PRE-MENSTRUAL SYNDROME
The pre-menstrual syndrome is a physical and psychological disorder with no known reasons. As we know during or before the menstrual and usually before the beginning of menstrual there are symptoms that are different from population to population and from patient to patient.
These symptoms are referred to anxiety, depression, irritability, chest pain, deep pelvic pain and fluid retention. Some of these symptoms occur approximately in 95% of all women of reproductive age.
On the other hand, 5% of women worldwide experience pre-menstrual syndrome. Also, in the general population only 5% of women of reproductive age are symptoms free.
SYMPTOMS: The symptoms of pre-menstrual syndrome are over 80, but the main ones are:
Abdominal pain, cold sweats, nausea and vomiting, burning sensation, weight gain with fluid retention, chest pain, difficulty to concentrate and make decisions, total stiffness, low back pain, feeling like crying, headache and insomnia.
These symptoms usually occur in the luteal period in the cycle that is 7-10 days before the start of menstrual. Most of them end on the end of the menstrual. These symptoms are sometimes more obvious and sometimes less. This leads to bad quality of life of patients and their interpersonal relationships.
RATIONALE: The reason is unknown.
We believe that some hormonal imbalance could be the explanation for this phenomenon, but this explanation even today has failed to prove this because the hormonal profile of patients who have pre-menstrual syndrome are the same with patients who are asymptomatic.
It is speculated that endogenous substances such as serotonin and opioid peptides might play a role in creating the syndrome.
DIAGNOSIS: The symptoms occur during the luteal phase of the cycle ie the phase that follows ovulation and end by the end of menstrual. To get a diagnosis of the syndrome it should be experienced at least 4 of the previous 6 cycles from the time the patient visits the doctor.
We may be able to assess the psychopathology of the syndrome by giving specific, specialized questionnaires, from psychiatrists.
One such questionnaire is the General Health Questioner which is widely used in England. This should be completed by patients only during the luteal phase of the cycle.
LABORATORY TESTS: It is necessary to make differential diagnosis along with other anomalies on the physiology of the female cycle as we call the menopause, like polycystic ovarian syndrome, hyperthyroidism and anemia. There are clinical tests with drug use like GNRH analogues for 3 months.
If symptoms continue to exist after these 3 months this means that there are serious psychological problems. There should be a good gynecological examination by the clinician in order to reassure the patient that there is no problem with ovarian cancer, cervical and breast. The patient should not receive any hormonal therapy especially if it has not previously examined thoroughly by the clinician.
TREATMENT: There is a wide range of treatments that we can use for the pre-menstrual syndrome. Progesterone is one of them in the form of injectable, pill or vaginal suppositories.
However last major work has been done around the world which has shown that progesterone compared with the Placebo have not shown any improvements in the pre-menstrual syndrome. Other drugs that we use are progenestenoids ie sulphate progesterone such as medrol-progesterone licensed in several countries in Europe and the United States for use in the pre-menstrual syndrome.
According to the research done around the world regarding to synthetic progesterone, there have been a great controversy. Many doctors believe that they help their patients, and others believe just the opposite.
200mg of Danazol a day is a medicine that also gave good results in the past mainly in terms of chest pains before menstrual, but we haven't being able to measure certain side effects patients had with this medication such as masculinisation of the female fetus if pregnant, acne, nausea and fluid retention.
Estrogen is another type of drugs that can be used but hasn't had great acceptance worldwide. They started using them because there was a study that claimed that if estrogen was produced in the ovaries, we in some cases cut down or even get rid of the pre-menstrual syndrome.
Another category is GNRH drugs which had good results on the Placebo that was used not widely though, because of problems created such as osteoporosis and their use is not recommended if the results are well over 6 months. G.N.R.H. though help us in many things such as determining the involvement of ovaries in the symptoms. Also in very severe cases help us realize which patients from those suffering from very severe pre-menstrual syndrome, could benefit from laparoscopic ovarian removal. As we mentioned before, the use of GNRH is only a short-term treatment which should not in any case exceed the period of 6 months.
They could also be used in women where estrogen is contraindicated in women who are close to menopause. 2,5 mg of Vromokryptini daily is another drug used and so far we have had very good results. It could assist women who have chest pains especially during the pre-menstrual syndrome. This drug has an increased rate of side effects such as nausea, dizziness, headaches, weight gain and edema. Another category of drugs used in some cases with a relative success is the contraceptive pill. There is also a controvercy there, but in many cases where it was tested, it had no effect.
Diuretics have helped a few cases and only in those women in the pre-menstrual syndrome that experience high water retention.
Speirolaktoni was proved that greatly improves symptoms such as feeling bloated mastalgies and lower abdomen.
Another category of drugs used are the ones that selectively block the reception of serotonin. In some cases the lack of this hormone can make women with severe pre-menstrual syndrome be more sensitive to endogenous hormones that are produced in the ovaries and thus to worsen the pre-menstrual syndrome.
In Great Britain a large study demonstrated that the use of drugs such as Prosac, which is an antidepressant, has helped tremendously in improving the symptoms of the syndrome, especially in cases having to do with mental disorders and irritability. Also, the B-blockers as a class of drugs has been proposed and used on several occasions but most of the women were stopped because of complications such as headaches and nausea. One group of ways in reducing the symptoms of the syndrome are dietary aids such as calcium, magnesium-vitamin B6.
Also some herbal preparations used widely in the United States and western Europe is the oil of the nightflower. This preparation contains key ingredients such as linoleic acid and gamma-linoleic acids. These are substances used to produce prosaglandinon to E1 and E2. Some studies have shown that the use of oil of night flowers can help in some cases to reduce the symptoms of pre-menstrual syndrome.
It is true that exercise can help much to reduce the symptoms of pre-menstrual syndrome.
In very severe cases surgical treatment has been proposed. This involves hysterectomy which in many cases can help but is an extreme solution. It would probably make sense in specific cases where another gynecological problem co-exist.Such surgery should include a proper hormonal replacement therapy.
Eventually we have to recognize that all those different types of treatments we can use have pros and cons. Treatment should be specifically designed for each patient, as well as the above symptoms are numerous and different from each other and also the intensity may vary from patient to patient.
Moreover, the use of Danazol can only help if we have intense pain as the main symptom of pre-menstrual syndrome, the speirolaktone could help in cases where the main symptom is water retention and medication antidepressants (such as Prozac) could help where there are strong psychological disorders. It is also certain that vitamin B6, oil of nightflowers, and estrogen should be taken.
It is also proven that exercise helps tremendously in reducing symptoms.
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