Premenstrual Syndrome

What is Premenstrual Syndrome?

Premenstrual syndrome (PMS) is a combination of pathological symptoms that occur several days before menstruation and disappear during menstruation. PMS is composed of disorders of the nervous, endocrine, vascular systems and metabolism.

The frequency of PMS increases with age: PMS is observed in 20% of women aged 19 to 29 years; after 30 years reaches 47%; after 40 years – 55%. PMS often occurs in emotionally labile women and women of intellectual labor.

Causes of Premenstrual Syndrome

PMS is a consequence of dysfunction of the corneal parts of the central nervous system and arises as a result of exposure to adverse factors. PMS is promoted by stress, neuroinfection, complicated labor and abortion, especially in women with congenital or acquired inferiority of the hypothalamic-pituitary system.

The main role in the pathogenesis of PMS is given to impaired metabolism of neuropeptides (serotonin, dopamine, opioids, norepinephrine, etc.) in the central nervous system and related peripheral neuroendocrine processes. It has been proven that estrogens and progesterone affect the central nervous system by interacting with cytoplasmic receptors. The effect of sex hormones is the opposite – estrogens, potentiating the activity of serotonin, norepinephrine and opioids, have an “exciting” effect and positively affect mood. Progesterone, acting on GABA, leads to the development of depression in the luteal phase. With severe depression, the metabolism of serotonin decreases. Suicidal attempts and aggression in the premenstrual period are associated with a decrease in serotonin levels in the cerebrospinal fluid.

“Water intoxication” and fluid retention are associated with the influence of serotonin levels. The water-electrolyte balance is partially controlled by the renin-angiotensin system, the activation of which increases the levels of serotonin and melatonin. In turn, serotonin and melatonin control the renin-angiotensin system by feedback. Estrogen can cause a delay in sodium and fluid by increasing aldosterone production.

In recent years, much attention has been paid to peptides of the intermediate pituitary gland, in particular the melanostimulating pituitary hormone. This hormone, when interacting with beta-endorphin, can contribute to mood changes. Endorphins increase prolactin, vasopressin and inhibit the action of prostaglandin E {in the intestine, resulting in breast engorgement, constipation and bloating.

The theory of psychosomatic disorders leading to PMS proves that somatic factors play a paramount role, and mental ones follow biochemical changes.

Symptoms of Premenstrual Syndrome

The clinical picture of PMS includes:

  • symptoms resulting from neuropsychiatric disorders (irritability, depression, tearfulness, aggressiveness);
  • symptoms reflecting vegetovascular disorders (headache, dizziness, nausea, vomiting, pain in the heart, tachycardia);
  • symptoms of endocrine-metabolic disorders (breast engorgement, swelling, flatulence, itching, chills and chills, thirst, shortness of breath, fever).

Depending on the predominance of certain symptoms, the neuropsychic, edematous, cephalgic and crisis forms of PMS are distinguished. The clinical picture of the neuropsychic form of PMS is dominated by irritability, depression, weakness, tearfulness, aggressiveness. While depression prevails in young women in PMS, aggressiveness is noted at perimenopausal age. The edematous form of PMS is manifested by severe engorgement and soreness of the mammary glands, swelling of the face, legs, fingers, bloating. Many women with an edematous form experience sweating and hypersensitivity to odors. The cephalgic form of PMS is manifested by an intense pulsating headache with radiation to the eyeball. Headache is accompanied by nausea, vomiting, blood pressure does not change. A third of patients with the cephalgic form of PMS have depression, pain in the heart, sweating, and numbness of the hands. Symptomatic-adrenal crises are inherent in the critical form of PMS. The crisis begins with an increase in blood pressure, there is a feeling of pressure behind the sternum, fear of death, palpitations. Typically, crises occur in the evening or at night and can be triggered by stress, fatigue, and an infectious disease. Crises often end in profuse urination.

Depending on the number, duration and intensity of symptoms, mild and severe PMS are distinguished. With a mild PMS, 3-4 symptoms are noted, 1 – 2 of them are significantly expressed, appear 2-10 days before the onset of menstruation; to a severe degree include 5-12 symptoms that occur 3-14 days before menstruation, 2-5 of them are pronounced.

There are 3 stages of PMS:

  • compensated – the symptoms do not progress over the years, appear only in the second phase of the menstrual cycle and stop when menstruation begins;
  • subcompensated – the symptoms progress over the years and disappear only with the end of menstruation;
  • decompensated – the symptoms persist several days after menstruation, and the intervals between the cessation and onset of symptoms are reduced.

Diagnosis of Premenstrual Syndrome

Diagnosis of PMS has certain difficulties due to the variety of clinical symptoms. The identification of PMS is facilitated by an active interrogation of the patient, in which the cyclicality of pathological symptoms that occur on premenstrual days is revealed. For all clinical forms of PMS, it is necessary to perform EEG and REG of cerebral vessels, X-ray of the skull, Turkish saddle and cervical spine, to conduct hormonal studies in both phases of the menstrual cycle.

X-ray and neurophysiological studies make it possible to objectively assess the functional state of the central nervous system, to clarify the levels of brain damage depending on the severity of the PMS and the patient’s age.

With the cephalgic form of PMS, pronounced radiological changes in the bones of the cranial vault and the Turkish saddle are noted: a combination of vascular pattern enhancement and hyperostosis or calcification of the pineal gland. Neurological manifestations depend on the localization of calcification sites. So, dura mater hyperostosis behind the back of the Turkish saddle and in the parietal region is accompanied by signs of impaired reticular formation of the midbrain in combination with stem neurological manifestations. Frontal bone hyperostosis causes signs of simultaneous damage to the cerebral cortex and hypothalamic structures.

A study of the electrical activity of the brain in patients with PMS revealed damage to the brain stem at different levels. In patients with the neuropsychic form of PMS, changes in EEG reflect functional changes mainly in diencephalic limbic structures. In patients with an edematous form of PMS, EEG indicates a certain increase in the activating effects of non-specific structures of the brain stem on the cerebral cortex. Changes in the EEG with the cephalgic form of PMS are a consequence of blocking the activating systems of the brain stem. In the critical form of PMS, EEG changes are regarded as indicators of dysfunction of the upper stem and diencephalic formations.

Hormonal status in patients with PMS reflects some features of the functional state of the hypothalamic-pituitary-ovarian-adrenal system. So, with the edematous form of PMS, the level of progesterone is reduced and the content of serotonin in the blood is increased; with the neuropsychic form, the level of prolactin and histamine is increased, with the cephalgic form the content of serotonin and histamine is increased, with the crisis form the level of prolactin and serotonin is increased in the second phase of the menstrual cycle.

The use of other additional diagnostic methods is more dependent on the form of PMS. With the edematous form of PMS, the measurement of diuresis, the study of excretory function of the kidneys are shown. Soreness and swelling of the mammary glands become an indication for ultrasound of the mammary glands and mammography in the first phase of the menstrual cycle for the differential diagnosis of mastodynia and mastopathy. A neurologist, psychiatrist, therapist, endocrinologist, allergist are involved in the examination of patients.

Premenstrual Syndrome Treatment

The first stage of treatment is psychotherapy, including confidential conversation, autogenic training. It is necessary to normalize the regime of work and rest, the exclusion of coffee, chocolate, spicy and salty foods, the limitation of fluid intake in the second phase of the menstrual cycle. Recommended general massage and massage of the collar zone; effective central electroanalgesia (8-10 procedures in the second phase of the menstrual cycle).

Drug therapy is carried out taking into account the duration of the disease, the clinical form of PMS, the age of the patient and concomitant extragenital pathology.

For neuropsychiatric disorders with any form of PMS, sedative and psychotropic drugs are recommended: tazepam, rudotel, seduxen 2-3 days before the onset of symptoms. With the edematous form of PMS, antihistamines are effective – tavegil, diazolin, teralen also in the second phase of the menstrual cycle; appoint veroshpiron 25 mg 2-3 times a day in the second phase of the menstrual cycle 3-4 days before the onset of clinical symptoms. To improve blood supply to the brain, it is advisable to use Nootropil 400 mg 3-4 times a day, aminolone 0.25 g from the 1st day of the menstrual cycle for 2-3 weeks (2-3 menstrual cycles). In order to reduce prolactin levels, parlodel is used at 1.25 mg per day in the second phase of the menstrual cycle for 8-9 days.

In connection with the role of prostaglandins in the pathogenesis of PMS, antiprostaglandin preparations naprosin and indomethacin in the second phase of the menstrual cycle are recommended, especially with edematous and cephalgic forms of PMS.

Hormone therapy is carried out in case of insufficiency of the second phase of the menstrual cycle; prescribe gestagens: Duphaston 10-20 mg, Utrozhestan 200-300 mg from the 16th to the 25th day of the menstrual cycle. In severe decompensated form, young women are shown combined estrogen-progestogen drugs or norkolut according to the contraceptive regimen (from the 5th day of the cycle, 5 mg for 21 days). In recent years, for the treatment of severe PMS, agonists of releasing hormones (zoladex, buserelin) have been proposed for 6 months. Their action is based on the antiestrogen effect.

Treatment of patients with PMS is carried out for 3 menstrual cycles, then take a break for 2-3 cycles. With relapse, treatment is resumed. With a positive effect, prophylactic supportive treatment, including vitamins and tranquilizers, is recommended.