Premenstrual syndrome.

It is most likely that the health professionals who regularly manage the menopause and read the journal Menopause International will be the same as those who also see patients who complain of premenstrual syndrome (PMS). Even if they do not do so by design, they will see many women who are approaching the menopause whose symptoms are indistinguishable from PMS or overlap with them. Moreover treatment options for PMS can result in the development of an induced menopause and all of the associated symptomatic and health consequences of estrogen deficiency. It must also be appreciated that administration of hormone therapy for symptoms of the natural menopause can result in the re-generation (or generation de novo) of PMS-like side-effects. This iatrogenic progestogen-induced PMS is not well recognized and often symptoms are attributed to the whole of the hormone replacement therapy (HRT) rather than just its progestogenic component. As editors of this special edition of Menopause International, we wish to emphasize to all practitioners managing the menopause that they should have a full understanding of PMS. The converse of this is equally true. We and the regular editors of Menopause International feel that this topic is sufficiently important that a whole special issue of what is predominantly a menopause journal should be dedicated to the subject of PMS. The penultimate article of this edition, a single case summary from a patient perspective, really says it all. The tortuous patient experience via general practitioners, psychiatrists and gynaecologists all with insufficient understanding of the subject of PMS, its diagnosis, consequences and treatment is eloquently described. A woman’s pathway passes through all known remedies to the eventual eradication of the problem by the necessary invasive procedure of hysterectomy and bilateral salpingo-oophorectomy – the only known permanent cure apart from the arrival of the spontaneous menopause. The story continues with the consequent iatrogenic premature surgical management and its management with complete resolution in the patient’s mind of all of her problems of the forgoing years. The issue begins by describing why the diagnosis, measurement and treatment of PMS is difficult. It bases this on a recent consensus publication of experts on classification. This should help all involved in management by giving an understanding of the many things that contribute to the concept of premenstrual disorders. The terminology in itself has been baffling. It is important to remember that virtually all women have some symptoms leading up to the period but if they do not cause impairment then they are normal and physiological. Hippocrates described this as ‘agitations’. It was then called PMT, PMS, LLPDD, premenstrual dysphoric disorder (PMDD) and PMD. What we suggest is that PMT is used as the non-medical colloquial term. Premenstrual disorders (PMD) is the generic term under which all these differing problems exist. LLPDD and PMDD should be avoided as they are really no more than research criteria used by American psychiatrists and represent an extreme form for which certain drugs are licensed in the USA. It is simplest to use the term PMS. Of course when referring to evidence in publications the diagnosis used in the paper being cited has to be the term used. Everyone understands PMS and it should be reserved for those patients who are significantly impaired by severe premenstrual symptoms and who have no residual symptoms after the period. Less well understood is the common confusion between severe PMS and bipolar disorder leading to misdiagnosis and years of mistreatment. The second article discusses the extent to which this problem has an impact on the individual, families, colleagues, the relevance to different age groups and different populations. It also looks at the socioeconomic challenge it presents. The remaining articles in the issue cover the theories of aetiology particularly their relevance to therapeutic strategy; mainly it considers that ovulation and subsequent progesterone or a progesterone metabolite production challenges the brain or peripheral tissues in women who are sensitive to their own endogenous progesterone; this sensitivity possibly being the product of one or more neurotransmitter anomalies. The view is thus that PMS can be treated by suppression of ovulation or modulation of the neurotransmitter systems throughout the body but particularly in the brain. Menopause International 2012; 18: 39–40. DOI: 10.1258/mi.2012.012012