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keeping a symptom diary, getting adequate rest and exercise, and making dietary changes. B.Sleep disturbances, ranging from insomnia to excessive sleep, are common. A structured sleep schedule with consistent sleep and wake times is recommended. Sodium restriction may minimize bloating, fluid retention, and breast swelling and tenderness. Caffeine restriction and aerobic exercise often reduce symptoms. III.Dietary Supplementation A.Vitamin E supplementation is a treatment for mastalgia. The administration of 400 IU per day of vitamin E during the luteal phase improves affective and somatic symptoms. B.Calcium carbonate in a dosage of 1200 mg per day for three menstrual cycles results in symptom improvement in 48 percent of women with PMS. IV.Pharmacologic Therapy A.Fluoxetine (Sarafem) and sertraline (Zoloft) have been approved for the treatment of PMDD. SSRIs are recom- mended as initial drug therapy in women with PMS and PMDD. Common side effects of SSRIs include insomnia, drowsiness, fatigue, nausea, nervousness, headache, mild tremor, and sexual dysfunction. B.Fluoxetine (Sarafem) 20 mg or sertraline (Zoloft) 50 mg, taken in the morning, is best tolerated and sufficient to improve symptoms. Fluoxetine or sertraline can be given during the 14 days before the menstrual period. C.Benefit has also been demonstrated for citalopram (Celexa) during the 14 days before the menstrual period. Prescription Medications Commonly Used in the Treatment of Premenstrual Syndrome (PMS) Drug class and represen- Recom- tative mendatio Side ef- agents Dosage ns fects SSRIs Fluoxetine 10 to 20 First-choic Insomnia, (Sarafem) mg per e agents drowsi- day for the ness, fa- treatment tigue, nau- of PMDD. sea, ner- Sertraline 50 to 150 Effective in vousness, (Zoloft) mg per alleviating headache, day behavioral mild and physi- tremor, cal symp- sexual Paroxetine 10 to 30 toms of dysfunc- (Paxil) mg per PMS and PMDDtion day Administer during Fluvoxami 25 to 50 luteal ne (Luvox) mg per phase (14 day days be- fore men- ses). Citalopram 20 to 40 (Celexa) mg per day Diuretics Spironolac 25 to 100 Effective in Antiestrog tone mg per alleviating enic ef- (Aldactone day luteal breast ten- fects, ) phase derness hyperkale and bloat- mia ing. Drug class and represen- Recom- tative mendatio Side ef- agents Dosage ns fects NSAIDs Naproxen 275 to 550 Effective in Nausea, sodium mg twice alleviating gastric (Anaprox) daily various ulceration, physical renal dys- symptoms function. of PMS. Use with Any caution in NSAID women Mefenamic 250 mg tid should be with preex- acid with meals effective. isting gas- (Ponstel) trointestina l or renal disease. Androgens Danazol 100 to 400 Somewhat Weight (Danocrine mg twice effective in gain, de- ) daily alleviating creased mastalgia breast when size, deep- taken dur- ening of ing luteal voice. phase. Monitor lipid profile and liver function. GnRH agonists Leuprolide 3.75 mg Somewhat Hot (Lupron) IM every effective in flashes, month or alleviating cardiovas- 11.25 mg physical cular ef- IM every and be- fects, and three havioral osteoporo- months symptoms sis of PMS Side effect profile and cost limit use. Goserelin 3.6 mg SC (Zoladex) every month or 10.8 mg SC every three months Nafarelin 200 to 400 (Synarel) mcg intranasall y twice daily D.Diuretics. Spironolactone (Aldactone) is the only diuretic that has been shown to effectively relieve breast tender- ness and fluid retention. Spironolactone is administered only during the luteal phase. E.Prostaglandin Inhibitors. Nonsteroidal anti-inflammatory drugs (NSAIDs) are traditional therapy for primary dysmenorrhea and menorrhagia. These agents include mefenamic acid (Ponstel) and naproxen sodium (Anaprox, Aleve). References: See page 255. Primary Amenorrhea Amenorrhea (absence of menses) results from dysfunction of the hypothalamus, pituitary, ovaries, uterus, or vagina. It is often classified as either primary (absence of menarche by age 16) or secondary (absence of menses for more than three cycle intervals or six months in women who were previously menstruating). I.Etiology A.Primary amenorrhea is usually the result of a genetic or anatomic abnormality. Common etiologies of primary amenorrhea: 1.Chromosomal abnormalities causing gonadal dysgenesis: 45 percent 2.Physiologic delay of puberty: 20 percent 3.Müllerian agenesis: 15 percent 4.Transverse vaginal septum or imperforate hymen: 5 percent 5.Absent production of gonadotropin-releasing hor- mone (GnRH) by the hypothalamus: 5 percent 6.Anorexia nervosa: 2 percent 7.Hypopituitarism: 2 percent Causes of Primary and Secondary Amenorrhea Abnormality Causes Pregnancy Anatomic abnormalities Congenital abnormality in Isolated defect Mullerian development Testicular feminization syn- drome 5-Alpha-reductase defi- ciency Vanishing testes syndrome Defect in testis determining factor Congenital defect of uro- Agenesis of lower vagina genital sinus develop- Imperforate hymen ment Acquired ablation or Asherman s syndrome scarring of the Tuberculosis endometrium Disorders of hypothalamic-pituitary ovarian axis Hypothalamic dysfunc- tion Pituitary dysfunction Ovarian dysfunction Causes of Amenorrhea due to Abnormalities in the Hypothalamic-Pituitary-Ovarian Axis Abnormality Causes Hypothalamic dys- Functional hypothalamic amenorrhea function Weight loss, eating disorders Exercise Stress Severe or prolonged illness Congenital gonadotropin-releasing hormone deficiency Inflammatory or infiltrative diseases Brain tumors - eg, craniopharyngioma Pituitary stalk dissection or compres- sion Cranial irradiation Brain injury - trauma, hemorrhage, hydrocephalus Other syndromes - Prader-Willi, Laurence-Moon-Biedl Pituitary dysfunc- Hyperprolactinemia tion Other pituitary tumors- acromegaly, corticotroph adenomas (Cushing's disease) Other tumors - meningioma, germinoma, glioma Empty sella syndrome Pituitary infarct or apoplexy Ovarian dysfunc- Ovarian failure (menopause) tion Spontaneous [ Pobierz caÅ‚ość w formacie PDF ] |