Premenstrual syndrome

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The following must be considered prior to diagnosis of PMS

The specific symptom

The timing with

which these symptoms occur

The severity of the symptoms

The absence of hormone or drug ingestion

Currently, the most commonly used set of diagnostic criteria are the American Psychiatric Association DSM-III-R criteria for late luteal phase dysphoric disorder, (called premenstrual dysphoric disorder (PMDD) in DSM-IV), and the University of California, San Diego (UCSD) criteria for PMS (table 1 above).

Based on the most commonly reported symptoms of PMS described above, a Calendar of Premenstrual Experiences (COPE) has been constructed. It includes a four-point Likert scale for each of the ten most commonly reported physical and 12 most commonly reported behavioral symptoms rated daily throughout the menstrual cycle (see Page 10). A total score on this inventory of less than 40 during days three to nine of the menstrual cycle combined with a score greater than 42 during the last seven days of the menstrual cycle has been shown to be an excellent predictor of women who meet inclusion criteria for PMS.

Differential diagnosis

The differential diagnosis of premenstrual syndrome includes a variety of psychiatric disorders, as well as perimenopause, which has been increasingly recognized as a possible cause for mood changes in women. The lifetime incidence of significant psychiatric disorder in women with PMS is up to 78%. The concurrent incidence of affective disorder has been reported to be approximately 50% in women with PMS. Women who present with PMS have a much higher incidence of major depression in the past and appear to be at greater risk for major depression in the future. There appears to also be a significant increased risk of alcohol abuse.

Abdominal bloating breast tenderness and fatigue most common.

Use COPE to establish diagnosis.

Co-existing psychiatric illness high.

Diagnostic approach

The assessment of patients with possible PMS should begin with the history, physical examination, chemistry profile, complete blood count, and serum TSH. Appropriate evaluation should be performed if the cycles are irregular (lengths less than 25 or greater than 36 days). Psychotropic medications, oral contraceptives or other ovarian steroid analogues should be discontinued. Provided the screening test for concomitant medical conditions is negative, and regular menstrual cycles are reported, the patient should be asked to record symptoms prospectively for two months. The Calendar of Premenstrual Experiences or a similar inventory may be used for this purpose. If the patient fails to demonstrate a symptom free interval in the follicular phase, she should be evaluated for a mood or anxiety disorder.

In women who show a clear symptom free interval in the follicular phase, the UCSD criteria for socioeconomic dysfunction determines whether a patient is a candidate for pharmacologic therapy. (see Section 4- Table 1- Page 6).

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