Updated: 8/21/2021

Premenstrual Syndrome (PMS)

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Questions
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Evidence
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Topic
Snapshot
  • A 29-year-old female patient complains of depression, poor sleep quality, and breast tenderness. These symptoms occur on a monthly basis, about 2 weeks before menstruation. Her symptoms greatly improve with menses.

Introduction
  • Recurrent physical and behavioral symptoms manifesting during the luteal phase of the menstrual cycle
    • resolve with menstruation
    • absence of secondary causes
    • severe: premenstrual dysphoric disorder (PMDD) 
Presentation
  • Physical and behavioral symptoms
    • physical
      • abdominal bloating, breast pain, cramps
    • behavioral
      • anger, irritability, changes in appetite
Evaluation
  • Diary of symptoms for >2 cycles    
    • temporal relationship of symptoms to cycle is important
Treatment
  • Selective serotonin re-uptake inhibitors (SSRIs)
    • severe PMS, PMDD
    • paroxetine is contraindicated in pregnancy
      • first trimester exposure may lead to congenital heart disease
  • Drospirenone + ethinyl estradiol (Yaz; Yasmin)
    • drospirenone is a spironolactone analog
      • antiandrogen and antimineralocorticoid effects
  • Gonadotropin-releasing hormone agonist (GnRH agonist)

A 29-year-old female patient complains of depression, poor sleep quality, breast tenderness and abdominal bloating. These symptoms occur on a monthly basis, about 2 weeks before menstruation. Her symptoms greatly improve with menses.

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Questions (2)
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(M2.GN.17.4799) A 26-year-old female presents to her primary care physician with several months of mood swings, which she feels are affecting her work and personal relationships. She states that on roughly a quarter of days each month, she feels highly irritable, sensitive to criticism and rejection, and easily saddened. She also feels that her appetite varies greatly, and on the days when she is particularly emotional, she also feels especially hungry. As a result of these symptoms, her performance at work has suffered, and her boyfriend has been complaining that she is difficult to live with. She is anxious that she cannot “get my mood under control.” The patient has no past medical history, regular periods every 28 days, and no obstetric history. She uses condoms for contraception. Her mother has major depressive disorder, and her father has hypertension and coronary artery disease. At this visit, the patient’s temperature is 98.4°F (36.9°C), pulse is 75/min, blood pressure is 130/76 mmHg, and respirations are 13/min. She appears slightly anxious but has overall normal affect and is pleasantly conversational. Physical exam is unremarkable. Which of the following is the best next step in management?

QID: 109267
1

Reassurance

3%

(1/36)

2

Selective serotonin reuptake inhibitor

78%

(28/36)

3

Combined oral contraceptive therapy

6%

(2/36)

4

Serotonin-norepinephrine reuptake inhibitor

3%

(1/36)

5

Cognitive behavioral therapy

11%

(4/36)

M 6 D

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EXPERT COMMENTS (7)
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