Case 26: Labile mood and abdominal pain

 

Case 26: Labile mood and abdominal pain

CASE 26: LABILE MOOD AND ABDOMINAL PAIN

History

A 37-year-old mother presents to her general practitioner with cyclical labile mood

swings. She says that she has always suffered with PMS (premenstrual syndrome) and that

it is in the family as her mother ‘had to have a hysterectomy’ for the same problem. She

reports her periods as always having been painful and that she has always been irritable

leading up to a period. However now she feels that she is not herself for at least 2 weeks

before her period and that the pain has worsened. She also notices headaches, swelling

and breast tenderness.

Her periods are generally regular with bleeding for up to 6 days every 27–31 days. She has had

three children all by normal vaginal delivery and the youngest is now 5 years old. She has no

other medical history of note.

She has been married for 14 years and she says she often feels aggressive toward her husband

or alternatively is tearful and low. Prior to having children she worked in a bank and is not

sure whether to return as she feels she might be unable to cope.

Examination

No abnormality is found on abdominal or neurological examination.

Questions

• What is the differential diagnosis?

• How would you further determine the cause of the symptoms and manage this patient?100 Cases in Obstetrics and Gynaecology

62

ANSWER 26

The woman clearly feels that this is a gynaecological problem and that she has PMS. The

diagnosis should be confirmed with evidence of symptoms occurring in the luteal phase and

resolving within a day or two of menstruation starting. The differential diagnosis is depression which can manifest in a similar way to PMS.

A symptom diary is needed for recording symptoms for each day, over a 3-month period. The

woman should annotate a chart with the severity of each symptom and when menstruation

occurs. PMS should start after midcycle, symptoms should resolve with the period and there

should be a number of symptom-free days each month.

An example of a symptom diary is shown in Fig. 26.1.

Management

If confirmed then the diagnosis should be discussed with the woman, offering appropriate

understanding and support but explaining that management is variable in the success for

each woman and that ‘one size does not fit all’. Vitamins and oil of evening primrose are not

proven in trials but may have a placebo effect.

Interruption of ovulation with the oral contraceptive pill is often successful in women under

the age of 35 years.

Selective serotonin reuptake inhibitors taken continuously or only in the luteal phase have

a good success rate in randomized trials, and the woman should be advised that they have

a specific effect with PMS rather than just a general antidepressant effect. There is limited

evidence for the role of continuous oestrogens or progestogens for the management

of PMS. In cases resistant to other treatments, a therapeutic trial of gonadotrophinreleasing hormone analogues to induce a pseudomenopause can be considered, though

the associated hypoestrogenic side effects may themselves need treating with added-back

oestrogen.

Hysterectomy would not be helpful unless the ovaries were also removed, and this would

involve risk of significant morbidity with the need for hormone-replacement therapy afterwards which may have its own side effects or complications.

KEY POINTS

• Premenstrual syndrome is diagnosed with a symptom diary.

• No single treatment is effective for all women.

• Selective serotonin reuptake inhibitors are effective in many women with premenstrual syndrome.