[ Pobierz całość w formacie PDF ]

h. Marked changes i n appeti te, w hich m ay be
associated w ith bi nge eati ng or cravi ng certai n
foods
i. Hypersomniao rin somnia
j. A subjective feelingofbei ngoverw helmedorout
ofcontrol
k. Otherphy sicals ymptoms,suchasbreasttender­
ness or sw elling, headaches, j oint or m uscle
pain,asensati onofbl oating,w eightgai n.
UCSDC riteriafor P remenstrualS yndrome
1. The presence by sel f report of at l east one of the
following som atic and affective sy mptoms duri ng the
fiveday spri ortom ensesi neach ofthethreem enstrual
cycles:
Affective Somatic
Depression Breasttenderness
Angryoutbursts Abdominalbl oating
Irritability Headache
Confusion Swollenex tremities
Socialw ithdrawal
Fatigue
2. Reliefoftheabovesy mptomsw ithinfourday softhe
onsetofm enses,w ithout recurrenceunti latl east
cycleday 12.
3. Thesy mptomsarepresenti ntheabsenceofany
pharmacologictherapy ,horm onei ngestion,drugor
alcoholuse.
4. Identifiabledy sfunctioni nsoci aloreconom icperfor­
manceby oneofthefol lowingcri teria:
Maritalorrel ationshipdi scordconfi rmedby part­
ner
Difficultiesin p arenting
Poorw orkorschool perform ance,atten­
dance/tardiness
Increasedsoci al i solation
Legaldi fficulties
Suicidal I deation
Seekingm edicalattenti onforasom aticsy mp­
tom(s)
E. Differentiald iagnosis
1. PMDD shoul d be di fferentiated from prem enstrual
exacerbation of an underl ying m ajor psy chiatric
disorder, as well as m edical condi tions such as
hyper-orhy pothyroidism.
2. About13percentof women with PMS arefoundto
have a psychiatricdi sorderal onew ithno evidence
ofP MS,w hile38percent had premenstrualex acer­
bation of underl ying depressi ve and anx iety di sor­
ders.
3. Womenw hopresentw ithP MShaveam uchhi gher
incidenceofm ajordepressi oni n the past andareat
greaterri skform ajordepressi oni nthefuture.
4. 39 percent of w omen w ith P MDD m eet criteria for
moodoranx ietydi sorders.
5. The assessm ent of pati ents w ith possi ble P MS or
PMDD shoul d begi n w ith the hi story, phy sical
examination, chem istry profi le, com plete bl ood
count,andserum T SH.T hehi storyshoul d focus in
particular on the regul arity of m enstrual c ycles.
Appropriate gy necologic endocrine eval uation
should be perform ed i f the cycles are i rregular
(lengthsl essthan25orgreaterthan36day s).
6. The p atient shoul d b e a sked t o r ecord sy mptoms
prospectivelyfor tw o m onths. I f the pati ent fai ls to
demonstratea sy mptom free interval inth efo llicular
phase, she shoul d be eval uated for a m ood or
anxietydi sorder.
II. Treatmentofpr emenstrualdy sphoricdisor der
A. Serotoninr euptakeinhibitor s
1. Fluoxetine(S arafem)i saneffecti vetreatm entfor
PMDD w hen gi ven i n a dai ly dose of 20 m g/day.
The response rate i s 60 to 75 percent. T he m ost
common reasons for fai lure to conti nue the treat­
mentareheadache,anx iety,andnausea.
2. Otherdrugsthati nhibitserotoni nreuptak e, such as
clomipramine( Anafranil[gi venei therthroughoutthe
menstrual cy cle or restricted to the l uteal phase]),
sertraline(Zol oft)50to150m g/daythroughoutthe
menstrual cy cle, an d nefazodone (S erzone) 100­
300m gbi dal som aybeeffecti vei nP MS.
3. Venlafaxine (E ffexor) sel ectively i nhibits the
reuptakeofbothserotoni nandnorepi nephrineand
isal soeffecti ve(50to200m g/day).
4. Intermittent therap y given duri ng the l uteal phase
only(starti ng on cy cle day 14) has been show n to
beeffecti ve.
B. Alprazolam (Xanax), 0.25 m g T ID OR qi d, has bee n
shown i n doubl e-blind, pl acebo-controlled crossover
studiestobebenefi ciali nP MS.
C. GnRH agonists (leupr olide [Lu pron] or buser elin)
have show n som e benefi t. H owever, w omen w ith
severe prem enstrual depressi on are unresponsive to
GnRHagoni sts.T hephy sical symptoms maybem ore
responsivethanm oodsy mptomsi nw omen with PMS,
and si de effects (hy poestrogenism) m ayl imit the use
ofthesedrugsforl ong-termtherapy .
1. GnRH agonists and " add-back" ther apy. A dd­
back therapy w ith estrogen (and a progesti n i f
indicated) mitigatesconcernsaboutbone loss from
prolonged adm inistration of GnRH agoni sts.
Leuprolide al one l ed to a 75 pe rcent i mprovement
in l uteal phase sy mptom scores. T his bene fit w as
maintained (60 percent i mprovement) dur ing a
crossover period i n w hich estrogen/progesti n
replacement w as added. A lendronate can be
considered in women whodonottol eratehorm onal
add-back therapy but need osteopo rosis prophy ­
laxis.
D. Danazoli nhibitspi tuitary gonadotropinsecreti on,and
is an effecti ve therapy for P MS. H owever, the
androgenic si de effects of danaz ol l imit its use to
patients w ho fai l to respond adequatel y to the above
therapies.
TreatmentofP remenstrualS yndrome
Fluoxetine(S arafem)5-20m gqd
Sertraline(Zol oft)25-50m gqd
Paroxetine(P axil)5-20m gqd
Buspirone(B uSpar)25m gqdi ndi videddoses
Alprazolam(X anax)0.25-0.50m gti d
Mefenamicaci d(P onstel)250m gti dw ithm eals
Other
Spirolactone(A ldactone)25-200m gqd
Cabergoline(D ostinex)0.25m g-1m gtw iceaw eek
duringthel utealphaseforbreastpai n
E. Treatmentswithpossibleefficacy inP MS
1. Exercise an d relaxation techniques. T here i s
suggestive evi dence that ex ercise, rel axation, and
reflexologym ayhel ptoal leviateP MSsy mptoms.
2. Diuretics. Spironolactone(A ldactone),25-200m g
qd, m ay si gnificantly decrease i n nega tive m ood
symptomscoresandsom aticsy mptom.
F. Recommendationsfor theclinicalm anagementof
PMS/PMDD
1. Because of the proven effi cacy and safety profi le,
serotonin reuptak e i nhibitors (S SRIs) are th e first
line thera py. Fl uoxetine (S arafem) has been the
beststudi ed.T heeffecti vedosei s20m g/day.
2. Approximately1 5p ercento fp atientsw ille xperience
significant side effects from an S SRI, i ncluding
nausea,j itteryness,andheadache.I nsuchpati ents,
a tri al of ei ther a l ower starti ng dose or a second
SSRI, such as sertral ine (Zol oft) 25-50 m g qd, i s
warranted.
3. Approximately 15 percent do not respond to a n
SSRIover severalm enstrualcy cles.T hesew omen
arecandi datesfor alprazolam (Xanax)0.25m gT ID
orQI Di nthel utealphaseofthecy cle.
4. Patients w ho do no t respond to S SRIs or
alprazolam ar e candi dates for ovul ation suppres­
sion agents.I npati entsw horespondw ell to GnRH
agonists, therapy may be ex tended bey ond si x
monthsw ithan attemptat" add-back"therapy w ith
estrogenandprogesterone.
References:S eepage166.
AbnormalVaginalBleeding
Menorrhagia(ex cessive bleeding) ism ostcom monlycaused
by anovulatory menstrual cycles.Occasi onallyi ti scaused by
thyroiddy sfunction,i nfectionsorcancer.
I. Pathophysiologyofnor malm enstruation
A. In response to gonadotropi n-releasing horm one fr om
the hy pothalamus, the pi tuitary gl and sy nthesizes
follicle-stimulating horm one (F SH) and luteiniz ing
hormone (LH ), w hich i nduce the ovari es to produce
estrogenandprogesterone.
B. Duringt hef ollicularphase, estrogenstim ulationcauses
an i ncrease i n endom etrial thi ckness. A fter ovul ation,
progesteronecausesendom etrialma turation.M enstru­
ation i s caused by estrogen and progesterone w ith­
drawal.
C. Abnormalbl eedingi sdefi nedasbl eeding that occurs
at i ntervals of l ess than 21 day s, m ore than 36 days,
lastingl ongerthan7day s,or blood lossgreaterthan80
mL.
II. Clinicalev aluationo fab normalv aginalb leeding
A. A menstrual and reproducti ve hi story shoul d i nclude
last m enstrual peri od, regul arity, durati on, frequency ;
the number of pads used per day , and i ntermenstrual
bleeding.
B. Stress, ex ercise, w eight changes and sy stemic di s­
eases,parti cularlythy roid, renalorhepati cdi seasesor
coagulopathies,shoul dbesough t. Them ethodofbi rth
controlshoul dbedeterm ined.
C. Pregnancycom plications,suchasspontaneousabor­
tion, ectopi c pregnancy , pl acenta previ a and abrupti o [ Pobierz całość w formacie PDF ]

  • zanotowane.pl
  • doc.pisz.pl
  • pdf.pisz.pl
  • szkla.opx.pl

    •