QuestionSBA
QuestionChoice
The intrauterine device is a copper-based system that provides contraception but does not deliver any hormones either systemically or locally. As such, it does not influence the hormonal variations that are thought to cause premenstrual syndrome and are of no benefit in managing this condition.
53069
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Intrauterine device
QuestionChoice
This patient describes symptoms in keeping with premenstrual syndrome (PMS). She experiences mood swings, cognitive issues and irritability during the luteal phase of her cycle, with symptom cessation with the onset of menses. All women are advised to keep a period diary to document the frequency and severity of their symptoms, although this patient already provides an adequate history. The severity of PMS is based on clinical judgement without any scoring criteria; features indicating more severe symptoms include impact on quality of life, mood disturbance or impact on function. Lifestyle changes are an important first-line measure in all women, such as exercise, regular sleep, good diet and restricting alcohol intake. However, this patient reports that the symptoms are affecting her day-to-day life and she is also seeking pharmacological therapy. She most likely has moderate disease, in the absence of more severe features such as depression and loss of function. The first-line treatment as per National Institute for Health and Care Excellence (NICE) guidelines for moderate PMS is the combined oral contraceptive. This will also help her periods, which she says are heavy. A selective serotonin reuptake inhibitor (SSRI) is an alternative, for example, where this may be indicated, or first-line for severe disease.
53067
a
Combined oral contraceptive
QuestionChoice
Although this patient suffers from irritability, she does not report any symptoms indicative of psychosis, such as hallucinations or delusions. If she were experiencing these, then specialist input would be appropriate to rule out any alternative diagnoses.
53070
d
Antipsychotic agent
QuestionChoice
As per the NICE guidelines, progesterone-only treatments do not have adequate evidence and are not recommended in the management of premenstrual syndrome. Moderate disease is treated with the combined oral contraceptive pill, and severe disease with SSRIs.
53068
b
Progesterone-only pill
QuestionChoice
An SSRI would be first-line for severe PMS, for example, if she were experiencing low mood and disabling emotional lability affecting her daily function. However, for moderate disease, the first-line agent is the combined oral contraceptive pill. This will also help her periods, which she reports are heavy.
53071
e
Selective serotonin reuptake inhibitor
QuestionComment
she has migraines??!?!!!
24465
QuestionComment
without aura in this case, migraines WITH aura will be classified under UKMEC4 where it is an absolute contraindication
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Kawasaki Neoplasia
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evieeee
QuestionComment
With or without aura... would any one realistically prescribe it to a pt with this history? Patient's aren't always great at describing their symptoms...
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QuestionComment
I think if you explain exactly what you mean by aura, ask specific "do you get feeling x or y" before/with the headache etc. a reasonable patient would be able to say yes or no and I would be confident in prescribing it
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Ale
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Tazocin Suture
Concept
Chapter
# Summary

Premenstrual syndrome (PMS) is characterised by psychological, physical or behavioural symptoms occurring in the luteal phase of the menstrual cycle that cause distress or disruption to the patient. Key signs and symptoms vary but often include mood swings, fatigue, and physical discomfort. Diagnosis is usually clinical and may involve the patient keeping a diary of symptoms. Management strategies include both non-pharmacological and pharmacological approaches, such as dietary modification, increasing exercise, stress reduction, and medication including the combined oral contraceptive pill and antidepressants.

# Definition

Premenstrual syndrome (PMS) refers to a cluster of psychological, physical, and behavioural symptoms that occur in the luteal phase of the menstrual cycle and cause distress or disruption to the patient's life. It is crucial to obtain a comprehensive medical history from the patient and consider suggesting the patient keep a diary of symptoms to aid in the diagnosis.

# Epidemiology

The prevalence and severity of PMS vary widely. It is estimated that as many as 30-40% of menstruating women experience some degree of PMS. Severe PMS, also known as premenstrual dysphoric disorder (PMDD), affects approximately 3-8% of women. 

# Aetiology

The exact cause of PMS is unclear. However, it is likely related to hormonal changes during the menstrual cycle. Some researchers believe that PMS is connected to the rise and fall of hormones, specifically estrogen and progesterone, during the menstrual cycle.

# Signs and Symptoms

Symptoms of PMS can vary widely from woman to woman and from cycle to cycle. They can be physical, emotional, or behavioural and commonly include:

- Mood swings and irritability
- Depression and anxiety
- Fatigue and sleep problems
- Physical symptoms such as bloating, breast tenderness, headaches, and joint or muscle pain
- Changes in appetite and food cravings
- Difficulty concentrating

# Differential Diagnosis

Conditions that can mimic PMS include:

- Thyroid disease: Symptoms can include fatigue, depression, and weight changes.
- Chronic fatigue syndrome: Main symptoms are persistent and unexplained fatigue, sleep problems, and post-exertional malaise.
- Depression or anxiety disorders: These conditions can cause mood changes, irritability, and fatigue, similar to PMS.

# Investigations 

PMS is usually a clinical diagnosis based on the patient's symptoms. Keeping a symptom diary for at least two menstrual cycles can be helpful in confirming the diagnosis. Further investigations may be needed if the diagnosis is uncertain or if other conditions are suspected.

# Management 

Management of PMS can include both non-pharmacological and pharmacological approaches:

Non-pharmacological:

- Dietary modification: reduce fat, sugar, caffeine, alcohol and increase fibre, fruit and aim for more frequent snacks.
- Increasing exercise
- Vitamin supplementation: there is some evidence for vitamin B supplementation
- Stress reduction: relaxation techniques
- Cognitive behavioural therapy

Pharmacological:

- Combined oral contraceptive pill (COCP)
- Danazol
- Transdermal oestrogen
- GnRH analogues: effectively induce a menopausal state
- Antidepressants: particularly selective serotonin reuptake inhibitors (SSRIs) and selective noradrenalin reuptake inhibitors (SNRIs)

# References

- [NICE Clinical Knowledge Summary (CKS): Premenstrual syndrome](https://cks.nice.org.uk/topics/premenstrual-syndrome/)
- [Royal College of Obstetricians & Gynaecologists: Management of premenstrual syndrome](https://www.rcog.org.uk/globalassets/documents/guidelines/gt48managementpremensturalsyndrome.pdf)
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Premenstrual syndrome
Topic
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Gynaecology
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Combined oral contraceptives are first-line treatment for moderate premenstrual syndrome, alleviating both mood symptoms and heavy menstrual bleeding.
Presentation
376
Menstrual problems
UkmlaTopic
18
Obstetrics and gynaecology
A 23-year-old woman attends her GP. She says she has been struggling with her periods recently and would like some help to make them more manageable. She says that in the days leading up to her period she becomes very irritable and has poor concentration. This gradually resolves once menstruation occurs. She says her periods are also heavy. She is concerned about the impact of her condition on her relationship, although her partner is very supportive. Her past medical history includes migraine without aura. She has no drug allergies. She is keen to start a medication that will help with her symptoms.

What is the next most suitable step in management?
a