Menopausal Transition and PMS/PMDD Symptoms

Menstrual & Menopause Disorders

• This presentation covers menstrual and menopause disorders, including premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD).
• PMDD is a more severe form of PMS, characterized by prominent symptoms of anger, irritability, and internal tension.
• PMS involves both physical and behavioral symptoms that repeatedly occur during the second half of the menstrual cycle, impacting aspects of a woman's life.
• Symptoms of PMS often include mood swings, irritability, anxiety/tension.
• Physical symptoms can include abdominal bloating, fatigue, breast tenderness, headaches, and dizziness.
• The symptoms of PMS generally last about six days per month.
• Symptoms of PMDD are typically most severe in the four days before menstruation and the first two to three days of menstruation.

Diagnosis

• PMS/PMDD symptoms can begin after menarche, usually in a woman's early twenties.
• Symptoms often continue throughout a woman's reproductive years.
• Women often experience more severe symptoms during their late reproductive years.
• Women with premenstrual disorders may have a higher risk of developing mood disorders during menopause.
• PMS resolves after menopause, and temporarily during pregnancy.
• No specific abnormalities are typically found on a physical exam for women with PMDD or PMS.
• There are no specific biochemical abnormalities associated with PMDD or PMS aside from those related to other underlying conditions.

Assessment

• A detailed menstrual history is important in assessing PMS/PMDD to understand the relationship between symptoms and cycle phases.
• This includes determining if the patient's cycles are regular (25-35 days intermenstrual interval).
• Detailed information is needed about the patient's symptoms including their type, pattern of onset, and severity, and if they have any impact on their daily functioning.
• For women with irregular cycles (less than 25 or greater than 35 days), a biochemical assessment isn't routinely necessary, but may be used in women of younger reproductive ages to understand the cause for irregular cycles.
• A serum evaluation of human chorionic gonadotropin (hCG), thyroid-stimulating hormone (TSH), prolactin, and follicle-stimulating hormone (FSH) is sometimes recommended.
• The presence of other conditions like hyper/hypothyroidism and chronic mild mood disorders such as persistent depressive disorder or major depressive disorder should be evaluated.
• To confirm the diagnosis, patients may be asked to track symptoms for two months.
• Evaluation of medications, such as hormonal treatments (including oral contraceptives), should be addressed.
• ACOG defines PMS as the presence of at least one symptom that occurs in the luteal phase of the menstrual cycle which leads to impairment in functioning.
• The symptoms must also remit at menstruation or soon after to satisfy a free-symptom interval.
• The DSM-5 criteria for PMDD require prospective documentation of physical and behavioral symptoms over a year.
• This also includes at least five symptoms that were present in the week prior to menstruation and resolve within a few days after menstruation.
• One or more symptoms of PMDD must be present from the following list to reach a total of five symptoms: Mood swings, sudden sadness, increased sensitivity to rejection, anger, sense of hopelessness, depressed mood, self-critical thoughts, tension, anxiety, feeling on edge, difficulty concentrating, change in appetite, food cravings, overeating, diminished interest in usual activities, easy fatigability, feeling overwhelmed, breast tenderness, bloating, weight gain, joint pain, or sleeping too much or not sleeping enough.

Management

• Mild symptoms can be managed with exercise and relaxation techniques.
• Dietary supplements like Vitex agnus castus (chasteberry) may be effective for mild cases.
• Vitamin B6, vitamin E, calcium, and magnesium have also been studied for treating PMS. However, high doses of calcium supplements and vitamin B6 may have adverse effects (neuropathy and renal calculi, respectively).
• Moderate to severe symptoms can be treated with lifestyle measures, including exercise and stress reduction.
• If lifestyle measures are not helpful, a trial of an SSRI (selective serotonin reuptake inhibitor) may be necessary.
• Several SSRIs may be used, with differing doses and dosing regimens including continuous daily dosing or intermittent regimens (luteal phase dosing).
• Side effects of SSRIs include nausea, headaches, insomnia, and reduced libido but in some cases, the side effects resolve quickly.
• The discontinuation of SSRIs can have side effects so a gradual dose reduction is necessary.
• For women with moderate to severe symptoms, combined estrogen-progestin contraceptives (COCs) may be useful, as they suppress the hypothalamic-pituitary-ovarian axis and ovulation.
• Drospirenone-containing COCs are effective for PMDD management and may be used in addition to an SSRI if the symptom improvement with COCs alone is insufficient.
• Alternative treatments may also include transdermal preparations, and vaginal or local preparations for genitourinary syndrome of menopause (GSM) symptoms.
• Natural products such as soy isoflavones, evening primrose oil and black cohosh can also be used. However, these natural products have not been as well-supported by reliable studies to date.

Menopause & Perimenopause

• Menopause is characterized by the cessation of menstruation for 1 year.
• It is sometimes associated with surgical procedures (like hysterectomy and oophorectomy), specific cancers treatments (like chemotherapy), genetic factors or without discernible cause.
• Perimenopause is the period when menopausal symptoms occur, but menstruation has not stopped yet.
• Perimenopause ends with menopause after 12 months with no return of menstruation.
• Common symptoms associated with menopause include vasomotor symptoms (like hot flashes), genitourinary syndrome of menopause (GSM) and insomnia.
• Treatments for menopause often involve hormone therapy (HT).
• HT can be used for vasomotor symptoms, GSM, osteoporosis prevention, hypoestrogenism, or for premature ovarian failure.

Recommendations

• HT treatments should be individualized to each patient and based on their unique medical history.
• Risks and benefits of HT should be outlined for the patient.
• For women under 60 years of age, the lowest effective dose of HT should be sought.
• For women over 60 or in perimenopause for more than 10 years, extreme care is advised in the consideration of HT and if possible, other treatment options should be sought first.
• Additional evaluations, including physical exams, blood tests, mammograms and Pap smears, are sometimes necessary when looking at all options for addressing various types of menopausal and premenstrual symptoms.

Formulations

• Oral medications are used to treat vasomotor symptoms, and can also treat other associated menopause, GSM and premenstrual issues.
• Transdermal forms may be helpful for women who do not tolerate the oral meds used.
• Vaginal or local preparations are sometimes used when women primarily have GSM symptoms.

Serotonin Reuptake Inhibitors

• SSRIs are often useful for vasomotor symptoms in high-risk patients in whom HT is unsuitable.
• Example SSRIs are paroxetine, venlafaxine, fluoxetine, escitalopram and citalopram.

Natural Products

• Some natural products, like soy isoflavones or evening primrose oil, may be used for symptomatic relief but are not always considered first line treatments.
• Black cohosh exhibits some effectiveness for vasomotor symptoms but has been associated with potential liver toxicity.

Other Treatments

• Clonidine, gabapentin, pregabalin, acupuncture, lifestyle changes, and hypnosis are other potential treatments for vasomotor symptoms. These treatments have not been proven, with as robust evidence, as other options in this presentation.

Test your knowledge about the common symptoms experienced by women with PMS or PMDD during the menopausal transition. This quiz covers symptoms, their frequencies, and changes in menstrual cycles associated with this period. Challenge yourself and learn more about the effects of menopause on women's health.