A 42-year-old woman comes to the office due to recurrent episodes of fatigue and hot flashes. The patient's most recent symptoms began 4 days ago; she says she feels "extremely cranky." She also has intermittent bloating, and her symptoms sometimes cause her to miss work. Her last menstrual period was 3 weeks ago. Menses occur every 30 days, with 2 days of heavy bleeding followed by 4 days of moderate flow. The patient had 2 vaginal deliveries in her 30s and stopped taking combined oral contraceptives last year after undergoing bilateral tubal ligation. She smokes cigarettes socially but does not use alcohol or illicit drugs. She takes no medications and has no known drug allergies. Vital signs and physical examination are normal. Which of the following is the best next step in management for this patient?
Premenstrual syndrome and premenstrual dysphoric disorder | |
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Evaluation |
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Treatment |
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This patient's recurrent episodes of fatigue, bloating, and mood changes may be due to premenstrual syndrome (PMS), which causes both physical (eg, headaches, hot flashes) and affective symptoms (eg, irritability, anxiety) that compromise the patient's quality of life (eg, missing work). Although PMS usually is diagnosed when women are in their 20s, some patients develop severe symptoms in their later reproductive years and are at increased risk for mood disorders in the perimenopausal period.
In patients with vague symptoms, such as this woman, evaluation aims to distinguish PMS from mood disorders (eg, major depressive disorder) or medical conditions (eg, hypothyroidism), which typically are not related to menses. For this reason, the diagnosis of PMS is supported by a symptom diary created by the patient over 2 menstrual cycles that reveals recurring symptoms during the luteal phase (1-2 weeks prior to menses) that resolve during the follicular phase (with onset of menses). If this pattern is confirmed, patients may opt for treatment with selective serotonin reuptake inhibitors taken daily or only during the luteal phase.
(Choice A) Benzodiazepines (eg, lorazepam) may be used acutely to treat certain mood disorders (eg, panic disorder). Although PMS causes affective symptoms (eg, irritability), the pattern is cyclic with menses and includes physical symptoms that do not resolve with benzodiazepines.
(Choice B) An FSH level can be measured to confirm menopause, which is unlikely in this regularly menstruating patient.
(Choice C) Pelvic ultrasound is used to evaluate abnormal uterine bleeding or an adnexal mass, which may cause fatigue and bloating. This patient has regular menses and a normal physical examination; therefore, imaging is not indicated.
(Choice D) Combined estrogen-progestin oral contraceptives are commonly used to treat PMS by inducing anovulation. However, this patient's age (≥35) and smoking history are relative contraindications to estrogen-containing medications due to the increased risk of thromboembolism. A symptom diary should be obtained prior to initiating treatment.
Educational objective:
Premenstrual syndrome causes both physical and affective symptoms, which commonly include fatigue, bloating, hot flashes, mood swings, and irritability. Diagnosis is supported with a symptom diary that reveals recurring symptoms in the luteal phase (ie, 1-2 weeks prior to menses) that resolve with menses.