32 years old nulliparous women seen in the gynecology clinic seen with premenstrual physical andmood symptoms..

32 years old nulliparous women seen in the gynecology clinic seen with premenstrual physical andmood symptoms.

She has normal BMI and currently using condoms as contraception.

how did you confirm the diagnosis of premenstrual syndrome.?
describe the first line management for women with premenstrual syndrome.
if she is not respond to first line treatment options what are the other available options
discuss the salient point in pre pregnancy counselling in relate to this disease.

premenstrual syndrome is collection of physical and psychological symptoms that affect daily living and interpersonal relationships of women.

patient should be asked to maintain a symptom diary for 2 months (daily record of severity of symptoms).
She should mention daily her symptoms and their
severity in daily basis.
This should be continued for 2 months.
Then at the end of 2 months’ clinician can analyse the symptoms and according to type of symptoms and timing of symptoms can come to final diagnosis.
If there are physical symptoms like mastalgia, bloating, psychological symptoms like
irritability, poor concentration, loss of libido present with cyclical manner with predominantly luteal phase may confirm the disease.
But is these symptoms occurring but non-cyclical manner then alternative diagnosis should be considered.
If still this confusing to come to definitive diagnosis GnRh analogues can be given for 2 months.
It will completely stop the ovulation thus her symptoms should be improved.
If her symptoms reduce with this diagnosis can be confirmed. If not alternative somatic or psychological disease should be considered.

2 Premenstrual symptoms occurs due to progesterone mediated effect that occur in luteal phase from progesterone produce form corpus luteum.

Most of the treatment target to stop the cycles thus the progesterone levels will reduce and symptoms will disappear.

Premenstrual symptom initially can be managed by a GP.

But if persistent symptoms that do not
resolved then should meet gynecologist and arrange further care.

Frist line management options are pharmacological treatment option and complementary treatment options.

Pharmacological options are combine oral contraceptive pills, and low dose serotonin noradranaline reuptake inhibitor ( SNRI/ SSRI).
Non pharmacological options are other complementary therapies

Combine oral contraceptive.

This is a one of most effective method of reliving of PMS, the estrogens will be act on
hypothalamo pitutary axis to prevent ovulation such PMS symptoms will be relived.
conventional progesterone levnogestral, norethisterone may give progesterone induced side
effects.
But drosperinone which is newer progestogen agent contain COC will have lesser
progestogen induced side effects and less PMS.
Continuous regime is better than cyclic progesterone supplementation.
SNRI/SSRI
Estrogen and progesterone act on serotonin receptors and regulate their receptor levels. In
pathophysiology of PMS low serotonin level also suggested theory.
Therefore, regulating serotonin levels can alleviate the symptoms.
These can be given either continuously throughout the cycle of only during luteal phase. This
both regimes are equally effective.
They should be long term and abrupt withdrawal should be as risk or disease exacerbations.
Complementary therapy.
There is no clear evidence of effectiveness but should be used first line treatment option with
conjugation of other pharmacological therapies.
Few of examples of complementary therapy
✓ Exercises, reflexology,
✓ Supplementation of Vit D, calcium
✓ Isoflavone
✓ Calcium
✓ Magnesium
✓ Evening primrose oil
✓ Acupuncture.
✓ Cognitive behavioral therapy
The effectives above treatment should be assessed with daily record of severity of problem (
DRSP.

if symptoms are not respond to above treatment option should go for second line treatment
options.
They include pharmacological treatment options GnRH therapy with ad back HRT, transdermal estradiol and progesterone therapy, high does SSRI/SNRI.
If patient not respond to pharmacological methods surgical methods should be used in severe disease. Surgical methods include TAH +BSO.
GnRh therapy

Gnrh will completely inhibit the ovulation and cycle and progesterone production. therefore
symptoms will be resolve.
But using more than 6 months may lead to reduce bone mineral
density and osteoporosis.
Therefore, it should be combine with continues combined Hormonal replacement therapy or tibolone therapy
Even with supplementation of HRT patient should involve exercise and do yearly dexa scan to screen for low BMD.
Transdermal estrogens with progesterone
Rather than oral progesterone transdermal estrogens can be supplied with cyclical progesterone.
This estrogen will enough to suppress the ovulation.
Progesterone Should be given lowest
effective does. It can be given as levonogestral releasing intrauterine device or micronized
vaginal progesterone.
Both of above preparation has low systemic side effects.
Danazol
Danazol is a androgenic drug with ante estrogen, ante progestogen effect. It will stop the cycles
and it will reduce the breast symptoms associated with PMS.
But there are virillization effect.
With danazole effective contraceptive should be used as if pregnancy occurs danzol exposure
will cause virillization of female fetus.
High dose SSRI/ SNRI
For severe symptoms high dose regime can be used. But they associated with more side effects
like drowsiness, insomnia, nausea, reduce libido.
Spironolactone
This also effective on PMS associated physical symptoms.
Surgical treatment options.
Total abdominal hysterectomy with bilateral salphingo oophorectomy
- If PMS very severe and not respond to any medical treatment, then TAH BSO can be used for
  permeant cure of disease.
- Apart form that women who need long term GnRh treatment also can consider this option.
- Before surgery PMS should be confirmed with GnRh therapy as if patient fail to respond to that diagnosis is unlikely.
- Once surgery done patient may need HRT. It can be supplies with estrogen alone regimes.
  Bilateral ooperctomy
  - This approach is not recommended as after surgery when HRT supplementation due to presence of uterus progesterone also need to be supplied. it will lead to reappearing of PMS symptoms.
    Endometrial ablation
This also not a recommended treatment option.