210 lines
9.0 KiB
Standard ML
210 lines
9.0 KiB
Standard ML
by: William Mann MD
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Univ of North Dakota School of Medicine
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PREMENSTRUAL SYNDROME
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Case History
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An unemployed nulliparous 19-year-old woman was arrested for stabbing
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her boyfriend while intoxicated. Menarche was at 13 years, and she had
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been well with no behavioral problem until l5, when she began to
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exhibit paroxysmal aberrant behavior including: slashing her wrists,
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shoplifting, arson, promiscuity, alcohol intoxication, expulsion from
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school for assaulting teachers, and mutilation of her hands and feet
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with cuts and cigarette burns. In prison, prior to her next four
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menstrual periods, she assaulted a guard, tried to hang herself, cut her
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wrists, and attempted to escape. During the rest of her cycle, she was
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cooperative, rational, and penitent. All past episodes of aberrant
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behavior which could be accurately dated, occurred on a cycle length of
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29+- 2.5 days.
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Initially in prison she was treated with Chlorpromazine 100mg bid and
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fluphenazine injections 20 mg every 10 days. She stated that she felt
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a little calmer, but depressed, with continued cyclic suicidal impulses
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and a wish to "escape from life". On several occasions during the
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premenstruum she requested that she be locked up alone and expressed
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fear that she was going to lose control.
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She was started on medroxyprogesterone 10 mg qd on day 22 of each cycle,
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and for the past two years has been free of premenstrual behavior
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changes, with only mild symptoms of restlessness and bloating. She is
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now working full time and married.
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Definition
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Premenstrual Syndrome is any combination of symptoms and signs occurring
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cyclically prior to menses and resolving with the onset of menses.
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Clinical Presentation
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Subjective
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The commonest symptoms are related to mood; - depression, irritability,
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tension, lability, lassitude, insomnia and impulsivity; to body fluid
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changes; - edema, weight gain, abdominal bloating, and breast fullness;
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and to physical discomfort - headache, breast pain, abdominal pain or
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generalized physical dysphoria.
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Polydipsia, polyphagia, diarrhea and acne are also common.
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Pre-existing physical and emotional problems may be exacerbated.
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Objective
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Weight gain is common, but so is weight loss, and affect changes may be
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apparent in familiar patients. Laboratory investigations are not
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generally helpful.
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Clinical Management
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Assessment
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Almost all women report some premenstrual symptoms. It is essential to
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differentiate between those who find their symptoms tolerable, and
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those who consider themselves ill and who have distressing symptoms and
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impaired functional capacity. It is also important to assess any
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exacerbation of ongoing health problems. The specific symptoms most
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troublesome to the patient and their severity guide rational therapy.
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Mechanisms
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The large number of theoretical models of the biochemical basis of PMS
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reflect the fragile, incomplete understanding of the problem and the
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complexity of its causative mechanisms. Likewise, the large number of
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recommended treatments, none of which are consistently effective,
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suggest a multiplicity of mechanisms with variable expression from
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patient to patient. In general terms, PMS seems to represent protean
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manifestations of psycho-neuro-endocrine flux, or dysfunction in the
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cycling of the hypothalamic-pituitary-ovarian axis. Particular
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symptoms suggest a role for specific mediators and provide some
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rationale for management of individual cases.
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Estrogen effects sodium and water retention, and in addition alters the
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metabolism of plasma renin and angiotesin II with a resultant increase
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in Aldosterone
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Progesterone has a natriuretic effect, but also increases aldosterone
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activity. PMS symptoms do not occur when physiologic progesterone
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levels are low in the pre-ovulatory phase and anovulatory cycles.
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Paradoxically, progesterone frequently is effective treatment.
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Although excreted levels of estrogren and progesterone are not
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measurably abnormal, an imbalance of estrogen/progesterone is a
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currently favored hypothesis. Further confusing this is the
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observation that as many patients are made worse as are made better
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with OCs.
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Prolactin and vasopressin secretion may play a role in breast and fluid
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balance changes, and although plasma levels have not correlated with
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symptoms, normal bromocriptine has been beneficial, as have ergot
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alkaloids.
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Changes in central catecholamines (dopamine, norepinephrine, and
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epinephrine) may play a role in affective and fluid balance changes.
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The measurable changes in other pituitary products - alpha MSH,GH,LH,
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FSH and Beta endorphin - which occur premenstrually probably contribute
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to the complexity of PMS.
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Numerous clinical therapeutic trials have been provoked by such
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possible causal associations as Vitamin B6 with abnormal tryptophan
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metabolism and estrogen metabolism, by the anti-estrogenic effect of
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Vitamin A, and its effect on acne, by possible allergy to endogenous
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progresterone, and by catharsis as a means of eliminating fluid and
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unspecified toxin in constipated patients.
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Plans
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The goal of therapy is to reduce symptoms to a level which is tolerable
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to the patient and which does not impair her function. Treatment
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should be aimed at the specifically troublesome symptoms, and frequent
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follow up should gauge the effect on these symptoms and the patient's
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improvement in function. Treatment should be carefully matched to the
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patient's distress, as many suggested therapies have significant
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toxicity.
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Documented weight gain can be rationally approached with spironolactone
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25-50 mg b-tid, and if this fails, hydrochlorothiazide, 25-50 mg qd.
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Headache, mastalgia, and generalized discomfort may be relieved with
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mild analgesics, and NSAIDs may be particularly useful with patients
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who also suffer from dysmenorrhea.
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Non-specific measures such as local heat, rest, and sodium restriction
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may be helpful, as may exercise and weight loss which, in theory, may
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have a beneficial effect on estrogen metabolism.
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In patients with sleep disturbance and depression, tricyclics and
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occasionally lithium may be indicated.
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Bellergal, a combination of ergot, phenobarbitol, and belladonna, is a
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non-specific but frequently useful treatment for patients with
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irritability, breast tenderness, and abdominal bloating. Except in low
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dose for occasional use, tranquilizers are best avoided as they are
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entirely non-specific, even though they will reduce any patient's
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complaints about most symptoms.
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Medroxy progesterone 10 mg daily during the symptomatic days, and
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progesterone suppositories are very frequently effective. The estrogen
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antagonist methyltestosterone is very effective, but rarely, if ever,
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indicated. Bromocriptine counteracts the osmoregulatory actions and
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breast stimulation of prolactin, but also has numerous poorly
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understood actions in the pituitary hyopthalamus and basal ganglia.
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Follow Up
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The fine adjustment of treatment against symptoms can generally be
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achieved in a few monthly visits.
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Education
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Explanation that PMS is not pathologic, accompanied by support from the
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physician and from acquaintances with PMS is very helpful. The patient
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should understand the goals of treatment and be given the
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responsibility for adjustment of therapy.
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Epidmiology
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Most women suffer some symptoms of PMS, and at least a third report
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significant incapacity. Psychiatric disturbance, crime and accidents
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are more frequent during the premenstrual period but still less
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frequent than the noncycling base line for males. The data, then, may
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suggest that women deteriorate toward the male level of functioning
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during the premenstrual period, or conversely that women have a
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syndrome of functional improvement during the rest of the cycle, with
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fewer seizures, fewer symptoms, less aberrant behavior, increased
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energy and self-esteem, and improved mood.
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Costs
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The very significant costs of functional disability, interpersonal
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discord, and personal distress may be greatly ameliorated with
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education, support, and carefully adjusted symptomatic treatment.
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Learning Issues
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In managing a problem with no consistent physical signs or laboratory
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abnormalities, it is essential to make an accurate assessment of the
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patient's function and symptomatic distress, to tailor treatment to
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these, and to set and move toward appropriate goals together with the
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patient.
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References
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Premenstrual Syndrome, Editorial; Lancet; December 1981, 1393-94.
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Reid, R.L. and Yen, S.S.C. Premenstrual Syndrome; American Journal of
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Obstetrics and Gynecology; 139; 85-104. 1981.
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Elsner, C.W., et.al. Bromocriptine in the Treatment of Premenstrual
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Tension Syndrome, Obstetrics and Gynecology; 56, 6; 723-26. 1980.
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in the pre-ovulatory phase and anovulatory cycles.
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Paradoxically, progesterone frequently is effective treatment.
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Although excreted levels of estrogren and progesterone are not
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measurably abnormal, an imbalance of estrogen/progesterone is a
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currently f |