Premenstrual Syndrome - Management of Normal and Altered Female Physiologic Processes

PREMENSTRUAL SYNDROME

Premenstrual syndrome (PMS) is a combination of symptoms that occur before the menses and subside with the onset of men-strual flow (Chart 46-10). The cause is unknown, but serotonin regulation is currently the most plausible theory. 

Other hormones may also be involved. Dietary factors may play a role because car-bohydrates may affect serotonin. Severe symptoms have been labeled as premenstrual dysphoric disorder (DiCarlo, Palomba, Tommaselli et al., 2001; Morse, 1999). This severe form of PMS, which interferes with the woman’s schoolwork, job, or social or family life, is uncommon.

Clinical Manifestations

Major symptoms of PMS include headache, fatigue, low back pain, painful breasts, and a feeling of abdominal fullness. General irritability, mood swings, fear of losing control, binge eating, and crying spells may also occur. Symptoms vary widely from one woman to another and from one cycle to the next in the same per-son. Great variability is found in the degree of symptoms. Many women are affected to some degree, but few are severely affected. Many women are not bothered at all, whereas some experience severe and disabling symptoms (Morse, 1999).

A generally stressful life and problematic relationships may be related to the intensity of physical symptoms. Some women re-port moderate to severe life disruption secondary to PMS that negatively affects their interpersonal relationships. PMS may also be a factor in reduced productivity, work-related accidents, and absenteeism.

Identifying the time when these symptoms occur helps in de-termining the diagnosis. Symptoms recur regularly at the same phase of each menstrual cycle, usually 1 week to a few days before menses, and subside once the menstrual flow starts.

Medical Management

Because there is no single treatment or known cure for PMS, the woman should chart her symptoms so she can possibly anticipate and therefore cope with them. Exercise is encouraged for all pa-tients as noncontrolled studies have shown a benefit. Many prac-titioners advise women to avoid caffeine, high-fat foods, and refined sugars, but there is little research to demonstrate the effi-cacy of dietary changes. Alternative therapies that women have used include vitamins B and E, magnesium, and oil of evening primrose capsules. No studies have evaluated the effectiveness of these therapies.

PHARMACOLOGIC THERAPY

Pharmacologic remedies include selective serotonin reuptake in-hibitors (eg, fluoxetine [Prozac, Sarafem]), gonadotropin-releasing hormone agonists, prostaglandin inhibitors (eg, ibuprofen and naproxen [Anaprox]), and antianxiety agents. Some clinicians prescribe analgesic agents, diuretic medications, and natural and synthetic progesterones, although the long-term risks of proges-terone use are unknown. Many women find over-the-counter carbohydrate products useful; they provide complex carbohy-drates along with vitamins and minerals. Ratios of serum levels of tryptophan to other amino acids are elevated in patients who use tryptophan. It may relieve psychological symptoms and food cravings. Calcium (1,200 mg/day) has been found to be effective, as has magnesium (200 to 400 mg/day).

Nursing Management

The nurse should establish rapport with the patient and obtain a health history, noting the time when symptoms began and their nature and intensity. The nurse then determines whether the onset of symptoms occurs before or shortly after the menstrual flow begins. Additionally, the nurse can show the patient how to develop a chart to record the timing and intensity of symptoms. A nutritional history is also elicited to determine if the diet is high in salt, caffeine, or alcohol or low in essential nutrients.

The patient’s goals may include reduction of anxiety (mood swings, crying, binge eating, fear of losing control), ability to cope with day-to-day stressors and relationships with family and co-workers, and increased knowledge about PMS with improved use of control measures.

Positive coping measures are facilitated. Partners can be ad-vised to assist by offering support and increased involvement with childcare. The patient can try to plan her working time to ac-commodate the days she will be less productive because of PMS. The nurse encourages the patient to use exercise, meditation, imagery, and creative activities to reduce stress. The nurse also encourages the patient to take medications as prescribed and provides instructions about the desired effects of the medications. Enrolling in a PMS group that meets to discuss problems may help the patient learn that others recognize and understand what she is experiencing.

If the patient has severe symptoms of PMS or premenstrual dysphoric disorder, the nurse assesses her for suicidal, uncontrol-lable, and violent behavior. Any suggestions of suicidal tenden-cies must be evaluated by psychiatric consultation immediately. Uncontrollable behavior may lead to violence toward family members. If abuse of children or other members of the patient’s family is suspected, reporting protocols are implemented and fol-lowed. Referral is made for immediate psychiatric or psycholog-ical care and counseling.