sugar snacks.  Excessive caffeine intake may be noticed as also a way of boosting your mood.  Smoking may increase and the use of alcohol or other drugs as well. It may be helpful for you to eat small, frequent meals which are high in protein and complex carbohydrates, rather than fast sugar snacks. A low fat diet is essential if you are trying to maintain your weight. Salt intake must be monitored.  Excessive salty foods may cause water retention.  Caffeine and alcohol may need to be eliminated from the diet.  Please ask us for nutritional help if you need it.

Vitamins may or may not be helpful.  There are studies showing that calcium, Vitamin E, B6, Magnesium, Zinc, and Chromium may all be helpful to relieve some of the symptoms. May we suggest a good vitamin and mineral combo for you to take on a regular basis?  Go to the store and look up WWP PMS Formula. Vitamin E (400 u) or Primrose Oil may help breast tenderness.

Exercise may increase endorphin levels and decrease anxiety and depression.  By committing yourself to a regular exercise regimen, you also ensure control over your lifestyle. Even if you have small children, give yourself several hours to concentrate on you.  We find that women notoriously sacrifice their own physical and emotional well being for the needs of their family.  While this may be necessary 90% of the time, there certainly should be a few hours left each week for you.  Consider exercise as part of your daily or every other day mental health maintenance.  We can help you find a program that is helpful to you.  If going out is impossible, a treadmill or exercise bike can be purchased for home use.  During good weather, walking several times a week at a brisk pace may suffice.  You may be able to get together with your neighbors and friends and this will also enhance your mood.

A good book you may want to read is Unmasking PMS - The Complete Medical Plan  by Joseph Martorano, MD and Maureen Morgan, CSW, RN, Berkley Books, 1994.  There are many organizations which offer self help programs.  Simply knowing that you have PMS will help you to understand the changes you go through each month. Some women feel they are going crazy.  You may want to invite your significant others to come to the office to discuss this problem also. It will undoubtedly affect those around you and if they understand that you are working on this, it will ease the tension in the household.  Stress reduction, meditation, or yoga, may be helpful also.  Private time to think, relax, and organize your thoughts is also very important.  Ask your significant other or a friend or relative to watch your children, if need be.  For those without children, a private time each day is also helpful to decrease stress. 

MEDICAL TREATMENTS 

Certain medical treatments may be helpful for specific symptoms.

I.          If water retention is your main problem, a diuretic may be helpful, including Spironolactone, (if you gain more than 1.4 kg during the premenstrual phase).  Limit salt intake to 3 grams per day.  For cramps, muscle and joint pain, backaches, breast tenderness and headaches, prostaglandin inhibitors such as Motrin may be useful.  Some foods are natural diuretics such as cucumbers.

II.        Some patients may benefit from menstrual cycle manipulation. One potential method is inhibiting ovulation with birth control pills or cyclic estrogen/progesterone.  However, some patients will respond with worsening symptoms.  In certain instances, oral or vaginal progesterone may be helpful. While progesterone has never been proven to help PMS in large studies done in the United States, it is used extensively in Europe.  Its benefit may be that it has a sedative effect and may help some patients get better sleep, concentrate better, and stabilize mood to some extent.

III.       Anti-anxiety agents such as:

            a.         Alprazolam (Xanax) three times a day during the luteal phase (2nd half of the cycle) may be helpful for patients with anxiety symptoms.  Alprazolam is a triazolobenzodiazepine with anxiolytic (anxiety reducing), antidepressant and smooth muscle relaxant properties.  From 0.25 mg three times a day to 4 mg four times a day may decrease nervous tension, mood swings, irritability, anxiety, depression, fatigue, forgetfulness, crying, craving for sweets, abdominal bloating, cramps, and headaches.  The side effect is sedation (drowsiness).  It may be used during the luteal phase and tapered when menstruation starts to avoid withdrawal. While this substance may be addictive, if it is used only during the luteal phase, this may be avoided.

            b.         Buspirone (Buspar), 5 - 10 mg twice a day may also be used during the luteal phase, or all month if necessary.  This is a new class of medication called the Azapirones; and act primarily as a serotonin 1A receptor agonist.  It is not a controlled substance, nor is it a habit forming drug, and there is no abuse potential. There is no withdrawal on cessation of the medication, and there is no high as there may be in Xanax, therefore, less potential to be abused.  It is not a tranquilizer, and does not cause sedation or any effects on motor functioning (driving or doing complex tasks).  The study on the use of Buspirone in PMS patients by Daniel David, and coworkers from the University of East Tennessee, patients with mild PMS showed an 80% helpful response, patients with moderate PMS showed an 92% helpful response, and patients with marked PMS showed a 100% helpful response.  All patients who responded had been on tranquilizers previously.

10 mg tablets may be dispensed and 1/2 to 1, 10 mg tablet three times a day for the first four days, followed by one full tablet 3 times a day, beginning with the first day of the menstrual cycle and continuing throughout the entire cycle, may be attempted for at least 3 menstrual cycles.   Following this, other treatment options are available:  the patient may be taken off Buspirone to see if it has effected a remission; to reduce the dose to 20 mg per day; or to cycle the patient beginning on the seventh or eighth day of the menstrual cycle and continuing until the onset of menstrual flow. Being cycled with Buspirone may give one a better sense of control because it indicates that PMS is a cyclic problem. Keep in mind that it takes at least seven days to reach a significant level in the brain to alleviate anxiety.  Therefore, the medication must be started with enough lead time in order to get the maximal beneficial affect during the days of the cycle where PMS is the worst.  Unlike tranquilizer medications, PMS patients on Buspirone may return to social drinking. However, beware; alcoholic beverages may make symptoms of PMS worse. 

IV.       Some of the new SSRI (Selective Serotonin Re-uptake Inhibitors) have been shown in recent studies to be very effective; especially for those in the premenstrual dysphoric or late luteal phase dysphoric disorder category (PMD and LLPDD).  The following medications may be prescribed for you.

            a.         Fluoxetine (Prozac)  (Steiner, N Engl J. Med, 1995, 332; 1529-34) PMS is a type of atypical depression and serotonin has a role in regulating the variations in mood, impulsivity, appetite and other types of behaviors that fluctuate in relation to menstrual cycles.  Also a study by Pearlstein and Stone (J. Clin Psych, 1994; 55:332-335) has shown Fluoxetine to be safe and efficient in treating LLPDD.  It may be possible to use this medication only during the luteal phase as it has a long half life.  For a dosage of 20 mg daily, the side effects are minimal but may include things like headache, nausea, dry mouth, decreased appetite, restlessness (initially), and sexual dysfunction rarely (difficulty achieving orgasm).

            b.         Paroxetine (Paxil) (Neuropsychopharmacology, April 1995, V12, p 167-76) was found to be better than other anti-depressants on symptoms of PMS (irritability, depressed mood, tension/anxiety, increased appetite, craving for carbohydrates, bloating, breast tenderness).  Dosage was 20 - 40 mg daily.  Use of this prescription during the luteal phase may also be possible.  Side effects possible like Prozac above.

            c.         Nefazodone (Serzone) (J. Clin Psychopharmacology, June 1994, V14, p. 180 - 186) - this is a phenylpiperazine antidepressant with Serotonin Type II antagonism and SSRI.  The initial dose was 100 mg titrated to 600 mg per bid (twice a day dosing).  Both pure PMS patients and patients with exacerbation of other depressive illness during the premenstrual phase were significantly helped.  The most common side effects were headache and nausea.

            d.         Venlafaxine (Effexor) (J. Clin Pharmacology, 1992, 32:716-724).  This is the first of a new class of phenethylamines - inhibit re-uptake of Serotonin, Norepinephrine and, to a lesser extent, Dopamine. They may have a broader spectrum of usage.

            e.         Sertraline (Zoloft).  A dose of 50 mg daily may be useful in managing depression.  Side effects most commonly experienced are gastro-intestinal/diarrhea.

Anxiety attacks/phobias:  The DSM-IV published by the American Psychiatric Association lists panic disorder as a separate entity.  Unlike a normal response to danger or threat, panic disorder is marked by attacks of overwhelming anxiety that occur with increasing frequency and magnitude over time.  Some panic attacks are prompted by phobias or irrational, involuntary intense fears.  Symptoms are physical and emotional and include a pounding heart, shortness of breath, weak, rubber legs, chest pains, headaches, dizziness,  trembling, and feelings that you are about to die or that you are going crazy.

Women with PMS often report panic attacks or feeling of overwhelming anxiety.  In addition, some PMS patients suffer from agoraphobia which literally means fear of the market place.  Agoraphobics are plagued by extreme fear of the outside world and may be frightened of leaving the house at all.  Agoraphobia may be the outcome of recurrent panic attacks.  A person who experiences a panic attack in the car or on the freeway or in the grocery store may develop a fear of returning to the place where the episode occurred.  The person is not actually afraid of the place, but fears losing control, fainting, or even dying during a panic attack.  When the attacks increase in frequency and occur in more settings, a woman may avoid going out whenever possible. Consequently, she isolates herself and her life becomes restricted.  Women who have suffered panic attacks for long periods of time may need the help of a therapist to overcome specific fears. Benzodiazepam group of drugs which includes Alprazolam (Xanax) and Diazepam (Valium) have been used with some success in treating anxiety.  Some antidepressants are also indicated.  Some of the SSRI agents are effective.

Gaining control of panic attacks and phobias may be a accomplished through therapy and self help mechanisms.  There is a work book called The Anxiety and Phobia Workbook by Edmond Bourne.  This book is available from Womens Health America, PO Box 9690, Madison, Wisconsin 53715, (608)833-9102.

Please feel free to ask us for any of the above references, or you may get them at the medical library or via the Internet. Some helpful phone numbers:

            The American Psychiatric Association (202) 336-5700 (Women and Depression)

            National Depression and Manic Depression Association 1-800-82-NDMDA

            Madison Pharmacy Associates - Providing Knowledge, Hope and Help to Women 1-800-558-7046

            Other References:

           

            Moline, Margaret, Pharmacologic Strategies for Managing VLRD (Review), Clin. Pharm. 12, March 1993, p 181-96.

            Wood, S. et al., Treatment of PMS with Fluoxetine, Obstet Gynecol 1992 V80, p. 339-44.

            Pearlstein, Teri, Advances in PMS (Review), Current Opinion in Psychology 1993, 6:809-15.

            Freeman, E.W., et al., Double Blind Trial of Oral Progesterone, Alprazolam, and Placebo in Treatment of PMS, JAMA 274: 51-7, 95.

            Rapkin, A.J., The Role of Serotonin in PMS Clin Obstet Gynecol, 1992, 35: 629-36.

            Backerman, Ivan A., Premenstrual Syndrome Update: 1991 Maryland Mod J,

For Progesterone Therapy:  Madison Pharmacy Associates, Mon-Fri 9AM - 5:30 PM

1-800-558-7046

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