A 27-year-old woman comes to the physician with a 1-year history of periodic irritability, anger, tension, and sleep disturbance. The symptoms begin predictably a week before her periods and resolve with menstrual bleeding. She has increased appetite, headaches, breast tenderness, and ankle swelling before her periods. The symptoms are severe enough to impair her performance at work. The patient's past medical history is insignificant. Her cycles are regular and last 29 days. She has no intermenstrual bleeding or vaginal discharge. She has never been pregnant. The patient does not use tobacco, alcohol, or illicit drugs. She has been sexually active with 1 partner for the last 3 years and uses condoms for contraception. The physician prescribes fluoxetine 20 mg/day. The patient returns after 4 months and says that her symptoms have not improved significantly. She stopped taking fluoxetine 5 days back. The patient returns in 6 months and says that she feels much better. Her symptoms are less disabling, and she is able to work without significant discomfort. She is concerned about the long-term prognosis and future risk of other disorders that may be associated with her condition. The patient is at increased risk for which of the following?

Question

A 27-year-old woman comes to the physician with a 1-year history of periodic irritability, anger, tension, and sleep disturbance.  The symptoms begin predictably a week before her periods and resolve with menstrual bleeding.  She has increased appetite, headaches, breast tenderness, and ankle swelling before her periods.  The symptoms are severe enough to impair her performance at work.  The patient's past medical history is insignificant.  Her cycles are regular and last 29 days.  She has no intermenstrual bleeding or vaginal discharge.  She has never been pregnant.  The patient does not use tobacco, alcohol, or illicit drugs.  She has been sexually active with 1 partner for the last 3 years and uses condoms for contraception.  The physician prescribes fluoxetine 20 mg/day.  The patient returns after 4 months and says that her symptoms have not improved significantly.  She stopped taking fluoxetine 5 days back. The patient returns in 6 months and says that she feels much better.  Her symptoms are less disabling, and she is able to work without significant discomfort.  She is concerned about the long-term prognosis and future risk of other disorders that may be associated with her condition.  The patient is at increased risk for which of the following?

Quizplus · Accepted Answer

Explanation: Premenstrual syndrome (PMS)/premenstrual dysphoric disorder (PMDD) has a significant association with a number of primary psychiatric disorders, primarily mood and anxiety disorders. It has been estimated that the lifetime risk of a psychiatric disorder in patients with PMS approaches 80% and is elevated in the years both before and after PMS symptoms. Underlying primary mood or anxiety disorders that worsen intermittently before menses are often misdiagnosed as PMS. Other conditions, such as migraine, irritable bowel syndrome, or chronic fatigue, may also be exacerbated prior to menses. However, these symptoms alone do not necessarily denote PMS/PMDD. (Choice A) Premenstrual alcohol consumption is increased in some patients with PMS/PMDD, and premenstrual symptoms may be a trigger for alcohol abuse in those with underlying alcoholism. Conversely, alcohol consumption may aggravate the affective symptoms of PMS/PMDD. However, studies on PMS/PMDD as an independent risk factor for alcoholism have had mixed results. (Choice C) Endometriosis can produce symptoms such as bloating and pelvic pain that may follow a cyclical pattern related to menses. Endometriosis should be considered in patients whose symptoms correlate with menses, especially if there is prominent pain. However, PMS/PMDD does not indicate the presence of endometriosis and does not increase the lifetime risk. (Choice D) Thyroid disorders often present with nonspecific symptoms, including bloating and depression, which may mimic PMS. Many clinicians advise checking thyroid function early in the evaluation of patients with prominent affective symptoms. Patients with PMS/PMDD do not otherwise have an increased risk of thyroid disorders. (Choice E) Osteoporosis is a potential risk in PMS/PMDD patients treated with GnRH agonists as these agents suppress endogenous estrogen production. Patients who are not treated with GnRH agonists have normal sex hormone levels and are not at increased risk for osteoporosis. Educational objective: The lifetime risk of a psychiatric disorder in patients with premenstrual syndrome approaches 80%. These include primarily mood and anxiety disorders. References: Premenstrual syndrome and premenstrual dysphoric disorder. (http://www.ncbi.nlm.nih.gov/pubmed/22010771)

A 27-Year-Old Woman Comes to the Physician with a 1-Year