Premenstrual Syndrome (PMS)

Casebank History
1

Patient Profile

  • Typically around 32 years old
  • Presenting complaint: Emotional disturbances

Key History Points

  1. Emotional symptoms:
    • Ask: “Can you describe how you feel emotionally before your period?”
    • Patient might say: “I get emotional. I shout at my husband and snap at my children.”
  2. Previous contraception:
    • Ask: “Have you used any contraception in the past?”
    • Patient might say: “I was on Depo Provera, but I stopped about 8 months ago.”
  3. Menstrual history:
    • Ask: “When did your periods restart after stopping Depo Provera?”
    • Patient might say: “My periods started again about 4 months ago.”

Approach to History Taking

  1. Start with psychological symptoms
    • Ask: “Do you notice any changes in your mood or emotions before your
      period?”
  2. Ask about physical symptoms
    • Ask: “Do you experience any physical symptoms like palpitations, sweating, or hot flashes?”
  3. Inquire about behavioral symptoms
    • Ask: “Do you notice any changes in your behavior or daily activities?”
  4. Ask about period-related symptoms
    • Ask: “Do you have any specific symptoms related to your period itself?”
  5. Look for risk factors:
    • Ask about mood disorders, weight gain, stress, family history, smoking,
      alcohol, relationship issues
  6. Assess effect on work and relationships (MAP-DOSA)
    • Ask: “How are these symptoms affecting your work and relationships?”

Diagnosis

  • Premenstrual Syndrome (PMS)
  • Explanation to patient: “Based on what you’ve told me, you could be experiencing a condition called premenstrual syndrome or PMS. It’s thought to be caused by hormonal changes throughout your menstrual cycle.”

Treatment

  1. Lifestyle changes:
    • Advise: “Try eating small, frequent meals rich in complex carbohydrates. This can help stabilize your mood.”
    • “Regular exercise and maintaining a good sleep routine can also help manage symptoms.”
    • “Try to reduce stress, alcohol consumption, and smoking if applicable.”
  2. Symptom management:
    • Advise: “For menstrual pain, you can take over-the-counter painkillers.”
  3. Monitoring:
    • Instruct: “Keep a symptom diary to track how you feel throughout your cycle.”
    • “We’ll follow up after 2-3 cycles to review your diary and see how you’re doing.”
  4. Further options:
    • Explain: “If these initial steps don’t help, we might consider options like Cognitive Behavioral Therapy (CBT).”
    • “We could also discuss contraceptive pills taken continuously to regulate
      your hormones.”
    • “In severe cases, we might consider antidepressants, but that’s not our first
      approach.”
1 Like
2

You are an FY2 in GP.
Miss Angela Di Caprio, aged 17, has come to you with complaint of headache.
Talk to her and address her concerns.

D: How can I help you?
P: I am having headaches on the right side of my head for the last one year.
D: What brought you to the hospital? P: I have been having headaches
D: Tell me more about your pain? P: Like what?
D: Where exactly do you have the pain? P: Right side of the head
D: When did it start? P: For the past 1 year
D: How did the pain start? P: It starts close to my periods
D: Is it continuous or comes and goes? P: Continuous during my periods
D: Is it sudden or gradual? P: Gradual
D: What type of pain is it? P: Dull
D: Does the pain go anywhere? P: No
D: Is there anything that makes the pain better or worse?
P: I had paracetamol, but it didn’t help
D: Could you please score the pain on a scale of 1 to 10, where 1 being no pain and 10 being the most severe pain you have ever experienced. P: 7/8
D: Anything else? P: No
D: Any visual problems? P: No
D: Any blurry vision? P: No
D: Any weight loss? P: No
D: Do you have the worst ever headache in the back of your head? (SAH) P: No
D: Do you have an early morning headache? (SOL) P: No
D: Do you have projectile vomiting? (SOL) P: No
D: Do you have any numbness in your arm or leg? (SOL) P: No
D: Do you have eye pain or red/watery eyes? (Glaucoma, cluster headache) P: No
D: Have you been diagnosed with any medical condition in the past? P: No
D: Are you currently taking any medications, OTC drugs or supplements? P: No
D: Are you taking any birth control pills? P: No
D: Any allergies from any food or medication? P: No
D: Any previous surgeries or procedures done? P: No
D: When was your last menstrual period? P: 2/3 weeks ago.
D: Are they regular? P: Yes.
D: How long does your period last? P: 5 days
D: Any bleeding or spotting between your periods? P: No.
D: Any painful or heavy periods? P: No
D: Have you been pregnant before? P: No
D: Are you currently sexually active? P: No
D: Do you smoke? P: No
D: Do you drink alcohol? P: No
D: Tell me about your diet? P: Good
D: Are you physically active? P: Yes/No
D: What do you do for a living? P: Student

I would like to do vitals, GPE, an examination of the tummy and neurological examination.
I would also like to do baseline investigations.

Patience concerns: What could this be? How can you help me with this?
D: From the history you have told me, it appears you have PMS. PMS (premenstrual syndrome) is the name for the symptoms women can experience in the weeks before their period. Most women have PMS at some point. Each woman’s symptoms are different and can vary from month to month.

The most common symptoms of PMS include:

  • mood swings
  • feeling upset, anxious or irritable
  • tiredness or trouble sleeping
  • bloating or tummy pain
  • breast tenderness
  • headaches
  • spotty skin or greasy hair
  • changes in appetite and sex drive

Treating PMS (premenstrual syndrome) as well as changes to your lifestyle, a GP can recommend treatments including:

  • hormonal medicine – such as the combined contraceptive pill
  • cognitive behavioural therapy – a talking therapy
  • antidepressants

If you still get symptoms after trying these treatments, you may be referred to a specialist.
This could be a gynaecologist, psychiatrist or counsellor.

Do

  • regular exercise
  • eat a healthy, balanced diet
  • get plenty of sleep – 7 to 8 hours is recommended
  • try reducing your stress by doing yoga or meditation
  • take painkillers such as ibuprofen or paracetamol to ease the pain
  • keep a diary of your symptoms for at least 2 to 3 menstrual cycles – you can take this to a
  • GP appointment

Don’t

  • do not smoke
  • do not drink too much alcohol
3

Who you are:
You are an FY2 in A&E

Who the patient is:
Rachel, a 33-year-old, presented with headache.

What you should do:
Talk to the patient and address her concerns.

(Don’t forget P4)
P1 (SOCRATES)
Doctor: How can I help you today?
Patient: I have a headache.

D: Tell me more about it? Where exactly do you have the pain? (site)
P: All over my head.
D: When did it start? (onset)
P: 2 days ago.
D: What were you doing when you had this pain?
P: Nothing.
D: Is it continuous or comes and goes?
P: It is continuous during the evening.
D: What type of pain is it? (character)
P: Dull.
D: Does the pain go anywhere else? (radiation)
P: No.
D: Is there anything that makes the pain better?
P: No.
D: Is there anything that makes the pain worse?
P: It always gets worse 3 to 4 days before my periods (+ve finding)
D: Could you please score the pain on a scale of 1 to 10 with 1 being no pain at all and 10 being the most severe pain you have ever experienced? (score)
P: 4.
D: Apart from the headache, anything else?
P: I am getting emotional and angry. I am shouting on my husband and children. I don’t know what’s going on. (+ve finding)
D: That must be distressing for you. Please don’t worry, we will look into this matter, how long have you been feeling like this?
P: The past 8 months.
D: That’s quite a long time, how’s your mood?
P: I have mood swings a lot, doctor and I feel low sometimes. (+ve finding)
D: Can you grade your mood for me?
P: It’s 5. (+ve finding)
D: When people feel low sometimes, they might think of hurting themselves or others,
has that been the case with you?
P: No.
D: Apart from this, what’s your main concern? (concern)
P: The headaches and my mood swings, that’s all.

DDs
D: Any problem with light? (Meningitis, SAH)
P: No.
D: Any neck stiffness? (SAH)
P: No.
D: Any early morning vomiting or headache? (SOL)
P: No.
D: Any weakness in your body? (SOL)
P: No.
D: Any pain while chewing or combing your hair? (GCA)
P: No.
D: Any history of any trauma to your head?
P: No.
D: Any red eye or watery eye? (Cluster headache)
P: No.
D: Do you see coloured haloes around light? (Glaucoma)
P: No.

PMS symptoms
D: Any breast tenderness?
P: No.
D: Any pain in your body?
P: No.
D: Any tummy bloating?
P: No.

+FLAWS
P2
D: Have you had this headache in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.

DESA
D: Do you smoke?
P: Yes.
D: Could you tell me more about that?
P: I have smoked 2 cigarettes a day for the past 4 years
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: It is fine.
D: Do you do physical exercise?
P: I don’t get time.

P4
D: When was your last menstrual period?
P: 3 weeks ago.
D: Are they regular?
P: Yes.
D: Any bleeding in-between your periods?
P: No.
D: Do you use any contraception?
P: Yes, I’m on the mini-pill.
D: When did you start it?
P: 5 months ago.
D: Are you taking it as prescribed?
P: Yes.

Don’t forget ICE.

Examination
General, physical and neurological examination.

Provisional Diagnosis
From the chat we had (mention the positive findings) you told me that you have had a headache which gets worse before your period and also you are having mood swings. Therefore, I suspect you may be suffering from premenstrual syndrome which is the name for the symptoms women can experience in the weeks before their period. Most women have PMS at some point in their lives. It may be because of changes in your hormone levels during the menstrual cycle. Some women may be more affected by these changes than others.

Management:

Senior

Lifestyle change

  • Regular exercise.
  • Eat a healthy, balanced diet.
  • Get plenty of sleep – 7 to 8 hours is recommended.
  • Try reducing your stress by doing yoga or meditation.
  • Take painkillers such as ibuprofen or paracetamol to ease the pain.
  • Keep a diary of your symptoms for at least 2 to 3 menstrual cycles.

Medications and CBT

  • Hormonal medicine – such as the combined contraceptive pill.
  • Cognitive behavioural therapy – a talking therapy.
  • Antidepressants.

Please avoid:

  • Smoking.
  • Drinking too much alcohol.

Specialist.

  • If you still get symptoms after trying these treatments, you may be referred to a specialist.
  • This could be a gynaecologist, psychiatrist or counsellor.

Safety netting.
Follow up.