Porth's Essentials of Pathophysiology, 4e

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Genitourinary and Reproductive Function

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a woman’s life. 48–51 The severity of this cyclic symptom complex can vary from premenstrual molimina on the mild end; through premenstrual syndrome (PMS), which is characterized by mild to moderate physical and psychological symptoms preceding menstruation and relieved by onset of the menses; to premenstrual dys- phoric disorder (PMDD), which is the most severe form of premenstrual distress and generally is associated with mood disorders. Up to 80% of women in the United States experi- ence some emotional or physical symptoms during the luteal phase of their menstrual cycle, without experienc- ing a substantial impact on their daily functioning. The PMS disorder, which results in moderate disruptions in a woman’s life, occurs in 20% to 30% of premenstrual women and another 3% to 8% suffer from the extreme or severe symptoms of PMDD. 50 The incidence of PMS and PMDD seems to increase with age. It is less com- mon in women in their teens and twenties, and most women seeking help for the problem are in their mid- thirties. The disorder is not culturally distinct; it affects both Westerners and non-Westerners. Physical symptoms of PMS include painful and swol- len breasts, bloating, abdominal pain, headache, and backache. Psychologically, there may be depression, anxiety, irritability, and behavioral changes. In some cases, there are puzzling alterations in motor function, such as clumsiness and altered handwriting. Women with PMS may report one or several symptoms, with symptoms varying from woman to woman and from month to month in the same woman. The disorder can significantly affect a woman’s ability to perform at nor- mal levels. Family responsibilities and relationships may suffer and she may lose time from or function ineffec- tively at work. Although the causes of PMS and PMDD are poorly documented, they probably are multifactorial. Like dys- menorrhea, it is only recently that PMS has been rec- ognized as a bona fide disorder rather than merely a psychosomatic illness. Because there appear to be nomea- surable differences in hormone levels between women with and without PMS, it is presumed that normal cyclic variation in the hormones is the trigger for symptoms in vulnerable or predisposed women. Currently, data sug- gest a relationship between normal gonadal fluctuations and central neurotransmitter activity, particularly sero- tonin. It is unclear whether decreased levels of serotonin are present during the luteal phase and only susceptible women respond with varying degrees of premenstrual symptoms, or if women with PMDD have a neurotrans- mitter abnormality. 48 Diagnosis of PMS and PMDD focuses on docu- mentation of the relationship of a woman’s symptoms to the luteal phase of the menstrual cycle. A com- plete history and physical examination are necessary to exclude other physical causes of the symptoms. Depending on the symptom pattern, blood studies, including thyroid hormones, glucose, and prolactin assays, may be done. Psychosocial evaluation is help- ful to exclude emotional illness that is merely exacer- bated premenstrually.

Management of PMS/PMDD has been largely symptomatic and includes education and support directed toward lifestyle changes for women with mild symptoms. 48–51 An integrated programof personal assess- ment by diary, regular exercise, avoidance of caffeine, and a diet low in simple sugars and high in lean proteins is often beneficial. In addition to lifestyle changes. In addition to lifestyle changes, pharmacologic treatment includes the use of diuretics to reduce fluid retention, nonsteroidal anti-inflammatory agents for pain, and anxiolytic drugs to treat mood changes. Because symp- toms are associated with ovulatory cycles, suppressing ovulation may be beneficial for some women with PMS and can be accomplished using hormonal contraceptives, danazol (a synthetic androgen), or GnRH agonists. 48 Hormonal contraceptives can be used for women who also require contraception. However, some women find their symptoms worsen when taking contraceptives. The pharmacologic treatment of PMDD differs from that of PMS. Ovulation suppression does not seem to help women with PMDD. Although many medications have been studied, only three antidepressants (fluoxetine, ser- traline, and paroxetine controlled release) and an oral contraceptive that contains drospirenone (a spironolac- tone derivative) have been approved for treatment of the emotional and physical symptoms of PMDD. 48 Menopause and Aging Changes Menopause is the cessation of menstrual cycles. Like menarche, it is more of a process than a single event. 52,53 Most women stop menstruating between 48 and 55 years of age. Perimenopause (the years immediately surround- ing menopause) precedes menopause by approximately 4 years and is characterized by menstrual irregularity and other menopausal symptoms. Climacteric refers to the entire transition to the nonreproductive period of life. Premature ovarian failure describes the approxi- mately 1% of women who experience menopause before the age of 40 years. A woman who has not menstruated for a full year or has an FSH level greater than 30 mIU/ mL is considered menopausal. Menopause results from the gradual cessation of ovarian function and the resultant diminished levels of estrogen. Although estrogens derived from the adrenal cortex continue to circulate in a woman’s body, they are insufficient to maintain the secondary sexual charac- teristics in the same manner as ovarian estrogens. As a result, breast tissue, body hair, skin elasticity, and subcu- taneous fat decrease; the ovaries and uterus diminish in size; and the cervix and vagina become pale and friable. Problems that can arise as a result of this urogenital atrophy include vaginal dryness, urinary stress incon- tinence, urgency, nocturia, vaginitis, and urinary tract infection. 52,53 The woman may find intercourse painful and traumatic, although some type of vaginal lubrica- tion may be helpful. Systemically, a woman may experience significant vasomotor instability secondary to the decrease in estro- gens and the relative increase in other hormones, includ- ing FSH, LH, GnRH, dehydroepiandrosterone, and