PMS and PMDD Week 3.pptx

PMS + PMDD CLS250 Dr. Stefanie Trowell,ND learning objectives Interpret the definitions, discrepancies, and diagnostic criteria for Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD) according to ACOG and APA (DSM), as well as their symptoms and clinical presentations. Evaluate t...

PMS + PMDD CLS250 Dr. Stefanie Trowell,ND learning objectives Interpret the definitions, discrepancies, and diagnostic criteria for Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD) according to ACOG and APA (DSM), as well as their symptoms and clinical presentations. Evaluate the prevalence and age range of women affected by PMS and PMDD, as well as the risk factors, potential genetic predisposition, and nutritional deficiencies associated with these conditions. Appraise the importance of meticulous evaluation, differential diagnosis, and support for patients with PMS/PMDD, including ruling out other medical and mental health conditions, including psychiatric disorders, and the role of the interprofessional team in providing care. learning objectives (cont.) Master how to assess and diagnose PMS and PMDD using tools such as the Daily Record of Severity of Problems (DRSP), prospective questionnaires, and symptom diaries, and comprehend the importance of monitoring symptoms during at least two menstrual cycles. Analyze the impact of PMS and PMDD on quality-of-life, work productivity, and healthcare utilization, as well as the potential factors contributing to the development and recurrence of these conditions, including hormonal changes and past traumatic events. Evaluate the importance of comprehensive history taking, detailed physical examination, and the use of prospective symptom diaries in diagnosing PMS and PMDD, as well as the role of clinical history and ruling out other conditions such as hypothyroidism and anemia. the menstrual cycle. premenstrual disorders premenstrual syndrome (PMS) - a group of physical (somatic) and behavioural (affective) changes that are cyclical and repetitive, leading to substantial distress and impairment in functional capacity in the luteal phase premenstrual dysphoric disorder (PMDD) - severe mood and physical symptoms usually starting about one to two weeks before the start of menses (during the luteal phase) with symptoms subsiding within a few days of menses onset. Grouped with depressive disorder premenstrual exacerbation (PME) - premenstrual worsening of the symptoms of another disorder, such as MDD, GAD, IBS, migraines and asthma, in the luteal phase (not an official DSM diagnosis) PMDD is a severe extension of PMS PMDD PMS increased number + severity of symptoms distress + impair epidemiology - prevalence 1 SYMPTOM PMS PMDD 70-90% of women report at least one symptom during the luteal phase - 47.8% reproductive-aged women affected with PMS worldwide - about 20% experience symptoms that disrupt their daily activities - 20-32% of premenopausal women affected by PMS (US) - 3-8% affected by PMDD (US) - highest rate among female university students premenstrual mood or anxiety symptoms (2022) reported by Flo mobile app users aged 18-55 years etiology - PMS physiological, psychosocial, and hormonal factors all seem to play a part suspected altered sensitivity to the normal hormonal fluctuations - possibly genetic predisposition - association trends in family (70% rsik if mother had PMS) + twin studies (905 concordance for monozygotes) - genetic influences mediated phenotypically through neurotransmitters and neuroreceptors nutrient deficiencies (Ca, Mg, Mn, vitamins: D, B6, E; linoleic acid) have been reported in females with PMS; however, inconsistent results in controlled studies. Ca supplementation dose improve PMS risk factors: stress, high BMI,​history of trauma/stressful life event/domestic violence, substance abuse,​affective disorders (MDD, postpartum depression), caffeine consumption etiology - PMDD suspected altered central nervous system (CNS) sensitivity to the normal hormonal fluctuations of the menstrual cycle - - females with PMDD have normal levels of gonadal steroid hormones (estrogen, progesterone), but enhanced amygdala and diminished frontocortical activation in response to emotional stimuli possibly genetic predisposition - approx. 31.5 - 56% heritability, association trends in family + twin studies - candidate genes: Estrogen Receptor-1 (ESR1), ESR2 gene, and Serotonin 1A receptor C(−1019) G polymorphism 30-76% of females with PMDD have history of depression; significant comorbidity Hormone Tx Add Back Add Back Mo.1 Mo.2+ symptoms Luteal Phase abnormal sensitivity to normal hormone changes. Schmidt et al, 2017) symptoms cognitive/behavioural aggression, irritability, anger physical acne lethargy headache anxiety appetite change, craving sweets mood lability hot flashes depression bloating, fluid retention, oliguria panic attacks muscle aches, breast pain or swelling fatigue nausea and vomiting, constipation poor concentration, forgetfulness pelvic heaviness or pressure reduced coping skills dizziness or vertigo hostility weight gain PMS predictability based on symptoms symptom OR aches 1.05 fatigue 1.03 irritability 0.83 poor concentration 0.95 mood swings 1.08 anxiety / tension 1.07 weight gain 1.02 guilty 0.98 food cravings 1.07 headache 1.01 cramps 0.93 no interest in usual activities 1.07 sad / depressed / blue 0.96 OR, odds ratio; bolded are statistically significant (p < 0.05) (Freeman et al, 2011) symptom timing - onset can occur any time after menarche until menopause - rare in adolescence - highest incidence in late 20s - early 30s - symptoms recur with each ovulatory cycle transgender individuals can have PMS or PMDD (anyone with ovaries can have symptoms). Transger individuals could be at a higher risk for PMDD - severity and frequency of symptoms can vary over time - symptom duration averages 6 days per month premenstrual syndrome (PMS) - ACOG at least one (1) of the following affective and somatic symptoms must be present during the 5 days prior to menses (and disappear within 4 days of the onset of menses) in each of the 3 previous menstrual cycles: (requires monitoring for 3 months) - affective symptoms: angry outbursts, anxiety, confusion, depression, irritability, social withdrawal - somatic symptoms: abdominal bloating, breast tenderness/swelling, headache, joint or muscle pain, swelling of extremities, weight gain note: symptoms must be in the absence of any pharmaceutical therapy, hormone injection, or drug or alcohol use (exclusions). The symptoms must occur reproducibly during 2 cycles of prospective recording. The patient must exhibit identifiable dysfunction in social, academic, or work performance. premenstrual dysphoric disorder (PMDD) - DSM-5 A. In the majority of menstrual cycles, at least 5 symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses. B. One (or more) of the following symptoms must be present: a. Marked affective lability (e.g. mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection) (common) b. Marked irritability or anger or increased interpersonal conflicts (common) c. Marked depressed mood, feelings of hopelessness, or self-depreciating thoughts d. Marked anxiety, tension, and/or feelings of being keyed up or on edge premenstrual dysphoric disorder (PMDD) - DSM-5 cont. C. One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B above. a. Decreased interest in usual activities (e.g. work, school, friends, hobbies) b. Subjective difficulty in concentration (a marked change in the luteal phase measured by their distress) c. d. e. f. Lethargy, easy fatigability, or marked lack of energy. Marked change in appetite; overeating; or specific food cravings. Hypersomnia or insomnia. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating” or weight gain. Note: the symptoms in Criteria A-C must have been met for most menstrual cycles in the preceding year. premenstrual dysphoric disorder (PMDD) - DSM-5 cont. D. The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g. avoidance of social activities; decreased productivity and efficiency at work, school, or home). E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders). F. Criterion A should be confirmed by prospective daily ratings during at least 2 symptomatic cycles (note: the diagnosis may be made provisionally before this confirmation). G. The symptoms are not attributable to the physiologic effects of a substance (e.g. a drug of abuse, a medication, other treatment) or another medical condition (e.g. hyperthyroidism). average premenstrual dysphoric disorder (PMDD) pattern symptom assessment + monitoring retrospective questionnaires - Premenstrual Symptom Screening Tool (PSST) - Premenstrual Assessment Form (PAF) - Rating Scale for Premenstrual Tension Syndrome (PMTS) prospective symptom tracking/diaries - Daily Record of Severity of Problems (DRSP) - Calendar of Premenstrual Experiences (COPE) - Premenstrual Experience Assessment (PEA) - Menstrual Distress Questionnaire (MDQ) - Prospective Record of the Impact and Severity of Menstrual Symptomatology (PRISM) Premenstrual Symptoms Screening Tool (PSST) Premenstrual Symptoms Screening Tool (PSST) cont. Do you experience some or any of the following premenstrual symptoms which start before your period and stop within a few days of bleeding? Symptom 1. Anger / irritability 2. Anxiety / tension 3. Tearful / increased sensitivity to rejection 4. Depressed mood / hopelessness 5. Decreased interest in work activities Not at all Mild Moderate Severe Premenstrual Symptoms Screening Tool (PSST) Symptom 6. Decreased interest in home activities 7. Decreased interest in social activities 8. Difficulty concentrating 9. Fatigue / lack of energy 10. Overeating / food cravings 11. Insomnia Not at all Mild Moderate cont. Severe Premenstrual Symptoms Screening Tool (PSST) Symptom 12. Hypersomnia (needing more sleep) 13. Feeling overwhelmed or out of control 14. Physical symptoms: breast tenderness, headaches, joint/ muscle pain, bloating, weight gain Not at all Mild Moderate cont. Severe Premenstrual Symptoms Screening Tool (PSST) cont. Have your symptoms, as listed above, interfered with: Not at all A. Your work efficiency or productivity B. Your relationships with coworkers C. Your relationships with your family D. Your social life activities E. Your home responsibilities Mild Moderate Severe Premenstrual Symptoms Screening Tool (PSST) cont. Scoring The following criteria must be present for a diagnosis of moderate to severe PMS 1. At least one of #1, #2, #3, #4 is moderate to severe 2. In addition at least four of #1 - #14 are moderate to severe 3. At least one of A, B, C, D, E is moderate to severe The following criteria must be present for a presumptive diagnosis of PMDD 4. At least one of #1, #2, #3, #4 is severe 5. In addition at least four of #1 - #14 are moderate to severe 6. At least one of A, B, C, D, E is severe Premenstrual Symptoms Screening Tool (PSST) validity low specificity a validated, simple, user-friendly screening tool to identify women who suffer from severe Premenstrual Syndrome (PMS) or Premenstrual Dysphoric Disorder (PMDD). Finding PMS / PMDD Diagnosis Finding PMS Sensitivity LR + LR - 79% 1.18 0.63 PPV (%) NPV (%) 81.4 30.0 PPV positive predictive value, NPV negative predictive value Steiner, M., Macdougall, M., & Brown, E. (2003). The premenstrual symptoms screening tool (PSST) for clinicians. Archives of Women’s Mental Health, 6, 203-209. prospective questionnaire the most accurate way to diagnose PMS and PMDD - patients tend to overestimate the cyclic nature of their symptoms - tracking may reveal symptoms to be erratic or exacerbated in the luteal cycle Daily Record of Severity of Problems (DRSP) - downloadable form (IAPMD) PreMentric S - iOS - Android daily record of severity of problems (DRSP) (psychscene, IAPMD) 1 - not at all 2 - minimal 3 - mild 4 - moderate 5 - severe Felt depressed, sad, “down” or “blue” Felt hopeless Felt worthless or guilty Felt anxious, tense, “keyed up” or “on edge” Had mood swings (i.e., suddenly feeling sad or tearful) Was sensitive to rejection or feelings were easily hurt Felt angry or irritable 6 - extreme daily record of severity of problems (DRSP) 1 - not at all 2 - minimal 3 - mild 4 - moderate 5 - severe Had conflicts or problems with people Had less interest in usual activities (work, school, friends, hobbies) Had difficulty concentrating Felt lethargic, tired, fatigued, or had a lack of energy Had increased appetite or overate Had cravings for specific foods Slept more, took naps, found it hard to get up when intended cont. 6 - extreme daily record of severity of problems (DRSP) 1 - not at all 2 - minimal 3 - mild 4 - moderate 5 - severe Had trouble getting to sleep or staying asleep Felt overwhelmed or that I could not cope Felt out of control Had breast tenderness Had breast swelling, felt bloated, or had weight gain Had headache Had joint or muscle pain cont. 6 - extreme daily record of severity of problems (DRSP) 1 - not at all 2 - minimal 3 - mild 4 - moderate 5 - severe cont. 6 - extreme At work, school, home, or in daily routine, at least one of the problems noted above caused reduction of production of efficiency At least one of the problems noted above caused avoidance of or less participation in hobbies or social activities At least one of the problems noted above interfered with relationships with others Endicott, J., Nee, J., & Harrison, W. (2006). Daily Record of Severity of Problems (DRSP): reliability and validity. Archives of women's mental health, 9, 41-49. daily record of severity of problems (DRSP) scoring PMS - total score ≥ 50 in first day of menses, suggests PMS - track for 2 cycles - PMS if: 3 or more items have a score ≥ 3 (mild) during the luteal phase, add the scores of the luteal (5 days prior to menses) and follicular (CD6-10) phases, AND if average luteal score is >30% follicular score for at least 1 item PMDD diagnosis - in the week prior to menses: - score ≥ 4 on 5 symptoms and on at least 1 impairment item for at least 2 days - above criteria met for 2 consecutive cycles or 2 out of 3 cycles - clinical judgement should correlate with daily rating assessment if average score ≥ 3 in mid-follicular phase (CD6-10) - seek alternate diagnosis * excused sx: appetite (obesity), insomnia (good reasons), pain (physical illness) daily record of severity of problems (DRSP) - validity valid and reliable questionnaire consists of 24 items, out of which 21 items are grouped into 11 distinct symptoms and 3 functional impairment items. can be used for PMS or PMDD diagnosis Finding Sensitivity LR + LR - PMS Diagnosis (standard-21) 81.3% 4.07 0.23 PMS Diagnosis (alternate-11) 75.0% 4.01 0.31 PPV (%) NPV (%) 63.2 - 63.4 88.4 - 90.0 Finding PMS PPV positive predictive value, NPV negative predictive value (Borenstein, 2007) Carolina Premenstrual Assessment Scoring System (C-PASS) a validated and reliable diagnostic algorithm for making the DSM-5 diagnosis of PMDD using two cycles of daily symptom ratings on the daily record of severity of problems (DRSP) [typically used in research] - compares data from days -7 to -1 (premenstrual week) and days 4 to 10 (postmenstrual week) excel macro download ( available from IAPMD) differential diagnosis symptoms may be due to psychiatric, medical, gynecological or psychosocial causes - Dysmenorrhea pain with the onset of flow - substance abuse disorders - endometriosis - affective disorders (e.g. anxiety, - physiologic ovarian cysts or depression) - migraine headaches polycystic ovary syndrome - hypothyroidism (sometimes hyper) - irritable bowel syndrome - anemia - arthritis or arthralgia - fibrocystic breast changes - anorexia or bulimia - diabetes - chronic fatigue syndrome - adverse effects from oral - perimenopause contraceptive (OCP) SYMPTOM SEVERITY symptom pattern comparison (PMDD vs. PME vs. AD) differential diagnosis symptom timing + tracking is crucial to differentiate PMS/PMDD dysmenorrhea - pain is associated with menstrual flow endometriosis - pain can occur at any time in menstrual cycle, but often intense pain with menstrual flow; may also have digestive or mood symptoms polycystic ovaries - menstrual irregularity, acne/elevated androgens, ovarian cysts hypothyroidism - non-cyclic fatigue, mood and weight changes anemia - non-cyclic fatigue, mood, weakness and difficulty concentrating differential diagnosis fibrocystic breast changes - pain can vary throughout the cycle, increased discomfort in premenstrual phase diabetes - changes in appetite, urination and weight perimenopause - life stage, symptoms can be more persistent affective disorder - absence of symptom-free week in follicular phase adverse effect of OCP - more persistent effects on mood, headache, breast tenderness, nausea and weight starting from initiating treatment - esp. in initial months anemia (iron-deficiency) - lower than normal level of red blood cells or hemoglobin on complete blood count 10% of menstruating females; increased risk with GI bleeds, menorrhagia, low iron diet (i.e. plant based), decreased/impaired absorption; childhood, pregnancy/lactation have increased demands fatigue, tachycardia, palpitations (part of PMS), dyspnea on exertion diagnosis: blood work (CBC, ferritin, possibly reticulocyte count) - pallor (conjunctival rim, palmar crease, palm) - Hb