Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Premenstrual Syndrome
N94.3 Premenstrual tension syndrome
I. DEFINITION
Premenstrual syndrome is a cluster of physical, emotional, and behavioral symptoms related to the menstrual cycle, developing or worsening during the luteal phase and clearing with the onset of the menstrual flow.
Premenstrual dysphoric disorder (PMDD) is a severe form of PMs, shar- ing symptoms but set apart by the exaggeration and severity.
II. ETIOLOGY
no single etiology explains the various symptoms associated with PMs. a multifactorial cause is probable, involving psychosocial, genetic, hor- monal, and neurotransmitter components (serotonergic dysfunction).
III. HISTORY
a. What the patient presents with (may include some or all of the follow- ing symptoms, in varying degrees)
1. Headache, backache, migraine, syncope
2. edema
3. Breast tenderness, engorgement, enlargement, heaviness
4. Hot flashes
5. Paresthesia of hands and feet, aggravation of epilepsy, joint or muscle pain
6. Weight gain
7. Fluid retention
8. abdominal bloating
9. increase in appetite and/or impulsive eating; craving for sweets and/or salt; food cravings in general
10. nausea, vomiting, constipation
11. Decreased urine output, cystitis, urethritis, enuresis
12. exacerbation or recurrence of acne, boils, urticaria, easy bruising, herpes, rhinitis, colds, hoarseness, increased asthma, sore throat, sinusitis
13. emotional lability (anxiety, depression, crying, fatigue, per- sistent and marked anger, aggression, irritability); difficulty concentrating; decreased interest in usual activities
14. Changes in libido
15. lethargy, fatigue, depression in mood, feeling hopeless
16. sleep disturbances—hypersomnia, insomnia
17. Palpitations
18. any symptoms, physical or emotional, that cluster during the same phase of menstrual cycle
B. additional information to be considered
1. When did these symptoms first occur in relationship to menarche?
2. When do they begin and end in relationship to menses?
3. Has there been a recent change in symptoms?
4. Do you have cramps with your period?
5. Has there been any change in your lifestyle (work, personal, family)?
6. What is your diet like?
7. How much exercise do you get?
8. are you or have you ever been in counseling?
9. What medications are you taking?
10. Do you have a history of chronic illness? if so, which, including depression?
11. When was your last menstrual period?
12. What birth control method do you use, if any?
13. Have you had tubal ligation and if so, when?
14. Have you ever thought about suicide or harm to others?
15. Have you experienced depression or agitation at other times in your life?
IV. PHYSICAL EXAMINATION
a. Vital signs
B. Complete physical and gynecologic exam within past year examination
C. Mental status examination
V. LABORATORY EXAMINATION
only as indicated medically
VI. TREATMENT
a. treatment is multifaceted and diverse, aimed at symptoms that the patient finds most debilitating. to aid in diagnosis and treatment, 2 months of retrospective daily logs or symptom calendars help to confirm diagnosis and guide selection of appropriate treatment.
1. Vitamin B6 (pyridoxine). Begin with 50 to 100 mg total daily dose. Do not exceed recommended dosage. this vitamin has been shown to be toxic in large doses.
2. Vitamin e 400 mg daily or twice a day
3. evening primrose oil. Begin with two capsules twice a day. May increase to four capsules twice a day. improvement will occur slowly, more than 3 to 9 months. Contains vitamin e, so patient should not take both.
4. Prostaglandin inhibitors may provide relief if taken during the second half of the menstrual cycle.
5. May consider
a. Diuretics
b. antidepressants
c. antianxiety drugs
d. Birth control pills (Yaz has been approved for PMDD), contra- ceptive patch, ring, Depo-Provera
6. Calcium 1,000 to 1,200 mg daily; magnesium 300 to 400 mg daily
B. General measures
1. lifestyle changes, including stress reduction (i.e., meditation, yoga, or other relaxation techniques)
2. Diet recommendations: these dietary changes should be ongoing. it is not enough to modify one’s diet only on the days prior to menstruation.
a. limit consumption of refined sugar (e.g., cookies, cakes, jelly, honey) to 5 tablespoons per day
b. limit salt intake to 3 grams or less per day (e.g., avoid using saltshaker)
c. limit intake of alcohol and nicotine
d. avoid caffeine (e.g., coffee, tea, chocolate, soft drinks)
e. increase intake of complex carbohydrates (e.g., fresh fruits, veg- etables, whole grains, pasta, rice, potatoes)
f. Consume moderate amounts of protein and fat (decrease animal fats and increase vegetable oils)
g. limit red meat consumption to twice weekly or less
3. exercise plan recommendations: exercise three times per week for 30 to 40 minutes (brisk walking, jogging, aerobic dancing, swimming)
4. Consider other complementary therapies, including botanicals, aroma and music therapy, acupuncture, and energy healing
5. Keep a diary of daily symptoms, diet, and body temperature
VII. DIFFERENTIAL DIAGNOSIS
a. sexual dysfunction
B. Chronic pelvic pain
C. endometriosis
D. Primary dysmenorrhea
e. Posttubal ligation syndrome
F. Prolactin-producing tumors
G. Perimenopausal symptoms
H. Fibrocystic breast disease
i. Depression
J. Psychopathology
K. somatization of stress
l. life stressors
M. systemic lupus erythematosus
n. Hypertension
o. Meningioma
P. attention deficit disorder (residual type)
Q. thyroid disorders
VIII. COMPLICATIONS
a. serious psychological problem misdiagnosed as PMs
B. systemic disease misdiagnosed as PMs
IX. CONSULTATION/REFERRAL
a. referral at discretion of the nurse practitioner after review of history and physical examination
B. Mental health referral if appropriate
C. referral to nutritionist if needed/desired by patient
D. support group referral if desired
X. FOLLOW-UP
a. Checkup once a month for each of 3 months
B. Yearly if improvement in relief of symptoms
C. if symptoms increase or change
See Appendix F, Complementary and Alternative Medicine; and Bibliographies. Website: womenshealth.gov
NOTE
1. approach this regime with caution, remembering that menstrual changes are recognized as an early phenomenon with progestin-only contracep- tion, decreasing with prolonged use. if patient is a long-time user, the onset of new bleeding may indicate underlying pathology.