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Premenstrual Syndrome and Premenstrual Dysphoric Disorder
经前综合征与经前情绪障碍
Premenstrual syndrome (PMS) is characterized by physical and behavioral symptoms that occur repetitively in the second half of the menstrual cycle and interfere with some aspects of the woman's life. Premenstrual dysphoric disorder (PMDD) is the most severe form of PMS, with the prominence anger, irritability, and internal tension. PMS affects up to 75 percent of women with regular menstrual cycles, while PMDD affects only 3 to 8 percent of women.
经前综合征（PMS）是指在月经周期后半部分反复出现的、影响妇女生活的一系列躯体和行为症状。经前情绪障碍（PMDD）是PMS中最严重的形式，表现为愤怒、易激惹、精神紧张。有规律月经周期的妇女有75％受到PMS的影响，但只有3-8％的妇女受PMDD的困扰。
I. Symptoms
I.症状
A. The most common physical manifestation of PMS is abdominal bloating, which occurs in 90 percent of women with this disorder; breast tenderness and headaches are also common, occurring in more than 50 percent of cases.
A. 经前综合征最常见的躯体症状是腹胀（90％患病妇女有此症状），乳房胀痛和头痛也很常见，发生率超过50％。
B. The most common behavioral symptom of PMS is an extreme sense of fatigue which is seen in more than 90 percent. Other frequent behavioral complaints
include irritability, tension, depressed mood, labile mood (80 percent), increased appetite (70 percent), and forgetfulness and difficulty concentrating (50 percent).
B. 经前综合征最常见的行为症状是严重疲倦感，发生率超过90％。其他常发生的行为改变包括易激惹、紧张、心情抑郁、情绪波动（80％）、食欲增加（70％）、健忘和注意力不集中（50％）。

Symptom Clusters Commonly Noted in Patients with PMS
经前综合征病人常见的症状群
Affective Symptoms
情感症状  Cognitive or performance
认知或行为症状
Depression or sadness
抑郁或悲伤  Mood instability or mood swings
情绪不稳定或情绪波动
Irritability
激惹  Difficulty in concentrating
注意力不集中
Tension
紧张  Decreased efficiency
办事效率下降
Anxiety
焦虑  Confusion
迷惘
Tearfulness or crying easily
容易哭泣  Forgetfulness
健忘
Restlessness or jitteriness
不安宁或神经过敏  Accident-prone
易惹事故
Anger
恼怒  Social avoidance
社交逃避
Loneliness
孤独感  Temper outbursts
情绪爆发
Appetite change
食欲改变  Energetic
精力过剩
Food cravings
渴望进食  Fluid retention
水潴留
Changes in sexual interest
性欲改变  Breast tenderness or swelling
乳房胀痛或肿胀
Pain
疼痛  Weight gain
体重增加
Headache or migraine
头痛或偏头痛  Abdominal bloating or swelling
腹胀或腹部肿胀
Back pain
背痛  Swelling of extremities
四肢肿胀
Breast pain
乳房痛  General somatic
全身躯体症状
Abdominal cramps
腹痛  Fatigue or tiredness
疲老或疲倦
General or muscular pain
全身或肌肉痛  Dizziness or vertigo
头晕
  Nausea
恶心
  Insomnia
失眠
C. Other common findings include acne, oversensitivity to environmental stimuli, anger, easy crying, and gastrointestinal upset. Hot flashes, heart palpitations,
and dizziness occur in 15 to 20 percent of patients. Symptoms should occur in the luteal phase only.
C.其他表现包括：痤疮、对外界刺激过度敏感、恼怒、容易哭泣以及胃肠道不适。大约15－20％患者发生潮热、心悸、头晕。这些症状只发生在黄体期。
UCSD Criteria for Premenstrual Syndrome
UCSD对经前期综合征的诊断标准
At least one of the following affective and somatic symptoms during the five days before menses in each of the three previous cycles:
在先前的三个周期中，每次月经来潮前5天至少出现下面一个情感和躯体症状：
Affective symptoms: depression, angry outbursts, irritability, anxiety, confusion, social withdrawal
Somatic symptoms: breast tenderness, abdominal bloating, headache, swelling of extremities Symptoms relieved from days 4 through 13 of the menstrual cycle
情感症状：抑郁、发作性恼怒、易激惹、焦虑、迷惘、社交逃避
躯体症状：乳房胀痛、腹胀、头痛、四肢肿胀。这些症状在月经周期4－13天缓解。
DSM-IV Criteria for Premenstrual Dysphoric Disorder
经前情绪障碍的DSM-IV标准
• Five or more symptoms
出现5个或5个以上症状
• At least one of the following four symptoms:
Markedly depressed mood, feelings of hopelessness,or self-deprecating thoughts
Marked anxiety, tension, feeling of being "keyed up" or "on edge"
Marked affective lability
Persistent and marked anger or irritability or increase in interpersonal conflicts
最少出现如下4个症状之一：
显著的抑郁情绪，失望感或自卑感
显著的焦虑、紧张、激动感或边缘感
显著的情感不稳定
持续而显著的恼怒或易激惹或人际关系冲突增加
• Additional symptoms that may be used to fulfill the criteria:
Decreased interest in usual activities
Subjective sense of difficulty in concentrating
Lethargy, easy fatigability, or marked lack of energy
Marked change in appetite, overeating, or specific food cravings
Hypersomnia or insomnia
Subjective sense of being overwhelmed or out of control
可能有助于诊断的附加症状：
日常活动兴趣下降
注意力集中困难的主观感觉
倦怠、易疲劳或显著的精力不足
食欲明显改变，暴食或偏食某种食物
嗜睡或失眠
被压抑或失控的主观感觉
• Other physical symptoms such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of bloating, or weight gain
其他躯体症状，如乳房胀痛或肿胀，头痛，关节或肌肉痛，肿胀感或体重增加
• Symptoms occurring during last week of luteal phase
症状发生在黄体期的最后一周
• Symptoms are absent postmenstrually
经后症状消失
• Disturbances that interfere with work or school or with usual social activities and relationships
这些不适可以影响工作、学习或日常社交活动或社交关系
• Disturbances that are not an exacerbation of symptoms of another disorder
这些不适不是另外一种失调症状的进一步恶化

Differential Diagnosis of Premenstrual Syndrome
经前综合征的鉴别诊断
Affective disorder (eg, depression, anxiety, dysthymia, panic)
情感失调（如抑郁、焦虑、精神抑郁、恐慌）
Anemia贫血
Anorexia or bulimia厌食症或易饿病
Chronic medical conditions (eg, diabetes mellitus)
慢性疾病（如糖尿病）
Dysmenorrhea
痛经  Endometriosis子宫内膜异位症
Hypothyroidism甲状腺机能减退
Oral contraceptive pill use口服避孕药
Perimenopause围绝经期
Personality disorder人格障碍
Substance abuse disorders
物质滥用障碍

D. Differential diagnosis
D.鉴别诊断
1. PMDD should be differentiated from premenstrual exacerbation of an underlying major psychiatric disorder, as well as medical conditions such as hyper- or hypothyroidism.
1.经前情绪障碍需要同精神性疾患经前症状加重以及医源性疾病如甲状腺功能亢进或减退相鉴别
2. About 13 percent of women with PMS are found to have a psychiatric disorder alone with no evidence of PMS, while 38 percent had premenstrual exacerbation of underlying depressive and anxiety disorders.
2. 大约13％经前综合征妇女有精神性疾患而无经前期综合征的症状，而38％的妇女其潜在抑郁或焦虑等障碍可在经前加重。
3. 39 percent of women with PMDD meet criteria for mood or anxiety disorders.
3.患有经前情绪障碍的妇女39％符合情绪障碍或焦虑障碍的诊断标准。
4. The assessment of patients with possible PMS or PMDD should begin with the history, physical examination, chemistry profile, complete blood count, and serum TSH. The history should focus in particular on the regularity of menstrual cycles. Appropriate gynecologic endocrine evaluation should be performed if the cycles are irregular (lengths less than 25 or greater than 36 days).
4.对可能患有经前期综合征或经前情绪障碍的患者需要从以下几方面进行评估：病史、体格检查、化学检查、全血检查及血清TSH。病史尤其需要集中在月经周期的规律性。如果月经周期不规则（短于25天或多于36天），需要进行适当的妇科内分泌检查。
5. The patient should be asked to record symptoms prospectively for two months. If the patient fails to demonstrate a symptom free interval in the follicular phase, she should be evaluated for a mood or anxiety disorder.
5.告知病人记录未来2个月的症状。如果不能显示卵泡期无症状期间的症状，需要对她进行情绪障碍或焦虑障碍评估。

II. Nonpharmacologic therapy
II.非药物治疗
A. Relaxation therapy and cognitive behavioral therapy have shown some benefit. Behavioral measures include keeping a symptom diary, getting adequate rest and exercise, and making dietary changes.
A.放松疗法及认知行为疗法一定程度上有效。行为疗法包括记症状日记，足够休息和运动锻炼，改变饮食习惯。
B. Sleep disturbances, ranging from insomnia to excessive sleep, are common. A structured sleep schedule with consistent sleep and wake times is recommended. Sodium restriction may minimize bloating, fluid retention, and breast swelling and tenderness. Caffeine restriction and aerobic exercise often reduce symptoms.
B.睡眠障碍很常见，从失眠到嗜睡都有。建议设计睡眠时间表，有一致的睡眠和清醒时间。限制钠盐摄入可以减轻腹胀、水潴留、乳房肿胀疼痛。限制咖啡和增氧健身运动可以减轻症状。
III.Dietary Supplementation
III.饮食补充疗法
A. Vitamin E supplementation is a treatment for mastalgia. The administration of 400 IU per day of vitamin E during the luteal phase improves affective and somatic symptoms.
A.补充维生素E可以治疗乳房痛。黄体期每日补充400 IU维生素E可以改善情感和躯体症状。
B. Calcium carbonate in a dosage of 1200 mg per day for three menstrual cycles results in symptom improvement in 48 percent of women with PMS.
B. 连续三个月经周期每日服用碳酸钙1200mg，可以使48％患有经前期综合征的妇女症状得到改善。
IV. Pharmacologic Therapy
IV.化学药物治疗
A. Fluoxetine (Sarafem) and sertraline (Zoloft) have been approved for the treatment of PMDD. SSRIs are recommended as initial drug therapy in women with PMS and PMDD. Common side effects of SSRIs include insomnia, drowsiness, fatigue, nausea, nervousness, headache, mild tremor, and sexual dysfunction.
A.已批准氟西丁（Sarafem）和舍曲林 (Zoloft)用来治疗经前情绪障碍。建议把5-羟色胺再摄取抑制剂(SSIR)类药物作为经前期综合征和经前情绪障碍的初始药物疗法。SSIR类药物常见副反应包括失眠、困倦欲睡、疲倦、恶心、神经过敏、头痛、轻度颤抖和性功能障碍。
B. Fluoxetine (Sarafem) 20 mg or sertraline (Zoloft) 50 mg, taken in the morning, is best tolerated and sufficient to improve symptoms. Fluoxetine or sertraline can be given during the 14 days before the menstrual period.
B. 每日早晨服用氟西丁(Sarafem) 20 mg或舍曲林 (Zoloft) 50 mg可以有效地改善症状，而且耐受性好。氟西丁或舍曲林可以在经前14天开始服用。
C. Benefit has also been demonstrated for citalopram (Celexa) during the 14 days before the menstrual period.
C. 经前14天服用西酞普兰也显示有效。
D. Diuretics. Spironolactone (Aldactone) is the only diuretic that has been shown to effectively relieve breast tenderness and fluid retention. Spironolactone is administered only during the luteal phase.
D.利尿药：安体舒通是唯一证明能够有效减轻乳房胀痛和水液潴留的利尿剂。安体舒通只在黄体期应用。
E. Prostaglandin Inhibitors. Nonsteroidal anti-inflammatory drugs (NSAIDs) are traditional therapy for primary dysmenorrhea and menorrhagia. These agents include mefenamic acid (Ponstel) and naproxen sodium (Anaprox, Aleve).
E.前列腺素抑制剂：非甾体类消炎药（NSAIDs）是治疗原发性痛经和月经过多的传统治疗药物。这些药物包括甲灭酸(Ponstel)和萘普生(Anaprox, Aleve).
References: See page 184.

Prescription Medications Commonly Used in the Treatment of Premenstrual Syndrome(PMS)
治疗经前期综合征的常用处方药物
Drug class and representative agents
药物分类和代表药物  Dosage
剂量  Recommendations
建议  Side effects
副反应
SSRIs5-羟色胺再摄取抑制剂
Fluoxetine
(Sarafem)
氟西丁  10 to 20mg per
day
10-20mg/日  First-choice agents for the treatment of PMDD. Effective in alleviating behavioral and physical symptoms of PMS and PMDD Administer during luteal phase (14 days before menses).
治疗经前情绪障碍的首选药物。可以有效地缓解经前综合征和经前情绪障碍的行为和躯体症状。黄体期用药（经前14天）
  Insomnia,
drowsiness,
fatigue,
nausea,
nervousness,
headache,
mild
tremor,
sexual
dysfunction
失眠、困倦欲睡、疲倦、恶心、神经过敏、头痛、轻度颤抖、性功能障碍
Sertraline
(Zoloft)
舍曲林  50 to 150mg per
day
50-150mg/日    
Paroxetine
(Paxil)
帕罗西汀  10 to 30mg per
day
10-30mg/日    
Fluvoxamine (Luvox)
氟伏沙明  25 to 50mg per
day
25-50mg/日    
Citalopra
m(Celexa)
西酞普兰  20 to 40mg per
day
20-40mg/日    
Diuretics利尿剂
Spironolactone (Aldactone)
安体舒通  25 to 100mg per day Luteal phase
黄体期每日服25-100mg   Effective in alleviating
Breast tenderness and bloating.
有效减轻乳房胀痛和腹胀  Antiestrogenic effects, hyperkalemia
抗雌激素效应、高血钾症
NSAIDs非甾体类消炎药
Naproxen
sodium
(Anaprox)
萘普生  275 to 550
mg twice
daily
275-550mg，每日2次  Effective in alleviating
Various physical symptoms of PMS. Any NSAID should be effective.
有效减轻经前期综合征的各种躯体症状。任何非甾体类消炎药都有效。  Nausea, gastric ulceration, renal dysfunction. Use with caution in women with preexisting gastrointestinal or renal disease.
恶心、胃溃疡、肾功能损害。胃肠道或肾疾病患者慎用。
Mefenamic acid
(Ponstel)
甲灭酸  250 mg tid
with meals
250 mg，每日三次，连同食物服用    
Androgens　雄激素类
Danazol
(Danocrin
e)
丹那唑
  100 to 400
mg twice
daily
100 -400mg，每日2次  Somewhat effective in alleviating mastalgia when taken during luteal phase.
黄体期服用可以适度减轻乳房痛。  Weight gain, decreased breast size, deepening of voice. Monitor lipid profile and liver function.
体重增加，乳房变小，声音增粗。监测血脂及肝功能。
GnRH agonists　促性腺激素释放激素激动剂
Leuprolide
(Lupron)
醋酸亮丙瑞林  3.75 mg IM every month or 11.25 mg IM every three
months
每月肌注3.75mg或每3个月肌注11.25mg  Somewhat effective in alleviating physical and behavioral symptoms of PMS Side effect profile and
cost limit use.
可以减轻经前综合征的躯体和行为症状。但副反应及费用限制其临床使用
  Hot flashes, cardiovascular effects, and osteoporosis
潮热、心血管效应和骨质疏松
Goserelin
(Zoladex)
戈舍瑞林
  3.6 mg SC every
month or 10.8 mg SC every three months
每个月皮下注射3.6mg或每3个月皮下注射10.8mg    
Nafarelin
(Synarel)
那法瑞林  200 to 400mcg intranasaly twice
daily