1040
U N I T 1 1
Genitourinary and Reproductive Function
a woman’s life.
48–51
The severity of this cyclic symptom
complex can vary from
premenstrual molimina
on
the mild end; through
premenstrual syndrome
(PMS),
which is characterized by mild to moderate physical and
psychological symptoms preceding menstruation and
relieved by onset of the menses; to
premenstrual dys-
phoric disorder
(PMDD), which is the most severe form
of premenstrual distress and generally is associated with
mood disorders.
Up to 80% of women in the United States experi-
ence some emotional or physical symptoms during the
luteal phase of their menstrual cycle, without experienc-
ing a substantial impact on their daily functioning. The
PMS disorder, which results in moderate disruptions in
a woman’s life, occurs in 20% to 30% of premenstrual
women and another 3% to 8% suffer from the extreme
or severe symptoms of PMDD.
50
The incidence of PMS
and PMDD seems to increase with age. It is less com-
mon in women in their teens and twenties, and most
women seeking help for the problem are in their mid-
thirties. The disorder is not culturally distinct; it affects
both Westerners and non-Westerners.
Physical symptoms of PMS include painful and swol-
len breasts, bloating, abdominal pain, headache, and
backache. Psychologically, there may be depression,
anxiety, irritability, and behavioral changes. In some
cases, there are puzzling alterations in motor function,
such as clumsiness and altered handwriting. Women
with PMS may report one or several symptoms, with
symptoms varying from woman to woman and from
month to month in the same woman. The disorder can
significantly affect a woman’s ability to perform at nor-
mal levels. Family responsibilities and relationships may
suffer and she may lose time from or function ineffec-
tively at work.
Although the causes of PMS and PMDD are poorly
documented, they probably are multifactorial. Like dys-
menorrhea, it is only recently that PMS has been rec-
ognized as a bona fide disorder rather than merely a
psychosomatic illness. Because there appear to be nomea-
surable differences in hormone levels between women
with and without PMS, it is presumed that normal cyclic
variation in the hormones is the trigger for symptoms in
vulnerable or predisposed women. Currently, data sug-
gest a relationship between normal gonadal fluctuations
and central neurotransmitter activity, particularly sero-
tonin. It is unclear whether decreased levels of serotonin
are present during the luteal phase and only susceptible
women respond with varying degrees of premenstrual
symptoms, or if women with PMDD have a neurotrans-
mitter abnormality.
48
Diagnosis of PMS and PMDD focuses on docu-
mentation of the relationship of a woman’s symptoms
to the luteal phase of the menstrual cycle. A com-
plete history and physical examination are necessary
to exclude other physical causes of the symptoms.
Depending on the symptom pattern, blood studies,
including thyroid hormones, glucose, and prolactin
assays, may be done. Psychosocial evaluation is help-
ful to exclude emotional illness that is merely exacer-
bated premenstrually.
Management of PMS/PMDD has been largely
symptomatic and includes education and support
directed toward lifestyle changes for women with mild
symptoms.
48–51
An integrated programof personal assess-
ment by diary, regular exercise, avoidance of caffeine,
and a diet low in simple sugars and high in lean proteins
is often beneficial. In addition to lifestyle changes. In
addition to lifestyle changes, pharmacologic treatment
includes the use of diuretics to reduce fluid retention,
nonsteroidal anti-inflammatory agents for pain, and
anxiolytic drugs to treat mood changes. Because symp-
toms are associated with ovulatory cycles, suppressing
ovulation may be beneficial for some women with PMS
and can be accomplished using hormonal contraceptives,
danazol (a synthetic androgen), or GnRH agonists.
48
Hormonal contraceptives can be used for women who
also require contraception. However, some women find
their symptoms worsen when taking contraceptives. The
pharmacologic treatment of PMDD differs from that
of PMS. Ovulation suppression does not seem to help
women with PMDD. Although many medications have
been studied, only three antidepressants (fluoxetine, ser-
traline, and paroxetine controlled release) and an oral
contraceptive that contains drospirenone (a spironolac-
tone derivative) have been approved for treatment of the
emotional and physical symptoms of PMDD.
48
Menopause and Aging Changes
Menopause
is the cessation of menstrual cycles. Like
menarche, it is more of a process than a single event.
52,53
Most women stop menstruating between 48 and 55 years
of age.
Perimenopause
(the years immediately surround-
ing menopause) precedes menopause by approximately
4 years and is characterized by menstrual irregularity
and other menopausal symptoms.
Climacteric
refers to
the entire transition to the nonreproductive period of
life. Premature ovarian failure describes the approxi-
mately 1% of women who experience menopause before
the age of 40 years. A woman who has not menstruated
for a full year or has an FSH level greater than 30 mIU/
mL is considered menopausal.
Menopause results from the gradual cessation of
ovarian function and the resultant diminished levels of
estrogen. Although estrogens derived from the adrenal
cortex continue to circulate in a woman’s body, they are
insufficient to maintain the secondary sexual charac-
teristics in the same manner as ovarian estrogens. As a
result, breast tissue, body hair, skin elasticity, and subcu-
taneous fat decrease; the ovaries and uterus diminish in
size; and the cervix and vagina become pale and friable.
Problems that can arise as a result of this urogenital
atrophy include vaginal dryness, urinary stress incon-
tinence, urgency, nocturia, vaginitis, and urinary tract
infection.
52,53
The woman may find intercourse painful
and traumatic, although some type of vaginal lubrica-
tion may be helpful.
Systemically, a woman may experience significant
vasomotor instability secondary to the decrease in estro-
gens and the relative increase in other hormones, includ-
ing FSH, LH, GnRH, dehydroepiandrosterone, and
