Clinical: Case Study: PMS and Hormones

Original materials created in September 1998 by Jan Werbinski, M.D., F.A.C.O.G.

History
Ms. S.R. is a 39-year-old married Caucasian woman with gradually worsening PMS symptoms over the past 18 months. Her symptoms appear in the seven days before her menses, then resolve completely at onset of bleeding. Most of her symptoms are emotional, consisting of mood swings - from sad withdrawal through rage, to remorse and feelings of self-deprecation. Physical symptoms include hot flashes (worse at night), breast tenderness, and cyclic weight gain. Menses occur monthly, but they are lighter than previously and sometimes last nine days, with variable spotting. She continues her work as a photographer despite PMS symptoms, but says sometimes she would like to stay home just to decrease her level of stress. Her mother “went through the change” in her late thirties with similar symptoms.

Exam
Normal breast, abdominal, neurologic, and pelvic exams. No vaginal bleeding or discharge. Trace ankle edema.

Laboratory Evaluation
Normal Hgb at 12 gm. UA and WBC normal. FSH level 18 mIU (menopausal levels &gt; 40 mIU); serum estradiol (drawn day 20 in the luteal phase) 236 ng/dl (menopausal levels &lt;50 ng/dl). Glucose and thyroid tests normal. Normal Pap.

Discussion
Many classic PMS symptoms mimic those that occur with labile levels of estrogen in the perimenopause. Notably, these symptoms are prevalent in women with unipolar depression. It is now evident that although cyclic bleeding results from changes in ovarian hormones, the hypothalamus regulates levels of ovarian hormones. Neuroendocrine hormones are a significant factor in the regulation of the menstrual cycle and are related to PMS symptoms. A diagnosis of “true PMS” can be made only if the patient experiences at least seven symptom-free days in the follicular phase of her menstrual cycle.

Suggestions
In cases where patients seem certain that their symptoms are related to “hormone imbalance” or “perimenopause,” I have found some useful tools. First, I think it is helpful to rule out menopause serologically by showing her a normal (&gt; 50 ng/dl) serum estradiol in the luteal phase (after day 14) of a cycle. Recently developed saliva assays for various hormones, especially estrogen, can also be helpful, although these tests may not be reimbursed by some insurance plans.

Secondly, I ask the patient to chart her symptoms for at least two cycles. Dr. Guy Abraham, in the Journal of Reproductive Medicine, has developed a useful chart that groups symptoms into four subcategories:


 * _PMT-A (Anxiety)
 * _PMT-H (H2O Retention)
 * _PMT-C (Carbohydrate Craving and Hypoglycemic Symptoms)
 * _PMT-D (Depression)

By clustering symptoms this way, it is easier to choose an initial therapy (anxiolytics for PMTA; diuretics for PMT-H; hypoglycemic diet for PMT-C; and antidepressants for PMT-D). If irregular or prolonged menses occur, cyclic natural progesterone can be very helpful (100 mg t.i.d. to begin day 14 of each cycle).

Another helpful tool is the Beck or Zung Depression Inventory. A patient completes an Inventory during the follicular phase and another during the luteal phase. If there is a marked discrepancy in the scores, a more definitive diagnosis of PMT-D can be made. Then antidepressant therapy in standard doses is a very useful option. Pharmacologic therapy is recommended for the entire cycle, even if symptoms occur only in the luteal phase. Some women benefit from cyclic variation of antidepressant dosages with lower doses in the follicular phase and higher doses in the luteal phase.

Management
Several manuals and guides have been written about the holistic management of PMS symptoms. I always suggest these first. They recommend stress management, salt restriction, increased exercise, vitamin therapy, and frequent small meals with a low refined carbohydrate content. Abraham recommends supplemental vitamins A, E, B6, and C, as well as magnesium and zinc. A 1998 article in the American Journal of Obstetrics