PRE-MENSTRUAL SYNDROME- A REVIEW
Mariam Zaka et al /J. Pharm. Sci. & Res. Vol.4(1), 2012, 1684-1691PRE-MENSTRUAL SYNDROME- A REVIEWMarriam Zaka1, Khawaja Tahir Mahmood21Department of Pharmacy, Lahore College for Women University, Lahore, Pakistan; 2Drug TestingLaboratory, Health Department, Punjab, Lahore, Pakistan.Abstract: Premenstrual Syndrome is described as a collection of predictable physical, cognitive, affective, andbehavioral symptoms that occur cyclically during the luteal phase of the menstrual cycle and resolve quickly at orwithin a few days of the onset of menstruation. Severe form of premenstrual syndrome is called PremenstrualDysphoric Disorder. The typical symptoms of premenstrual syndrome normally involves the symptoms related tomood (mood swings, anxiety, and irritability) and physical conditions – like headache, fatigue, bloating, sleepdisturbances, nausea, and breast tenderness. 90% of the women all over the world including Pakistan, experiencethese symptoms during their child bearing age. Several factors such as hormonal change, diet and lifestyle maycause premenstrual syndrome. PMS affects the daily life of menstruating women of any age; race; and part ofworld. A large population of Pakistani women is also a victim of PMS. Prescribed medications as oralcontraceptives and antidepressants, some over-the-counter drugs like ibuprofen, paracetamol and home remedies aretaken as a treatment by the women in Pakistan. Hence Changing lifestyle, modifying diet, exercises, stress reductionand provision of services by health providers, such as counseling by pharmacist can optimize Quality of life andoverall health of women suffering from PMS not only in Pakistan but also in the rest of the world.Key words: Premenstrual Syndrome, Premenstrual Dysphoric Syndrome, Prevalence, Quality of life, Symptoms.Introduction:Background:For centuries, and still at present, the socialhistory of premenstrual syndrome (PMS) andphenomena is entangled with the socialhistory of gender relations. [1]In early 1980sPMS became a household term. Popular pressarticles told women how to “beat the Blues”,“overcome the menstrual uglies” and negotiateinterpersonal relations during those times ofmonth. Clinicians and researchers met atinternationalconferencestodiscussdefination, etiology and possible treatment ofa syndrome estimated by some to affect 80%of women. Feminist and legal scholarsdebated the validity of term and its use as adefense for criminal behaviour. SincePremenstrual Tension (PMT), as PMS wasfirst termed, has been in medical discoursesince Frank (1931) associated it withhormonal imbalances. [2]The premenstrualsyndrome (PMS) was first described in 1931by Frank and Horney, who speculated on thepossible physiopathological origins of thecondition and on some forms of treatment [3]The World Health Organization’s (WHO)International Classification of Disease, 10theditionincludespremenstrualtensionsyndrome in its section of gynecologicdisorders, as a disorder of the female genitalorgans. [4]Definition:There is no single precise definition of thePMS, but it is generally accepted thatPremenstrual syndrome can be broadlydefined as any constellation of psychologicaland physical symptoms that recur regularly inthe luteal phase of the menstrual cycle, remitfor at least 1 week in the follicular phase andcause distress and functional impairment. [5]Premenstrual syndrome (PMS), occurs 7–14days before the onset of menstruation andsubsides with the commencement of menstrualflow, affects women during their reproductiveage, and is associated with physical,psychological and behavioral changes [6]Premenstrual syndrome (PMS) is a cyclicrecurrence of distressing somatic and affectivesymptoms in the luteal phase of menstrualcycle and in the few days (1-3days) of the nextfollicular phase. [7]If the mental symptoms predominate, are verysevere, and are associated with impairment,then the patient is classified as havingpremenstrual dysphoric disorder (PMDD)which may be viewed as a severe subtype ofPMS [8]Premenstrual syndrome (PMS) can be definedas a recurrent disorder that occurs every1684
Mariam Zaka et al /J. Pharm. Sci. & Res. Vol.4(1), 2012, 1684-1691month in the luteal phase of the menstrualcycle, and remits with the onset ofmenstruation. PMS is characterized by acomplex set of symptoms which includephysical, psychological and behaviouralchanges of varying severity. This can interferewith the lives of the affected, as well as theirinterpersonal relationships. [9]Prevalence: It has been estimated fromretrospective community surveys that nearly90% of women have experienced at least onepremenstrual syndrome .Epidemiologicalsurveys have estimated that as many as 75%of reproductive age women experience somesymptoms attributed to the premenstrual phaseof menstrual cycle. One study on adolescentsample (N 78) showed that 100% of theparticipants reported at least one premenstrualsymptom of minimal severity [10,11]There exists very little population based datafrom Pakistan regarding the prevalence ofPMS and PMDD. A few studies have usedconvenience sampling of medical students andother groups of women from major cities inPakistan. However, because of conveniencesampling they remain biased. [12]Symptoms and Clinical Manifestations: Thesymptoms reappear monthly and last for anaverage of 6 days per month for the majorityof the reproductive years. It has beencalculated that affected women experiencealmost 3000 days of severe symptoms duringthe reproductive years. [13]More than 200 symptoms of PMS/PMDDhave been described in literature, ranging frommild symptoms to those severe enough tointerfere with normal activities.[14]It is estimated that up to 85% ofpremenopausal women experience at least onepremenstrual symptom and 15-20% meetclinical criteria for premenstrual syndrome(PMS).[15]The most important somatic symptoms arefeeling over whelmed ,food craving, insomniaor hypersomnia , headache, pelvic pain anddiscomfort, breast tenderness, joint pain,bloating ; and the most common anddistressing affective symptoms are irritability,anxiety, depression, mood swing, awal and interpersonal conflicts. Thesignificant appearance of these symptomsstarts from the teen years and worsen throughthe process of aging .During the childbearingage, up to 40% of women have some form ofPMS , but only 3-8% have severepsychological manifestations -PremenstrualDysphoric Disorder (PMDD).Symptoms ofpremenstrual syndrome may be emotional,physical, behavioral and it may vary inintensity. Premenstrual dysphoric disorder(PMDD) is a severe form of premenstrualsyndrome.Themainsymptomsofpremenstrual syndrome include mood swing,anger, fatigue, abdominal cramp, abdominalbloating, and back ache [7, 16]These symptoms should interfere with thenormal activities of a woman including social,occupational, interpersonal and even thesexual functioning and are not related to anyorganic and functional disease. [17]Patho-physiology, Etiology, and Riskfactors: Within the past decade, premenstrualsyndrome (PMS) has become the subject ofrigorous scientific scrutiny. As a result,diagnostic criteria have been developed, andthe pathophysiology of the disorder has beenpartially elucidated. The preponderance ofevidence suggests that the disorder is theresult of the interaction of cyclic changes inestrogen and progesterone with specificneurotransmitters. Serotonin and gammaamino butyric acid (GABA) appear to beespecially important in this regard. Increasedunderstanding of PMS has enabled thedevelopment of specific treatment modalitiesthat, unlike previous prescriptions, havedemonstrated efficacy in rigorous andreproducible studies. [18]The implication is that ovulation, or ovulationrelated processes, are an important factor inthe patho-biology of PMS. Menstrually related1685
Mariam Zaka et al /J. Pharm. Sci. & Res. Vol.4(1), 2012, 1684-1691disorders affect a significant number ofwomen of reproductive age. The pathobiologyof menstrually related disorders, specificallypremenstrual syndromes, involve multifacetedinteractions between processes of the centralnervous system, hormones, and othermodulators. These interactions includegonadal hormones, their metabolites, andseveral neurotransmitters and neurohormonalsystems, including serotonin, γ-aminobutyricacid, and rennin-angiotensin-aldosteronesystem. In vulnerable women, response ofthese systems to normal fluctuations ofgonadal hormones may contribute toexpressionsofsymptoms.Disruptedhomeostasis and impaired adaptation may bean important underlying mechanism.[8]Individual variation in stress responsivenessmay be involved in pathophsiology ofpremenstrual symptoms. [19]Reduced laryngeal functioning is a reality forcertain women to the extent that researchershave now given it an official name:Premenstrual Voice Syndrome (PMVS). Otherresearchers call this syndrome alis." The syndrome or pathologyis characterized by vocal fatigue, decrease inrange, loss of power, faint hoarseness, loss ofrange,andlossofagility.[20]The etiology of Premenstrual syndromeremains unknown and may be complex andmultifactorial. The role of ovarian hormones isunclear, but symptoms often improve whenovulation is suppressed. Changes in hormoneslevel may influence centrally activeneurotransmitters such as serotonin, but incirculation sex hormones levels are typicallynormal in women with Premenstrualsyndrome. [21]Factors such as hormonal change, diet andlifestyle may cause premenstrual syndrome.[22]A variety of risk factors is associated withpatterns of symptom reporting and mayprovide clues to the etiology of perimenstrualsymptoms and help to identify women mostvulnerable to them. A woman's age and cyclecharacteristics are predictors of the type andseverity of perimenstrual symptoms sheexperiences.In addition, a history of affectiveillness may be associated with increasedreporting of perimenstrual symptoms Riskfactors for PMS include advancing age(beyond 30 years) and genetic factors. PMSsymptoms are identified in adolescents andcan begin around age 14, or 2 years postmenarche, and persist until menopause. Somestudies suggest that women whose mothersreport PMS are more likely to develop PMS(70%, versus 37% of daughters of unaffectedmothers). In addition, concordance rates forPMS are significantly higher in monozygotictwins (93%) compared with dizygotic twins(44%). There are no significant differences inpersonality profile or level of stress in womenwith PMS compared with asymptomaticwomen. However, women with PMS may nothandle stress as well [14, 23]There have been few studies in whichpremenstrual symptoms in women sufferingfrom depressive disorders were assessed. [24]The risk of incident PMS tended to increasewith the quantity of cigarette smoking and wassignificantly higher for women who begansmoking during adolescence. [25]Diagnosis: The premenstrual syndrome(PMS) is an amalgum of mental and physicalsymptoms arising in the luteal phase of themenstrual cycle. The symptoms disappearafter the start of menstruation. During the restof the follicular phase the patient is free fromsymptoms. The cyclic nature of the symptominterpretation is a diagnosis of the syndrome.[26]Premenstrual symptoms are experienced by upto 90% of women of child bearing age. Asmaller subset meet criteria for premenstrualsyndrome (PMS) and less than 10% arediagnosed as having premenstrual dysphoricdisorder (PMDD).There are no specificphysical findings or laboratory tests can be1686
Mariam Zaka et al /J. Pharm. Sci. & Res. Vol.4(1), 2012, 1684-1691utilized to make the diagnosis of PMS. Thevarious bodies that have published definitionsinclude the American College of Obstetriciansand Gynecologists (ACOG), the AmericanPsychiatric Association, and the NationalInstitutes of Mental Health. There is noseparate diagnostic code for PMS or PMDD.In a Practice Bulletin published in the year2000, ACOG defined diagnostic criteria forPMS based on the work of Mortola describesthat PMS can be diagnosed if at least one ofthe affective and one of the somatic symptomsis reported five days prior to the onset ofmenses in the three prior menstrual cycles.The symptoms must be prospectively recordedin at least two cycles and must cease within 4days of onset of menses and not recur untilafter day 12 of the cycle. These symptomsmust be recorded in the absence ofpharmacologic therapy, or use of hormones,drugs, or alcohol, and cause identifieddysfunction in social or work relatedactivities. [14]A variety of instruments have been developedfor evaluating PMS, and these have taken intoconsideration varying numbers of symptomsand intensity levels. Since PMS does not havea characteristic clinical condition, the firstquestionnaires on PMS were long and directedtowards application in clinics. [27]Published criteria for diagnosis vary greatlybetween authoritative bodies; a newclassification from the International Societyfor Premenstrual Disorders (ISPMD) willallow this to be resolved. It will also enableclinicians to provide accurate diagnosis andeffective management. [28]Management: The management of PMS isoften frustrating for both patients andphysicians. Initially, all patients with PMSshould be offered linterventions for PMS include patienteducation, supportive therapy and behavioralchange. Therapies for PMS vary in theirefficacy and risk of adverse events. Sometherapies, such as eating a healthy diet, areknown to have a variety of health benefitswith very low risk of adverse events, andshould be recommended to virtually allwomen. Pharmacologic therapies carry agreater risk of adverse events, and this must beconsidered when selecting such therapy, andshould be only offered to patients withpersistent symptoms of PMS. [29]PMS has a high morbidity level and reducesthe quality of life for many women ofreproductive age, with pharmaceuticaltreatments having limited efficacy andsubstantial side effects. Physical activity hasbeen recommended as a method of reducingmenstrual symptom severity. However, littleevidence exists to support a clear relationshipbetween physical activity and PMS. Treatmentgoals for PMS are to ameliorate or eliminatesymptoms, reduce their impact on activitiesand interpersonal relationships, and minimizeadverse effects of treatment. Althoughnumerous treatment strategies are available,few have been adequately evaluated inrandomized, controlled trials. Initially, allpatients with PMS should be offerednonpharmacologic therapy. Medication shouldbe offered to patients with persistentsymptoms of PMS and those who meet criteriafor PMDD. Surgical treatment, principallyhysterectomy plus bilateral oophorectomy, iscontroversial because it is irreversible andassociated with significant risks. Surgery maybe considered in severely affected patientswho fail to respond to other therapies and alsohave significant gynecologic problems forwhich surgery would be appropriate. [15, 30]A number of mineral/vitamin supplementshave been shown to be useful treatments forPMS. Progesterone and progestogens arecommonly prescribed for PMS. In fact, manywomen who suffer from PMS developdepressive side effects from the commonlyused progestogens. There is some evidencethat the newer contraceptive pills may helpsome women who suffer from PMS. There is1687
Mariam Zaka et al /J. Pharm. Sci. & Res. Vol.4(1), 2012, 1684-1691little doubt that the most effective drugtreatments for PMS are the SSRIs. If thepatient knows exactly when her symptomsoccur then the drug may be started two daysbefore the onset of symptoms and then native therapies as herbalmedicine, homeopathy, dietary supplements,relaxation, massage, reflexology, chiropracticare popular with women who havepremenstrual syndrome. [31]Calcium carbonate should be recommendedas first-line therapy for women with mild-tomoderate PMS. Selective serotonin reuptakeinhibitors can be considered as first-linetherapy for women with severe affectivesymptoms and for women with mildersymptoms who have failed to respond to othertherapies. Other therapies may be tried if thesemeasures fail to provide adequate relief. [32]No single treatment is universally recognizedas effective and many patients often turn totherapeuticapproachesoutsideofconventional medicine. Some herb remediesseem useful for the treatment of PMS. [33]Traditional Chinese medicine (TCM) hassignificantadvantagesintreatinggynaecological disorders, one of them is PMS.[34]The physical and affective symptoms of abroad range of conditions are improvedfollowing mindfulness based practices.Mindfulness is predictive of improvedsymptomatologyandwell-being.Development of a mindfulness basedintervention aimed at reducing symptomseverity in premenstrual symptom sufferers.[35]Very recent studies with large samples ofwomen with premenstrual syndrome, havereported a reduction in depressive symptomsand premenstrual tension as a result of lighttherapy. [36]A wide range of therapeutic interventionshave been advocated in the treatment of PMS,many of which have side effects. Assymptoms of PMS can be chronic and longterm, special attention should be paid to theside-effects of pharmacological interventions.For this reason, alternative approaches may berecommended. [9, 37]The most effective current management ofPMS is a conservative one including accuratediagnosis, stress control, sensible levels of dietand exercise and perhaps the use ofalprazolam in the premenstrual period. Otherapproaches such as the use of mefenamic acidand evening oil of primrose remain unproven.Progesterone has been proven ineffective.Further research is required into the value ofantidepressant medication. [38]The majority of PMS cases are dealt with ingeneral practice but severe cases should bemanaged by a multidisciplinary teamincluding a gynecologist, psychiatrist orpsychologist,dietitianandcounselor.Unfortunately this approach is rarelyavailable. [39]It's a real biological condition for whichwomen seek treatment--and for whicheffective treatment is available, the mostimportant thing is to give women who seekhelp. [40]Impact of PMS on Quality of life offemales: PMS is associated with reduction inhealth related quality of life and women withPMS have greater work productivityimpairment than women without PMS. [11]PMS is a commonly encountered complaintamong women and may affect women'squality of life and reduce their occupationalproductivity. [41]Steps in the Treatment of PMS/PMDD:The following steps for treating PMS/PMDDare based on recommendations outlined in anACOG Practice Bulletin:Step 1: A. If mild/moderate symptoms:Recommend supportive therapy with goodnutrition, complex carbohydrates, aerobicexercise, calcium supplements, and possiblymagnesium or chasteberry fruit. B. If physicalsymptoms predominate: Try spironolactone or1688
Mariam Zaka et al /J. Pharm. Sci. & Res. Vol.4(1), 2012, 1684-1691NSAIDs, or hormonal suppression with OCPsor medroxyprogesterone acetate. Step 2:When mood symptoms predominate and aresignificantly impairing function: Initiate SSRItherapy. An anxiolytic can be used for specificsymptoms not relieved by the SSRImedication. Step 3: If not responsive to steps 1or 2: Try GnRH agonists. This would not bedone in an adolescent without consultationwith a gynecologist. [14]Education about PMS: Efficacy of aneducation program helped in increasingknowledge and decreasing the severity ofsymptoms of premenstrual syndrome (PMS).After the education program, the schoolgirls inthe experimental group had significantlyincreased knowledge scores as measured bythe Premenstrual Syndrome KnowledgeQuestionnaire. Three months following theeducation program, a significant reduction intotal PMS scores and three of the subscalescores was measured by a translated version ofAbraham'sMenstrualSymptomQuestionnaire, suggesting that the educationprog
PRE-MENSTRUAL SYNDROME- A REVIEW Marriam Zaka1, Khawaja Tahir Mahmood2 1Department of Pharmacy, Lahore College for Women University, Lahore, Pakistan; 2Drug Testing Laboratory, Health Department, Punjab, Lahore, Pakistan. Abstract: Premenstrual Syndrome is described as a collection of predictable physical, cognitive, affective, a
The cycle ends just before the next menstrual period. Menstrual cycles normally range from about 25 to 36 days. The description of the phases of the menstrual cycle below assumes a cycle length of 28 days. However, only 10% to 15% of women have cycles that are exactly 28 days. The menstrual and ovarian cy
Name _ Regents Biology 7 of 15 Adapted by Kim B. Foglia www.ExploreBiology.com 2008 Part C. The Calendar of the Menstrual Cycle In this section we will explore the events of the menstrual cycle across a calendar month to relate the internal stages of the menstrual cycle to the days of the month. 1.
menstrual blood, that can be changed in privacy as often as necessary for the duration of a menstrual period, using soap and water for washing the body as required, and having access to safe and convenient facilities to dispose of used menstrual management materials. They understand
female athletes (Cobb et al., 2003; Gibson, Mitchell, Reeve, & Harries, 1999). When an athlete couples excessive physical training with insufficient energy intake, a physiological alteration of the hormone-controlled menstrual cycle can result. Athlete or non-athlete, sufficient menstrual cycle is an indicator of good health. When menstrual
menstrual cycle patterns and cycle length, medical and social history, and physical examination findings was routinely obtained at the first consultation. Menorrhagia was defined as the subjective complaint of heavy menstrual flow. Short menstrual cycle
in menstrual cycle onsets. Initial menstrual onset difference was influenced by woman's body mass and menstrual cycle irregularity. These results provide further . Answers were categorized into three categories on a scale of 1 to 3:1-3 hours per day 1,
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Here are a few suggested references for this course, [2,19,22]. The latter two references are downloadable if you are logging into MathSci net through your UCSD account. For a proof that all p{ variation paths have some extension to a rough path see, [21] and also see [9, Theorem 9.12 and Remark 9.13]. For other perspectives on the the theory, see [6] and also see Gubinelli [10,11] Also see .
