Introduction: Managing the Spectrum of Premenstrual Symptoms

Premenstrual symptoms are usuallymild, but can be a source of long-termconcern and distress for approximately70% to 90% of reproductive-aged women,with occasional extreme negative effects onquality of life (QOL).¹ Somatic and moodsymptoms vary considerably in severity—from mildly disturbing, to what is recognizedas the premenstrual syndrome (PMS) inabout 20% to 40% of this group, to the mostserious premenstrual dysphoric disorder(PMDD) in 3% to 8% of women in the UnitedStates. Women who suffer from PMDD complainthat symptoms are severe enough tosignificantly undermine their ability to functionacross multiple settings, including work,school, and home.

To appreciate the extent to which thesesymptoms adversely affect women duringtheir childbearing years, both tangible andintangible impact of functioning must beconsidered at a suboptimal level during severaldays of each menstrual cycle. Tangibleimpact can be viewed in terms of higherdirect medical costs for women and, byextension, for the health plans in which theyare enrolled when seeking medical attention.Outpatient visits to healthcare practitioners,laboratory testing and radiologyprocedures, and costs for treatment arehigher for patients with PMS than for thosewithout this disorder.² In addition, indirectcosts of menstrually related disorders, whichare more difficult to quantify, stem fromabsenteeism, lost wages, and lower productivity,or presenteeism in the workplace.Intangible effects appear most apparently inthe psychologic and emotional toll taken onsocial interactions and interpersonal relationships,and on women's overall sense ofpersonal well-being.

The American Journal of Managed Care

The articles in this supplement to providean overview of the severe nature of symptomsin premenstrual disorders and theirpervasive effects on the lives of women ofchildbearing age, as well as diagnostic andtherapeutic strategies for premenstrualsymptoms. To begin, Daniel R. Mishell, Jr,MD, describes the epidemiology, diseaseburden, and etiology of PMS and PMDD. Healso relates how diagnostic criteria for theseconditions evolved, helping to overcome thefrustration of researchers lacking a consensusas to what symptoms constitute eitherdisorder.

Diagnostic and Statistical

Manual of Mental Disorders, Fourth

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The criteria established by the AmericanCollege of Obstetricians and Gynecologistsfor PMS and by the American PsychiatricAssociation's , for PMDD have sincebeen used in increasing numbers of studies.^3,4 With the development of acceptedobjective measures for these disorders,physicians could more readily recognize thecomplex constellation of their patients' symptoms at presentation and be less proneto mistakenly diagnose women's menstruallyrelated complaints as another medicalcondition.

In designing studies and developing criteriafor the diagnosis of menstrually relateddisorders, investigators scrutinized the biologicprocesses of the menstrual cycle andhow fluctuating hormone levels affectedother physiologic systems. Researchers alsosurveyed reproductive-aged women for insightsinto the array of symptoms experiencedby patient populations in the UnitedStates and abroad to gain perspective aboutindividual response to the physical, emotional, and behavioral changes wrought byPMS and the more extreme PMDD. At leastin part because of this, clinicians have developeda greater appreciation for the complexityof cyclic hormonal changes that womenundergo, as well as the escalating levels ofdistress they experience as the severity oftheir premenstrual symptoms increases.This improved level of understandingenables physicians to better inform andcounsel their female patients about thephysiologic basis for their symptoms, toevaluate their complaints in light of establisheddiagnostic criteria, and to educatethem about available options—nonpharmacologicand pharmacologic—for relief.

Current US Food and Drug Administration-approved treatment options forPMDD are limited to selective serotoninreceptor inhibitors, with their attendant relativehigh costs and adverse effects; but, asAndrea J. Rapkin, MD, points out in her article,other treatment approaches are beingstudied. Because the cyclic nature of premenstrualsymptoms suggests a strong rolefor sex hormones, oral contraceptives (OCs)are often used to treat the physical menstruallyrelated symptoms. OCs offer a range ofnoncontraceptive health benefits and arereadily accepted by women who use them asan easily reversible contraceptive method.The combination of estrogen and progestincontained in OCs suppress ovulation, andthereby work to alleviate premenstrualsymptoms, as Patricia J. Sulak, MD,describes in her article. Concerns about notsuppressing ovulation during the traditionalOC regimen in which there is a hormone-free7-day interval have led to trials withextended regimens and shorter hormone-freeintervals to determine how OC usersmay benefit. Other variations in OC preparationsinclude the use of different estrogensand progestins in different dosages.

Clinicians need to be informed of the newresearch, including OC formulations containingprogestin and the use of extended orcontinuous OC regimens to minimize cyclicsymptoms, and about the serious nature ofand treatment options for premenstrualsymptoms. In this way, they will be morefully equipped to provide the most effectivecounseling for their patients with premenstrualsymptoms and to offer therapeuticchoices best suited to improving each individual'sdaily QOL and overall state ofhealth. Improving symptom control also islikely to affect both direct and indirect costsassociated with this condition.

Practical Strategies in Obstetrics and

Gynecology.

1. Ginsburg KA, Dinsay R. Premenstrual syndrome. In:Ransom SB, ed. Philadelphia, Pa: WB Saunders Co; 2000:684-694.

J Occup Environ Med.

2. Borenstein J, Chiou CF, Dean B, Wong J, Wade S.Estimating direct and indirect costs of premenstrual syndrome.2005;47:26-33.

ACOG Practice Bulletin No. 15.

3. Davis AJ, Johnson SR. Premenstrual syndrome. In:Washington, DC:American College of Obstetricians and Gynecologists;2000:1-9.

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Statistical Manual of Mental Disorders, Fourth Edition,

Text Revision.

4. Premenstrual dysphoric disorder. In: Washington, DC: American PsychiatricAssociation; 2000:771-774.

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