A 25-year-old woman comes to the office due to abdominal bloating, headache, fatigue, weight gain, mood swings, and decreased libido. She says, "The symptoms last about a week and then seem to subside, but they always come back again." During these episodes, her appetite increases and she craves sweet and salty foods. The episodes have been occurring for years. The patient has a history of depression as a teenager that responded well to cognitive-behavioral therapy and a family history of bipolar disorder in a maternal uncle. She has no recent change in sleep pattern or interest in activities, or feelings of hopelessness or guilt. She takes no medications and physical examination is normal. Complete blood count, serum chemistries, pregnancy test, and TSH levels are within normal limits. Which of the following is the most appropriate next step in management of this patient?

Question

A 25-year-old woman comes to the office due to abdominal bloating, headache, fatigue, weight gain, mood swings, and decreased libido.  She says, "The symptoms last about a week and then seem to subside, but they always come back again."  During these episodes, her appetite increases and she craves sweet and salty foods.  The episodes have been occurring for years.  The patient has a history of depression as a teenager that responded well to cognitive-behavioral therapy and a family history of bipolar disorder in a maternal uncle.  She has no recent change in sleep pattern or interest in activities, or feelings of hopelessness or guilt.  She takes no medications and physical examination is normal.  Complete blood count, serum chemistries, pregnancy test, and TSH levels are within normal limits.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient's presentation is suggestive of premenstrual syndrome (PMS). The most common physical manifestations of PMS are bloating, fatigue, headaches, and breast tenderness. Psychological symptoms may include mood swings, anxiety, difficulty concentrating, decreased libido, and irritability. Symptoms usually begin a week prior to menses and resolve within a few days after menses start. Patients are symptom free during the follicular phase. Premenstrual dysphoric disorder (PMDD) is a severe variant of PMS, with prominent irritability, hopelessness, depressed mood, self-critical thoughts, anger, and greater psychosocial impairment. Prior to recommending a treatment approach, a clear diagnosis of PMS/PMDD must be established. This requires ruling out an underlying psychiatric disorder that may be exacerbated during the premenstrual phase but is still present at other times (eg, dysthymia, cyclothymia, personality disorder). A detailed menstrual history (diary) with prospective charting of daily mood and physical symptoms over the course of 2 or 3 menstrual cycles is commonly used. Demonstration that symptoms occur repeatedly and predictably prior to menstruation and resolve with menses confirms the diagnosis. If symptoms occur irregularly or throughout the menstrual cycle, a primary mood or personality disorder is more likely. Mild PMS can be managed with exercise and stress reduction. Selective serotonin reuptake inhibitors (SSRIs) (eg, fluoxetine) are first-line treatment for moderate to severe PMS/PMDD. (Choice A) Studies have shown mixed results with cognitive-behavioral therapy in PMS. It may be helpful in reducing affective symptoms and the preoccupation with physical symptoms in patients who wish to avoid medication. However, in this patient, the optimal approach would be to first confirm the diagnosis with a symptom diary and then present treatment options. (Choices B, D, and F) It is premature to recommend treatment without first confirming the diagnosis using a menstrual diary. Both continuous and late luteal-phase-only (starting on cycle day 14) SSRI treatments are effective in PMS/PMDD. Valproate is an anticonvulsant mood stabilizer used in bipolar disorder; it is not used to treat PMS/PMDD. (Choices C and G) There is no evidence that special diets or vitamin supplements are effective in PMS/PMDD. Educational objective: Premenstrual syndrome and premenstrual dysphoric disorder are characterized by physical (eg, fatigue, bloating, breast tenderness) and psychological (eg, mood swings, irritability) symptoms that occur in the week prior to menses and resolve during the follicular phase. Assessment should begin with a menstrual diary to determine the relationship of symptoms to menstrual cycle phase. References: Premenstrual syndrome and premenstrual dysphoric disorder. (http://www.ncbi.nlm.nih.gov/pubmed/27479626) Daily symptom ratings for studying premenstrual dysphoric disorder: A review. (http://www.ncbi.nlm.nih.gov/pubmed/26406968)

A 25-Year-Old Woman Comes to the Office Due to Abdominal