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Premenstrual Dysphoric DisorderManagement

Introduction: Background and history

Patient biodata and history of the condition

Thecase is about a female patient named Mrs. Mary Johnston. She is fifty years old and lives with her fifteen year old daughter and her husband. She is probably a working class woman from a high social stature. Her physical examination showed that her BP=120/80, Height=5’9”, Pulse=70/min, Estrogen level =180 and weight =140lb.

Over the last three months she has been experiencing hot chills and sweats which is often accompanied with an increased emotions and cry outbursts. She has also experienced irregular monthly periods for the past twelve months, with some of the menstrual flow being lighter and others heavier. Her sleep has been affected and she has also experiences a low sexual drive with libido and some dryness despite sexually active. Moreover, she also experiences frequent headaches.

Biological aspects of the disease

Description of the condition

Based on the medical examination by her high school friend Dr. Linda, Mary was probably suffering from a menopause-related ailment or insomnia or anxiety which she might have inherited from her 70-year old mother. The menstrual irregularity is more probably as a result of acquired conditions. It has been noted that she had a stress-related hypothalamic dysfunction. She feels worried, anxious and guilty as her family does like seeing her in her low condition. The fact that she has a low sex drive also troubles her and might have caused her a lot of stress. Similarly, the inconsistent menstrual flow might have been as a result of endocrine gland related causes such as thyroid dysfunction, polycystic ovary syndrome or primary ovarian insufficiency. The feeling of insomnia, anxiety and stress might also have affected her menstrual flow. Moreover, she was a drug addict and this might also have had some influence on her menstrual cycle.

dysphasia which is a condition of feeling unhappy or unwell, a feeling of mental and emotional discomfort. More often she as restless, discontented, malaise, dissatisfied, anxiety and depressed. Mary also suffered from

Risk factors

dysphoria condition was more likely of the anxiety and insomnia she was suffering from. Her insomnia condition can affect her both physically and mentally and can result in lower performance at work, psychiatric problems such as anxiety and depression, increased severity and risk of long-term condition or diseases such as diabetes, high blood pressure and heart diseases. It can also result to irritability and substance abuse. There are risk factors that are most likely associated to her health conditions. The

Premenstrual Dysphoric Disorder epidemiology and clinical presentation

The DSM-5 presents 4-research criteria from A to D for clinical treatment of PMDD.

Criterion A puts forth that at least some of these symptoms have been experienced for the past one year during the menstrual cycles. The symptoms comprise of feeling of hopelessness, depressed mood, anxiety, and tension, a feeling of affective liability, increased anger, and irritability and reduced interest in day to day activities and problems in paying attention. Other symptoms include insomnia or hyper insomnia, change in appetite and other physical signs include sensation of bloating, breast swelling and tenderness and headache. Criterion B shows that the symptoms must have severe influence with the sexual, occupational and social functioning. The C criterion indicates that the signs have to be linked to menstrual periods. Criterion D of the DSM-5 is that the A, B and criterion have to be ascertained through possible regular ratings of more than two signs monthly period cycles.

. DisorderFrom the epidemiology and clinical presentation it is certain that Mary exhibited more than five of the above symptoms and thus must be suffering from premenstrual Dysphoric

Pathophysiology changes and disease progression

There are numerous that have been put forth to explain premenstrual Dysphoric Disorder, however, current theories and studies affirms that changes in the cycles in ovarian steroid associate with the central neurotransmitters to bring about the symptoms of premenstrual Dysphoric Disorder (PMDD). Premenstrual disorders are associated to the production of progesterone which is done by the ovary (Huston & Fujitsubo, 2005). The neurotransmitter systems that are considered to be the genesis of the symptoms are the serotonergic and the GABArgic systems. the Metabolites of progesterone that are made in the ovary specifically in the corpus luteum as well as in the brain and then to a neurosteroid-merging site on the walls of the GABA receptors (gamma-aminobutyric acid), which transforms its configuration making it resistant to induction and consequently reducing the GABA-mediated inhibition. There are some contraceptives that are also perceived to have adverse effects to the GABAergic system (Huston & Fujitsubo, 2005). Furthermore, the reduction of the serotonin can result to symptoms that are associated with PMDD. Sometimes the serotonergic functioning is considered ineffective in comparison to other techniques of measuring serotonergic activity in the human brain. PMDD is also considered not to be associated with the lack of regulation of the individual neurotransmitters. It is therefore, clear that Path physiology specifically brain imaging studies illustrates the intricate brain circuitry causal behavior and effect. It has also helps to explain the complexity of the neurophysiologic foundation of the PMDD syndrome.

Examination and diagnostic process

examination process involves looking into past medical history and conducting a pelvic exam on the patient at hand. Typically, to diagnosis PMMD, more than four of the signs should be experienced and must have been experienced continuously for at least one year. the symptoms that are often examined include: moodiness, depression, irritability or anger, increased appetite, lack or small interest in normal activities or once enjoyed by the patient, having trouble in concentration, being out of control, a feeling of abdominal bloating, headache, tenderness and breast (In Mitsikostas & In Paemeleire, 2016). Other differential diagnosis of premenstrual dysphoric disorder includes anemia, psychiatric disorder, thyroid disorder, migraines, seizures, substance abuse and chronic fatigue syndrome. Furthermore, the diagnostic testing must include an extensive and complete blood test, evaluation for anemia, chemistry profile, electrolyte abnormalities, as well as an evaluation of any thyroid problems (In Mitsikostas & In Paemeleire, 2016). The

The treatment of the PMMD involves an admission of different medications. However, the first step should involve a change in the person’s lifestyle before seeking for medications. Some of the common medications include SSRIs, ovulation suppressants such as provision of oral contraceptives, danazol, or GnRH agonist, provision of anxiolytics such as buspirone and alprazolam (Pfaff, 2002). Treatments such as ovariectomy can also be used for women who refract from medical treatment.


Pharmacological management of Oestrogen and progesterone (HRT) A)

: in order to manage Oestrogen and progesterone step by step process need to be applied to ensure a complete treatment to the condition. Normally, the first recommended therapy is a change of lifestyle. This is because most of the causes as a result of lifestyle behavior. Lifestyle conditions such as anxiety, stress and insomnia can be improved through a change of lifestyle by embracing a positive lifestyle and being social. Progesterone can be managed through the progesterone therapy. This is done by the use of a progesterone cream for treating menopausal symptoms including hot flushes. Treatment of breast tenderness, bloating, depression, fatigue, reduced sex drive, low blood sugar, headaches, memory loss, increased blood clotting, brittle bones, lumpy breasts, thyroid problems, vaginal irritation, uterine fibroids and all the symptoms of the PMDD involves the application of the progesterone therapy is of great significance in the treatment of PMDD. Preparation

Similarly, Oestrogen therapy is mostly applied to women with a low dose of oestrogen. The hormone is given as a gel, a vaginal ring or a spray (Kieffer, 2005). The dose can also be administered as a tablet.

: as outlined above application of the dosage is only given when the low of oestrogen or progesterone is at low levels.Indication

: first of all the dosage is dependent on the age of the woman and the duration of time in which the woman has suffered from the condition. For women who have experienced the PMDD symptoms for less than 12 months, Femoston, Estalis sequi 50/250, Femoston ,Trisequens and Estalis sequi 50/140 which are prescribed and are all offered as a tablet.Dosage

: the action that is taken to a woman suffering from a premenstrual disorder should be procedural. The first action should involve a change of personal lifestyle. In case a change of lifestyle does not result in improved results then the woman can seek medical advice for further advice and treatment. A doctor would either prescribe taking of an oral contraceptive to regulate and possibly eliminate the menopause-related symptoms, insomnia, dysphoria or any other appropriate medication. Provision of Oestrogen and progesterone can also be recommended and is considered the best effective way of dealing with premenstrual dysfunction. These therapies involve giving off a gel containing the hormones (Freeman, 2001). It can be administered through the vagina, as a tablet or as a spray.Mechanism of action

the condition is treatable and can be eliminated when preventive measures are put in place, and strict measures are put to ensure adherence to the medication procedures. It can also be eliminated through the creation of awareness (Yonkers & Kimberly, 2002). The public especially the women can be taught and told the significance of maintaining a healthy lifestyle to prevent this condition. They can also be made aware of the risk factors, the symptoms and the measures they can undertake to prevent and control the condition. Pharmacokinetics (elimination):

: in case the condition is not corrected on time, the condition can worsen and result in adverse effects. Excessive stress, insomnia or depression can result in high blood pressure, heart problems or even diabetes. Therefore, it is recommended that once a woman experiences a continuous irregular menstrual flow for more than twelve, it is prudent that she seeks a medication attention to prevent further effects of the condition. Common adverse effects

: clinical complications can also result if the doctor or the physician administers the wrong medication or makes an under dose or an overdose of the medication (Pearlstein et. al, 2005). An overdose or an under dose of the oestrogen or the progesterone gel can have an adverse effect on the hormonal balance of the patient which can consequently affect the health and overall wellbeing of the woman.Clinical consideration e.g. serious complications

it is advisable that these medications should not be administered to pregnant women as it might have side effects to the fetus. Furthermore, it should not be taken by a person who is under a drug influence. Contraindications:

Nonpharmacological management

These involve the reliance on a change of an individual’s lifestyle to correct the condition. There are some non pharmacological conditions that can be implemented to correct menstrual dysfunction. Some of the management options include:

) Self-care and lifestyle (Biopsychosocial model

: Stress can be managed by sharing out the problems, seeking help from a mental psychiatric. Engaging in social events can also help in mitigating stress as a risk factor. Stress management

: regular and consistent exercise helps in releasing tension, anxiety or tension it also helps in maintaining a healthy body it thus can have a significant impact on reducing the severity of the condition and event correct the dysfunction. This is because the causes of the PMDD are as a result of lack of physical exercise (Yonkers & Kimberly, 2002). Causes such as stress, overweight and anxiety can be prevented through regular exercises. Exercise

: doctors affirm that one of the causes of menstrual problems is as a result of either overeating which then lead to obesity and consequently indirectly impact the menstrual cycle. Thus, it is prudent to feed on the right type and quantity of food to maintain a healthy lifestyle. Nutrition

humans are social being and when one is alienated or neglected their self-esteem and confidence falls which can result in stress and consequently affect their menstrual cycle (Pearlstein et. al, 2005).Connectedness (feeling about care by family, friends):

typically, attitude is key to the quick recovery of a condition, for a patient to have a quick recovery, she must have a positive attitude and faith of recovering.Attitude to the condition:

: availability of healthcare facility is also essential in getting the required medical attention. In availability of medical facilities means that the patient will not get the required medication on time and can result in worsening of the condition. Access to health care

: this is another essential factor; the patient must comply with the doctor’s prescriptions, keeping in mind not skipping medication, not overdosing or under dosing to ensure a full recovery.Compliance

: the condition can also be managed through prevention of specific conditions that result in the menstrual problem. If the condition is as a result of regular headaches then the patient can seek for a headache medication. Similarly, if the condition is caused by stress or depression the patient can visit a rehabilitation center to gain appropriate psychological therapy (Ciccone, 2016).Prevention of illness and relapse and rehabilitation

Personal perception

Based on the above discussion it is clear that menstrual dysfunction is a major problem among the women. The condition is caused by some risk factors such as excessive drinking, stress, depression, anxiety and insomnia as is in the case of Mary. The condition results in a lot of adverse effects that if now prevented or managed early can result in detrimental impacts such as diabetes, high blood pressure or hypertension. It is, therefore, appropriate that once a woman experiences the above-discussed signs, they should seek medical intervention. However, before seeking medical attention they can try out the non pharmacological management techniques such as regular exercise, good nutrition, and connectedness.


. Pharmacology in rehabilitationCiccone, C. D. (2016).

Freeman, E. W., Kroll, R., Rapkin, A., Pearlstein, T., Brown, C., Parsey, K., … & Foegh, M. (2001). Evaluation of a unique oral contraceptive in the treatment of premenstrual dysphoric disorder. Journal of women’s health & gender-based medicine, 10(6), 561-569.

. Oakland, Calif: New HarbingerPMDD: A guide to coping with premenstrual dysphoric disorderHuston, J. E., & Fujitsubo, L. C. (2002).

. Pharmacological management of headachesIn Mitsikostas, D. D., & In Paemeleire, K. (2016).

. Murray, Ky.: Murray State University. The relationship between premenstrual dysphoric disorder (PMDD) and depressionKieffer, M. T. (2005).

Pearlstein, T. B., Bachmann, G. A., Zacur, H. A., & Yonkers, K. A. (2005). Treatment of premenstrual dysphoric disorder with a new drospirenone-containing oral contraceptive formulation. Contraception, 72(6), 414-421.

. Amsterdam: Academic Press. Hormones, brain and behavior: Vol. 5Pfaff, D. W. (2002).

Rapkin, A. (2003). A review of treatment of premenstrual syndrome & premenstrual dysphoric disorder. Psychoneuroendocrinology, 28, 39-53.

Yonkers, K. A., Brown, C., Pearlstein, T. B., Foegh, M., Sampson-Landers, C., & Rapkin, A. (2005). Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder. Obstetrics & Gynecology, 106(3), 492-501.

Yonkers, Kimberly A., et al. «Symptomatic improvement of premenstrual dysphoric disorder with sertraline treatment: a randomized controlled trial.» Jama 278.12 (1997): 983-988.