Premenstrual Syndrome

AORN JOURNAL

APRIL 1988, VOL. 47, NO 4

Premenstrual Syndrome ETIOLOGYAND TREATMENT POSSIBILITIES Judith E. Ensign, RN; Jean Rowe, RN; Karren Kowalski, RN

P

remenstrual syndrome (PMS) is a problem that affects more than five million women in the United States. The operating room nurse who is cognizant of the physical and emotional implications of PMS can offer additional support to patients who present in this phase of the menstrual cycle. The female operating room nurse may find that PMS symptoms affect her efficiency and job satisfaction. Our patients report that this is true for them, and that they are more likely to miss work in the premenstrual phase of the cycle. Recognition of PMS among staff and support for

the woman so affected can help eradicate negative effects in the workplace. Stress is known to exacerbate premenstrual symptoms. In the high-stress environment of the operating room, creative efforts to reduce tension will enhance the health of all personnelespecially those with PMS. Several definitions of premenstrual syndrome have been proposed. Researchers believe that PMS is “any combination of emotional and physical features which occur cyclically in the female before menstruation and which regress or disappear during menstruation.”’ As early as 1931 experts School of Nursing, Denver. Jean Rowe, RN,BS, is the coordinator of the PMS Treatment Centers at AMI PresbyterianAurora (Colo) Hospital, and the AMI PMS Centers in Thomton, Colo, and Lakewood, Colo. She eamed her nursing diploma from Holy Cross Hospital School of Nursing, South Bend, I d , and her bachelor of science degree in health arts from the College of St Francis, Joliet, Ill.

Judith E. Ensign

Jean Rowe

Judith E. Ensign, RN, MS, FNl! is the coordinator of the PMS Treatment Centers at Women’sHospital at AMI Presbyterian-St Luke’s Medical Center, and A MI Healthcare PlazaCentennial, Denver. She received her bachelor of science degree in nursing from Jamestown (NO)College, and her master of science degree in nursing from the University of Colorado %2

Karren Kowalski, RN, PhD, FAAN, is the director of the WomenS Hospital at AMI Presbyterian-St Luke ’s Medical Center, Denver. She earned her bachelor of science degree in nursingfrom Indiana University,Indianapolis, her master of science in nursing from the University of Colorado School of Nursing, Denver, and her doctorate in sociology from the University of Colorado, Boulder.

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identified premenstrual tension as a separate treatable medical problem.2 An English physician, Katharina Dalton, MD, first used the phrase premenstrual syndrome to represent the collection of symptoms that occur in some women prior to the menstrual p e r i ~ d .More ~ than 150 symptoms have been identified with the syndrome, and every system of a woman’s body can be involved (Table 1). Although the primary focus is often on the emotional or psychological manifestations, physical complaints can be equally troublesome for women who suffer from PMS.

Table I

Common PMS Symptoms Irritability Decreased/increased libido Fatigue, low energy Cravings for sweets Feelings of isolation Muscle aches, weakness Feeling out of control Nervousness, anxiety Sleeping difficulties Breast pain, swelling

Physiologv

T

he average menstrual cycle is 28 days in duration, but cycles may range from 20 to 40 days and still be considered normal. The first day of the female cycle is the first day of menstruation. The two major hormones influencing the female cycle, estrogen and progesterone, are secreted by the ovaries in response to stimulation by two anterior pituitary hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH). Estrogen is present in both phases, but it is predominant in the follicular or preovulatory phase. Progesterone is present in significant amounts only after ovulation. Both hormone levels fall sharply approximately two days prior to menstruation (Fig 1). In assessing clients who complain of PMS, the nurse must evaluate the correlation between the pattern of symptom manifestation and fluctuating hormonal levels (Fig 2).

Etiologv/Treatment

T

he most common time for premenstrual syndrome to begin is after pregnancy. Other times are at menarche, during or after the use of oral contraceptives, after an episode of amenorrhea, and after tuba1 ligation, hysterectomy, or other pelvic surgery. It may also begin after a serious illness, heavy use of antibiotics,

Edema, weight gain Mood changes, crying spells Headaches Salt cravings Confusion Increased argumentativeness Depression Eating binges Memory loss Panic attacks

or major stress. Seven PMS etiologies are listed in this article. Variations in levels of ovarian hormones. Premenstrual symptoms have been related to excessive estrogen blood levels resulting from diminished renal excretion of the hormone! A relative deficiency of progesterone in relation to a possible estrogen ex- has been documented, although conflicting data are reported.’ Treatment. Progesterone has been widely advocated for the management of PMS. The treatment remains controversial and the precise role of ovarian hormones in PMS is still unclear. Uncontrolled studies as well as anecdotal data have reported favorable results with the use of progesterone$ most double-blind and controlled studies have failed to show the effectiveness of progesterone over a placebo.’ Proskglandins and essential fatty acids. Abnormalities of essential fatty acid levels have been demonstrated in women with PMS.8 Essential fatty acids are precursors to prostaglandins, potent biochemical mediators that have been implicated in the regulation of the central nervous system, fluid and electrolyte balance, gastrointestinal function, and uterine contractility. Because the primary symptoms of premenstrual syndrome could result from prostaglandin-regulated disturbances, it is conceivable that changes in prostaglandin metabolism are involved in the etiology of PMS? Changes in prostaglandin biosynthesis

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may lead to excessive responsiveness or sensitivity to the effects of luteal-phase hormones.1° Instead of abnormal hormonal levels causing the syndrome, the problem may lie in the body's response to normal levels of hormones. Treatment. Treatment involves the prescription of prostaglandin inhibitors or precursors. Candida albicans overgrowth. It has been theorized that women develop PMS because of hormonal dysfunctiontriggered by immune system problems related to C albicans.l' Symptoms such as depression, memory impairment, and anxiety are shared by both PMS and C albicans overgrowth syndrome. C albicans problems also can be aggravated or promoted by antibiotics, oral contraceptives, immunosuppressant drugs, and high-carbohydrate diets.l2 The connection between the presence of C albicans and immune defects has been noted because hormonal imbalances due to pregnancy, corticosteroid therapy, or the use of oral contraceptives can lead to depressed cellular immunity. C albicans is thought to be highly immunogenic. An appropriately functioning cellular immune system is essential for proper balance of C albicans and host bacteria.13 Treatment. Immunological or endocrine abnormalities have been reversed with antifungal therapies.14 Since 1982, we have evaluated more than 1,500 patients referred for PMS treatment. We have used anti-Calbicanstreatments and other treatments aimed at reducing yeast and mold sensitivity in patients reporting specific histories and symptoms. In some of these patients, the symptoms were aggravated by exposure to environmental allergens such as foods and chemicals. A substantial number of clients have reported significant improvement in symptoms by elimination of yeast, molds, and other allergens. Endorphins. Altered endorphin levels are associated with both exercise and moods.ls The mean plasma levels of betaendorphins are slightly lower in both the luteal and follicular phases of the cycle in women with PMS than in the control group studied. The possibility exists that abnormal activity of endogenous opioids in the central nervous system is a factor in premenstrual syndrome.16

t

M = menstruation

M

7

14

21

28

Days of menstrual cycle

Fig 1. Hormonal variations during the menstrual cycle. (Reprintedfrom Depression After Childbirth (1 980) K Dalton with permission from William Heinemann Medical Books Ltd, London)

Treatment. Levels of beta endorphins rise with exercise.17 Research has indicated that increased exercise can decrease menstrual symptoms.l* At our centers, we recommend aerobic exercise for a minimum of 20 minutes every other day. Psychological. The relationship between psychiatric disorders such as depression and premenstrual dysphoric changes has been studied.Ig Even though there is considerable overlap between PMS and psychiatric disorders, they are clearly separable.20 Treatment. Education and counseling play an important role in helping women with PMS. It also has been the experience of our staff that relief of psychological and physical symptoms occurs with physiological treatments. Diet. Diet has been linked to the control of mild and moderate PMS symptoms.2' Treatment. Restricting foods high in sodium and refined carbohydrates, as well as foods containing methylxanthines (coffee, tea, cocoa, cola) and caffeine,helps to alleviate PMS symptoms. It has been suggested that women with PMS satisfy cravings for simple sugars by substituting complex carbohydrates.22 Decreasing saturated fats (animal fat and hydrogenated vegetable oils) is recom-

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Fig. 2

Patterns of Symptoms

Day 1

14

28

Symptoms (shaded area) may begin 3-10 days before the period and end with the onset of menstruation.

Day 1

14

28

Symptoms may begin at ovulation (14 days premenses) and end with menstruation.

Day 1

28

14

Symptoms occur around ovulation, diminish for several days and then return 3-10 days prior to menstruation. Symptoms may extend into menstruation.

Day 1

14

28

Symptoms may begin at ovulation and continue through menstruation. mended. Increased intake of vegetable oils such as olive and saMower oil often is recommended. Dietary modifications are necessary for the treatment of PMS. Vitamin B, has improved some premenstrual symptoms.23 In an 1 1-month, double-blind crossover study using 300 mg pyridoxine from day 12 until menstruation, significant improvement was noted in seven out of 13 symptoms.24 Research has indicated that when vitamin B, is given without other supplements, some women develop a tolerance to the vitamin within six months and require increased doses to obtain relief. The researcher recommends that vitamin

B, be used concomitantly with other supplements. Other vitamins and minerals important in the treatment of PMS are magnesium, calcium, vitamin A, and trace elernent~.~s Essential fatty acid supplements are often recommended. Other areas under investigation include abnormal thyroid function, altered pituitary hormones, and abnormalities in renal hormones. Another area of PMS research is changes in neurotransmitters, including the tryptophanserotonin pathway. All neurotransmitters have nutritional precursors. The precursor for serotonin is Ltryptophan. Pyridoxine (B,) is important in the conversion of serotonin from Ltryptophan.26 %I

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Code for PMS Symptoms

Name Month

Chart letter on the day you have symptoms. The larger the letter, the more severe the symptom. D - Depression E - Edema/swelling X - Anxiety A - Abdominal bloating I - Irritability F - Fatigue C - Menstrual cramps B - Breast tenderness H - Headaches Add codes for other symptoms

List medicines, vitamins and other therapy used this month.

Symptom Chart Instructions Write in the initial for the day of the

The number in the top left corner refers to the day of your menstrual cycle. Day I is the first day of flow. (Start a new sheet at the start of each period.)

F week and the calendar date. Fill in this part of your chart on the first day of your period so it will be easier to keep track of the date.

Mark an “M” in this corner on the days you have your period. Mark an “S” for day you have spotting.

This box is for the stress score for the

2.

1

The initial inside the large box refers to the symptoms you are experiencing on that day. Use lower case letters (a,b,c) for mild symptoms. Use upper case letters for more severe symptoms (ie: A,B,C). The larger the letter, the more severe the symptom.

f

0-no stress 1-minimal 2-mild 3-moderate 4-very stressful 5-severe

(Make note on back of chart about the cause of the stress if #4 or #5.)

Fig 3. A symptom/cycle chart helps nurses track the course of each woman’s premenstrual symptoms. (Reprinted courtesy of AMI Presbyterian-St Luke’s Medical Center, Denver) 969

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Dhcussion

A

complete medical and social history is a key tool in assessing each client. Another tool is the symptom calendar that patients fill out for two months (Fig 3). Using this tool both the patient and the nurse get an accurate view of symptomatology, the relationship of symptoms to menstrual cycle, and the improvement that occurs as treatment progresses. It has not been explored how the luteal-phase symptoms of anxiety, depression, increased vulnerability, possible altered immune response, and other symptoms experienced by women with PMS affect preoperative and postoperative states. Certainly the possibility exists that these factors would affect the patient’s emotional and physical 0 recovery. Notes 1. H Sutherland, I Stewart, “A critical analysis of the premenstrual syndrome,” Lancet (June 5, 1965) 1180-1183. 2. L Brunetti, M L Taff, “The premenstrual syndrome,” TheAmerican Journal of Forensic Medicine and Pathology 5 (September 1984) 265-268. 3. K Dalton, The Premenstrual Syndrome and

Progesterone Therapy (London: William Heinemann, 1977). 4. Brunetti, Taff, “The premenstural syndrome,” 265-268. 5. R Norris, “Progesterone for premenstrual tension,” Journal of Reproductive Medicine 28 (August 1983) 509-5 16. 6. Dalton, The Premenstrual Syndrome and

Progesterone Therapy; Norris, “Progesterone for premenstrual tension,” 509-5 16. 7. G D Burrows et al, “Progesterone and the premenstrual syndrome: A double-blind crossover trial,’’ British Medical Journal (Clinical Research Mition) 290 (June 1985) 1617-1621; G A Sampson, “Premenstrual syndrome: A double-blind controlled trial of progesterone and placebo,’’ Bribh Journal of Psychiaty 135 (September 1979) 209-215; S Maddocks et al, “A double-blind placehntrolled trial of progesterone vaginal suppositories in the treatment of premenstrual syndrome,” American Journal of Obstetrics and Gynecology 154 (March 1986) 573-581. 8. M G Brush, H Massil, P M S OBrien, “The role of essential fatty acids in the premenstrual syndrome,” Abstracts of the Second International Symposium on Prememtmal Postpurlurn and Mood Disorders (Kiawah Island, SC) 1987.

9. J Puolakka et al, “Biochemicaland clinical effects of treating the premenstrual syndrome with prostaglandin synthesis precursors,” Journal of Reproductive Medicine 3 (March 1985) 149-153. 10. M Brush et al, “Abnormal essential fatty acid levels in plasma of women with premenstrual syndrome,” American Journal of Obstetrics and Gynecology 150 (Oct 15, 1984) 363-366. 11. W G Crook, “PMS and yeasts: An etiological connection,” in The Yeast Connection. A Medical Breakthrough (Jackson, Tenn: Professional Books, 1984) 21,24. 12. C 0 Truss, “The role of candida albicans in human illness,” Journal of Orthomolecular Psychiatiy 10 (1981) 228-238. 13. S Witkin, “Defective immune responses in

patients with recurrent candidiasis,” Injections in Medicine (MayIJune 1985) 129-132. 14. Ibia! 15. J Prior, Y Vigna, “Exercise and premenstrual symptoms,”Journal OfReproductiveMedicine 32 (June 1987) 423-427. 16. A Tulenheimo, T Laatikainen, K Salminen,

“Plasma beta-endorphin immunoreactivity in premenstrual tension,” British Journal of Obstetrics and Cynecologv 94 (January 1987) 26-29. 17. D B Carr et al, “Physical conditioning facilitating exercise-induced secretion of beta-endorphin and betalipotrophin in women,” New England Journal of Medicine 305 (September 198 1) 560-563; T A Howlett et al, “Release of beta-endorphin and met-enkephalin during exercisein normal women: Response to training,’’ British Medical Journal 288 (June 30, 1984) 19501952. 18. Prior, Vigna, “Exercise and premenstrual symptoms,” 423-427. 19. U Halbreich, J Endicott, “Relationship of

dysphoric premenstrual changes to depressive disorders,” ACTA Psychiatrica Scandinavica 7 1 (April 1985) 331-338. 20. D Rubinow, P Roy-Byrne, “Premenstrual

syndromes: Overview from a methodologic perspective,” American Journal of Psychiatry 141 (February 1984) 163-172. 21. H J Chihal, “Indications for drug therapy in premenstrual syndrome patients.” Journal of Reproductive Medicine 32 (June 1987) 449-452. 22. G A Shangold, “Nutrition and the premenstrual syndrome,” Numtion and the MD 12 (May 1986) 13. 23. K E Kendall, P P Schnurr, “The effects of vitamin

B, supplementation on premenstrual symptoms,” Obstetrics and Gynecology 70 (February 1987) 145149. 24. H Jarmila, 0 Lars, “Effect of vitamin B,in premenstrual syndrome,” Abstracts of the Second

International Symposium on Premenstrual, Postpurlurn

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and Mood Disorders (Kiawah Island, SC) 1987. 25. G E Abraham, “Nutrition and the premenstrual tension syndromes,” Journal of Applied Nutrilion 36 (February 1984) 103-124; G E Abraham, R E Rumley, “Role of nutrition in managing the premenstrual tension syndromes,”Journal ofReproductiveMedicine 32 (June 1987) 405-422. 26. J Friedrich, The Premenstrual Solution-How to Time the Shrew in You (San Jose, Calif: Arrow Press, 1987).

Halas, M. Relief from Premenstmal Syndrome. New York City: Frederick Fell Publishers, 1984. Norris, V; Sullivan, C. PMS Premenstrual Syndrome: The Cause and Cure of the Syndrome that Affects 5,000,000 American Women. New York City: Rawson and Associates, 1983. Randolph, G; Moss, R W. An Alternative Approach to Allergies. New York City: Bantam Books, 1982.

Further Discussion on Routine Circumcision

New Polio Vaccine Licensed

The American Academy of Pediatrics (AAP) is reconsidering its opposition to routine circumcision because of a report that links foreskins to urinary tract infections. A professor of urology at Tulane University, New Orleans, exposed dozens of human and animal foreskins to a bacteria and found the most common urinary tract pathogens were the most likely to adhere, according to an article in the Dec 28, 1987 issue of Medical World News. The physician said the bacteria cling to the underside of the foreskin either by hydrophobic interaction between the bacteria and epithelial cells, which repels water and leads to adherence, or by the attraction of the bacteria to specific glycolipid receptors on uroepithelial cells. The findings support the results of several other clinical studies, according to the physician. One study indicated that 95%of urinary tract infections that occurred in boys studied occurred in uncircumcised boys. Another study showed that urinary tract infections occurred in a greater percentage of uncircumcised boys compared to circumcised boys. Sixteen years ago, the AAP found no medical indication for routine circumcision, but now it will investigate the new information and possibly change its stance. The organization will not change without a good medical indication, said Gerald Merenstein, MD, member of the AAP committee on the fetus and newborn. A decision is expected within a year, according to the article.

Jonas Salk, MD, developed the first polio vaccine-an inactivated vaccine-using monkey kidney cells in 1955. Eight years later, Albert Sabin, MD, developed the live, oral vaccine that virtually eliminated polio in the United States. Now, the Food and Drug Administration (FDA) has licensed a more potent version of the original Salk inactivated poliovirus vaccine. The new vaccine is manufactured using human cell cultures and requires three primary immunizations instead of four. It was made possible by advances in cell culture technology and in methods for purifying vaccine components, according to a Dec 11, 1987 report from the FDA. Inactivated poliovirus vaccines are preferred only for small portions of the population, and, for the time being, the enhanced vaccine will be recommended for the same groups. They include adults who have not been immunized and are either household contacts of children receiving the oral polio vaccine or are at increased risk of exposure, such as those traveling to areas where polio is common. Children with suppressed immune systems also should receive the inactivated rather than the live vaccine, according to the FDA. For most immunization programs, the Sabin vaccine will continue to be used. It induces immunity to intestinal infection and is well accepted by patients. It also prevents the spread of the virus among nonvaccinated people.

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