Premenstrual Dysphoric Disorder: Symptoms, Diagnosis, and Differential Diagnosis

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome (PMS) characterized by psychological and behavioral symptoms in the absence of physical symptoms. PMS is a condition that affects the majority of women in reproductive age, with symptoms occurring in the luteal phase of the menstrual cycle and resolving with menstruation. The exact causes of PMS and PMDD are not yet identified, but hormonal effects on neurotransmitters and psychological and environmental factors may play a role.

To diagnose PMS or PMDD, organic causes must be excluded through a full history, examination, and blood tests. A prospective diary of symptoms over 2-3 menstrual cycles can also aid in diagnosis. Symptoms must be present in the luteal phase and improve or resolve with menstruation.

Differential diagnosis for PMDD includes depression, hypothyroidism, and hyperthyroidism. Depression symptoms are continuous and not subject to regular cycling, while hypothyroidism symptoms are persistent and not cyclical. Hyperthyroidism may present with symptoms mimicking mania and psychosis.

Mild PMS does not interfere with daily activities or social and professional life, while moderate and severe PMS can impact a woman’s ability to carry out activities. PMDD is a severe form of PMS characterized by psychological and behavioral symptoms in the absence of physical symptoms.

The risk of breast cancer is increased when progesterone is added to HRT. However, it is important to note that the risk is minimal and patients should be informed of this. According to the Women Health Institute, if 1000 women on HRT for 5 years were compared to 1000 women not on HRT for 5 years, there would only be 4 more cases of breast cancer. Women who start HRT under the age of 60 are not at an increased risk of dying from cardiovascular disease. Norethisterone, a progesterone, reduces the risk of endometrial carcinoma, so women with a uterus are always started on combined HRT. Women without a uterus are started on unopposed oestrogen. While HRT may increase the risk of headaches, this is less important to mention compared to the risk of breast cancer.

Adverse Effects of Hormone Replacement Therapy

Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progesterone in women with a uterus, to alleviate menopausal symptoms. While it can be effective in reducing symptoms such as hot flashes and vaginal dryness, HRT can also have adverse effects and potential complications.

Some common side-effects of HRT include nausea, breast tenderness, fluid retention, and weight gain. However, there are also more serious potential complications associated with HRT. For example, the use of HRT has been linked to an increased risk of breast cancer, particularly when a progesterone is added. The Women’s Health Initiative study found a relative risk of 1.26 at 5 years of developing breast cancer with HRT use. The risk of breast cancer is also related to the duration of use, and it begins to decline when HRT is stopped.

Another potential complication of HRT is an increased risk of endometrial cancer. Oestrogen by itself should not be given as HRT to women with a womb, as this can increase the risk of endometrial cancer. The addition of a progesterone can reduce this risk, but it is not eliminated completely. The British National Formulary states that the additional risk is eliminated if a progesterone is given continuously.

HRT has also been associated with an increased risk of venous thromboembolism (VTE), particularly when a progesterone is added. However, transdermal HRT does not appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any treatment, even transdermal, according to the National Institute for Health and Care Excellence (NICE).

Finally, HRT has been linked to an increased risk of stroke and ischaemic heart disease if taken more than 10 years after menopause. It is important for women considering HRT to discuss the potential risks and benefits with their healthcare provider and make an informed decision based on their individual circumstances.

The Most Appropriate Initial Investigation for Amenorrhoea: Urine Pregnancy Test

When a patient presents with amenorrhoea, the most appropriate initial investigation is always a pregnancy test. If pregnancy is excluded, further investigations may be necessary to determine the underlying cause. For example, a diagnosis of polycystic ovary syndrome (PCOS) may be supported by high levels of free testosterone with low levels of sex-hormone binding globulin, which can be tested after excluding pregnancy. A pelvic ultrasound is also a useful investigation for PCOS and should be done following β-HCG estimation. While a raised LH: FSH ratio may be suggestive of PCOS, it is not diagnostic and not the initial investigation of choice here. Similarly, an oral glucose tolerance test might be useful in patients diagnosed with PCOS, but it would not be an appropriate initial investigation. Therefore, a urine pregnancy test is the most important first step in investigating amenorrhoea.

To ensure maximum safety when switching from a traditional POP to COCP, it is recommended to use barrier contraception for 7 days while starting the combined oral contraceptive. This is the standard duration of protection required when starting this medication outside of menstruation. It is not necessary to use barrier contraception for 10 or 14 days, as the standard recommendation is 7 days. Using barrier contraception for only 3 days is too short, as it is the duration recommended for starting a traditional progesterone-only pill. While there may be some protection, it is still advisable to use additional contraception for 7 days to prevent unwanted pregnancy.

Special Situations for Combined Oral Contraceptive Pill

Concurrent antibiotic use has been a concern for many years in the UK, as doctors have advised that it may interfere with the effectiveness of the combined oral contraceptive pill. However, this approach is not taken in the US or most of mainland Europe. In 2011, the Faculty of Sexual & Reproductive Healthcare updated their guidelines to abandon the extra precautions previously advised during antibiotic treatment and for 7 days afterwards. The latest edition of the British National Formulary (BNF) has also been updated to reflect this guidance, although precautions should still be taken with enzyme-inducing antibiotics such as rifampicin.

When it comes to switching combined oral contraceptive pills, the BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give contradictory advice. The FSRH’s Combined Oral Contraception guidelines state that the pill-free interval does not need to be omitted, while the BNF advises missing the pill-free interval if the progesterone changes. Given this uncertainty, it is best to follow the BNF’s advice.

Homologous Cells in Male and Female Reproductive Systems

The male and female reproductive systems have homologous cells that perform similar functions. Leydig cells, also known as pure Leydig cell tumors, are found in both males and females. In females, these cells are located in the ovarian hilus and secrete androgens, causing masculinization when a tumor arises. Sertoli cells, on the other hand, have a female homologue called granulosa cells, both of which are sensitive to follicle-stimulating hormone. Epithelial cells in the epididymis have a vestigial structure in females called the epoophoron, which is lined by cells similar to those found in the epididymis. Spermatocytes have female homologues in oocytes and polar bodies, while spermatogonia have female homologues in oogonia. Understanding these homologous cells can aid in the diagnosis and treatment of reproductive system disorders.

If a woman with stage IA cervical cancer desires to preserve her fertility, a cone biopsy with negative margins may be considered as an option. However, for women who do not wish to have children, a hysterectomy with lymph node clearance is recommended. Cisplatin chemotherapy and radiotherapy are not appropriate for this stage of cervical cancer, while laser ablation is only used for cervical intraepithelial dysplasias. Radical trachelectomy is not recommended as it may negatively impact fertility.

Management of Cervical Cancer Based on FIGO Staging

Cervical cancer management is determined by the FIGO staging and the patient’s desire to maintain fertility. The FIGO staging system categorizes cervical cancer into four stages based on the extent of the tumor’s spread. Stage IA and IB tumors are confined to the cervix, with IA tumors only visible under a microscope and less than 7 mm wide. Stage II tumors have spread beyond the cervix but not to the pelvic wall, while stage III tumors have spread to the pelvic wall. Stage IV tumors have spread beyond the pelvis or involve the bladder or rectum.

The management of stage IA tumors involves a hysterectomy with or without lymph node clearance. For patients who want to maintain fertility, a cone biopsy with negative margins can be performed, but close follow-up is necessary. Stage IB tumors are managed with radiotherapy and concurrent chemotherapy for B1 tumors and radical hysterectomy with pelvic lymph node dissection for B2 tumors.

Stage II and III tumors are managed with radiation and concurrent chemotherapy, with consideration for nephrostomy if hydronephrosis is present. Stage IV tumors are treated with radiation and/or chemotherapy, with palliative chemotherapy being the best option for stage IVB. Recurrent disease is managed with either surgical treatment followed by chemoradiation or radiotherapy followed by surgical therapy.

The prognosis of cervical cancer depends on the FIGO staging, with higher survival rates for earlier stages. Complications of treatments include standard surgical risks, increased risk of preterm birth with cone biopsies and radical trachelectomy, and ureteral fistula with radical hysterectomy. Complications of radiotherapy include short-term symptoms such as diarrhea and vaginal bleeding and long-term effects such as ovarian failure and fibrosis of various organs.

Co-cyprindiol is a medication that combines cyproterone acetate and ethinyl estradiol. It is commonly used to treat women with PCOS who have hirsutism and acne. Cyproterone acetate is an anti-androgen that reduces sebum production, leading to a reduction in acne and hirsutism. It also inhibits ovulation and induces regular withdrawal bleeds. However, it should not be used solely for contraception due to its higher risk of venous thromboembolism compared to other conventional contraceptives.

Topical retinoids are a first-line treatment for mild to moderate acne. They can be used alone or in combination with benzoyl peroxide.

Clomiphene citrate is a medication used to induce ovulation in women with PCOS who wish to conceive. It has been associated with increased rates of pregnancy.

Desogestrel is a progesterone-only pill that induces regular bleeds and provides contraception. However, its effect on improving acne and hirsutism is inferior to combination drugs like co-cyprindiol.

Isotretinoin is a medication that regulates epithelial cell growth and is used to treat severe acne resistant to other treatments. It is highly teratogenic and should only be started by an experienced dermatologist in secondary care. Adequate contraceptive cover is necessary, and patients should avoid conception for two years after completing treatment.

Understanding Premenstrual Syndrome (PMS)

Premenstrual syndrome (PMS) is a condition that affects women during the luteal phase of their menstrual cycle. It is characterized by emotional and physical symptoms that can range from mild to severe. PMS only occurs in women who have ovulatory menstrual cycles and does not occur before puberty, during pregnancy, or after menopause.

Emotional symptoms of PMS include anxiety, stress, fatigue, and mood swings. Physical symptoms may include bloating and breast pain. The severity of symptoms varies from woman to woman, and management options depend on the severity of symptoms.

Mild symptoms can be managed with lifestyle advice, such as getting enough sleep, exercising regularly, and avoiding smoking and alcohol. Specific advice includes eating regular, frequent, small, balanced meals that are rich in complex carbohydrates.

Moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP), such as Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg). Severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI), which can be taken continuously or just during the luteal phase of the menstrual cycle (for example, days 15-28, depending on the length of the cycle). Understanding PMS and its management options can help women better cope with this common condition.

Understanding Mittelschmerz: Mid-Cycle Pain in Women

Mittelschmerz, which translates to middle pain in German, is a common experience for approximately 20% of women during mid-cycle. This pain or discomfort occurs when the membrane covering the ovary stretches to release the egg, resulting in pressure and pain. While the amount of pain varies from person to person, some may experience intense pain that can last for days. In severe cases, the pain may be mistaken for appendicitis.

However, other conditions such as acute appendicitis, ruptured ectopic pregnancy, incarcerated hernia, and pelvic inflammatory disease should also be considered and ruled out through physical examination and investigations. It is important to note that a ruptured ectopic pregnancy is a medical emergency and can present with profuse internal bleeding and hypovolaemic shock.

In this case, the patient’s physical examination and investigations suggest recent ovulation and fluid in the pouch of Douglas, making Mittelschmerz the most likely diagnosis. It is important for women to understand and recognize this common experience to differentiate it from other potential conditions.

Treatment options for menorrhagia caused by fibroids in a patient hoping to conceive

Menorrhagia, or heavy menstrual bleeding, can be caused by fibroids in the uterus. In a patient hoping to conceive, treatment options must be carefully considered. One option is myomectomy, which involves removing the fibroids while preserving the uterus. However, this procedure can lead to heavy bleeding during surgery and may result in a hysterectomy. Endometrial ablation, which destroys the lining of the uterus, is not suitable for a patient hoping to have another child. Tranexamic acid may help reduce bleeding, but it may not be a definitive treatment if the fibroids are large or in a problematic location. Laparoscopic hysterectomy, which removes the uterus, is a definitive treatment for menorrhagia but is not suitable for a patient hoping to conceive. The Mirena® intrauterine system is an effective treatment for menorrhagia but is not suitable for a patient hoping to conceive. Ultimately, the best treatment option for this patient will depend on the size and location of the fibroids and the patient’s desire to conceive.