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MRCOG PART 2 SBAs and EMQs

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notes	336
EMQ	1502
SBA	2115

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Essay 337 - PMT

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		Posted by GULSHAN R. Mon Aug 16, 2010 10:06 am
Initial assesment should be done in a careful & sensitive way.Patient concern should be taken seriously.Active listening of the patient\'s factors-relationship,financial & occupational stress,any recent change in life should be done. Details history of her pain-duration of pain,character of pain,specific time relation with menstrual cycle.Associated symptoms such as-irritability,mood disturbance,headache,depression should be discussed.Patient can be ask to make a symptom diary at least for 2 months & evaluate the symptoms.Details about her sexual history,any sexual abuse ,any vaginal discharge should be discussed.Any surgical history & her thinking about any relation with her pain.Any bladder or bowel symptom,alteration of bowel habit to exclude IBD or IBS.Any change of pain with movement to exclude musculoskeletal pain. Examination should be done to exclude other causes.P/A/E to see any muscle guarding,pelvic mass.P/V/E to see any discharge,any mass or other pathology. Investigation to exclude other causes of pain-urethral & endocervical swab to exclude PID.FBC &CRP to exclude inflammatory conditions.Pelvic USG to see pelvic pathology. Test with GnRHa-if relieve symptoms is diagnostic.Before doing laparoscopy GnRHa test should be done. (b)Management should be done by a multidisciplinary team.Treatment options are- General-Active listening of the patient is very important.Discuss about the options and help her to make inform choice about modalities of treatment.Advice about avoidence of alcohol,caffeine can improve symptom.Regular exersice gives some health benifit.Discuss about cognitive behavioral therapy-specialist personnel is required.But it is a nondrug therapy. MEDICAL-There are various hormonal options.COCP especially new generation pill (Yasmin) containing Drospeirenone has better physical & psychological symptoms.Continuous therapy is better than cyclical.It has also contraceptive efficacy. SSRI & SNRI -continuous or luteal phase improve symptom.it block serotonin -a mediator of PMS.Side effect include nausea, insomnia & reduction in libido. Abrupt withdrawal should be avoided. Progestogen- in high doses can supress ovulation but have no benefit. Oestrogen patch(100 microgram) with oral progestogen or IUS improve physical & psycological symptoms .But progestogen even IUS have its effect. Danazol-supress cyclical activity.Side effects are-androgenic effect-weight gain,hirsutism,loss of libido,breast atrophy,voice change. GnRha-supress ovarian steroid production.it has both therapeutic & diagnostic importace.If symptoms not relieve alternative diagnosis .If use more than 6 month addback therapy should be used.Significant vasomotor symptom & 5% loss of trabecular bone. SURGICAL:Bilateral ophorectomy is the last resort for severe intractable symptom where family is complete or no reproductive issue.need tertiary level opinion.Causes premature menopause.Need HRT-have its own side effect of VTE & cardiovascular.HRT has progestogenic arm which has also PMS like side effect. OTHERs: Vitamin B6 can be used.but avoid abrupt withdrawal .chance of neuropathy. Magnesium have some benefit. Phyto estrogen is recommended. Oil of evening primrose oil -studies show no benefit. Reflexology is also effective. Calcium & vit D can be helpful.
		Posted by Kiran J. Mon Aug 16, 2010 11:02 am
A healthy 25 year old woman has been referred to the gynaecology clinic with a 2 year history of worsening pre-menstrual tension. (a) Discuss your initial assessment [8 marks]. (b) Discuss and justify the treatment options [12 marks] a)I will take a detailed history regarding timing and severity of symptoms.Are the symptoms substantially effecting the quality of her life and disrupting interpersonal relationships.I would ask her regarding the onset of symptoms as they may start from the leuteal phase of the cycle and relieved after the onset of menstruation.Does she have any of the classical symptoms which include irritability,mood swings,insomnia,aggression,depression,food cravings,bloatedness,mastalgia,headache and backache. I would ask her regarding history of periods,regular /irregular,dysmennorhea along with dysparunia to rule out endometrioses.I would ask her regarding associated symptoms of hotflushes and night sweats to rule out menopause.any history of psyciatric disorders including depression and chronic fatigue syndrome.Examination will consist of abdominal and pelvic examination for pelvic/abdominal tenderness/organomegaly or pelvic massess and to do STI screening to rule out any organic cause of her symptoms. There are no biochemical tests to diagnose PMT and diagnosis can be made on history and patient keeping a prospective symptom chart including using such subjective devices such as COPE (Calendar of premenstrual experience) or daily record of severity of symptoms (DRSP) .the PSST (Premenstrual symptoms screening tool) can also be used .A tvs can be requested to rule out gross pelvic pathologies like ovarian cysts or fibroid uterus. It can be of value to give GnRH depot for 3 cycles to see to what extent the ovarian cycle contributes to the symptoms. B).Treatment consists of Hormonal treatment constitutes Combined oral contraceptive pill as she is in child bearing age and may be wanting contraception and it will supress ovulation thereby preventing PMT.The new oral formulations consisting of ethinyleestradiol and droprinone have been found to decrease symptoms of PMT.Progesterone can be used orally,vaginal gells pessarys or injections and the rational is incases progesterone deficiency bieng the cause of PMT.It is slightly better than placebo in managing physical symptoms but not behaviour symtoms.Oestrogen in the form of patches or subcutaneous impants can be used in cases of PMT secondary to progesterone intolerance but suggest endometrial protection in her with Mirena IUS as less systemic effects of progesterone would be inflicted in this case.GnRH analogues supress ovarian function and determine the extent to which the symptoms are associated with ovarian endocrine origin and also which patients will benefit from prophylactic oopherectomy.The addback therapy can reduce troublesome simulated menopause effects associated with GnRH analogues ie hot flushes and night sweats. Non hormonal treatment constitutes SSRIs which can help alleviate the physical and psychological symptoms of PMT and the administration in leuteal phase can be as effective as continous dosing.Lower doses of drugs is as effective as higher doses and with fewer side effects which consist of GIT upset,anorexia,wt loss and insomnia and sexual dysfunction. For women who experience pre-menstrual water retention and breast tenderness,diuretics in small doses(ie spironolactone 25-50mg/day)can be used.Prostaglandin inhibitors such as mefenamic acid and naproxen sodium may be effective in relief of pain and mood symptoms.Anxiolytics and antidepresants can also be used if symptoms point more strongly towards panic,anxiety and depression,advisable to involve psyciatric opinion. Behaviourial therapy consists of CBT(Cognitive behaviour therapy) as it focuses on adaptive technique to combat PMT symtoms,it helps alleviate negative thinking as it can give maladaption to PMT psycological symptoms.Excersise can help release natural endorphins in vivo and help alleviate fluid retention and mood swings.A diet comprisisng of short regular carbohydrate snacks can increase dietry availibility of tryptophan which increases serotinin synthesis.Reducing alcohol,salt and caffine can help.Dietry intake of calcium,magnesium,Vitamin B6 and vitmain E can also be tried although evidence is weak. Surgical management includes oopherectomy induces irreversible menopause and a complete cure but left as a last resort in a woman completeing her fertility wishes with evidence of improved symptomtology with GNrh analogues and in whom the the ist line treatment with medical treatment has failed.
		Posted by F N. Mon Aug 16, 2010 02:19 pm
PMT is a cluster of psychological,physical and behavi oural sypmtoms which recurs during the luteal phase of menstural cycle each month and then significantly improves or disappears at the end of mensturation. History of onset of menarche, last menstural period,cycle regularity should be obtained. Absense of symptoms before menarche will be suggestive of PMT.Detailed History of symtoms like headache,,breast tenderness,bloating,irrtability,mood swings,insomnia and feeling of out of control should be obtained.It is essentail to establish from history the onset,severity and duration of these symptoms, and its association with menstural cycle. It is of utmost importance to establish the degree of severity of her condition and the effect on her quality of life,as it can put significant strain on her relation ships at home and work. History of contraception should be obtained and any evidence of improvment of symptoms with combined pills may favour the diagnosis of PMT. It is impotant to establish her parity and future fertility plans.It will help to choose the suitable treatment option for her.Improvment of the condition during any pregnancy may favour the diagnosis of PMT. Psychiatric history like psychosis,depression and current or any past use of psychiatric medications should be noted. History of smoking,alcohol ,lack of exercise may be risk factors for PMT.raised BMI is anothe risk factor for it. Diagnosis of PMT is history based,the lady should be asked to maintain a prospective record of her symptoms for atleast 3 months. The role of clinical examination and investigation is very limited as PMT is mostly a history based diagnosis however if the history is suggestive of pelvic abnormality then a full abdominal ,speculam and vaginal examination should be done.Swabs for chlamydia and gonorrhea can be sent to exclude STIs,TVs can be requested to exclude a pelvic pathology. B; The treatment options can be conservative,medical and surgical.There choice depends on the degree of severity of condition and the effect on her quality of life,her future fertility plans, any previous treatment and patient choice. A multidisciplinary team consisting of her GP,gynaecologist,Psychatrist,dietician and counseller can be involved in the management. Conservative treatment can be tried as a first line treatment,which stresses on healthy life style on smoking,alcohol and regular exercise.complementary therapy like vitamin B6,evening primrose oil, and magnesium can be tried,though there is no good evidence about its efficacy. Cognitive behvioual therapy has been shown to be of benifit in PMT and should be considered ist. Medical treatment consist of combined pills,SSRIs/SNRIs,estradiol,GNRH anologes,danazol and mirena. As atiology of PMT considered to be the cyclical ovarian activity leading to the production of estrogen and progesterone and there effect on GABA/serotonin recepters in brain.Therefore harmonal treatment like Combined pills can be given cyclicaly or during the the luteal phase of the cycle.It inhibit ovulation,thus particularly lowering the progesterone level in the second half of the menstural cycle. newer OCP containg a progestogen with antimineralocorticoid function has been helpful especialy in relieving the physical symptoms like bloating,mastalgia and headache. SSRIs/SNRIs (fluoxetine,venlafaxine) can be given along with OCP starting with a lower dose and gradulay the dose can be increased according to response.Abrupt withdrawl of SSRIs should be avoided as it can cause anxiety,insomnia,headache and GI disturbence.Idealy this regiemen should be started in conjunction with the psychiatric team. If the patient does doesnot respond or tolerate to OCP then then estradiol implant/patch can be tried with luteal phase oral progesterone.The lower possible dose of progesterone should be given. The above treatment regiemn should be tried for at least 6 months.symptom diary shoud be used to asses any improvment. if there is no improvment in her symptoms,then options of trial of Gnrh anologue with add back HRT can be discussed.She should be counselled about the risk of decrease in bone mineral density,and menopausal symptoms.Therefore this treatment not recommended for more than 6-12 months.The risk of her bone mineral density loss at 25 yrs of age with 6-12 months of Gnrh and HRT is extreamly small,however she should be made aware that it can not be given on a long term basis.In exceptional circomstances if treatment is continued,annual bone mineral density scans are recommended. Danazol may be tried to treat PMT,however its use has declined significantly due to its androgenic side effects,adequate contraception is recommended with it. The role of progesterone/mirena in the treatment of PMT is not well established. if all the above options fail,then the last option is Sugery in the form of hysterectomy with bilateral sapingoophrectomy.She will need detailed counselling regarding the risks of surgery, long term HRT and testosterone use.
		Posted by Chitra.s M. Mon Aug 16, 2010 02:52 pm
A.History is taken regarding the nature of symptoms - bloating, mastalgia,mood changes,irritability and depression.The duration of symptoms and resolution of symptoms with menstruation is noted.The woman is enquired about the effect of symptoms on the quality of life. She is asked about treatment taken and its effect on symptom relief.Menstrual history is taken regarding cycle length, regularity and LMP.Current method of contraception followed and future contraceptive needs are enquired.The woman is examined to note her BMI, pulse and BP.Abdominal examination is done to note presence of any mass and tenderness.Vaginal examination is performed to note presence of uterine/adnexal mass and tenderness.Diagnosis is made based of history.The woman is asked to maintain a prospective symptom dairy over 2-3 cycles like daily record of severity of symptoms.A pelvic USS is done for presence of any pathology. Complete relief of symptoms following ovarian suppression with GnRH agonists helps in confirming the diagnosis. B.The woman is managed by a multidisciplinary team of gynaecologist, psychologist,dietician and counsellor with input from the GP.This helps in provision of a range of interventions which can be individualised according to the woman\'s needs.Advice is given about lifestyle modification comprising of stress reduction,exercise and low glycaemic diet as these can reduce the symptoms and potentially avoid complex treatments.Cognitive behavioral therapy is offered as first line treatment as they are associated with improvement of symptoms and maintenance of symptom control.Low dose serotonin reuptake inhibitors(SSRIs) used continuously or during luteal phase is offred as one of the first line pharmacotherapy as they relieve both physical and psychological symptoms.Luteal phase SSRIs have the advantage of better tolerability and continuation of symptom control into postmenstrual phase .COCP containinig drosperinone used tricyclically can be offered as one of the first line treatment.This results in symptom control due to supression of ovulation.Progestogenic effects are avoided as the progestogen component is antiandrogenic and antimineralocorticoid and is a suitable option when contraception is required.Estradiol patches or implants can help in resolution of symptoms and are tried as second line therapy.Additional contraception and endometrial protection with progesterone is required during estrogen therapy.Use of LNG-IUS can serve both purposes.If oral progestogen is used it should be at lowest possible dose to minimise the adverse effects.Higher dosese of SSRIs or SNRIs continuously or luteal phase can be tried.Newer SSRIs like escitalopram used during luteal phase may be associated with better tolerability and symptom control.Danazol though effective in relieving mastalgia ,is not routinely used due to its adverse effects like breast atrophy,voice change which can be potentially irreversible.GnRH agonists are used when the woman has severe symptoms and is offered as the thirdline treatment as it results in a hypoestrogenic state.It results in cycle suppression and symptom relief.Add back therpy with combined HRT or tibolone is required to prevent menopausal symptoms and reduce bone density loss.Complementary therpies may be of some benefit.Evening primrose oil is useful in cyclical mastalgia.Calcium, magnesium, gingko biloba and isoflavones may offer some benefit but have limited clinical studies to back their use.Total abdominal hysterectomy with bilateral oophorectomy completely removes the ovarian cycle and is curative .It results in surgical menopause and is unsuitable for young women.It is the last resort in women who have completed their family and have severe symptoms not responding to medical management.
		Posted by H H. Mon Aug 16, 2010 04:14 pm
I will adopt a sensitive approach in dealing with the patient and establish a rapport.I will ask her about her symptoms which may be physical as headache, bloatedness or breast tenderness , psychological as anxiety and depression , or emotional as aggression . Will ask about the effect of these symptoms on the quality of her life and her relation with other members of her family or at work and in what way these symptoms worsen in the last 2 years. Will ask her about the timing of these symptoms in relation to her menstrual cycle and if they repeatedly occur before having her periods and disappear with its establishment . Will ask which type of symptoms are more severe( physical,emotional or psychological). I will ask regarding her menstrual period, age of menarche ,LMP, cycle length and regularity. Will ask regarding her parity , were her symptoms relieved with pregnancy, and wether her family is complete or wish to have more children. Will ask if using contraception or used one as COCP and its effects on her symptoms. Will ask about previous treatments and were they effective. Examination will not give any clue to her symptoms. Her BMI is measured I will look in her notes for the previous two years as usually a menstrual diary would have been done that show her symptoms, which one more severe and their relation to her menstrual cycle for 3 successive months. I will also look for previous treatments given and response. As the patient is already diagnosed as PMT with worsening of symptoms for two years, I will see which lines of treatments were given before and did not work so as not to repeat them with no use. My treatment should be multidisciplinary and I would involve the psychologist if her symptoms are mainly psychological. I will follow local guidelines and protocols for management of PMT. First line therapy will include ,assurance and discussion of her symptoms, cognitive behaviour therapy can be effective. Evening primprose oil will reduce breast tenderness but no evidence it will affect other symptoms. Vitamin B6 was used but with out effect. COCP will inhibit ovulation and can be effective in some women. Serotonin release reuptake inhibitors(SRRIS) as fluxetine or paroxetine will act by increasing the serotonin transmitter in the brain and are effective if used continuosly or only during the luteal phase. Second line therapy will include the use of estradiol patches, these were effective in treatment of PMT. Also increasing the dose of SRRIS will improve symptoms, but their side effects as nausea, dry mouth , suicidal tendencies are increased. Third line treatments are considered when the previous lines did not work and as a preliminary step to see if bilateral oophrectomy will work. It include giving GNRH agonists to stop the work of the ovaries. Side effects include menopausal symptoms . Bone density will decrease if used for more than 6months.Add back therapy with Tibilone can prolong its use. Fourth line therapy as bilateral oophrectomy (BSO)+/- hysterectomy(TAH). Will need HRT . If BSO done only estrogen only HRT will need to be opposed with progesterone and the latter can lead to return of PMT. Patient given written information about PMT and address of support group.
		Posted by Im F. Mon Aug 16, 2010 05:26 pm
a) Premenstrual symptoms (PMS) affect around 5% of females. The first thing in her initial assessment should be a proper history for confirmation of PMS. She should be asked about physical symptoms like breast pain, bloating or headache; psychiatric symptoms like anxiety, depression, irritability and feeling out of control and lastly behavioral symptoms like reduced visuospatial and cognitive ability. Next she should be asked about severity of symptoms by asking her its effect on quality of life, so that her symptoms can be triaged to mild, moderate and severe. For this purpose, she can use daily record of severity of problem diary (DRSP). Her past history for any underlying psychiatric illness should be asked and whether she is on any psychiatric medications. Her menstrual history whether regular or not should be asked. Symptoms appearing in luteal phase and disappearing after periods, points toward diagnosing PMS. Any drug history like progesterone or methyldopa can be asked, which can also produce almost the same symptoms. Her obstetric history and future fertility wishes should be asked so that a treatment plan can be made. Usually, examination is unremarkable, but a GPE, BMI, abdominal and pelvic examination still should be performed to rule out any other pathology. b) Treatment will depend upon her severity of symptoms,her plans for pregnancy and its effect on her daily routine activities. First line of options, are life style changes daily exercise,weight loss, low glycemic diet and stress reduction. Those women who have severe symptoms with more psychological symptoms should be referred to a psychiatrist .DRSP should be reviewed. Cognitive behavioural therapy helps in patient with severe depression and psychological symptoms. Complimentary therapies along with some unlicensed treatment can also be tried but she should be explained that data on these therapies is very limited. Some of the complimentary drugs can have interaction with conventional drugs. Drugs like magnesium, calcium or vitamin D and reflexogy has some benefits and comparatively safe, while drugs like isoflavons, agnus cactus, pollen extract and ginkgo biloba are beneficial. Mild to moderate disease, not responding to above measures should be offered low dose SSRI and SNRI(cyclical or luteal phase) like fluoxetine (20-60mg) daily. But side effects like insomnia and loss of libido should be explained to patient. Luteal phase SSRI is not associated with withdrawal symptoms. If patient still does not respond, then high dose SSRI and newer agents can be given like citalopram which is associated with lesser side effects. She can be offered OCP like Yasmin and drospirenone on continuous basis rather than cyclical but compliance can be a problem. Second line drug like estrogen patch combined with cyclical progesterone are also beneficial. Alternative contraception should be offered. Even Mirena IUS can be used instead of oral progestogen but it can initially cause PMS like symptoms. Cycle suppressing agent like danazole can be given but irreversible virilising effects should be explained to patient and should be advised for contraception during treatment.. As a third line of management, she can be offered GnRH analogues for 6 months with add back therapy (HRT) because it can cause loss of bone mineral density. Hysterectomy and BSO ,or BSO alone with ERT as a last resort is not a sensible choice in this young patient . Lastly she should be given information leaflet and patient support groups.
		Posted by R v P. Mon Aug 16, 2010 08:02 pm
RVP A healthy 25 year old woman has been referred to the gynaecology clinic with a 2 year history of worsening pre-menstrual tension. (a) Discuss your initial assessment [8 marks]. Her cyclicity of symtoms (symptoms during luteal phase and settled by the end of menstruation) should be enquired. Also the type of symptoms she is experiencing such as irritability, depression,anxiety, insomnia, bloating and mastalgia should be explored. Symptoms should be assessed prospectively over two cycles. A validated symptom diary such as DRSP (daily record of severity of problems) could be used to asess symptoms as well as response to treatment. DRSP will help to categorise her symptoms as mild(not effecting her lifestyle), moderate(able to function with some loss of function) or severe(patient unable to function with symptoms). Treatment she has already tried will have an influence in planning her care. Her obstetric history and future fertility aspirations should be enquired as these will influence her treatment options. her menstrual history including LMP should be noted. Social history including stress at work, home should be sensitively explored as these may have an impact on symptoms. Smoking, exessive alchohol intake or drug abuse should be inquired as some patients may revert to such as coping mechanisms. General physical examination including the BMI should be calculated. If she is clinically depressed, a formal psychiatric assessment should be organised. Abdominal and pelvic examination are likely to be negative. (b) Discuss and justify the treatment options [12 marks] Teatment should be integrated with medical and complimentery treatment (RCOG) due to the nature of symptoms. A multideciplinary team including a gynaecologist with special interest in PMS, clinical psychologist, psychiatrist and her GP should be involved in her care depending on the nature and severity of her symptoms. General lifestyle adjustments including healthy diet, exercise and stop smoking/alchohol if relevent may improve her symptoms and these should be encouraged. Complimentery therapy such as yoga, Accupuncture, homeopathy,vitamin B, Agnus cactus, Gingko and primrose oil etc have limited evidence on the efficacy on PMS and this should be explained to patient. If she is using them, she may be allowed to use them if there is symptom relief. First line treatment includes CBT by a clinical psychologist as this has shown to improve PMS symptoms. Low dose SSRI,SNRI could be prescribed by a psychatrist or specialist GP to be used continuously or during luteal phase as these have shown to be effective in treating PMS. Newer generation COC such as Yasmin or Cilest could be used to supress ovulation as they improve PMS symptoms. COCs could be used trycyclically(without a break) or in the usual way eventhough the former is better in relieving symptoms. Second line treatment includes high dose SSRI/SNRI. Patient should be informed of the withdrawal symptoms with prolonged use. She should be also warned of the side effects such as nausia, loss of libido, insomnia and the very small risk of suicide observed in young people on SSRI. Transdermal estradiol 100mcg patches with progesterone support with mirena or duphasten 10mg has shown to be effective in PMS. She should be warned that Mirena can produce side effects similar to PMS especially during 1st six months. Thirdline treatment include GNRH analoguse with add back HRT/tibolone. GNRHa may cause loss of trabecular bone density with long term use and therefore annual bone density measurement should be adviced to her if she wants to continue treatment more than 12 months. If she has completed family and her symptoms are refractory to all above treatment, she could be offered bi lateral oopharectomy+hysterectomy. If so, a trial of GnRHa should be offered as a test of cure. She should be offered HRT and testosterone to help with menopausal symptoms, to prevent bone density loss and for libido. Written information and websites should be provided to her to understand the condition and treatment. Support groups help her to cope with symptoms and this should be encouraged.
		Posted by S P. Mon Aug 16, 2010 09:28 pm
The women should be delt sensitively.History is important.The timing and severity of her symptoms and how they are affecting her quality of life, interpersonal relationships and work.the nature of her symptoms and which is most troublesome to her shold be asked.Does she experience the classical symptoms -headache , visual disturbances , mastagia , GI distubances , pelvic pain .Presence of psychatric symptoms - depression , anxiety, tension , decreased libido shold be asked. Is she prone to accidents and feels clumsy during the later phase of her cycle.details of her LMP , cycle duration ,dysmenorrhoea to be taken . Any past or family history of ppsychatric illness, should be explored.Her obstretic history and fertility wishesAs will help in treatment options .Her life style and level of stress at work/ home to be asked.Any previous treatment and its response . Limited roll of clinical examination and investigation in diagnosis of PMS . BMI must be noted .In presence of physical symptoms detail examination to r/o pathology. Abdominal & pelvic examination if indicated by history again.DRSP- dailly record of symptom severity for at least 2 cycles would be helpful . As prospective recording of symptoms is more reliable than retrospective recall.PMS is a diagnosis of exclusion. B.Management by MDT including gynaecologist , psychatrist ,dietician with input from GP. this will provide a range of intervensions that can be tailored to the womems needs.life style changes - exercise , weight loss , low glycemic diet , stress reduction found to improve symptoms and prevent more complex treatment and side affects. Cognetive behavioral therapy helps in reducing and maintaining control of symptoms. Treatment of PMS has high placebo action anduse of Unlicensed treatment options such as Vit d , calcium , B6 , vinka alkaloids , primerose are of benefit though weak evidence .Low dose SSRI can be used continously / luteal phase/as needed basis . As there is serotonin deficeincy seen in those who experiense PMs .Side eefects should be explained and abrupt withdrawal avoided ,they benefit specially those who experince psycological symptoms. Combined new generation pills { Yasmin-]can be used continously / cyclically . su[press ovulation and hence endogeneous progertrone release considered to responsible for symptoms . Can be used in those wanting contraception too. The progestrone component being drosperone which has anti androgenic &anti mineralocorticoid action further helping in symptom improvement.2nd lne of treatment being Esradiol paches with low dose progesteronefor endometrial protection .Help those with physical and psycological symptoms.ACt by supressing ovulation{ added contraception needed].LNG_IUS can be used as alternative to oral progestrone with redused systemic side effectsand as an contaceptive devise . High dose newer SSRi - citralopam,can be used ,again luteal phase only is a better option. If above treatment fail GNRH analogues can be used to supress ovulation , but add back HRt will be needed to combat menopausal symptoms associated with it and reduse loss of bone density. Danasol low dose can be helpful as supresses ovulation and has anti progestrogenic effect but side effect profile limits it use, [ added contraception needed]Last resort being Hysterectomy + BSO in those where all above options have failed to bring response, and in those dysmennohea is present.She will need HRT following surgeryto avoid menopausal symptoms which can be more distressing , pre op assessment with GNRH and HRT should be done to assess benefit from BSO and tolerence to HRT.
		Posted by L S. Mon Aug 16, 2010 10:30 pm
LS: (a) Discuss your initial assessment [8 marks]. I take a detailed history on onset of her symptoms which should include physical symptoms like breast tenderness or bloating, psychological symptoms like mood swings, irritabilitity and depression with behavioural symptoms like reduced cognitive ability and accident prone and association to her menstrual cycle whether it occurs during the luteal phase of her menstrual cycle and regresses by the end of menstruation. Underlying organic and psychiatric cause should be ruled out by history like previous personal or family history of psychiatric illness. The effect of symptoms on her quality of life and social function should be assessed. Any previous treatments which she has had and the outcome asked. Physical examination is usually normal. Diagnosis is confirmed prospectively with symptoms diary for two cycles and these symptoms should have been present for at least four out of six previous cycles. (b) Discuss and justify the treatment options [12 marks] Treatment options should be an integrated approach and she should be sensitive approach and explained on possible cause of her symptoms and that treatment will take time. Multidisciplinary team management with gynaecologist, psychologist, GP and community support nurse should be involved in her care. A dedicated practitioner should follow her up so that she will more likely to response to counselling and treatment approach. First line treatment would include exercise and increasing physical activity to reduce stress, cognitive behavioural therapy to reduce accident prone effect and use of new generation combined oral contraception like Yasmin which has antiduretic effect to reduce water retention and bloating sensation. The use of low dose selective serotonin reuptake inhibitors like fluoxetine either during the luteal phase only or continuously to stabilise her mood swings and depressive symptoms can be considered but should only be prescriped by specialist with special interest in this condition or a psychiatrist as it has suicidal risk as a side effect. Second line treatment would be use of estrogen patches with levonorgestral intrauterine system or luteal phase oral progestogens to suppress ovarian function especially in moderate to severe cases of this condition and if not responding to first line treatment. Third line would be use of Gonadotrophin analogue (GnRH) with addback therapy with Tibolone as use prolong use more than six months of GnRH has risk of osteoporosis. Surgery only considered in severe retracted cases with hysterectomy and bilateral salpingooophorectomy with estrogen and possibly testosterone replacement after surgery. Prior to surgery there should be demonstrable response to GnRH and addback therapy. She should be provided information leaflet and support group about her condition to help her cope better with her condition.
		Posted by sonu P. Tue Aug 17, 2010 03:27 am
S A) Initial assessment should include a complete biopsychosocial history. The exact details of symptoms in general and most predominant symptoms in particular are asked and details of their severity and effect on quality of physical, social and psychological aspects of life. A menstrual calendar helps in distinguishing PMS and other psychiatric illnesses with premenstrual aggaravation. If symptoms do not completely resolve after menstruation, it goes against a diagnosis of PMS. Other objective tools are General Health Questionnaire, SF-36 and new hand held computerized PMS symptometres. Examination is usually to rule out co-existing conditions, e.g chronic PID, PCOS, endometriosis, fibroids etc. A baseline breast examination may be necessary to rule out malignancy. A baseline weight and BMI measurement may help in monitoring the condition if bloatedness in the mani symptom.Other medical conditions mimicking PMS should be ruled by investigations like FBC for anaemia, TFT for hypo or hyperthyroidism. Cervical smear results must be ascertaimed before undertaking any hormonal treatment. B) In cases of mild PMS, where significant pathology has been ruled out; reassurance may be all that is required.Various non pharmacological methods likelife style modifications should be tried first. They are- identifying trigger factors and dietary modifications accordingly, aerobics,meditation and yoga; but strenuous exercise should be avoided. Reflexology and acupuncture have been shown to be of benefit but need well organized trials. Weight reduction, stopping smoking and alcohol management may also be beneficial as a part of holistic approach to the condition. In moderate cases, where other psychological morbidities have been assessed and ruled out; a trial of progestogens can be done with natural progesterone(dydrogesterone) 10 mg in the luteal phase. Combined oral contraceptives can also be tried and newer agent like yasmin which have drosperinone (antidiuretic effect) have been shown to be more effective than others. Diuretics on their own are not advisable, although they are effective in reducing the feeling of bloatedness. Fluoxetine either continuously or in luteal phase is another effective option where mood symptoms like depression,irritability,insomnia etc are predominant, rather than more physical symptoms.Oestrogen patches have also been tried in women who complain about progestogenic side effects.In severe cases, where other modalities have failed, GnRH analogues can be used. It can be used as “goserelin test”, diagnostic and therapeutic trial in cases of doubtful etiology.If the symptoms are significantly improved on it, a major ovarian component can be assumed and symptoms can be attributed to PMS mainly. Improvement also indicates which patients will benefit from TAH+BSO which should be used as the last resort in the management of PMS. GnRH also helps in patients where menopause in expected soon. Long term GnRH use (>6months) is not recommended due to risks of menopausal symptoms which can be worse than PMS and also chance of osteoporosis.
		Posted by sonu P. Tue Aug 17, 2010 03:29 am
S A) Initial assessment should include a complete biopsychosocial history. The exact details of symptoms in general and most predominant symptoms in particular are asked and details of their severity and effect on quality of physical, social and psychological aspects of life. A menstrual calendar helps in distinguishing PMS and other psychiatric illnesses with premenstrual aggaravation. If symptoms do not completely resolve after menstruation, it goes against a diagnosis of PMS. Other objective tools are General Health Questionnaire, SF-36 and new hand held computerized PMS symptometres. Examination is usually to rule out co-existing conditions, e.g chronic PID, PCOS, endometriosis, fibroids etc. A baseline breast examination may be necessary to rule out malignancy. A baseline weight and BMI measurement may help in monitoring the condition if bloatedness in the mani symptom.Other medical conditions mimicking PMS should be ruled by investigations like FBC for anaemia, TFT for hypo or hyperthyroidism. Cervical smear results must be ascertaimed before undertaking any hormonal treatment. B) In cases of mild PMS, where significant pathology has been ruled out; reassurance may be all that is required.Various non pharmacological methods likelife style modifications should be tried first. They are- identifying trigger factors and dietary modifications accordingly, aerobics,meditation and yoga; but strenuous exercise should be avoided. Reflexology and acupuncture have been shown to be of benefit but need well organized trials. Weight reduction, stopping smoking and alcohol management may also be beneficial as a part of holistic approach to the condition. In moderate cases, where other psychological morbidities have been assessed and ruled out; a trial of progestogens can be done with natural progesterone(dydrogesterone) 10 mg in the luteal phase. Combined oral contraceptives can also be tried and newer agent like yasmin which have drosperinone (antidiuretic effect) have been shown to be more effective than others. Diuretics on their own are not advisable, although they are effective in reducing the feeling of bloatedness. Fluoxetine either continuously or in luteal phase is another effective option where mood symptoms like depression,irritability,insomnia etc are predominant, rather than more physical symptoms.Oestrogen patches have also been tried in women who complain about progestogenic side effects.In severe cases, where other modalities have failed, GnRH analogues can be used. It can be used as “goserelin test”, diagnostic and therapeutic trial in cases of doubtful etiology.If the symptoms are significantly improved on it, a major ovarian component can be assumed and symptoms can be attributed to PMS mainly. Improvement also indicates which patients will benefit from TAH+BSO which should be used as the last resort in the management of PMS. GnRH also helps in patients where menopause in expected soon. Long term GnRH use (>6months) is not recommended due to risks of menopausal symptoms which can be worse than PMS and also chance of osteoporosis.
		Posted by A A. Tue Aug 17, 2010 04:45 am
AA K.S.A. a)I would approach her sensitively, give her time to express her concern , ideas & expectation. .Ask about the severity & type of symptoms ( physical, psychological & behavioural) & their impact on her quality of life. Her cyclical occurence of symtoms (symptoms during luteal phase and settled by the end of menstruation) should be enquired. I would take menstrual history regarding LMP, cycle regularity & associated problems like dysmenorrhea or menorrhagia. Treatment used previously. Her sexual history , whether sexually active or not, if yes her current & past method of contraception as hormonal method might be reason for her physical & mood changes. Any history of sexual abuse, domestic violence, or other social factors like financial crisis, should be asked in a sensitive manner. Her fertility desire , as hormonal treatment would not be suitable if she wishes to conceive. Examination is usually inconclusive, Check BMI. To confirm diagnosis I would advice her prospective record of symptoms over at least 2 cycles using a symptom diary (such as the Daily Record of Severity of Problems) and symptoms should have been present for at least 4 of the previous 6 months. b) Treatment options are general ,complementary, medical ( Nonhormonal & hormonal) & surgical .General advice about exercise, diet and stress reduction can reduce symptoms & should be considered before starting treatment .Complementry therapy like cognitive behavioural therapy , Magnesium Calcium / vitamin D shown to have beneficial but due to limited data these drugs are unlicensed for PMS. MEDICAL- Non hormonal treatment with SSRI & SNRI -continuous or luteal phase improve symptoms. Side effect include nausea, insomnia & reduction in libido. Abrupt withdrawal should be avoided. Should be prescribed on expert advice as few reports of suicides have been reported in young women. There are various hormonal options, which act by suppression of ovulation. COCP especially new generation pill (Yasmin) containing Drospeirenone considered first line, has better control of physical & psychological symptoms .Continuous therapy is better than cyclical .It also provide contraception. Oestradiol patch(100 microgram) with oral progestogen on day 17- 28 or IUS improve physical & psycological symptoms .But progestogen even IUS have its PMS like effects. GnRH analogues therapy results in ovarian suppression and elimination of PMS. Lack of efficacy suggests a questionable diagnosis. Use as second- or even third-line treatment as there is risk of loss of bone mineral density .Use add-back hormone therapy when use for > 6month.Danazol is also effective but limited use due to irreversible virilising effects. advised to use contraception during treatment. SURGICAL: Hysterectomy +Bilateral ophorectomy is the last resort for severe intractable symptoms. . Balance potential benefits with long term risks of hypo-oestrogenaemia and need for HRT. Surgery should not be contemplated without preoperative use of GnRH analogues as a test of cure and to ensure that HRT is tolerated. Treatment choice will depend upon her severity of symptoms, patient’s wishes &fertility desire .Provide written information leaflets.
		Posted by Bee N. Tue Aug 17, 2010 04:53 am
A healthy 25 year old woman has been referred to the gynaecology clinic with a 2 year history of worsening pre-menstrual tension. (a) Discuss your initial assessment [8 marks]. (b) Discuss and justify the treatment options [12 marks] (Bee) A) Premenstrual tension is a diagnosis of exclusion. History will aim to assess severity of symptoms and rule out differentials. She may have a symptom diary if she has been having the problem for 2 years and this will help in objectively assessing her condition. I will enquire about somatic symptoms including headache and mastalgia as this may require symptomatic treatment with analgesia. I will ask about psychological symptoms such as agoraphobia, depression and anxiety as patients with such will benefit from psychiatric imput. I will ask about sypmtoms of depression and irritability as well as anxiety which if present will support the use of antidepressant as opposed to other modes of treatment and necessitate psychiatric referral to assess suicidal tendency. I will ask about quality of life and how debilitating the problem is for her for instance if she is still able to continue work and day to day activities. I will ask if she has any social problems including recent bereavment and braekup with a partner as such could cause worsening of already existing PMT. I will ask for any recent use of drugs or medication (including non prescibed) as some anti androgens such as cyproterone acetate or progestrogens when used alone can cause similar symptoms. I will ask about her obstetric history and desire for future pregnancy as use of contraceptives and hysterectomy(last resort) are options of management. I will take a menstrual history as problems with peroids may need COCP as choice of treatment instead of antodepressant. LMP is taken to rule out pregnancy. I will ask her about past treatments if any that she has recieved for the illness. Examination will be based on evidence from history as PMT does not have any specific physical examination finding associated with it. I will do a general exmination to check for palor and general well being including weight and height for BMI. If she has breast symptoms I will examine her breast to rule out any swelling or pathology. Abdominal and pelvic examination is done if pregnancy or pelvic pathology is suspected is suspected. Investigation will include FBC if anaemia is suspected and TFT if their is history of depression or low mood. B) Patient should be approached sensitively as this can be quite distressing for her and ofetn associated with psychaitric symptom such as depression. If it hasnt been commenced, a symptom diary is necessary for objective assessment of symptom and traetment. Exercise is necessary as it has been shown to ameliorate symptoms. Dietary changes is also useful and may require expertise of deiticians. PMT is managed under multidisciplinary setting which may include the GP, Gynaecologist, community nurse specialist, psychiatrist. Antidepressant such has fluoxetine (SSRI) have been found to be useful for treatment of PMT if used during the luteal phase or used continously. She must be informed of side effects such as reduced libido and nausea. This is especially useful if she has mostly psychological symptoms. Congnitive behavioural therapy may be helpful depending on severity of symptom. This treatments are usually administered by psychiatrist. New generation Combined pills such as Yasmin (ethinylestradiol 20mg and drospirenone 3mg) are equally effective and useful especially if irregularities in period is present of if patient is also wishing to use contraception. Pills with as minimum a dose of progestogen are preferable since side effect of progestrogen is similar to PMS. Alternatively estrogen patches or implants can be used with addition progesterone tabs like the minipill or levonorgestrel intrauterine device. Other hormonal treatments which are not considered first line are danazol and GnRH analogues. If she chooses danazol, she has to use an effective contraception since it can cause irreversible masculinisation of female fetus and has some androgenic effect of patient such as male voice changes. GnRh can be used in a short term alone if no menopausal symptom is precipitated. If menopausal symptom is precipitated or need to use for longer than 6 months,add back therapy with HRT is adviced. Though it prevents ovulation, is not a licensed as contraception and contraception should still be used if desired. It is used if definite diagnosis is to be made as failure to experience benefit is a sign of wrong diagnosis rather than treatment failure. complimentary treatment such as Ginko biloba, ca and mg suppliments have been found useful and should be considered. I will consider inform her that assocition for PMT can be useful and offer her information leaflets both that will tell her about the illness and suggest any association/society relating to PMT locally. For severly debilitating illness which has been found to be ameliorated by GnRH analogue, hysterectomy is an option but this will obviously compromise her fertility at such a young age and should only be considered in extreme cases. Patient may choose to remain on GnRH therapy with add back therapy on a long term instead of surgery and bone density should be measured yearly in such instance. Treatment choice must put into consideration, patients choice. Follow up is arranged to assess benefit and compliance with treatment.
		Posted by A H. Tue Aug 17, 2010 05:19 pm
AH a)Premenstrual tension (PMT) or premenstrual syndrome (PMS) is a diagnosis of exclusion. I will ask her about her symptoms which start in the days before onset of periods and end when her periods end. I will ask her to fill a prospective validated symptom diary, for example, Daily Record of Severity of Problems (DRSP) for at least 2 cycles. Symptoms should be present for at least 4 to 6 months. I will take a detailed history to exclude physical or psychiatric causes for her symptoms, for example hypothyroidism and depression respectively. I will enquire about possible stressors related to family, job and finances which may contribute to her inability to cope with her cyclical symptoms and hence her \'worsening symptoms\'. A menstrual history enquiring about menorrhagia and possible anaemia or dysmenorrhoea suggestive of endometriosis will be asked. Contraception use in particular combined oral contraception containing levonorgestrel or norethisterone may cause PMS-like symptoms. Fertility plans wil be discussed. A general examination will be done with emphasis on signs of anaemia and BMI. The breasts, abdomen and, if indicated, a pelvic examination will be done to exclude obvious concomitant pathology prior to using hormonal treatment.Normal examination findings may be reassuring to her. There are no investigations to diagnose PMS but relevant tests based on examination findings will be requested, for example, haemoglobin level, TFTs,and pelvic ultrasound. b)She will be managed by a multidisciplinary team consisting of GP,gynaecologist, psychologist or psychiatrist, counsellor and dietitian, ideally in a dedicated PMS clinic if available. General lifestyle measures like diet , exercise and cessation cigarette smoking may not treat treat PMS but will improve her general well being and possibly help her in coping with her symptoms. Firstline treatment include cognitive behavioral therapy (CBT),and luteal phase or continuous SSRI/SNRI, both of which were proven effective. CBT has a better maintenance effect when compared to SSRIs which have quicker onset of action .SSRIs have significant side effects including decreased libido, depression and insomnia and should be prescribed by a pychiatrist or gynaecologist with experience. SSRIs should be gradually withdrawn to reduce withdrawal symptoms. Newer SSRIs like citalopram are effective with better tolerability. The combined oral contraceptive pill containing drosperinone ( Yasmin and the lower dose (20 microgram estrogen formula Yaz from Schering Health). are both proven to be effective treatment. Yaz is not licensed in the UK for PMS. Levonorgestrel and norethisterone containig preparations may cause PMS-like symptoms and should be avoided. Complementary therapy proven to have some benefit include Vitamin D, Calcium, Agnus Castus, magnesium and Gingko biloba. Vitamin B6 is not effective. Estrogen patches or implants are effective. They must be used with progestogens for endometrial protection. Reliable contraception should be used. Levonorgestrel intauterine system(mirena) can provide endometrial protection and is a reliable contraception but may induce PMS symptoms.Effect of estrogen on breast and endometrium in long term unknown. Danazol is effective for cyclical mastalgia but causes irreversible virilisation and reliable contraception is needed during treatment. GnRH analogues are effective but can be used for only six months if used alone, as it causes troublesome menopausal symptoms and reduced trabecular bone density. If used for more than six months add-back therapy in the form of continuous HRT or tibolone must be used. Yearly bone density(BMD) measurements using DEXA must be done and treatment stopped if BMD falls after one year. TAH and BSO is the last resort but may not be acceptable nor is it appropriate in this young girl except her symptoms are debilitating. Multidisciplinary input as well as opinion from other senior consultants must be sought and details of counselling carefully documented if this decision is taken. GnRH will be used as a diagnostic as well as a test of cure prior to embarking on this drastic measure. Lifelong HRT with unknown side effects will be required.
		Posted by Bobey B. Tue Aug 17, 2010 06:51 pm
Careful history should be taken ruling out differentials such as anxiety, depression, medical conditions such as migraine and domestic violence. The diagnosis should be made following prospective symptoms chart identifying the type of symptoms, their severity and timing to the menstrual period. PMS must be sufficient severe to distrupt the woman\'s normal functioning, quality of life and interpersonal relationships. PMS should be distinguished from the normal premenstrual physiological symptoms. Symptoms must occur in the luteal phase of the cycle and relieved by menstruation. They must present for at least four of the previous six cycles. The classical symptoms usually tension, irritability, aggression, depression, feeling out of control, food carving, bloating, mastalgia, headache and backache. Examination and investigations will be normal. There are no biochemical tests to diagnose PMS and the diagnosis is made on history and by the patient keeping a prospective symptom chart identifying the type of symptom and severity. Daily record of severity of problems ( DRSP) is a simple for patient to use and provide good tools for measuring PMS symptoms in a routine clinic. b) There are many different management options available for severe PMS, but medical treatment is mainly aimed at ovarian suppression or correction of neuroendocrine anomaly. Treatment should begin simply under care of multidisciplinary team which might involve gynaecologist , psychiatrist or psychologist , dietician and counselor . Several treatment options have been suggested for PMS include : Cognitive behavioural therapy can result in coping with premenstrual symptoms and better maintenance of symptoms control. A sympathetic approach , coupled with general advice regarding diet and life style may well be of benefit. Exercise has shown been to be beneficial for mood symptoms , fluid retention and breast tenderness. Support groups which focused on varying areas such psychoeducation, problem solving approach or empathetic listening. Complementary therapies and diet supplements such as calcium, magnesium (is involved in the activity of serotonin, vascular contraction, neuromuscular function) would reduce PMS specially mood changes. Vitamin B6 (pyridoxine) in small doses 50 mg / d. may release PMS including depression. If the woman chooses to take vit.B6 despite lack of clear evidence of efficacy, she should be aware that high doses can cause sensory neuropathy. Hormonal treatment in the form of oestradiol patches or implants result in suppression of cyclical ovarian function and are effective therapies. Progestogen is required to protect the endometrium and maintain a regular cycle and may result in progestogenic side effects similar to PMS. Gonadotrophin-realeasing hormone agonists are effective for the most severe PMS and should be combined with add-back therapy ( oestrogen and progestogen ) due to its hypooestrogenic effects. GnRH agonists results in profound cycle suppression and elimination of premenstrual symptoms. Danazol in doses 200-400 mg/d. is effective treatment of PMS by suppressing ovulation. Luteal phase danazol is effective for premenstrual breast pain ,but its use is limited its side effect profile. Non-hormonal treatment in the form of selective serotonin re-uptake inhibitors (SSRIs) has rapid action on the physical and psychological of PMS, but treatment of depression requires several weeks. Tibilone is synthetic steroid, increases the b-endorphin concentration and is used as add-back therapy during treatment with GnRH analogues. Progestogens , bromocriptine , COCP, and NSAIDs have not been shown to be superior to placebo. Surgical treatment in the form of hysterectomy and bilateral salpingo-oophorectomy is an effective treatment of severe PMS. This might be indicated if there are co-existing gynaecological problems of sufficient severity to justify pelvic surgery .Surgery is usually followed by oestrogen replacement. This option should not be used with this young lady.
		Posted by NIRMALA M. Tue Aug 17, 2010 09:57 pm
Nirmala a. She should be approached sensitively and active listening to her symptoms is the key step in the initial assessment. Her symptomatology might be worsening physical, behavioural, psycological occurring cyclically in the luteal phase of the menstrual cycle which gets better or relieved postmenstrually in the absence of any organic or psychiatric disease . History to include how these symptoms affects her quality of life. Physical symptoms to include generalized aches and pains, breast tenderness, bloating. Psychological symptoms to mood changes, irritability, feeling low, anxious. Behavioural symptoms to include difficulty to concentrate, sleep disturbances, staying indoors premenstrually. Retrospective recall of these symptoms is very difficult to make a diagnosis of PMS. Therefore prospective review of all these symptoms written on a symptom diary for more than 2 months is helpful in making a diagnosis of PMS in the presence of cyclical worsening of symptoms in the luteal phase with subsiding of symptoms postmenstrually. Any associated psychiatric illness should be ruled out before embarking on the diagnosis of PMS. As PMS is associated with sedentary life, lack of exercise, smoking, alcohol, high glycemic index diet, caffeinated drinks, detailed history to know the precipitating factors is helpful. b. Depending on the history, the severity of the PMS is assessed and the treatment is planned accordingly. Treatment involves multidisciplinary approach involving Gynaecologist, psychologist, dietician and counselor. Patients wishes, her plan for future fertility and need for contraception should be considered in making treatment plan because Suppression of ovulation relieves PMS symptoms. Her treatment is by integrated approach with complementary therapy, drugs, hormones followed by surgery if all other measures fail. Complementary therapy includes CBT, dietary changes to increase low glycemic index diet, to stop caffeinated drinks, modify life style factors like exercise which increases the mood, stop smoking and alcohol, add supplements like pyridoxine not more than 10 mgs/day, calcium, magnesium and vitamin D, relaxation techniques. One of the first line treatment options is SSRI/SNRI is due to the effects on neurotransmitters by the cyclical hormone changes. Newer generation SSRI, citalopram is recommended as low dose in the luteal phase/ continuously due to the low side effects. It should be prescribed by a doctor with expertise in this field. Proper counseling about sideeffects and follow up is necessary as few suicides have been reported when treating young women for depression. It should be withdrawn slowly if on continuous regimen. Side effects include headache, vomiting, insomnia, loss of libido. COC pills having drosperinone as the progesterone component is the recommended first line due to the low side effects. This COC pill along with SSRIs as luteal phase/ continuous especially if the woman needs contraception. If symptoms not controlled, second line treatment is increasing dose of SSRIs in the luteal phase/ continuously, increasing oestrogen component dose to 100-200 micrograms by prescribing patch/implant along with luteal phase progesterone, duphaston 10 mgs with contraception cover or alternatively mirena can be tried if long term contraception is needed. No role for progesterone only treatment as it might worsen the symptoms. If symptoms not controlled, third line treatment is high dose GnRH agonists along with HRT if GnRH is to be given for more than 6 months provided proper follow up with DEXA scan to monitor bone mineral density and proper dietary advise and lifestyle modifications to prevent osteoporosis. If PMS not controlled with GnRH agonists, then the diagnosis of PMS is questionable rather than treatment failure. If GnRH agonist is successful, oophorectomy is beneficial in these patients. If bone mineral density is reducing in 2 DEXA scans taken 1 year apart, GnRH agonist treatment should be stopped. Danazol could be tried along with contraceptive cover but virilisation is a side effect. If the women wants permanent cure, if she has completed her family, with severe PMS symptoms , she should be properly counseled for TAH with BSO along with HRT and testosterone to increase libido is the last resort to treat her symptoms.
		Posted by HM .. Wed Aug 18, 2010 02:59 am
Paul, I just thought I bring it to your attemtion. Is the numbering off for the last 2 questions and this should be Essay 337? Just so it can be corrected with the next.
		Posted by zara A. Wed Aug 18, 2010 04:52 am
A]The patient should inquired about the nature of symptoms,whether physical [ bloatednes ,headache,breast tenderness],pshycological [irritibility,mood swings ,anxiety,] and behavioural symptoms [agression ;reduced cognitive ability].She should asked the severity of symptoms and the effect on quality of life ,and effect on social functioning ,and effect on maritial life.She should asked that symptoms persist throughout menstrual cycle or appear before menstruation [luteal phase]and regress after menstruation and there is symptom free period.She should asked any treatment she has taken and effect and side effects of treatment.Her need for contraception and current method of contraception asked .She should asked about the intake of alcohal and smoking .She should beasked about her occupation and any stress at home.Any family history of pshycatric disorders .HER LMP ,cycle length,menstrual loss and dysmenorrhea should asked.HER BMI noted.ABdominal examination and pelvic examination indicated if history suggest o rganic cause .If history suggest s any pshycatric problem she should referred to psychatrist .She should asked to record her symptoms prospectively over 2 to 4 cycles in symptom diary [Dialy record of severity of problems DRSP].B]The manage ment of patient depends on severity of symptoms ,previous treatment taken ,patient chioce and contraceptive needs .IF symptoms severe she should be managed by multidisciplinary team including gynaecologist ,psycologist ,dietician and counseller .She should be given ressurence and explanation of her condition .She should told about life style modification ,exercise and diet from low glycemic index,She should advise to stop smoking .STRESS management relaxation techniques ,and cognitive behaviourl therapy can be beneficial.integated approach is beneficial .Complementery therapies like reflexology ,magnesium,isoflavones are unliscenced but these have evidence of efficacy so can be prescribed if patient well informed .SSRI are first line treatment option as the premenstrual symptoms could be due to altered serotonergic activity .SSRIS improve physical and pshycological symptoms .SSRIS[flouxitine and citalopram] can be given in luteal phase or continuously .THe side effects are insomnia,decreased libido,nausea .Cycle modifying hormonal agents OCPS can be given as these supperss the ovarian cycle .OCPS YASMIN]containing drosiperinone CANBE given .OCPS should be given continuously .ocps provide added advantage of contraception.Estrogen implants or patch can be given .The patiet require additional contraception.To avoid unopposed estrogen action on endometrium these should combined with systemic progestogens [norethisterone] 10 t0 12 day of cycle or MIRENA to prevent endometrial hyper plasia.PATIENT should be counselled about insuficient data to advise long term effects on endometrium and breast.DANAZOL is effective but it causes irreversible changes in vioce .hirsstism and acne.IF prescribe with contraception.GnRH analogues considered as third line and given if symptoms severe and other treatment failure, these completely supress cycle effecive ,has therapeutic and diagnostic benefits if symptoms disappear with GnRH administrationit confirm diagnosis .IF symptoms persist suggest questionable diagnosis.lisenced for 6months,SHOULD be prescribed with addback therapy to preventmenopausal symptoms bone mineral density loss and need to moniter bone density.SURGER Y either BSO or TAH WITH bso is an option considered as last resort after family completed and in intractable sy mptoms when all other treatment options fail.PREOPERATIVE confirmation withGNRH analogues is mandatory and HRT given.PAtient should given information leaflets.
		Posted by millionaire2004 A. Wed Aug 18, 2010 05:29 pm
Ag A healthy 25 year old woman has been referred to the gynaecology clinic with a 2 year history of worsening pre-menstrual tension. (a) Discuss your initial assessment [8 marks]. History is important to diagnose premenstrual syndrome (PMS). Ask about menstrual history including age of menarche, cycle regularity and duration, menstrual flow pattern. Ask about last menstrual period. Ask about psychological (depression,anxiety, insomnia, loss of libido), somatic (abdominal pain, bloatedness,headache, mastalgia) and behavioural (clumsiness, reduced cognitive ability, agoraphobia) symptoms. Determine which symptom is predominant. Ask about the time of onset of the symptoms and when it reduced or resolve. In PMS, symptoms begin in luteal phase of menstrual cycle and resolve at the end of menstruation. Look at her symptom diary. Determine that the symptoms are present in the last 4 out of 6 menstrual cycles (by history or by symptom diary). Ask about the effect of the symptoms on her quality of life, interpersonal relationship and professional relationship. This can determine severity of PMS. Ask about any previous treatment taken and the response to treatment. Ask about past/current use of hormonal contraception and its side effects on her. Enquire about social history such as her job, professional/personal relationship. This is to identify any stress factors. If the woman is on a relationship/married, sensitively ask about domestic violence. Ask about her future reproductive plan as this can guide management(ie avoid COCP if she wants to get pregnant). Do a general physical examination, but expect it to be normal. Mental state examination done if predominant symptom is psychological. There is no biochemical investigation to diagnose PMS. Discuss and justify the treatment options [12 marks], She should be treated in tertiary centre with multidisciplinary approach team (gynaecologist, psychiatrist, psychologist, and dietician). Treatment should combine both conventional and complementary approach. If the symptoms are mild/moderate, reassure her that it is a physiological symptoms occurring premenstrual. Tell her that she is not suffering from a life threatening condition. Give general advice regarding exercise, diet and stress reduction. Offer her support group. Offer referral to psychologist. These have been shown to help some women. Assess efficacy by symptom diary (daily record of severity of problem). First line pharmacological treatment is selective serotonin reuptake inhibitor (SSRI) like fluoxetine and/or selective noradrenalin reuptake inhibitor (SNRI) like venlafaxine. This can be used either continuosly or during luteal phase (day 15-28 in a 28 day cycle). This drug is non-hormonal and avoid PMS-like symptoms due to progesterone. If used continuously, it should be withdrawn slowly to avoid withdrawal symptoms. However, it can cause reduced libido and sexually active woman should be warned. Hormonal treatment include combined oral contraception (ie Yasmin) taken orally continuously. It can reduce symptoms as well as provide contraception. Suitable for sexually active woman not planning to get pregnant. Other hormonal option is oestradiol patch (100 mcg twice weekly). However, the woman need to take cyclical progesterone for endometrial protection. Lowest progesterone dose should be used to minimise PMS-like side effects. She need additional barrier or intrauterine contraception. Alternatively, levonorgestrel releasing intrauterine system can be used, but it can initially cause PMS-like symptoms. Danazol is effective (200mg twice daily) but associated with potential irreversible virilising side effect. The woman needs contraception if using danazol. Gonadotrophin releasing hormone (GnRH) agonist needed if the woman not responding to the above treatments. It can effectively suppress ovulation and improve symptoms. Not suitable if she want to conceive. Treatment limited for 6 months if used alone due to trabecullar bone loss. Longer duration possible with add back therapy (with Tibolone, continuous combine HRT). She needs yearly bone scan and treatment stopped if bone loss evident. Surgical treatment only if in severe PMS not responding to medical management. Abdominal hysterectomy can help the symptoms but usually bilateral oophorectomy needed to suppress ovulation. Can be considered for woman who have completed family. Preoperative ovarian suppression with GnRH agonist mandatory as test of cure to assess likehood of successful surgery. Complimentary treatments include cognitive behavioural therapy. Diet supplement such as calcium,magnesium,isoflavone, Agnus Castus, Gingko Biloba or polent extract may help some woman. Provide written information and arrange follow up visits.
		Posted by KWASI RICHARD A. Thu Aug 19, 2010 12:01 am
KRA A) i would take a detailed history about her menstural cycle, Last menstural period, cycle length and the number of days she bleeds for. I would elicit from the history the type of symptoms she experiances, specifically enquiring about physical symptoms of bloatedness, masalgia, weight gain dizziness and palpitations psychological symptoms of tension, irritability, depression anxiety and loss of libido, and behavioural symptoms of clumsiness and reduced cugnitive ability. I would try to find out what time in her cycle she thinks this symptoms are worse because symptoms of premenstural tension occur in the luteal phase and disappear by the end of menstruation. I would find out the impact of the symptoms on her quality of life. I would perform a general examination like her body mass index and compare with previous ones if available because there is the sensation of weight gain associated with premenstural tension and also do a blood pressure and pulse check, because of the associated headache, palpitation and dizziness. No specific investigation would be required, however, i would recomment she keeps a prospective diary of record of severity of problems for at least two cycles. B) She would be managed by a multidisciplinary team including the general practitioner, community gynaecologists, psychiatrist/psychologist and dietician treatment would be conservative, medical, and surgical. I would give her general advice about exercise diet and stress reduction because there is some evidence that exercise reduces pms symptoms. If she has marked psychopathology aswell as pms i would reger her to see a psychiatrist. I would use her symptom diary to assess the effect of treatment. Complimentary treatment like using vitamin b6 which is not beneficial, calcium and vitamin D which provides some benefit evening primrose and reflecology would be discussed. I would tell her there is no evidence for there benefit and there is the risk of interaction with conventional medicine. I would tell her about conventional medicine and the first line is to use combined oral contraceptive pill either cyclically or continuously has been shown to be effective by suppressing ovulation. Selective serutonin peuptake inhibitors (SSRIs) and selective serotonin and noradrenaline reuptake inhibitors (SNRIs) given continously or low dose has been shown to be eggicacious butshe would be warned of edverse side effects like nausea, insomnia and reduction in libido. Another option would be offer estradiol patch 100 micrograms with oral progestogen like duphaston 10mg from Day 17-Day 28 or insertion of mirena coil. This has been shown to be effective for the mangement of physical and physcological symptoms. I would tell her that the mirena coil may initially produce PMS type adverce effects and that there insufficient data of the long term effect of oestradiol on breast and endometrial tissue. Treatmen with danazol is another option 200mg twice daily is effective, however she would be watned about irreversible vivisiling effect. Contraception would be adviced. Gonodotrophin releasing hormone is another option which results in profound cycle suppression and elimination of PMS with ad back therapy, treatment for only 6 months. If treated for more than oneyear bone density measurement is recommended and general advice about diet and exercise given, Hysteractomy with bilateral salpingo opherectomy is effective for PMS however it would be too drastic of a measure in this 25 year old.
		Posted by Tendai C. Thu Aug 19, 2010 12:36 am
A healthy 25 year old woman has been referred to the gynaecology clinic with a 2 year history of worsening pre-menstrual tension. (a) Discuss your initial assessment [8 marks]. This is a common often benign condition mainfesting with distressing pschological, behavioural and physical symptoms in the luteal phase of the menstrual cycle and disappears or significantly regresses at the end of menstruation. I would specifically enquire about these factors in the history. I would determine if she has psychological symptoms of tension, irritability, restlessness, mood swings etc. Somatic symptoms would include mastalgia, bloatedness, hot flushes, sensation of weight gain. She may report behavioural problems like agorophobia,, clumsiness, decreased visiospacial and cognitive ability. I would also determine if her symptoms are mild where they do not affect her personal, social or professional life. Moderate syptoms would interfer with her life but she would still be able to function. With sever symptoms she would be unable to function socially personally and professionally and withdraw from social and professional activities. I would take a full gynaecological history as she may aslo suffer from other symptoms like dysmenorrhoea and menorrhagia. Past medical history and symptoms review may indicate a psychopathalogical cause of her symptoms like hypothyroidism. Drug history may reveal a cause for her symptoms as well as increased alcohol intake. There may be a family history of premenstrual symptoms. On examination I would make a general assessment for any cause of the symptoms like a goitre indication hypothyroidism. bdominal examination may reveal a pelvic mass. A neurological examination may reveal a pathological cause for her symptoms. (b) Discuss and justify the treatment options [12 marks] Most women who seek treatment do not have severe premenstrual syndrome. Severe symptoms may be resistant to treatment and should be managed ny a multidisciplinary team involving her GP, a community gynaecologist, psychiartist or psychologist and dietician. General advice ahould be offered regarding diet and stress reduction before treatment is started as there is some evidence exercise decreases symptoms. An underlying psychological disease should be refered to a psychiatrist. Symptom diaries will assess effect of treatment. Complementary treatment include exercise and cognitive behavioural therapy. Vitamin B6 supplement is not effective. Magnesium may benefit in the premenstrual phase. Calcium, vitamin D have some benifit as well as isoflavines, agnus cactus, ginko bilboa and pollen extract. first line conventional therapy is serotonin reuptake inhibitors and SNRI in low doses prescribed by a psychiatrist or doctor with a special interest as suicide from depression has been reported. It can be continuous which should be withdrawn slowly to prevent withdrawal symptoms or luteal phase (day 15 to 28). Adverse effects may be nausea, insomnia and reduced libido. Citalopram may relieve symptoms where other medications fail. New generation combined oral contraceptive pill have been shown to be effective, with continuous more than cyclical treatment. Percutaneous oestradiol as a patch or implant with lowest dose of cyclical progesterone is effective for physical and psychological symptoms. Alternative contraception may be needed. Mirena may initially produce PMS type adverse effects. The effect of oesradiol on breast and endometrial tissue is still to be determined. Second and third line includes GnRH analogues resulting in significant cycle suppression and elimintion of symptoms. If it doesnt work, there may be a question about the diagnosis. Add back woth HRT or Tibolone is recommended with bone mineral density scans. When used alone treat for 6 months. Low dose danazol is effective but use is limited by virilising side effects. Women need additional contraception. Hysterectomy and bilateral oophrectomy in refractory symptoms is effective but risks and benefits have to be weighed.
		Posted by Bgk H. Thu Aug 19, 2010 05:09 am
bgk a. Premenstrual tension is a distressing disease to patient. A sensitive and non-judgemental approach needed. I will asked about any associated symptoms such as lower abdominal pain, low self-esteem, lethargy and insomnia. The worst and disturbing symptoms should be identified. I will ask about the severity of her symptoms and the significant impact on her life. Any trigger that causing he severity need to be identified. I will asked about treatment that she has before if any. Medication history need to be asked. Any drug allergy or adverse effect on COCP before such as migrane with aura need to be determined. I will ask her about the regularity of her menses and its associated dysmenorrhoea, dyspareunia and abnormal vaginal bleeding. On examination I will measure her height and weight and calculate her BMI. I will perform an abdominal examination to rule out any underlying gynae pathology. Symptoms diary about her problem is beneficial to assess the severity at least for two cycle using Daily Record Severity of Problem. b. She needs multidisciplinary approach to tackle this problem involving gynaecologist with special interest and psychiatrist. I will explain to patient regarding her problem options of treatment and expectation. Any evidence of underlying psychiatric concern, referral to psychiatrist should be made. I will treat her conservatively by modifying her lifestyle. Exercise should be encouraged and her dietary change is recommended. Any stressor such as work related or relationship disharmony should be dealt with. I will prescribe her with compliment therapy such as vitamin B. I will refer her for cognitive behavioural therapy as this a proven to improve her symptoms. A low dose of new generation of COCP can be prescribed. This includes Yasmin. Low dose SSRI can be prescribed continuously or during her luteal phase. If no or poor response, a high dose of SSRI can be given continuously or during luteal phase. Oestradiol patch can also be given. This may need to be in conjunction with Mirena Coil for the progesterone arm to avoid endometrial hyperplasia. GnRH analogue can be given but it is limited with unwanted side effect and can be given up to 6 months. If patient responded well, longer duration can be given, but add back therapy need to be given in the form of HRT. DRSP need to be continued to monitor the tretment response.She can also be manage surgically by performing TAHBSO, but she must be fully inform that it may not relieve her symptoms. Patient need to be given ptient information sheet.
		Posted by Mohamed D. Thu Aug 19, 2010 09:59 am
Mohamed Any psychopathology or previous psychiatric treatment should be checked for possibility of psychiatric element. Sexual history and number of sexual partners over the last year to check if she is at risk of STIs. Menstrual history with any signs of postcoital bleeding or intermenstrual bending should be elicited to find if there is STIs risk. Contraception history and use of safe sex to guard against STIs. Any past history of treatment for PID should be checked. Past medical history and use of any medications as antiepileptics or psychiatric medication that may interfere with treatment option for her. Any previous treatment for this condition and result of the treatment and adverse effect should be checked. Effect of the condition on her quality of life and days off work or study should be identified to categorize the severity of the condition. History of cervical smear if had been done, and any previous Chlamydia screening result if done. Abdominal examination to rule out any pelvi-abdominal mass prior to treatment. Pelvic examination may be considered if pelvic pathology is suspected and to take a cervical swab for NAAT for Chlamydia (and gonorrhoea in high risk areas). Record of symptoms on a diary as DRSP, as retrospective recall of symptoms are always unreliable. b) General advises as diet, exercise, and stress reduction mostly had been advised by primary care before referral. If any psychopathology suspected, referral to psychiatrist and MDT should be arranged. In most of the severe cases there is a psychiatric element and MDT will help to deliver effective management. The symptoms diary as DRSP can be used to assess treatment. The first line treatment should be exercise and cognitive behavioural therapy with vitamin B6. For some of the mild to merate cases this will be enough treamnet for them. Also new COCP as yasmin or cilest can be used, continuously for 3-6 cycles or cyclically, as first line to stop ovulation and decrease progesterone levels in the luteal phase which is responsible for her symptoms. Low dose continuous or luteal phase (days 15-28) SSRIs can be also used as an alternative or in combination, which had been found very effective in mild to moderate cases. The second line if the previous treatment fail to show improvement is estradiol patches with luteal phase oral progesterone or Mirena IUS. There is not enough data about the effect of estradiol patches on the endometrium, so the use of progersterone is to counteract its aeffect on the endometrium. It acts by inhibiting ovulation. High dose SSRIs either luteal phase or continuoes can be used which is very effective treatment. Danazol can be used but advice for good contraception as there is high risk of masculanization of female fetus if pregnant. She should be also counselled about the androgenic side effects as hirsutism and deepening of voice. The third line of treatment is to use GnRH analogues injection with add back therapy of estrogen and progesterone or tibolone to reduce the risk of osteoporoses. This will subject her to climacteric symptoms and she should have bone densiometry measurement if treatment extends for more than 2 years for risk of osteoporoses. The last option would be hysterectomy and removal of ovaries which is the last resort if all previous medication fail. She should be counselled that this will bring her to menopause with its morbidities and she will need estrogen and testesterone replacement therapy till the age of 50.
		Posted by Ir A. Thu Aug 19, 2010 09:00 pm
A healthy 25 year old woman has been referred to the gynaecology clinic with a 2 year history of worsening pre-menstrual tension. (a) Discuss your initial assessment [8 marks]. (b) Discuss and justify the treatment options [12 marks] If a)I will ask the patient about the impact of the worsening symptoms on her quality of life. I will note down the details of her symptoms: irritability, anxiety, insomnia, depression, breast tenderness, bloating, pelvic congestion and/or change in bowel habits. I will enquire about the length and regularity of her menstrual cycle. I will take her contraceptive history. Her obstetric history should be sought. History of smoking and level of activity and exercise should be taken. I will ask whether she has taken any treatment for her symptoms and whether there was any improvement. I will enquire about any significant past medical history especially any history of depression or other psychiatric illness. I will encourage her to maintain a symptom diary which allows an accurate assessment of the symptoms. I will note her BMI. b) The patient should be given advice about lifestyle changes, regular exercise and diet modification as these have been found to be effective in reducing PMT. Complementary therapy like multivitamins, vitamin B6 supplements, isoflavones, evening primrose oil may be offered; however none of these has any evidence to support their role. Cognitive behavioural therapy can be offered. The pharmacological management will be guided by the impact of symptoms on her quality of life. If she is not planning a pregnancy, combined oral contraceptive pills like yasmin may be tried as a first line measure as these have been shown to alleviate symptoms of PMT. Low dose selective serotonin uptake inhibitors (SSRI) and serotonin and noradrenaline uptake inhibitors (SNRIs) either continuously or restricted to lutael phase can be offered. Physical and psychological symptoms of PMT improve with fluoxetine. Higher doses of SSRIs may be used if there is no relief with low doses. Other options include estrogen patches (200 mcg twice weekly). She will require progesterone for endometrial protection and can be prescribed luteal phase duphaston or mirena. Other options include danazol, an androgenic steroid. She should be advised to use contraception due to petential virilizing effect on a female fetus. GnRH agonists may be used as last resort after discussion with her. Add back therapy with estrogen or tibolone will be required to prevent loss of bone density. She should be provided with written information and contact details of support groups. She will require multidisciplinary management in conjunction with dietician, counsellor, clinical psychologist and if required a psychiatrist.
		Posted by Ir A. Thu Aug 19, 2010 09:01 pm
A healthy 25 year old woman has been referred to the gynaecology clinic with a 2 year history of worsening pre-menstrual tension. (a) Discuss your initial assessment [8 marks]. (b) Discuss and justify the treatment options [12 marks] If a)I will ask the patient about the impact of the worsening symptoms on her quality of life. I will note down the details of her symptoms: irritability, anxiety, insomnia, depression, breast tenderness, bloating, pelvic congestion and/or change in bowel habits. I will enquire about the length and regularity of her menstrual cycle. I will take her contraceptive history. Her obstetric history should be sought. History of smoking and level of activity and exercise should be taken. I will ask whether she has taken any treatment for her symptoms and whether there was any improvement. I will enquire about any significant past medical history especially any history of depression or other psychiatric illness. I will encourage her to maintain a symptom diary which allows an accurate assessment of the symptoms. I will note her BMI. b) The patient should be given advice about lifestyle changes, regular exercise and diet modification as these have been found to be effective in reducing PMT. Complementary therapy like multivitamins, vitamin B6 supplements, isoflavones, evening primrose oil may be offered; however none of these has any evidence to support their role. Cognitive behavioural therapy can be offered. The pharmacological management will be guided by the impact of symptoms on her quality of life. If she is not planning a pregnancy, combined oral contraceptive pills like yasmin may be tried as a first line measure as these have been shown to alleviate symptoms of PMT. Low dose selective serotonin uptake inhibitors (SSRI) and serotonin and noradrenaline uptake inhibitors (SNRIs) either continuously or restricted to lutael phase can be offered. Physical and psychological symptoms of PMT improve with fluoxetine. Higher doses of SSRIs may be used if there is no relief with low doses. Other options include estrogen patches (200 mcg twice weekly). She will require progesterone for endometrial protection and can be prescribed luteal phase duphaston or mirena. Other options include danazol, an androgenic steroid. She should be advised to use contraception due to petential virilizing effect on a female fetus. GnRH agonists may be used as last resort after discussion with her. Add back therapy with estrogen or tibolone will be required to prevent loss of bone density. She should be provided with written information and contact details of support groups. She will require multidisciplinary management in conjunction with dietician, counsellor, clinical psychologist and if required a psychiatrist.
		Posted by Dr Dyslexia V. Fri Aug 20, 2010 01:06 am
X a) The symptoms and severity of premenstrual tension must be established. The symptoms will occur during the luteal phase of menstrual cycle and resolves upon menstruation. The symptoms could be divided to psychological, physical and behavior. They psychological symptoms include mood swings, depression, irritability, anxiety and feeling of out of control. The physical symptoms include mastalgia, crampy abdominal pain, headache and lethargy. The behavioral symptoms include reduce visuo spatial and cognitive ability and increase in accidents. This symptoms should be recorded in a symptom diary over two cycles of menstrual cycle. Family history of psychiatric disease, substance abuse, alcohol abuse should be taken to rule out any underlying psychiatric disease. Other menstrual abnormalities usage of contraception should be taken to guide type of treatment for the patient. Physical examination which include weight and height, BMI should be taken as well. Abdominal examination should be done to exclude any pelvic mass and vaginal examination done to elicit adnexal tenderness and pouch of Douglas nodule in endometriosis. b) A multi-disciplinary approach should be advocated for the management of this disease. It should include the gynaecologists, the general practitioner, the psychiatrist, the psychologist, the dietician and counselor. General advice about exercising, diet modification, weight reduction, and stress reduction should be given prior to starting formal treatment. The symptoms should be monitored with symptom diaries to monitor the effectiveness of treatment and the progress of the disease. First line therapy include exercise, cognitive behavioral therapy which includes sessions with psychologists. It could also be used in conjunction with combine oral contraceptive pills such as yasmin with the use of low dose SSRI such as fluoxetine during the Luteal phase as day 15 to day 28 of mensors. The COCPs would benefit by preventing ovulation and cycle regulation. In more severe cases, estradiol 100mg preparation could be used in conjunction with oral progestogen such as duphaston 10mg during Luteal phase day 17 to day 28 or with Mirena. The use of high dose SSRI continuously could be considered and it’s side effect such as nausea and loss of libido should be informed. Continous dose of high dose of SSRI should be withdrawn gradually upon successful treatment as it can cause withdrawal symptoms. Other modalities include use of GnRH analog which could also be used to suppress ovulation. The side effects of GnRH such as decrease in voice, bone mass density and voice changes should be informed to the patient. The use GnRH could be supplemented with estrogen such as premarin in an add back therapy. Other options such as total abdominal hysterectomy and bilateral salphingoopherectomy should be informed but discouraged in her age group. She should also be referred to support group such as NAPS for further support. Other alternative treatments are available such as use of magnesium, vitamin D, magnesium and Agnus Castus which are found to be of benefit.
		Posted by A- N. Fri Aug 20, 2010 03:55 am
AA--- I will ask her nature of symptums, relation with menstrual cycle and effect on quality of life. Physical symptums could be bloatedness, headache, breast tenderness, behavioural symptums like reduced visuospatial, prone for accidents and cognitive activity, Psychological symptums like mood changes, lack of concentration. these symptums come prior to onest of mentruation and subside or decrease after onet of menstruation. I would ask her to record these symptums prospectively for 2 cycles as retrospective assessment is in inappropriate. I woul enquire abou predisposing factor for PMS like stress, lack of exercise, sedentary life style,. I would assess her psychological symptums, may need referal to psychiatrist if required. Chronic pelvic pain, dysparunia, dysmenorrhea shoul be asked to rule ot organic pathology like endometriosis. Social history like smoking, alcohol intake ,may have impact on her quality of life. Gastrointestinal symptums to rule out IBS, if present may need refferal to gastroenterolosist. b Treatment options are non medical, complementary, medical and surgical. Intgrated approach is beneficial.Non medical options like, exercise, low glycemic food,less spicy food, stress reduction should be tried as first line of management . Complentery therapie are effective, safe , however not evidence based. The proven benefit is seen with intake of calcium, magnesium, vitamin D,, agnus castus. These should be prescribed only after discussion about risks and benefits with patient. SSRIs or SNRIs are first line of management. these can be used either continously or in lutal phase. initially low dose and later higher dose if no response. Side effects are insomnia, sleep disturbances, nausea , vomitting. These should be prescribed by health proffessionals. To prevent withdraawal symptums , gradual stopping of medication is advised when taking contnous SSRIs. These can be taken along with cognitive behavioral therapy. Newer COC like drosperinone are taken as continouly. continous intake without breakthrough bleeding has shon to be more effective. other harmonal methode are estrogen patches, which needs aditional contraception. LNG-IUS can be used along with estadiol patches. Progestrone are not effectve in treating PMS. GNRH analogues are used as second or therd line of management because of risk of osteoporosis. These are used along with addback therapy like continuous combined HRT or tibulone. GNRH analogues are used maximum for 6 months, if used for longer duration(2 years) , she needs DEXA scans of bones. Surgery is the last resort which includes Bilateral salpingo-oophorectomy. Before contemplating surgery she needs GNRH therapeutic test to check whether ovarian suppession relieves her symptums.HRT is offered till the age of 50yrs. Testesterone implants can be used to increase libido.
		Posted by Penelope T. Fri Aug 20, 2010 11:15 am
a) History and examination should aim to exclude underlying physical or psychiatric cause for her symptoms. PMT is usually suggested by the history: recurrent cyclical constellation of physical, behavioural and psychological symptoms that occur in the luteal phase and are relieved with the end of menstruation. My history would ask about physical symptoms such as bloating and breast tenderness, psychological symptoms such as mood swings, poor concentration, irritability and depression, and changes in behaviour such as accidents or risk taking. Cyclicity in the luteal phase and significant effect of normal daily life is important to clarify. Family and work relationships may be affected, and ability to work significantly impaired or impossible. It is also important to clarify underlying or past psychiatric disease and any physical symptoms that might suggest another pathology. Examination should be based on specific symptoms and establishing normality (vital signs, abdomen and pelvic exam). If significant psychological symptoms are present a formal psychiatric assessment should be done. b) Treatment should be implemented in a step-wise manner, with multidisciplinary input with GP, gynaecologist, psychologist and/or psychiatrist is important. First line therapy would include cognitive behaviour therapy. The combined pill (eg. Yasmin) can be used continuously, or continuous or luteal low dose SSRI (as effective as CBT). Complementary therapies can be used, with evidence of benefit for magnesium. Oil of evening primrose can be used although there is no evidence of benefit. In mild or moderate PMS no further treatment may be needed. Second line treatment includes higher dose SSRI or estrogen. Estrogen should be given as patch (100mcg) with progestogen orally or as Mirena(Levonorgetsrel IUS) for endometrial protection. There is a chnce of initial symptoms of PMS being produced by Mirena use. Third line treatment is GnRH analogues with add-back HRT (Continuous combined or tibolone) for bone protection. This is very effective due to ovulation suppresions and induction of a medical menopause, however GnRH analogues should not be used longer than 6 months due to the risk of bone loss. Menopausal side effects occur. Symptoms of PMT can recur after treatment. In extreme cases however it has been used indefinitely. Success of treatment with GnRH analogues would also indicate success of surgical management in severe cases. Surgery (bilateral salpngo-oophorectomy +- hysterectomy) is a last option as it is permanent. It is a curative procedure. It be used in women with severe refractory symptoms unresponsive to medical treatment who have been shown to respond to GnRH analogues. Following surgery women will require HRT for bone and cardiovascular protection.
		Posted by Ir A. Sun Aug 22, 2010 12:01 pm
Dear DR Paul, should we talk about TAHBSO in a 25 yr old woman? Why not? If you were the patient and your life was ruined by PMT but GNRHa gave you your life back then why should this not be an option?