PMS/PMDD

Question 1

how does estrogen affect mood normally

Answer 1

pro-serotonin
- synthesis, receptor up-regulation, binding affinity

pro-noradrenaline
pro-dopamine

Question 2

how does progesterone affect mood normally

Answer 2

pro-serotonin uptake and turnover (making more serotonin)

metabolite binds to GABA receptors, therefore pro-GABA

Question 3

what do PMS and PMDD stand for

Answer 3

PMS - premenstrual syndrome
PMDD - premenstrual dysphoric disorder

Question 3

when does PMD/PMDD happen

Answer 3

before menstruation
~25-35 years of age
(realistically happens earlier)

Question 4

PMDD could be categorize as..?

Answer 4

severe PMS

Question 5

which progesterone metabolite is an agonist of GABA

Answer 5

allopregnanolone

Question 6

why does PMS/PMDD happen

Answer 6

low serotonin due to a disproportionate ratio between E + P

decrease in GABA

calcium dysregulation
- need external supplementation

Question 7

so basically what’s happening during PMS/PMDD

Answer 7

mood/cognitive/physical sx

GABA is low right before period starts

serotonin is also low before period starts

Question 8

risk factors for PMS/PMDD

Answer 8

genetics
trauma/abuse
depression/anxiety
low social support

Question 9

what is the criteria to be approved as a sign/sx of PMS

Answer 9

has to be felt 5 days before period, and must happen 3 times (3 periods)
sx must improve within 4 days after period starting
must be severe enough to affect normal activities

Question 10

what are the emotional sx of PMS

Answer 10

angry outbursts
anxiety
changes in sexual desire
confusion
crying spells
depression
more naps
insomnia
irritability
poor concentration
social withdrawal

Question 11

what are the physical sx of PMS

Answer 11

ab pain/bloating
aches and pain
weight gain
breast tenderness
fatigue
GI
headache
skin problems
swelling of hands/feet
thirst
food cravings

Question 12

how is PMS/PMDD diagnosed

Answer 12

sx must be present
happening during luteal phase (worsens before period starts)

impact daily life
not explained by any other dx

Question 13

what are the criteria for PMDD

Answer 13

5 sx during final week before period and improves a few days after period starts

Section B
1+ of: depression, anxiety, sudden sadness, anger

Section C
1+ of: decreased interest in work/school, hard to concentrate, lethargy, change in appetite, insomnia, feeling overwhelmed, PMS sx

must have 5 of the above (at least one from each section)

Question 14

assessment algorithm for PMS/PMDD

Answer 14

are sx consistent with PMS?
are sx during luteal phase?
do sx affect daily living?

if yes to all 3, then it may be PMS/PMDD
(have to then check the sx criteria for the conditions)

Question 15

what are non-pharm options for PMS/PMDD

Answer 15

pt education
daily charting of sx
exercise
rest and relaxation
stress reduction using CBT
sodium + caffeine restriction
complex carb diets
bananas?

Question 16

what are vitamins to tx PMS/PMDD

Answer 16

calcium high dose
- for mood and fluid retention
magnesium
- for fluid retention/bloating, maybe mood
Vitamin B6
- mood
Vitamin E
- breast tenderness, mood

Question 17

evidence supports which vitamin the most

Answer 17

calcium

Question 18

what are NHPs to tx PMS/PMDD

Answer 18

chasteberry fruit
- breast tenderness, mood
evening primrose oil
- breast tenderness
St John’s Wort
- mood
gingko
- physical, mood

Question 19

which of the NHPs doesn’t have a study that supports its use

Answer 19

evening primrose oil

Question 20

what are pharm options to tx PMS/PMDD

Answer 20

NSAIDs started in luteal phase, then 1-2 days after period starts

spironolactone during luteal phase
- breast tenderness, bloating

Midol
- acetaminophen + pamabrom + pyrilamine +/- caffeine

Question 21

what is pamabrom

Answer 21

diuretic

Question 22

what is pyrilamine

Answer 22

antihistamine

Question 23

can CHC be used for PMS/PMDD

Answer 23

yes if used continuously, but has mixed results

Question 24

which progestin in CHC should be considered if pt has fluid retention

Answer 24

drospirenone

Question 25

can progesterone be used to tx PMS/PMDD

Answer 25

micronized (aka natural) can be used during luteal phase NO BENEFIT based on evidence

Question 26

What is the drug of choice to tx PMDD

Answer 26

SSRIs also helps PMS

Question 27

how should SSRIs be used

Answer 27

intermittent (luteal phase only) or continuous work the same

Question 28

how long will it take to see a full benefit from SSRIs

Answer 28

3 menstrual cycles

Question 29

what to do if pt is on intermittent SSRI and it isn't working

Answer 29

switch to continuous

Question 30

if SSRIs don't work, what else can either be trialed or added on?

Answer 30

Benzos like alprazolam during luteal phase

Question 31

what is a last resort drug to use for PMS/PMDD

Answer 31

ovulation suppression using GnRH agonists or danazol

Question 32

what is a last resort tx for PMS/PMDD

Answer 32

bilateral oophorectomy

Question 33

how long should one pharm option be trialed for, before switching to a different therapy

Answer 33

~3 cycles

Question 34

how do you differentiate bw PMS and PMDD

Answer 34

sx, especially cognitive, are severe and debilitating? PMDD

Question 35

tx for moderate PMS sx

Answer 35

first non-pharm then calcium, B6, magnesium, and NSAIDs

Question 36

tx for moderate PMS sx if first line didn't work

Answer 36

spironolactone continuous CHC

Question 37

tx for severe PMS/PMDD

Answer 37

SSRIs continuous or intermittent then switch to continuous if intermittent didn't work then 2 SSRIs if 1 didn't work (try at least 2 before saying SSRIs didn't work)