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MFSRH part 2 > PMS > Flashcards

PMS Flashcards

1
Q

Evidence re PMS and vitamin B6?

A

Sudies for vitamin B6 efficacy in PMS are contradictory.

Advise dose restriction to 10mg

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2
Q

Risk of high dose of vitamin B6?

A

Peripheral neuropathy

restrict dose to 10mg OD

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3
Q

What is Core premenstrual disorder (PMD)
(premenstrual syndrome, PMS
or premenstrual dysphoric
disorder)

A

Core PMD also known as premenstrual syndrome, PMS
or premenstrual dysphoric disorder)

Cyclical pre-menstrual symptoms present during the luteal phase
Abate as menstruation begins
Followed by a symptom-free week
Affects quality of life

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4
Q

what is Premenstrual exacerbation?

A

The pre-menstrual exacerbation of an underlying disorder.
Symptoms cyclical and relieved by menstruation
But NO symptom-free week
Affects quality of life
Regular menstruation
Existing non-menstrual condition

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5
Q

what is Non-ovulatory PMD?

A

PMS symptoms occur in presence of ovarian activity without ovulation.
Mechanism not fully understood

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6
Q

Progestogen induced PMDs

A

Cyclical pre-menstrual symptoms
Symptom-free week
Affects quality of life
Associated with exogenous progestogen treatment

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7
Q

what is PMDs with absent menstruation

A 
Functioning ovarian cycle
No menstruation - Reasons such as hysterectomy, endometrial ablation or LNG-IUS 
cyclical symptoms 
Symptom-free week
Affects QOL
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8
Q

what are symptoms of PMS?

A 
Combination of psychological and physical symptoms. 
Impact on daily activity during the luteal phase 
Fatigue
Headaches
Anxiety
Low mood
Irritability
Mood swings
Bloating 
Mastalgia
Altered appetite
Altered libido
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9
Q

Prevalence of PMS?

A

Prevalence PMS 24-40%.

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10
Q

How is PMS diagnosed?

A

Diagnosis is confirmed using a symptom diary
The symptom diary should not be done retrospectively

Daily Record of Severity of Problems (DRSP) is the preferred tool.

GnRH analogues may be used for three months to establish diagnosis if symptom diary inconclusive.

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11
Q

First line treatments for PMS

A

First line treatments for PMS are

  • Exercise
  • Cognitive behavioural therapy (CBT)
  • Vitamin B6
  • Combined new generation pill (cyclically or continuous)
  • Continuous or luteal phase (day 15-28) low dose SSRI e.g. citalopram 10 mg
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12
Q

Second line treatment for PMS

A

Second line treatment for PMS

  • Estradiol patches (100 micrograms) WITH micronised progesterone (100-200 mg on day 17-28 orally or vaginally) ORLNG-IUS 52 mg
  • Higher dose SSRI continuously or luteal phase e.g. citalopram 20-40 mg
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13
Q

Third line treatment for PMS

A

Third line treatment for PMS

  • GnRH analogues AND add-back HRT (continuous combined oestrogen + progesterone)
  • Tibolone
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14
Q

Fourth line treatment for PMS

A

Surgical treatment ± HRT

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15
Q

When should women with PMS be referred to a gynaecologist?

A

Referral to a gynaecologist should be considered when simple measures have failed
(e.g. combined oral contraceptives, vitamin B6, selective serotonin reuptake inhibitors, exercise)

And when the severity of the PMS justifies gynaecological intervention.

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16
Q

What is the role for CBT in PMS management

A

CBT should be considered routinely as one of the first line treatment options

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17
Q

Which COC has the best evidence for managing PMS, including regimens delivering ethinylestradiol?

A

drospirenone-containing COCs

should be considered as a first-line intervention

18
Q

What is the optimum COC pill regimen

e.g. continuous, cyclical or flexible?

A

When treating women with PMS, emerging data suggest use of the contraceptive pill continuously rather than cyclically

19
Q

How efficacious is percutaneous estradiol for treating PMS?

A

Percutaneous estradiol combined with cyclical progestogens has been shown to be effective for
the management of physical and psychological symptoms of severe PMS.

A barrier or intrauterine method of contraception
should be used alongside

20
Q

What is the safety of using estradiol for PMS on the premenopausal endometrium and breast tissue?

A

When treating women with PMS using estradiol, women should be informed that there is insufficient data to advise on the long-term effects on breast and endometrial tissue.

21
Q

What is the evidence for efficacy and adverse effects of danazol in the treatment of PMS?

A

Danazol low dose - 200mg BD - is effective in the luteal phase for breast symptoms
Potential SE = irreversible virilising effects.
Advise to use contraception due to its potential virilising effects on female fetuses

22
Q

what is danazol?

A

Synthetic androgen
Danazol inhibits pituitary gonadotrophins;
combines androgenic activity with antioestrogenic and antiprogestogenic activity

23
Q

How effective are GnRH analogues for treating severe PMS?

A

GnRH analogues are highly effective in treating severe PMS.
When treating women with PMS, GnRH analogues should be reserved for women with
severe symptoms.
Not recommended routinely unless they are being used to aid diagnosis or treat severe cases.

24
Q

when is add-back HRT advised for Women using GnRH analogues for severe PMS?

A

Severe PMS treated with GnRH analogues for more than 6 months should have addback hormone therapy s

Continuous combined hormone replacement
therapy (HRT)
or tibolone

25
Q

what advice should be given regarding BMD for Women using longterm GnRH analogues and add-back HRT for severe PMS?

A

General advice regarding bone mineral density and the effects of
exercise,
diet
smoking
Offer measurement of BMD - DEXA - annually e
Stop treatment if BMD declines
significantly

26
Q

What is the role for progesterone and progestogens in treating PMS?

A

Evidence suggests treating PMS with progestogens is NOT appropriate.

No evidence to support LNG-IUS 52 mg alone - Its role should be confined to opposing action of estrogen therapy on the endometrium.

27
Q

What are the risks and adverse effects of SSRIs?

A

Women with PMS treated with SSRIs should be warned of the possible adverse effects

  • nausea,
  • insomnia,
  • somnolence,
  • fatigue
  • reduction in libido
28
Q

Is there evidence for one SSRI regimens over another in treatment of PMS?

A

SSRI for PMS can be given continuously or luteal-phase.

Efficacy may be improved and adverse effects minimised by luteal-phase regimens with newer agents

29
Q

What preconception and early pregnancy advice should be given regarding SSRIs/ SNRI treatment for PMS?

A

Provide pre-pregnancy counselling at every opportunity.

Inform that PMS symptoms will abate during pregnancy and SSRIs should be discontinued prior to and during pregnancy

30
Q

Are diuretics efficacious in the treatment of PMS?

A

Spironolactone can be used in women with PMS to improve mood and somatic
symptoms

31
Q

Can PMS be managed surgically?

A

In severe PMS - hysterectomy and bilateral oophorectomy has been shown to be of benefit.

Can be considered when medical management has failed, long-term GnRH analogue treatment is required or other gynaecological conditions indicate surgery
Can then use estrogen only HRT.

32
Q

If considering surgical treatment for PMS, should efficacy always be predicted by the prior use of GnRH analogues?

A

For severe PMS, surgery should not be contemplated without pre-operative use of GnRH analogues as a test of cure and to ensure that HRT is tolerated.

33
Q

What is the role of HRT after surgical management of PMS with hysterectomy and BSO?

A

Women being surgically treated for PMS should be recommended to use HRT
Especially if younger than 45 years of age

34
Q

Is there a role for endometrial ablation, oophorectomy or hysterectomy alone in mamangement of PMS?

A

For severe PMS
endometrial ablation or
hysterectomy with conservation of the ovaries are not recommended
Bilateral oophorectomy, without removal of the uterus, will necessitate use of progestogen as part of HRT which risks reintroducing PMS-like symptoms (progestogen-induced premenstrual disorder)

35
Q

What is physiological (mild)

premenstrual disorder

A 
Symptoms cyclical and relieved by menstruation
Symptom-free week
No influence on quality  of life
Menstruation
No additional factors
36
Q

What management is advised for physiological (mild)

premenstrual disorder

A

Counselling and reassurance

No need for treatment

37
Q

what features would suggest an underlying psychological disorder, not a premenstrual disorder

A 
Non-cyclical symptoms
No symptom-free week
Constant influence on  quality of life
Menstruation not associated with symptom severity
No additional factors
38
Q

Management strategy for pre-menstrual exacerbation

A

Treatment should aim to treat the underlying medical,
physical. or psychiatric condition
OR suppress ovulation
(or both)

39
Q

Management of premenstrual disorder

with absent menstruation

A

Managed as Core PMS

1st line = Exercise, cognitve behavioural therapy, vitamin B6, Combined new generaton pill (cyclical or continuous)
Low dose SSRI - Continuous or luteal phase (day 15–28) e.g. citalopram/escitalopram 10 mg

40
Q

Are complementary therapies effective in treating PMS?

A 
Calcium/ vitamin - beneficial 
Saffron - beneficial 
Evening primrose oil - some benefit
Vitex agnus castus L. (chasteberry) - some benefity but inadequate safety data 
Reflexology -  Some benefit
Ginkgo biloba -  Some benefit
Acupuncture -  Some benefit
Lemon balm -  Some benefit
Curcumin -  Some benefit
Wheat germ -  Some benefit
Exercise - some benefit
Vitamin B6 - mixed results
Isoflavones -  Mixed results
St John’s Wort - Mixed results

Magnesium - ?some benefit

41
Q

Peak age prevelence of severe PMS

A

40 - 50 yrs

MFSRH part 2 (24 decks)

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