Symptoms, Triggers, Prevention, and Treatment

If you feel fine for weeks or months but your multiple sclerosis symptoms pop up again, you probably have what doctors call a relapse or flare-up. There are a lot of ways to treat or prevent them.

What Are the Symptoms of a Flare-Up?

Everyone’s flare-ups are different. Some are mild. Others are severe.

During a flare-up, you’ll get new symptoms, or the ones you already have will get worse.

You might have one or more of these problems:

What Causes Flare-Ups?

Flare-ups happen when inflammation in your nervous system damages the layer that covers and protects nerve cells. This slows or stops nerve cell signals from getting to the parts of your body where they need to go.

If you have relapsing-remitting MS, you may have flare-ups followed by symptom-free periods called remissions. To be a true relapse, the symptom must start at least 30 days after your last flare-up and should stick around for at least 24 hours.

Certain things can start a relapse. Everyone’s triggers are different. Learn what brings on your symptoms so you can avoid them. Triggers include:

• Infection (viral or bacterial)
• Fever
• High body temp (from hot sun, illness, and other causes)
• New medications
• Too much exercise or activity
• Stress 

How to Prevent Flare-Ups

Take your medicines. The drugs your doctor prescribes slow your MS from getting worse and help prevent relapses. If you have side effects, don’t just stop taking them. Ask your doctor about other options.

Stay healthy. A bout of cold or flu can set off your MS symptoms. A bladder infection can trigger a flare-up, too. Wash your hands with warm water and soap during the day, get your yearly flu shot, and avoid people who look sick. Stay hydrated. Ask your doctor for other ways to avoid bladder infections.

If you smoke, quit.  It’s bad for you in so many ways, and it can make your MS symptoms worse. Talk to you doctor about ways to break the habit.

Continued

Relax. In some people, stress can bring on a relapse. Chill out with meditation, yoga, or anything else that’s good for you and helps you unwind.

Rest. You won’t feel well when you’re worn out. Sleep problems are common in people with MS. Symptoms like pain and muscle spasms can keep you up at night. Some of the medicines that treat MS interrupt sleep, too. Work with your doctor to get your symptoms under control so you can sleep. Adjust your medicines if they keep you awake.

Ways to Treat a Flare-Up

Your symptoms might go away on their own if they’re mild. Even so, let your doctor know what’s going on.

Treating symptoms can shorten your flare-ups and help you recover faster. The goal is to bring down the inflammation that caused your symptoms.

Your doctor will likely prescribe a steroid drug. Steroids curb inflammation and can help you get over a relapse faster. But they can’t undo the damage that’s been done or slow the disease. Methylprednisolone is the most common steroid used for this. You might take it as tablets or get it through an IV in a hospital or your doctor’s office.

Some people can’t take steroids. Others are bothered by side effects, which include weight gain, mood changes, trouble sleeping, and upset stomach. Another option is ACTH gel (Acthar gel). It’s injected into your muscle or under the skin. ACTH triggers your adrenal gland to release hormones that bring down inflammation.

For a very severe flare-up that doesn’t get better with steroids, you can try plasma exchange. First, a health care professional will take some of your blood. The liquid part, called plasma, is taken out. It’s replaced with a substitute plasma fluid or with plasma from a donor. Then, the blood is returned to your body.

During a relapse, you might feel more tired than usual. Try to get enough rest. Also avoid heat, which can make your symptoms worse.

What to Do After a Flare-Up

You can recover fully after a relapse, but it might take weeks or months to get over all your symptoms. If you had a lot of nerve damage, some symptoms might not fully go away.

You may need extra help to get back to your normal life. A rehab program can put you back on track. Your rehab team will help you with:

• Exercise
• Speech
• Dressing and personal care
• Movement
• Home chores
• Problems with thinking and memory

If you also see a neurologist (a doctor who specializes in problems with your brain, spinal cord, or nerves) for your MS, let them know about your flare-up. It could affect which medicines they prescribe for you.

Flare-ups in Multiple Sclerosis – Multiple Sclerosis News Today

Multiple sclerosis (MS) flare-ups are distinct, sudden episodes of either new symptoms or a worsening of existing symptoms. They are characteristic in  relapsing-remitting MS (RRMS), which is marked by recurrent acute flares (relapses) followed by partial or complete recovery (remission).

Approximately 85 percent of all MS patients are diagnosed initially with RRMS. The remaining 15 percent have what is called primary-progressive MS (PPMS), and undergo a gradual physical decline with no noticeable remissions.

Characteristics of MS flare-ups

A flare-up may consist of one or more symptoms that last for at least 24 hours and up to weeks or months. To be a flare-up symptoms must be specific to MS and not due to other factors, such as an infection. Two distinct flares-ups are separated by a remission period of at least 30 days.

Flare-ups also are known as attacks, relapses, episodes, or exacerbations.

The underlying mechanism of a flare-up is the immune attack on the myelin sheath (outer insulating layer on nerve fibers), which causes slow or interrupted neuronal signals in the brain and spinal cord. This results in flare-up symptoms such as problems with balance, coordination, eyesight, bladder function, memory or concentration, mobility, fatigue, weakness, numbness or needle-like sensations. Remission occurs when acute inflammation decreases.

Flare-ups could be triggered by various factors such as stress, infections, or pregnancy and symptoms may vary from mild to severe.

Managing relapses

Mild symptoms such as fatigue, numbness, and needle-like sensations could be left to subside and may need no treatment.

For severe flare-ups such as vision loss, extreme weakness, and poor balance that interfere with patients’ everyday activities, experts recommend a short-course with high-dose of corticosteroids. These facilitate recovery from a relapse by reducing inflammation, but do not affect the course of the disease. The most common treatment regime is a three-to-five day course of intravenous Solu-Medrol (methylprednisolone). Oral Deltasone (prednisone) also may be used.

Steroid treatment works best if started immediately after the onset of the flare-up. However, steroids have side effects that may include increased appetite, weight gain, high blood pressure, and thinning of bones.

For MS patients who do not tolerate the side effects of high doses of corticosteroids, or who have been treated unsuccessfully with corticosteroids, H.P. Acthar Gel (adrenocorticotropic hormone, ACTH) is used as a second-line therapy. Acthar Gel is administered via under the skin (subcutaneously) or into a muscle self-injection.

Plasmapheresis, a blood-cleansing method to remove the myelin-attacking antibodies from the blood, is another option for treating severe relapses that do not respond to the standard steroid treatment.

Patient rehabilitation aims to restore the essential everyday functions after a relapse. It combines different approaches, including physiotherapy, dietary advice, employment services, and support at home. The rehabilitation team can help the patient with difficulties in swallowing, mobility, dressing, personal care, and office work.

Recovery from a relapse may take weeks or months, with symptoms disappearing partially or completely. 

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Multiple Sclerosis News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.

Relapsing-Remitting Multiple Sclerosis | Johns Hopkins Medicine

What is relapsing-remitting multiple sclerosis?

In multiple sclerosis (MS), the central nervous system, which includes the brain and spinal cord, becomes damaged. MS causes the immune system to attack the myelin, which is the insulation protecting the nerves. The nerves themselves can also be damaged. When myelin or the nerves become damaged, nerves cannot properly pass along their signals. The damaging process forms scar tissue called sclerosis, which gives the disease its name of multiple sclerosis.

Different types of MS affect people in different ways. One type is called relapsing-remitting MS. With this type, you have flare-ups of the disease, or relapses. Between these flare-ups, you have periods of recovery, or remissions.

Most people diagnosed with MS start off with the relapsing-remitting type. In most cases, the course of the disease changes after a few decades and is then likely to become steadily worse.

MS most often develops in people in their 20s and 30s. Women are twice as likely to have MS as men.

What causes relapsing-remitting MS?

Multiple sclerosis occurs when your body’s immune system attacks the central nervous system, damaging the myelin that protects nerve fibers. Experts believe that environmental factors trigger the disease in people whose genetics make them susceptible to MS.

Who is at risk for MS?

• Scientists think MS may be caused by an infection that lays dormant in the body such as Epstein-Barr Virus (the virus that causes infectious mononucleosis)

• Scientists also think there may be a genetic susceptibility for some people

• Cigarette smoking appears to increase risk

What are the symptoms of relapsing-remitting MS?

These are often the earliest symptoms of MS:

• Trouble seeing

• Sensitivity to heat

• Numbness, especially in the feet

• Weakness

• Fatigue

• Difficulty thinking clearly

• Depression

• Needing to urinate urgently

• Trouble with balance

• Lack of coordination

Relapsing-remitting MS is marked by relapses that last at least 24 hours. During a relapse, symptoms get worse. A relapse will be followed by a remission. During a remission, symptoms partly or completely go away.

How is relapsing-remitting MS diagnosed?

Healthcare providers use many tests to help diagnose MS. Your healthcare provider will ask you questions about your symptoms. It’s important to rule out other diseases that can cause similar symptoms.

Your healthcare provider will also check to see how well your vision, your sense of balance, and other functions are working. You will need an MRI scan of your brain and spine. This may find areas of damage in your brain or spinal cord that suggest you may have MS.

Another possible test measures what’s called visual evoked potentials. Painless electrodes placed on your scalp measure how your brain responds to things you see.

Your healthcare provider may want to check your blood for other signs of disease. He or she may also order a test called a spinal tap (also called a lumbar puncture) to look at a sample of your spinal fluid.

How is relapsing-remitting MS treated?

MS is not considered curable, but different types of medicine are available to decrease inflammation and slow down the progression of the disease. These medicines include:

• Beta-interferon

• Glatiramer acetate

• Monoclonal antibodies

• Dimethyl fumarate

• Fingolimod

Other medicines can be prescribed to treat:

• Muscle spasms

• Urge to urinate

• Depression

• Erectile dysfunction

• Fatigue

Your healthcare provider may also suggest steroids to reduce symptoms during flare-ups. If steroids are not effective your healthcare provider may recommend plasmapheresis, a blood cleansing procedure.

What are the complications of relapsing-remitting MS?

In most cases, relapsing-remitting MS is mild, although you may need to use a cane or other mobility device. In some cases, the disease is severe and causes the inability to care for yourself. Seldom does it cause death.

Living with relapsing-remitting MS

If you have relapsing-remitting MS, you can take steps to manage your condition.

• Physical therapy may help relieve muscle spasms.

• Eat a diet low in saturated fat and trans-fat. Eat more foods with healthy omega-3 fatty acids because these nutrients are believed to fight inflammation.

• Talk with a counselor to help with depression.

• Avoid situations that cause you to become overheated.

• Avoid smoking.

• Get a moderate amount of exercise and enough sleep.

Key points about relapsing-remitting MS

• Multiple sclerosis affects young people in their 20’s and 30’s.

• MS affects the way your muscles and eyes work.

• Although there is no cure, medicines can help you manage your symptoms.

• Adopting a healthy life-style can also help you manage your disease.

• Avoiding overheating or other triggers can prevent flares of MS.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.

• Before your visit, write down questions you want answered.

• Bring someone with you to help you ask questions and remember what your provider tells you.

• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.

• Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.

• Ask if your condition can be treated in other ways.

• Know why a test or procedure is recommended and what the results could mean.

• Know what to expect if you do not take the medicine or have the test or procedure.

• If you have a follow-up appointment, write down the date, time, and purpose for that visit.

• Know how you can contact your provider if you have questions.

What is it and how to cope

Multiple sclerosis is a condition that results in nerve damage. People with multiple sclerosis sometimes experience exacerbations where old symptoms get worse or new ones develop.

In multiple sclerosis (MS), a person experiences an abnormal immune response. The body attacks the protective covering around the nerve fibers, disrupting communications from the brain.

This can potentially cause permanent nerve damage and disability.

Estimates vary as to how many people MS affects. The National Institutes for Neurological Diseases and Stroke (NINDS) estimate that 250,000–350,000 people in the U.S. have MS, but they note that it is difficult to know the exact number. The National Multiple Sclerosis Society put the number closer to 1 million.

In this article, we look at the different types of MS exacerbations or relapses and how to recognize and manage them.

Share on PinterestMS exacerbations can be debilitating, but preparing for them can help preserve quality of life.

Knowing when an exacerbation or relapse is taking place is critical, as receiving treatment early on can help reduce the impact of an exacerbation on everyday living.

A new MS exacerbation would have the following criteria:

• Previous symptoms have become more severe, or new symptoms have started growing evident.
• Symptoms have persisted for longer than 24 hours. More commonly, symptoms last for weeks or even months.
• A period of 30 days must have passed since the start of the previous relapse.
• A healthcare professional has ruled out other possible causes for flare-ups, including infections, heat, and stress.

Certain flare-ups of symptoms can occur for a variety of reasons, but these typically resolve without active treatment and would not qualify as exacerbations.

Examples include:

• Symptoms getting worse in high or low temperatures that resolve after moderate temperature resumes.
• Daily fluctuations in symptoms that may vary without reason, or might occur due to fatigue or stress.
• A mild bout of infection that makes symptoms worse without triggering a full relapse, such as a stomach bug.

Common relapse symptoms

The most common symptoms of MS that occur during a relapse include:

• balance, coordination, and dizziness issues
• fatigue
• vision problems
• bladder weakness
• leg or arm weakness
• numb sensations
• pins and needles
• reduction in mobility
• memory and concentration issues

Some relapses are mild and do not severely impede on daily functioning. Others will require hospitalization.

Triggers

Share on PinterestCertain vaccines, such as those containing live pathogens, might trigger MS exacerbations in people who have the disease.

Possible triggers of an MS exacerbation can include:

• Infection: Viral, bacterial, and fungal infections may trigger an MS exacerbation. People with MS may wish to take steps to reduce their risk of infection, such as avoiding people with colds.
• Vaccinations: Certain vaccines may have links to triggering an MS relapse. Doctors do not recommend some vaccines for people with MS, such as those shots that contain live pathogens, including the vaccines for shingles and yellow fever.
• Childbirth: Exacerbations might occur during the time just after childbirth in some women who have MS. Breastfeeding may offer some protection, however.
• Vitamin D deficiency: Low levels of vitamin D can contribute to the risk of MS exacerbations. People with MS should regularly monitor vitamin D levels and boost them when appropriate.

Common symptoms of MS can include:

• limb numbness or weakness
• pain
• tingling or itching
• tremors, unsteadiness, or coordination problems
• partial or complete loss of vision
• double vision
• headache
• breathing or swallowing difficulties
• slurring of speech
• tiredness
• dizziness
• bowel and bladder problems
• sexual problems
• emotional disturbances, such as depression and mood swings
• changes in thinking and concentration
• seizures
• hearing loss

During exacerbations, these will start to flare or get worse. Depending on the type of MS, these will either recover during a remission period or become permanent.

Exacerbations work differently in each type of MS.

Clinically isolated syndrome

Clinically isolated syndrome (CIS) is the first episode of central nervous system inflammation and damage to the protective coating of nerve cells. It produces symptoms that last for at least 24 hours.

People with CIS sometimes develop brain lesions typical of people with MS. These lesions usually suggest a higher risk of developing relapsing-remitting MS (RRMS). Brain lesions are scars, and they usually show up on MRI scans.

Not all people with CIS develop MS. However, since 2017, diagnostic criteria have indicated specific findings on an MRI that suggest earlier damage in a different location in the brain, as well as active inflammation in a region that is not causing the episode of symptoms.

People who have CIS without these brain lesions have a lower risk of developing MS. High-risk CIS patients who receive early treatment may experience a delay in developing MS.

Relapsing-remitting multiple sclerosis

People who have a diagnosis of RRMS will often experience exacerbations. These have a clear start and end point. Symptoms will recover either partially or fully outside of these attacks.

Sometimes all symptoms improve, but specific symptoms may persist and become permanent during other times.

During remission, MS will not often progress. These periods of recovery might last for months or years. Relapses will often lead to changes in MRI results as new brain lesions occur.

RRMS is the most common type of MS, making up 85 percent of initial diagnoses for MS.

Primary progressive MS

Primary progressive MS, or PPMS, is an escalating type of MS that gets worse from the start of any symptoms without any early remissions or relapse. Symptoms may go through periods of not being active or not progressing, but they do not get better.

Exacerbations do not often occur in PPMS, as the symptoms get worse without remission.

Around 15 percent of people with MS have the PPMS form of the condition.

Secondary progressive MS

This form of MS, which specialists abbreviate to SPMS, is a progressive condition.

It usually starts with a period of RRMS that later develops into a type in which brain and nerve function become gradually worse without periods of remission. People are more likely to experience exacerbation during this initial episode of RRMS.

Every person’s experience with RRMS, PPMS, and SPMS will be different, with varying symptoms escalating at different rates.

No single test can diagnose MS. Doctors use many different tests to rule out other causes of a person’s symptoms.

Symptoms must meet specific criteria for a doctor to make a diagnosis of MS. The National Multiple Sclerosis Society define the criteria as:

• at least two separate areas of damage in the central nervous system
• evidence that the above damage occurred at least one month apart
• the ruling out of all other possible causes

Some of the tests that doctors may use to help identify MS include:

• MRI scanning
• spinal tap to obtain spinal fluid samples
• evoked potentials, or measurements of the brain’s electrical activity response to nerve stimulation
• certain blood serum tests

Share on PinterestYour employer should make adjustments to the workspace to accommodate developing MS symptoms.

People experiencing an exacerbation might find that they need to make adjustments in their personal lives to allow for a relapse to pass as comfortably as possible.

These include:

Home life and chores: Less mobility and fatigue can reduce a person’s ability to complete all their usual tasks around the home. Ask friends or family for help with daily chores and tasks. Alternatively, short-term home care can provide support.

Emotional impact: An MS relapse can take a toll on emotional well-being. Exacerbations might occur without warning, causing frustration, anger, and anxiety about the future and leading to similar feelings in the people around the individual with MS.

Relapses can lead to concerns about work and relationships, as well as sleep issues due to medications and physical pain.

Know that the feelings during an exacerbation are not forever and will become easier once symptoms pass or improve.

Work: When possible and necessary, during a relapse, take time off work. If this is not possible, then an individual can talk to their manager about working fewer hours or having a more flexible arrangement.

Cognitive difficulties: During an exacerbation, thoughts might be slower and concentration difficult.

These effects might be due to the stress of a relapse being overwhelming but can also be a direct effect of the exacerbation. Doctors refer to this as a cognitive relapse.

While these symptoms will often pass, people may wish to seek support from an occupational therapist or neuropsychologist. They will be able to help the individual manage the cognitive effects of an MS exacerbation.

The following actions might also help a person prepare for the effects of an exacerbation:

• Keeping track of daily MS symptoms plus physical or cognitive changes in a symptom log.
• Having a dedicated emergency contact to call if a relapse occurs, and a contingency plan in case they do not respond.
• Developing a support network, having a list of people who can assist with more difficult tasks, and opening a dialogue about needing help at times.
• Knowing the sick leave and return-to-work policy for your employer, or the benefits to which self-employed people are entitled if they cannot work for health reasons.
• Having a supply of everyday essentials, including milk and food with long expiry dates, toiletries, and easy meals.

People may or may not need treatment for exacerbations, as most mild symptoms, such as fatigue, may resolve without intervention.

In more severe cases, medications that doctors use to treat exacerbations include high-dose oral and intravenous (IV) methylprednisolone. Methylprednisolone is a steroid that can help reduce inflammation.

Another option for treating MS exacerbations is plasmapheresis, or a plasma exchange. During this therapy, the medical team separates plasma from the blood cells, mixes it with a water-soluble protein called albumin, and introduces it back into the body.

People with MS should speak to their healthcare team, and gauge the best treatment approach for their MS exacerbations. Physical rehabilitation programs may also provide benefit.

Treatment for MS

No full cure for MS currently exists. However, a range of treatments can help recovery during relapses, slow the progression of the disease, and help manage symptoms.

Treatment of MS includes the use of medications, rehabilitation, and complementary and alternative therapies.

The United States Food and Drug Administration (FDA) have approved several medications for treating the various forms of MS.

Medications for injection include:

• interferon beta-1a (Avonex, Rebif)
• interferon beta-1b (Betaseron, Extavia)
• glatiramer acetate (Copaxone)
• glatiramer acetate, a generic equivalent of Copaxone 20 milligram dose (Glatopa)
• peginterferon beta-1a (Plegridy)

Oral medications include:

• teriflunomide (Aubagio)
• fingolimod (Gilenya)
• dimethyl fumarate (Tecfidera)
• siponimod (Mayzent)
• cladribine (Mavenclad)

Infused medications include:

• alemtuzumab (Lemtrada)
• mitoxantrone (Novantrone)
• natalizumab (Tysabri)

Various treatment options are available for the different symptoms of MS. Doctors will customize treatment, depending on the specific symptoms that the individual with MS is experiencing.

A person with MS can include rehabilitative interventions in their treatment plan to help with everyday tasks. These services typically include physical, occupational, vocational, and cognitive therapies, as well as speech-language pathology services.

In addition to mainstream MS treatment, some people may find complementary alternative therapies useful. These include the use of acupuncture, diet modification, massage, exercise, yoga, meditation, and stress management.

The American Academy of Neurology advise that medical marijuana might also help treat some symptoms of MS-related pain and muscle problems.

Q:

What are the earliest signs of MS?

A:

The earliest signs of MS are most commonly disturbances in a person’s vision. These signs could involve loss of vision or double vision.

Answers represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.

Identifying MS Attack Symptoms | Shepherd Center

Learn more About MS Attack, Relapses and Flare Ups

Most forms of multiple sclerosis (MS) involve stretches of time when you feel good and other times when your symptoms act up. You might hear those worse periods called:

• Attacks
• Relapses
• Flare-ups
• Episodes
• Exacerbations

What is an MS attack?

An exacerbation of MS causes new symptoms or the worsening of old symptoms. It can be very mild, or severe enough to interfere with a person’s ability to function at home and at work. No two exacerbations are alike, and symptoms vary from person to person and from one exacerbation to another.

Some relapses produce only one symptom (related to inflammation in a single area of the central nervous system), while other relapses cause two or more symptoms at the same time (related to inflammation in more than one area of the central nervous system). To be a true exacerbation, the attack must last at least 24 hours and be separated from the previous attack by at least 30 days.

Most exacerbations last from a few days to several weeks or even months.

MS Attack Symptoms

During an attack, a person may experience new or worsening common MS symptoms. These symptoms can include:

• Fatigue
• Dizziness
• Problems with balance and coordination
• Trouble with your vision
• Issues with your bladder
• Numb or tingling feelings (pins and needles)
• Problems with your memory
• Trouble concentrating

MS Institute Information & Appointments

At Shepherd Center, multiple sclerosis treatment is specific to the individual’s needs and goals. Submit a request for more information about the MS Institute at Shepherd Center to learn about our MS treatment and services.

Call us directly to get specific information, schedule an appointment, or plan a visit:

Phone: 404-352-2020
Hours: 8:30 a.m. – 4 p.m. Monday – Friday

New patients may also download a form, complete it and follow the instructions on the form for submitting it to the MS Institute.

Download New Patient Referral Form

Symptoms, Causes, Diagnosis & Treatments

Overview

What is multiple sclerosis (MS)?

Multiple sclerosis (MS) is an autoimmune disease. With these conditions, your immune system mistakenly attacks healthy cells. In people with MS, the immune system attacks cells in the myelin, the protective sheath that surrounds nerves in the brain and spinal cord.

Damage to the myelin sheath interrupts nerve signals from your brain to other parts of your body. The damage can lead to symptoms affecting your brain, spinal cord and eyes.

There are four types of multiple sclerosis:

• Clinically isolated syndrome (CIS): When someone has a first episode of MS symptoms, healthcare providers often categorize it as CIS. Not everyone who has CIS goes on to develop multiple sclerosis.
• Relapsing-remitting MS (RRMS): This is the most common form of multiple sclerosis. People with RRMS have flare-ups — also called relapse or exacerbation — of new or worsening symptoms. Periods of remission follow (when symptoms stabilize or go away).
• Primary progressive MS (PPMS): People diagnosed with PPMS have symptoms that slowly and gradually worsen without any periods of relapse or remission.
• Secondary progressive MS (SPMS): In many cases, people originally diagnosed with RRMS eventually progress to SPMS. With secondary-progressive multiple sclerosis, you continue to accumulate nerve damage. Your symptoms progressively worsen. While you may still experience some relapses or flares (when symptoms increase), you no longer have periods of remission afterward (when symptoms stabilize or go away).

How common is multiple sclerosis (MS)?

Nearly 1 million adults in the U.S. are living with multiple sclerosis. MS commonly affects more women than men. Most people with MS receive a diagnosis between the ages of 20 and 40.

Symptoms and Causes

What causes multiple sclerosis (MS)?

Experts still don’t know for sure what causes multiple sclerosis. Research is ongoing to help identify what causes the disease. Factors that may trigger MS include:

• Exposure to certain viruses or bacteria: Some research suggests that being exposed to certain infections (such as Epstein-Barr virus) can trigger MS later in life.
• Where you live: Your environment may play a role in your risk for developing MS. Certain parts of the world have significantly higher rates of the disease than others. Areas farther from the equator have higher rates of MS. That may be because these regions receive less intense sun. People who get less sun have lower levels of vitamin D, a risk factor for developing MS.
• How your immune system functions: Multiple sclerosis is an autoimmune disease. Researchers are working to figure out what causes some people’s immune cells to mistakenly attack healthy cells.
• Gene mutations: Having a family member with MS does increase your risk of the disease. But it’s still unclear exactly how and which genes play a role in triggering multiple sclerosis.

What are the symptoms of multiple sclerosis?

Vision problems — such as optic neuritis (blurriness and pain in one eye) — are often one of the first signs of multiple sclerosis. Other common symptoms include:

• Changes in gait.
• Fatigue.
• Loss of balance or coordination.
• Muscle spasms.
• Muscle weakness.
• Tingling or numbness, especially in your legs or arms.

What are the complications of multiple sclerosis?

If MS progresses, worsening symptoms may lead to complications such as:

• Difficulty walking that may result in needing a cane, walker or wheelchair.
• Loss of bowel or bladder control.
• Memory problems.
• Sexual difficulties.

###

Diagnosis and Tests

Who diagnoses multiple sclerosis (MS)?

Many conditions could cause similar neurological symptoms. Getting an accurate diagnosis is sometimes difficult. Some people see multiple providers over years before receiving a diagnosis. While the search can be frustrating, it’s important to keep looking for answers. Identifying and treating MS as soon as possible can help slow the disease’s progression.

If your primary care provider suspects you may have MS, you will need to see a neurologist. A neurologist is a doctor who specializes in treating conditions that affect the nervous system, which includes your brain and spinal cord.

How is multiple sclerosis diagnosed?

No one test can provide a definitive MS diagnosis. To understand what’s causing symptoms, your healthcare provider will do a physical exam. You may also have blood tests and imaging tests, such as MRI. An MRI looks for evidence of lesions (areas of damage) in the brain or spinal cord that indicate multiple sclerosis. Lesions develop as a result of damage to the myelin sheath surrounding the nerves. A spinal tap (lumbar puncture) may also need to be done.

If these tests don’t provide a clear answer, your neurologist may recommend an evoked potentials test. This test checks your nerve function by measuring electrical activity in the brain and spinal cord.

Management and Treatment

How is multiple sclerosis (MS) managed or treated?

There is currently no cure for MS. Treatment focuses on managing symptoms, reducing relapses (periods when symptoms worsen) and slowing the disease’s progression. Your comprehensive treatment plan may include:

• Disease-modifying therapies (DMTs): Several medications have FDA approval for long-term MS treatment. These drugs help reduce relapses (also called flare-ups or attacks). They slow down the disease’s progression. And they can prevent new lesions from forming on the brain and spinal cord.
• Relapse management medications: If you have a severe attack, your neurologist may recommend a high dose of corticosteroids. The medication can quickly reduce inflammation. They slow damage to the myelin sheath surrounding your nerve cells.
• Physical rehabilitation: Multiple sclerosis can affect your physical function. Staying physically fit and strong will help you maintain your mobility.
• Mental health counseling: Coping with a chronic condition can be emotionally challenging. And MS can sometimes affect your mood and memory. Working with a neuropsychologist or getting other emotional support is an essential part of managing the disease.

Prevention

How can I prevent a multiple sclerosis flare-up?

Disease-modifying therapies are the most effective way to reduce the number of flare-ups (also called relapses or attacks) you experience. Leading a healthy lifestyle is also important. The choices you make can help slow disease progression. Good care can also lessen your symptoms and improve your quality of life.

Lifestyle changes that can improve your condition include:

• Eating a healthy diet: There is no magic MS diet. Experts recommend a balanced diet that includes lots of fruit and vegetables, whole grains, healthy fats and lean protein. You should also limit your intake of added sugars, unhealthy fats and processed foods.
• Getting regular exercise: Multiple sclerosis can cause muscle weakness, loss of balance and difficulty walking. Aerobic exercise, flexibility and strength training are essential to help keep muscles strong and maintain physical function.
• Managing stress: Stress can take a physical and emotional toll. It can also interfere with sleep, which can worsen MS-related fatigue. It’s important to find ways to manage stress — such as yoga, meditation, exercise, and working with a mental health provider.
• Not smoking and limiting alcohol intake: Smoking and alcohol are linked to worsening MS symptoms and could speed the disease’s progression. Quitting smoking will support your health.

Outlook / Prognosis

What is the prognosis (outlook) for people with multiple sclerosis (MS)?

In some cases, multiple sclerosis does lead to disability and loss of some physical or mental function. But thanks to advances in treatment, most people with MS will continue to lead full, active and productive lives. Taking steps to manage your health and lifestyle can help improve your long-term outcome.

Is it common for people with multiple sclerosis (MS) to experience depression?

Depression is very common in people with multiple sclerosis (MS). In fact, symptoms of depression severe enough to require medical intervention affect up to half of all people with MS at some point during their illness.

Depression may be the result of a difficult situation or stress. It is easy to understand how having MS, with its potential for progressing to permanent disability, can bring on depression.

Depression might be actually caused by MS. MS may affect the insulating myelin that surrounds nerves which transmit signals affecting mood.

Depression is also a side effect of some drugs used to treat MS, such as steroids or interferon.

How does heat or humidity impact people with multiple sclerosis (MS)?

Heat or high humidity can cause many people with MS to experience a temporary worsening of their symptoms. Doctors believe that this occurs because heat causes nerves (whose myelin covering has been removed by MS) to conduct electrical signals even less efficiently.

For reasons that are not well understood, extremely cold temperatures and changes in temperature can also cause MS symptoms, usually spasticity (muscle stiffness), to flare.

###

Living With

When should I call the doctor?

You should call your healthcare provider if you experience:

• Feeling overly sensitive to heat.
• Feeling unsteady or off balance.
• Memory problems.
• Numbness or tingling, especially in your arms or legs.
• Sudden vision changes.
• Weakness in your arms or legs.

What questions should I ask my doctor?

You may want to ask your healthcare provider:

• How do we know for sure that I have multiple sclerosis and not another neurological condition?
• Do I need to start taking disease-modifying therapy medication?
• What are the benefits and risks of various DMTs?
• Will I need to stay on medication for the rest of my life?
• What lifestyle changes can I make to help manage MS?

A note from Cleveland Clinic

Multiple sclerosis is a disease that affects the central nervous system (brain, spinal cord and optic nerves). It is an autoimmune disease that causes your immune cells to mistakenly attack your healthy nerve cells. These attacks lead to inflammation and damage to the myelin sheath that covers and protects your nerve cells. This damage causes neurological symptoms — such as loss of balance, vision problems and muscle weakness. Several effective treatments exist for MS. These medications reduce relapses and help slow the progression of the disease. Most people with MS are able to manage their symptoms and lead full, active lives.

Managing relapses | MS Trust

If you’re going through a relapse, it’s important to bear in mind that it will usually settle down of its own accord. It’s likely that you will feel unwell and more tired than usual while you’re recovering from your relapse. This can have an impact both at home and at work.

Home life

You might find you’re not able to do all the household tasks that you’d normally undertake. Try to be kind to yourself and keep within your limits while you’re recovering. Consider asking for some help from family and friends while you’re recovering – perhaps help with the shopping, washing up or collecting children from school could make all the difference. Asking for help can be one of the hardest things to do but the chances are that your family and friends really want to help and perhaps just aren’t sure what they should offer to do – so talk to them!

If you need additional support, talk to your MS nurse. If you are struggling more than usual it may be possible to arrange some social services support, just to help in the short-term. Organisations such as Home Start may also be able to help you cope with family life.

Work

You may need to reduce your working hours or take time off work while you’re recovering.

Taking time off work isn’t easy or always possible and some people with MS have no alternative but to continue to work during a relapse, which can be difficult. If this is the case, it may help to let your manager or supervisor know that you’re having a relapse. It may be possible to arrange for you to work from home, temporarily reduce your hours, take some flexi-time or have longer or more flexible breaks during your working day depending on your needs. Under the Equality Act, if you’ve been diagnosed with MS you’re entitled to ask your employer to make reasonable adjustments to help you remain in work.

If you’ve had to stop working for a period of time, it’s a good idea to stay in regular contact with your manager or supervisor rather than just sending in the required paperwork. Keeping people informed will give you the opportunity to talk things through and discuss the best solution for everyone. When you’re planning your return to work, it may be helpful to request a phased return, slowly building up the number of hours/days that you work over a period of time. 

More information about working with MS

Feeling emotional

Relapses can take you by surprise and the symptoms can be difficult to deal with. This can trigger reactions such as anger that this has happened to you at this particular time, or you may feel that you should’ve been able to avoid the relapse. You might also have concerns about what the future holds for you or be concerned about the impact that MS will have on your relationships or your work. It’s normal to feel emotional, depressed or worried in this situation but try to remember that these feelings won’t last forever. If they do become overwhelming, you could make an appointment to discuss your concerns with your GP or MS nurse.

If you are finding it hard to sleep well, you may find it more difficult to deal with everyday situations which wouldn’t usually be a problem.

Some medications, including steroids, can also have an impact on your emotions.

Relapses could also have an impact on people close to you. Your family and friends may experience a range of emotions such as anxiety, guilt or anger. Being aware that they may have these feelings during a relapse, and that it’s a completely normal reaction, can help all of you to manage.

Thinking processes affected

Because a relapse is often stressful, many people can feel distracted and a bit overwhelmed and may have problems thinking through complex tasks. These thinking problems are fairly common during a relapse but should become less of an issue as you recover.

During some relapses, you may have more obvious problems with thinking. You may find that your speed of thinking is slower and that you have trouble concentrating. If these symptoms have come on quite suddenly, it’s possible your relapse is directly affecting your thinking processes – this is called a cognitive relapse.

These symptoms will usually settle down. If they interfere with your ability to do important tasks, an occupational therapist or neuropsychologist can work with you to develop strategies to help you manage. You’ll find all sorts of tips and tricks to help with cognitive symptoms on the MS Trust website Staying Smart.

90,000 Premenstrual Syndrome: Neurological Aspects | Kurushina O.V., Miroshnikova V.V., Barulin A.E.

The article is devoted to the neurological aspects of premenstrual syndrome

Premenstrual syndrome, or PMS. How often do we now hear these words from the TV screen or use them in everyday conversations. Sometimes this is a reason for jokes and ridicule, sometimes – a way of caustically pricking the interlocutor. We are almost used to such a frivolous, non-medical approach to PMS.In fact, this state does not always manifest itself in emotional outbursts, incontinence, and aggressive behavior.
From the point of view of medicine, PMS is a syndromic complex characterized by a variety of psychoemotional, neurovegetative, metabolic endocrine symptoms that appear 2-14 days before menstruation. The complete disappearance of symptoms is observed with the onset of menstruation, and relief is maintained for at least 7 days, so there is an asymptomatic week after the end of menstruation.In addition, premenstrual changes must be confirmed at least during two consecutive menstrual cycles [1].
Officially, the “year of birth” of the diagnosis of “premenstrual syndrome” is 1931, when in the neurological journal R. Frank published an article “Hormonal causes of premenstrual tension”. But it would be wrong to believe that this was the discovery of this disease. Even Hippocrates in his writings described the fluctuations in the mood and behavior of women, depending on the lunar cycle.Cyclic symptoms in women are also mentioned in the Ebers papyrus, the oldest medical document.
But scientific research into the nature of these states began only in the twentieth century. Russian researchers E.I. Landa (1908) and I.V. Voitsekhovsky (1909) demonstrated rhythmic fluctuations of neuropsychic activity in women, depending on the phase of the menstrual cycle. It is their work describing mood changes, depression, lethargy, depression and irritability that appears before menstruation that can be attributed to the first descriptions of PMS.Later, several works appeared describing endocrine, sexual, pain disorders in women during this period [2].
Currently, PMS is a multidisciplinary disease and a place where the interests of doctors of various specialties intersect: gynecologists, endocrinologists, neurologists, cardiologists and many others.
The presence of PMS in women interferes with their professional activities, training, habitual social activity, and interferes with interpersonal relationships. Its feature is clinical polymorphism and a close relationship with autonomic, emotional and motivational disorders.Psychological, social and biological factors play a role in the formation of this syndrome. With the progression of the disease, its transformation into a severe climacteric syndrome is possible, which must be taken into account when treating these patients [3].
The prevalence of PMS, according to domestic and foreign researchers, varies from 18 to 92%. This variability is due to the lack of a unified theory of etiopathogenesis, a clear classification of the clinical picture. In the last decade, interest in PMS has significantly increased in connection with new data on its occurrence at an early reproductive age.It has been established that the age of the highest vulnerability fluctuates between 25 and 35 years, that is, women of working age suffer, which further emphasizes the medical and social significance of this problem [4].
A number of studies have shown that PMS develops more often in women engaged in mental work, in patients with vegetative dystonia syndrome, and also 4 times more often in women with underweight. This syndrome can occur under the influence of various factors caused by physical or mental stress, professional problems, social insecurity, chronic emotional stress.As a result of their own research, the authors have demonstrated that the presence of complications such as prolonged labor, intrauterine hypoxia and fetal malnutrition in the perinatal period of development of women are unfavorable factors for the occurrence of incompetence of the hypothalamic-pituitary system, which subsequently transforms into PMS. In addition, it was revealed that the adverse factors are high infectious morbidity at the age of 5 to 7 years, the presence of extragenital diseases in patients (brain injury, diseases of ENT organs, appendectomy at prepubertal age) [2].
Some researchers emphasize that unrealized motherhood can be a provoking factor in the development of PMS.
Pathogenesis
The pathogenesis of PMS is complex and insufficiently studied, as evidenced by the existence of many theories that claim to explain it.
The first theories of the etiology of PMS were theories of psychological stress, since psychoemotional disorders are the most common symptoms. For a long time, PMS was considered the lot of urban women, and especially representatives of intellectual labor, but later this syndrome began to be found in residents of provinces and third world countries.
With the development of methods for determining hormones in blood plasma, there have been many assumptions about hormonal imbalance as a leading factor in the etiology of PMS. Thus, the founder of the hormonal theory R. Frank in 1931 suggested that PMS is caused by an excess level of estrogenic hormones. A number of researchers have noted in this disease an increase in the level of 17β-estradiol and a decrease in the level of progesterone in the luteal phase of the cycle. At the same time, along with a deficiency of progesterone, many authors found normal or even overestimated indicators of progesterone production in this category of patients [5].
The role of prolactin in the development of this syndrome complex is also controversial. For the first time in 1971, Horrobin proposed a possible role for prolactin in the onset of PMS. Soon after, studies appeared indicating an increase in prolactin levels in the luteal phase of the menstrual cycle in patients with this pathology. At the same time, an increase in the level of prolactin did not always lead to the development of PMS.
For a long time, there was a theory of “water intoxication” of the occurrence of PMS.Disturbances in the renin-angiotensin-aldosterone system were considered of great importance in the genesis of fluid retention in PMS [6].
The theory of psychosomatic disorders has many supporters. It is believed that a large role in the pathogenesis of PMS belongs to the girl’s attitude to menarche, the fear of the onset of menstruation due to ignorance, the girl’s attitude to her own psychosocial role, as well as the woman’s dissatisfaction with her intimate family life. However, other authors believe that somatic factors are of paramount importance, and mental ones follow biochemical changes resulting from neurohormonal disorders [7].
With the advent of methods for determining the secretion of prostaglandins, the theory of prostaglandin disorders became the dominant theory of PMS. Studying the levels of prostaglandins in PMS, Horrobin (1983) concluded that a deficiency of prostaglandin E1 can be clinically manifested by depression, and an excess can lead to affective disorders. The influence of prostaglandin E2 explains migraines, a pronounced neurotic component of PMS in some women, since prostaglandin E2 contracts intracranial and expands extracranial vessels [8].
A number of researchers attach importance to the lack of magnesium and vitamin B6 as a possible causative factor of PMS. Magnesium deficiency can lead to a selective deficiency of dopamine in the brain, which explains the symptoms of anxiety and irritability. In addition, magnesium deficiency causes hypertrophy of the glomerular adrenal cortex, which leads to an increase in aldosterone secretion and explains the syndrome of overhydration [9].
Theories of imbalance in the rhythms of serotonin and γ-aminobutyric acid (GABA) in the central nervous system and related peripheral neuroendocrine processes have been proposed as universal factors for all types of PMS.In scientific studies of the pathogenesis of PMS, considerable attention is paid to peptides of the intermediate lobe of the pituitary gland: α-melanostimulating hormone and endogenous opioid peptides – endorphins.
Proponents of the theory of disorders of the functional state of the autonomic nervous system (ANS), based on the predominance of the tone of the sympathetic division of the ANS in the second half of the menstrual cycle, believe that the onset and development of PMS is a consequence of excessive functional activity of the sympathetic nervous system.
Thus, many theories of the pathogenesis of PMS indicate that provoking factors should be considered not in opposition, but in interrelation and interdependence. The approach to the diagnosis and treatment of this syndrome must be comprehensive.
Clinical picture
Domestic clinicians, depending on the prevalence of a certain group of symptoms, conditionally distinguish several clinical forms of PMS: neuropsychic, edematous, cephalgic and crisis [10].
The clinical picture of the neuropsychic form of PMS is dominated by a variety of psychoemotional symptoms (irritability, depression, weakness, tearfulness, aggressiveness). If in young women with PMS depression prevails, then aggressiveness is noted in the transitional age.
The clinical picture of the edematous form of PMS is dominated by painful engorgement of the mammary glands, swelling of the face, legs, hands, bloating, irritability, sweating, itching of the skin, weight gain in premenstrual days.
The main symptom of the cephalgic form of PMS is headache of a different nature; a number of women have precursors of headache in the form of a feeling of anxiety, fear, irritability and excitability. Headache attacks are often accompanied by vegetative manifestations: nausea, pale skin of the face, increased sensitivity to light stimuli, less often – vomiting.
Among the various forms of headache in PMS, menstrual (catamenial) migraine (MM) is especially distinguished.Due to the lack of a clear definition, the recorded frequency of MM varies from 4 to 73%. According to the definition of the International Society for Headaches, MM is a migraine without an aura, if 70% of attacks occur in the period from 2 days before the onset of menstruation to its last day. The most accurate is the definition of Lignieres Smits (1995): “Attacks of a common migraine in the period from two days before the onset of menstruation to its last day, provided that there is no headache on other days of the cycle, attacks are regular, observed for at least 12 cycles” [eleven].
The clinical picture of a crisis form of PMS is characterized by vegetative paroxysms of a sympathoadrenal nature (“panic attacks”), which occur acutely, without precursors and are characterized by a paroxysmal increase in blood pressure, acute headache, chills, palpitations, a sense of fear of death and end with abundant secretion of light urine [12].
There are atypical forms of PMS: vegetative-dis-ovarian myocardial dystrophy, hyperthermic, hypersomnic forms, cyclical severe allergic reactions up to Quincke’s edema, ulcerative gingivitis and stomatitis, cyclic “bronchial asthma”, indomitable vomiting, etc.
Since pain syndrome of varying severity and localization is a frequent leading complaint of patients, it is advisable to isolate the algic form of PMS.
Diagnostics
The diagnosis of PMS is a diagnosis of exclusion, that is, in the process of a diagnostic search, the doctor’s task is to exclude somatic and mental diseases that may worsen before menstruation. A thoroughly collected life history and medical history, as well as a complete general somatic and gynecological examination are important.Age is not a significant factor, meaning that any woman between menarche and menopause can experience PMS symptoms. We have proposed an algorithm for the diagnosis of PMS, which focuses on the leading group of complaints and allows you to identify one form or another of this syndrome.
In addition, the leading role is assigned to self-diagnosis with keeping a diary of complaints during 3 menstrual cycles. Women are encouraged to rate complaints using a visual analogue scale, with a score of 1 to 10 points for each symptom.The presence of significant differences between the number and severity of complaints in the 1st and 2nd half of the menstrual cycle suggests that this patient is diagnosed with PMS.
Treatment
When treating PMS, the severity of symptoms should be guided by the severity of symptoms, but most women need to be prescribed drugs in combination with non-drug treatments.
There have been many studies on the effectiveness of psychological treatments. These include lifestyle changes (eg diet modification, relaxation, exercise) as well as special psychotherapeutic approaches (eg support groups and cognitive behavioral therapy) [13].
The need to include psychotherapeutic methods is based on the fact that women with PMS can negatively interpret the physiological changes taking place in the body. Repeated anticipation of negative experiences can increase feelings of anxiety and depression, especially against the background of existing psychosocial stressors. The expected somatic changes can disrupt normal adaptation mechanisms, which are considered by the patient as uncontrollable and further increase gloomy moods and anxiety, causing a feeling of imminent loss of control.The vicious circle of negative thoughts and self-deprecating behavior supports a maladaptive response to physiological changes. The use of a cognitive behavioral therapy model involves an attempt to find more adaptive ways to overcome premenstrual changes.
Relaxation training is a useful addition to a therapeutic package of psychotherapeutic techniques. But there is little research evidence to support its effectiveness in its own right. Exercise has been studied more rigorously.Women who exercise regularly are less likely to complain before menstruation. With prospective observation for 6 months. in women who are sedentary, exercise has been shown to have beneficial effects on mood, fluid retention, and breast tenderness. In a randomized controlled study of women with a confirmed PMS diagnosis, aerobics was also rated positively, with more intense exercise being more effective.
A modification of the diet is recommended: reducing the consumption of foods containing caffeine, alcohol, salt and refined sugar. Frequent consumption of carbohydrate-rich snacks can increase dietary tryptophan, which in turn increases serotonin synthesis. There is emerging evidence of the beneficial effects of increased pre-menstrual carbohydrate intake on mood and libido [14].
The use of various physiotherapy methods has also been studied.Along with procedures that reduce the severity of symptoms, such as massage, balneotherapy, pearl and pine baths, endonasal galvanization, mud applications, it is also possible to use transcranial electrical stimulation of endorphin brain structures (TES). Considering the multifaceted nature of the procedure, in particular the positive effect on the ANS, a significant decrease in the intensity of cephalgia, the effect on the emotional sphere, it seems promising to use the TES method for correcting algic manifestations and neurovegetative disorders in PMS patients [15].
Pharmacological correction of PMS can be divided into etiological and symptomatic.
All methods of suppressing natural cyclicity can be attributed to etiological therapy. This difficult type of therapy is the method of choice in the case of severe PMS, in particular with a crisis form, causing a long-term loss of the patient’s performance and leading to a significant deterioration in her health and quality of life.
Suppression of cyclic hormonal and biochemical processes is achieved by the appointment of hormone therapy (gonadoliberin agonists, antigonadotropins, combined oral contraceptives, gestagens).But one should take into account the fact that with prolonged blocking of natural hormonal cycling, side effects (adrenergic, moderately expressed androgenic and menopausal symptoms) may develop [16].
A milder variant of the etiological drug treatment of PMS is combined oral contraceptives containing highly selective third-generation gestagens. It is possible to prescribe drugs under the supervision of a gynecologist in a continuous mode for 3-4 months.nonstop. However, it should be remembered that this group of drugs is ineffective in the case of PMS symptoms in women taking these drugs for contraception [17].
In connection with the presence of absolute or relative hyperestrogenism in this condition, therapy with gestagens is indicated, which help to normalize psychoemotional disorders and reduce fluid retention in the body and are prescribed after examining the patient’s hormonal background [18].
For the pathogenetic therapy of the neuropsychic form of the disease (especially moderate and severe), antidepressants are used: selective serotonin reuptake inhibitors and selective serotonin and norepinephrine reuptake inhibitors.The use of tranquilizers can also be useful in the complex therapy of PMS. When choosing a tranquilizer, preference is given to drugs with a vegetative-correcting effect.
The complex therapy schemes traditionally include vitamins A, E, B6 (especially in combination with magnesium).
It should be noted that PMS therapy can be quite lengthy. It is advisable to carry out the treatment in cycles of 3-6 months. with a break of 3 months. [nineteen]. Given the insufficient knowledge of the pathogenesis of PMS and the lack of a drug that is effective against all symptoms of the disease at the same time, with a variety of cyclic therapy used, a positive result of treatment will depend on the patience of the doctor and the persistence of the woman herself.The low compliance of this category of patients, the lack of uniform standards for diagnosis and therapy, and the frivolous attitude of society towards the very existence of this medical problem make the treatment of PMS a difficult clinical task for the doctor. But its solution reduces the disability of patients, the percentage of interpersonal conflicts in society and, in general, makes it possible to change the quality of a woman’s life for the better.

.

what is, signs and symptoms, duration. How can you relieve premenstrual syndrome and reduce emotional swings?

PMS has long ceased to be an exclusively medical term.People who are ignorant tend to explain PMS to any relationship problems, frustration, irritability, and the complex nature of some women in general. However, PMS – premenstrual syndrome – is not only manifested by changes in mood. This is a complex set of symptoms, and all of them cause a lot of torment for women with PMS.

Signs of PMS

PMS is an insufficiently studied phenomenon and to some extent mysterious even for doctors. Most likely, for PMS to be pronounced, several factors must converge.There is no doubt that the main cause of PMS is monthly fluctuations in hormone levels, which cause a decrease in the production of certain neurotransmitters – in particular, endorphins, which are responsible for good mood.

However, things are not so simple. Not all women experience the effects of PMS on a regular basis, and some are not at all familiar with this phenomenon in their own practice. Others experience a full set of all symptoms on a monthly basis. Scientists believe that both genetics (identical twins, genetically identical, experience PMS equally) and lifestyle (an unbalanced diet and a lack of vitamins and minerals cause aggravation of symptoms) play a role.

Premenstrual syndrome appears 2-10 days before the onset of menstruation and usually stops with the first discharge. It is noticed that the older a woman is, the longer her PMS continues and the more pronounced it becomes.

Forms of premenstrual syndrome and their manifestations

Mood swings are far from the only sign of PMS. This condition can seriously affect both the psychological and physical condition of a woman.

Psychological symptoms of PMS:

• Anxiety, irritability, tearfulness, feeling of depression.
• Frequent and abrupt mood swings.
• Sleep problems – insomnia, constant night awakenings, daytime sleepiness.
• Loss of strength, lethargy and passivity.
• Absent-mindedness, difficulty concentrating.

Physical symptoms of PMS:

• Soreness of the mammary glands, an increase in their volume.
• Swelling, sometimes quite noticeable.
• Migraine or dizziness.
• Nausea and vomiting.
• Back and joint pain.
• Thirst, accompanied by increased urination.
• Gastrointestinal disorders.
• Attacks of rapid heartbeat, fever.
• Skin irritation.
• Food cravings – predominantly sweet and savory.

BTW
Stress and overwork are risk factors for PMS sufferers. It was noticed that residents of large cities suffer from premenstrual syndrome more often than residents of villages, and workers more often than housewives.

If the case is limited to only 2-3 symptoms from this list, then we can talk about a mild form of PMS. If in practice you are familiar with 5 signs of PMS or more or fewer symptoms, but they are pronounced and make themselves felt 2 weeks before the onset of menstruation, then this is already a severe degree.

PMS can become a very serious problem – this syndrome deprives some women of their ability to work for several days, it does not have the best effect on relationships with family members, and it can be difficult for a woman herself to endure a “little depression” every month, which is also accompanied by discord in everything. the body.

How to deal with PMS symptoms and should you do it?

PMS is not a disease in the literal sense of the word, but only a specific reaction of the body to changes in the hormonal background. However, this does not mean that such an unpleasant state should be taken for granted. PMS symptoms can be stopped, and comprehensive measures will help to completely reduce the manifestations of premenstrual syndrome to zero. To choose an effective therapy regimen, you should consult with an endocrinologist or gynecologist – doctors will determine the severity of the situation and recommend complementary methods.

Drug-Free Approach

All researchers agree on one thing – moderate exercise actually relieves PMS by reducing cardiovascular problems and raising endorphins. Therefore, women with PMS need to move more (on an ongoing basis, not during PMS), and ideally, sign up for a fitness club.

Diet therapy is also indicated – the diet should contain as little fat, salt and simple carbohydrates and as much fiber as possible, as well as foods rich in B vitamins and magnesium.

Since stress and fatigue provoke a worsening of PMS symptoms, it is necessary to seriously engage in relaxing practices – for some, classes with a psychotherapist help reduce anxiety and improve stress resistance, others prefer yoga and meditation, and for others, a course of relaxing massage has approximately the same effect.

Hormone therapy

If the symptoms of PMS are numerous and very pronounced, the doctor, after a comprehensive examination, may prescribe hormone therapy.These funds are approached with caution – hormone-containing drugs have many contraindications and side effects. In no case should they be assigned to themselves. And it’s not just about the side effects. Severe PMS can be caused by a variety of hormonal imbalances. Without research, it is impossible to understand exactly what the problem is and to prescribe the right drug in the correct dosage.

Pharmacological method

PMS drug therapy includes several groups of drugs:

Phytopreparations , as a rule, are herbal preparations with a mild sedative and diuretic effect, they help to cope with nervousness and edema.For mild PMS, they can be beneficial.

Vitamin-mineral complexes and dietary supplements give a general strengthening effect. If the main cause of PMS is a lack of nutrients, then a properly selected vitamin complex can help smooth out the signs of premenstrual syndrome.

OTC and prescription sedatives and nootropics are so-called sedatives, they have a very pronounced effect and significantly alleviate the psychological state during PMS, helping to cope with anxiety, insomnia and bad mood.Prescription drugs are taken under the strict supervision of a physician.

Among the well-known OTC anxiolytics (anti-anxiety drugs) that help to cope with the symptoms of PMS, is, for example, “Afobazol”.

Afobazol is a sedative and anti-anxiety agent with a minimum of side effects. The drug normalizes mood and sleep, but does not cause daytime sleepiness and, which is especially important for modern women, does not in any way affect the reaction rate. “Afobazol” has a complex effect, relieving several PMS symptoms at once: it reduces anxiety, tension, nervousness and irritability, improves the ability to concentrate, helps with insomnia, and eliminates dizziness.To achieve a lasting effect in the treatment of PMS, it is recommended to take “Afobazol” for 2-4 weeks. “Afobazol” has practically no contraindications. However, before you start taking it, you should consult your doctor.

Antipsychotics are prescribed for very severe PMS, these are potent drugs. They, too, should be prescribed only by a specialist.

Diuretics – or diuretics – are prescribed for noticeable swelling.

Anti-inflammatory and pain relievers are prescribed to relieve pain in the abdomen, joints and back, as well as migraines.

The danger of PMS is that, without a medical opinion, the patient can take for it other, much more serious diseases that require different treatment. Often, severe neuroses, depression and other nervous diseases are mistaken for PMS, migraine can be caused by vascular problems, tumors and diseases of the spine, edema – by kidney pathology. Therefore, for the treatment of PMS, it is imperative to consult a specialist and undergo all prescribed examinations.

Why PMS is not a joke – Wonderzine

The first attempts to thoroughly standardize the diagnosis of PMS have appeared quite recently, but there is still no consensus on this issue.At the same time, for the average person who is not burdened with knowledge about the functioning of the female body, premenstrual syndrome does not seem to be a disease that requires careful study. For the majority, this is primarily a set of behavioral characteristics that lie in a common cauldron of stereotypes along with “female logic” and “female friendship”. Such ignorant ideas can not only discourage women from doctors’ offices for many years, but can really destroy relationships and well-being – and not for one week at all.

Professional help can help alleviate the situation. The fluctuation of hormones takes a lot of energy and resources from the body, so why not help it? Most often, doctors resort to hormone therapy, prescribing oral contraceptives, if there is an indication. Antidepressants may be prescribed for confirmed dysphoric disorder. However, in milder cases, you can try to change your lifestyle in order to facilitate the course of PMS, says Valentina Yavnuk: “Hormonal activity strongly affects the processes occurring in the central nervous system, but there is also a feedback.Constant stress, work and emotional overload, lack of mobility, and a generally poor lifestyle can aggravate the course of PMS. Proper nutrition, moderate physical activity, emotional comfort and satisfaction with one’s sexual and social life have a positive effect on the body’s resistance to stress, which means it helps to cope with PMS more easily. ”

Whatever the reason, the first step is to abandon the misogynistic perception of this feature, which throws us back in those days when a woman was considered unclean during her menstruation.Most likely, this is an excuse to take a day off (quite acceptable practice in developed countries), sit at home in shorts and a T-shirt and read a book, sort out the heaps of letters, or just finally get some sleep. More recently, it was considered indecent to inform anyone that you have your period, and we know many examples of activist struggle for the appearance of such a normal phenomenon as menstruation. It is important to understand: do not hide everything that accompanies her. It is the reticence that gives rise to myths and conjectures about natural processes and phenomena, as a result of which they move into the category of taboo topics.A woman may or may not have PMS, and this is normal.

Perhaps we will see the first sane studies in the near future, and along with them, much more understandable explanations and prevention schemes will appear. The most important tasks today are to establish an open conversation about the problem, not hush up its importance and direct efforts to study it. So we will leave in the past the legends about the obligatory uncontrollable hysteria and the complete dependence of women on biological factors, which someone uses for self-justification, and then something – for discrimination.It would be nice to be in a world where the phrase “I have PMS” will cause not horror or ridicule, but the understanding of others.

Photo: Sanrio

90,000 “I thought I was going crazy.” What is it like to remove the uterus at 28

• Natasha Lipman
• BBC

March 9, 2018

Every month for a couple of weeks Lucy became a different person – suffering from pain and mental disorders. Nobody understood why. For many years she was looking for a doctor in Britain who could explain what was happening to her.At the age of 28, she decided on a hysterectomy – an operation to remove the uterus.

“Then every day I woke up with the feeling that I was going to live a hard day. It felt like a heavy load was pressing on me. At some point I went to the doctor and told him that I was obsessed.”

Until puberty, Lucy was a quiet, friendly and carefree girl. But from the age of 13, she began to have panic attacks. She began to suffer from anxiety and severe depression.

She hurt herself and experienced sudden mood swings.At the age of 14, she left school and was admitted to a mental hospital for teenagers.

“I was diagnosed with post-traumatic stress disorder and obsessive-compulsive disorder. Bipolar disorder was also frequently mentioned,” she recalls.

However, none of these diagnoses matched the cyclical nature of her symptoms.

Everything changed dramatically when she became pregnant at 16 with her first child, son Toby.

“After a few months of pregnancy, I was released from the hospital.The symptoms were gone and I was happy. I felt really good. My psyche became so stable that everyone was given a marvel. “

I was feeling well throughout pregnancy and lactation. But as soon as the critical days returned to Lucy, the same torment came with them.

Caption,

Painful during pregnancy the symptoms disappeared and Lucy was feeling very well

Several years later Lucy returned to school to take exams, but occasionally fell into such frustration that she could not study and eventually dropped out.

Later she began preparing for the national professional qualification, which gave the opportunity to become a teacher. This time, Lucy decided to fight to the end, but she never qualified. She left school two months before graduation when the symptoms became completely unbearable.

At 23, Lucy became pregnant again with her daughter Bella. And again she felt much better, despite the fact that she had to go to the hospital with severe toxicosis.

After Bella’s birth, Lucy’s symptoms returned with renewed vigor.

The agony was physical (pain in joints and muscles, increased sensitivity to sounds and extreme fatigue) and mental (obsessive thoughts, irrational behavior, extreme forgetfulness and oppressive feeling of hopelessness).

“The most terrible feeling for me was the feeling of depersonalization. That is, the feeling that consciousness was separated from the body, as if I was in a dream. Sometimes I did not recognize the people close to me. I knew that I should know who they were, but their faces seemed unfamiliar to me.” – says Lucy.

“At some point I felt so bad that my own voice began to be heard as a stranger to me.I did not recognize my voice or the reflection in the mirror. “

Lucy suffered from suicidal thoughts, which often put herself at risk, wanting to commit suicide.

All this happened at monthly intervals, and no one noticed the cyclicality, until Lucy’s husband Martin once casually dropped the phrase that he tries to keep his mouth shut on the eve of his wife’s critical days so as not to annoy her. Then Lucy thought about the connection between her period and her symptoms.

“It became clear what was happening.I knew that after just a few hours after the start of my period, my health would improve. Although my periods have always been very painful, I really felt my best during this period. I even chose my wedding day so that at this time I had my period, because only then did I feel good, “says Lucy.

Before that, Lucy assumed that hormonal changes exacerbated her mental problems. Now she began to suspect that they were the cause of all the problems.

Armed with a list of three dozen symptoms and information she found on the Internet, Lucy went to her doctor. At the time, she was told that she was suffering from postpartum depression after the birth of her daughter, but since Lucy had suffered from it before, she knew that this was not the case.

As a teenager, she began taking antidepressants, tranquilizers and sleeping pills. She has now also been given antipsychotics.

“Every time I was prescribed and removed some medicine.I took a hefty dose of antidepressants. But I told the doctors that I was not depressed, that something else was happening to me. I thought I was going crazy, “Lucy says.

Lucy’s doctor referred her to a psychiatrist, who explained to her that although some of her symptoms were mental, he could not help her because her problem was physical. When Lucy returned to her doctor, she asked to refer her to a gynecologist, but he again referred her to a psychiatrist.

At this stage, Lucy learned from the psychiatrist what her ailment is called – premenstrual dysphoric disorder (PMDD), which is a severe form premenstrual syndrome (PMS).Now she was finally referred to a gynecologist, advised to “think about getting rid of ovulation for good.”

What is premenstrual dysphoric disorder (PMDD)?

• Severe PMS / PMDD affects 5-10% of menstruating women and often these disorders are triggered by fluctuations in hormone levels.
• Research shows the genetic footprint of PMS: Someone inherits sensitivity to fluctuations in hormone levels from their parents.
• Although PMS / PMDD is mainly accompanied by bodily suffering, it is their mental symptoms (depression, irritability, aggression) that bring the greatest harm to a person.
• PMS / PMDD can affect anyone with critical days, but most often occurs during adolescence, when menstruation begins for the first time, or after 35 years.
• PMS / PMDD hysterectomy is difficult. However, experts say that for patients with PMS / PMDD, removal of the uterus is necessary to avoid even greater problems during menopause.

This knowledge was a breakthrough for Lucy, but her doctor disagreed with the psychiatrist’s diagnosis and insisted that she undergo three alternative treatments before sending her to the gynecologist.

She began taking various hormonal contraceptives, which only made her worse, and as soon as the course of treatment with one antidepressant ended, she was prescribed another.

She was prescribed mirtazapine, sertraline, Prozac, diazepam and sleeping pills, which made her feel as if she fell into a daze and could not resist the decisions of the doctors.

“It was very difficult. I was at the bottom. I could not go to the doctors, because I could not connect two words there. I could not conduct a dialogue.And when my health improved, I practically did not remember what happened the day before. Everything was in a daze, “says Lucy.

Lucy’s husband Martin insisted that she return to the clinic and try to see another doctor. In the end, she met someone who admitted that none of the tried options treatment did not work and referred her to the gynecologist.

The decisive appointment with the gynecologist happened a year after Lucy was diagnosed with PMDD.She was prescribed injections every four weeks to block the production of the hormone estrogen in her body.

It was supposed to artificially place her in the menopause. The effectiveness of the injections would have confirmed the diagnosis.

For the first two weeks, Lucy suffered desperately as her worst symptoms worsened. But after that, when she was already expecting the next monthly “blow”, she suddenly felt good. Better than ever in the past ten years.

“Suddenly everything changed … all the symptoms were gone,” she recalls. “I didn’t even realize how much I suffered until I was released.”

In the next two months, she miraculously got off the drugs that she had been treated with since adolescence.

At a secondary appointment with a gynecologist after five months of saving injections, she was confirmed with the diagnosis of PMDD. And they proposed the final plan for defeating the disease – hysterectomy, that is, the surgical removal of the uterus.

Up to this point, Lucy was 100% sure that she wanted to give birth again.But then she realized how shaky that desire was.

“It was really important to me, but I understood that a new pregnancy would mean the end of the injections, the return of periods and everything connected with it. It was unbearable. I thought that I could not go through it all again. I I was afraid that I could not stand it and would commit suicide. It was very scary, “explains Lucy.

When she discussed with her husband the plan to have a hysterectomy, he supported her, but warned that in the future she might regret her decision, which would mean not only that she will no longer be able to give birth, but also that she has at such a young age menopause will begin.

Lucy was also worried about this, but when she looked at the list of symptoms that she had suffered from all these years, it turned out that their number had grown to 42.

“After looking at all this, I realized that there is only one way out Then I already knew what a normal life was. Before, I didn’t even know what it was. Martin also noticed a change in me and in our family life for the better. It was so good. ”

Photo caption,

Martin, Toby, Bella and Lucy

While Lucy was reconciled with her decision, the agonizing symptoms began to slowly return to her.

“Symptoms started coming back one after another. It was very scary and I started thinking about suicide again. I was in desperate need of injections. I knew that they helped before, but suddenly they stopped working. I started asking them to give me everything. earlier and earlier for a month. I was like an addict, “she says.

Gynecologist Lucy explained to her that the injections could not lose their effectiveness and that perhaps the reason was that her diagnosis was wrong. She had to discontinue the course of injections and return to hormonal contraceptives.

“I thought I couldn’t do this anymore. That I would rather die than return to my old life.”

A nurse who had given Lucy injections for a long time advised her to see another doctor. He agreed to refer Lucy to a specialist, whom she had heard a lot about, from London’s Chelsea and Westminster hospital.

A few months later, Lucy finally got an appointment, during which she told the doctor about her experience of the past fifteen years. When she said that the injections had stopped working, he reassured her that it was a common thing in this situation.

Lucy was offered shots every ten weeks instead of four, and for a while it worked so effectively that hysterectomy began to seem unnecessary.

Later she had problems associated with temporary menopause, into which she was injected. In particular, her bone tissue was losing density. This often leads to osteoporosis, a systemic skeletal disorder that reduces bone strength.

She was prescribed hormone replacement therapy, but it only made Lucy worse.

Then she made the final decision. In December 2016, at the age of 28, she underwent a hysterectomy.

Photo caption,

Lucy after a hysterectomy in the hospital

Until then, she had often asked herself if this was really the only right decision.

In the year after the operation, despite recurrent migraines, Lucy managed to do more than in the previous ten years. She qualified and now works as a teaching assistant and does work for which she thought she would never be healthy enough.

“I still find it difficult to believe that I will always feel this way,” says Lucy.

She has no regrets about the lost years: “In the end I won. And I was lucky that it was something that responded to treatment and met the right people on my way. I know that when I was younger, my symptoms were associated with PMDD. I have no doubt about that. It’s just that the diagnosis was not yet as common as it is now. ”

“People just brushed it off, saying that everyone has PMS, but my problem was different.”Lucy regrets that the doctors did not take her seriously after the birth of her second child, when her condition became simply unbearable.

“I am so sorry that no one listened to me before. If you feel the same as I did then, you obviously have big health problems.”

The operation affected not only the life of Lucy herself, but also the lives of those around her. Her husband Martin, a musician, can now work harder because Lucy can devote more time to her children. Toby is old enough to notice a change for the better in his mother.

Lucy hopes Bella does not remember her as she was before she was cured of PMDD. Now their family is happier.

“Do people always live like this? They have no idea how lucky they are. I can never take such a life for granted,” says Lucy.

What is PMS (premenstrual syndrome) – symptoms and how to deal with them

The main symptoms of PMS

PMS manifests itself as a combination of mental, emotional and physiological disorders that can occur 10-12 days before menstruation (in the luteal phase of the menstrual cycle) and subside with the onset of bleeding.Depending on the severity of the course, the following signs of premenstrual syndrome can occur in different combinations: both individually and all together.

• Feeling of depression, anxiety, dissatisfaction with oneself
• Sudden tearfulness, irritability and mood swings
• Headaches, dizziness, sleep disturbance
• Distraction of attention, rapid fatigue, general weakness
• Nausea, disturbances in the functioning of the gastrointestinal tract, changes in appetite, cravings for certain (usually sweet or salty) foods
• Joint or muscle pain, mastalgia (soreness, discomfort or swelling of the breast)

Agree that it is rather difficult to call this a “normal state” of the organism.

True, there is one important remark: it is important to separate the “concomitant” diseases from the manifestations of the premenstrual syndrome itself. After all, depressive conditions or problems with the gastrointestinal tract can worsen not only against the background of PMS, but have independent causes that are not directly related to the menstrual cycle. Therefore, consultation with a specialist is strictly required.

What to do with PMS?

To begin with, understand that assistance to the body should be comprehensive.With this approach, you can effectively alleviate your condition.

Non-drug methods

For mild
to moderate symptoms, lifestyle interventions are often sufficient.

Compliance with work and rest, a balanced diet, quitting smoking, reducing the amount of salt, sugar, coffee and alcohol consumed, as well as walking in the fresh air and moderate physical activity can significantly improve your well-being.

Medication

In more difficult situations, modern means will help you to stop the manifestations of premenstrual syndrome.

Your doctor may prescribe pain relievers or sedatives to ease your emotional and physical well-being.

To eliminate edema (which are caused by a violation of water-salt metabolism) – mild diuretics.

But, as you most likely already know, hormonal imbalance is considered one of the causes of premenstrual syndrome in modern medicine. At the same time, most experts are sure that those suffering from PMS do not have an absolute deficiency or excess of estrogen and progesterone, but a change in their ratio.

And then the time has come to talk about the new Italian non-hormonal drug Dikirogen.

Dikirogen

In fact, this could be the starting point for the article. Why? Because the two active forms of inositol contained in this product are involved in the hormonal regulation of the female reproductive system and contribute to the normalization of the menstrual cycle. And folic acid and manganese, which are included in its composition, improve various metabolic reactions, and also demonstrate the ability to eliminate the manifestations of premenstrual syndrome.

And if you think that this is some kind of miracle, then yes. This is a little miracle of modern science that you can use at any time.

About the product
90,000 PMS: what is it and how to cope with it – Family Medical Center

Premenstrual syndrome (PMS) is widespread and manifests itself in the form of deterioration in physical well-being, changes in behavior, emotional instability.Such signs usually begin to disturb a woman a few days or a couple of weeks before menstruation and disappear a few days after its onset.

In most cases, patients are faced with mild symptoms. But, about 5% of women are faced with such acutely expressed signs that during such periods the quality of life deteriorates, physical and social activity decreases, as well as working capacity. In such cases, we can talk about premenstrual dysphoric disorder.

PMS symptoms

There are many PMS symptoms, the set of which may be individual for each woman. Most often, patients are faced with the following manifestations:

• anxiety, irritability, unpredictable mood swings;
• nausea, vomiting;

90,089 bloating, diarrhea;

• emotional depression, melancholy;
• change in libido – its weakening or strengthening;
• alcohol intolerance;
• acne;
• increased appetite.

Sleep disorders often appear, concentration of attention worsens, engorgement of the mammary glands occurs and their soreness is felt, body weight increases (mainly due to fluid retention). Sometimes in women, chronic diseases are exacerbated. The complex of symptoms can change from cycle to cycle.

Possible causes of PMS

The exact reasons for the development of premenstrual syndrome cannot be indicated even by scientists who have been studying this issue for a long time.But, there are several theories. Thus, there are suggestions that the onset of PMS symptoms is associated with changes in hormonal levels (fluctuations in the level of progesterone and estrogen), imbalance in water-salt metabolism, insufficient production of serotonin, and beta-endorphin deficiency.

As predisposing factors contributing to the development of PMS, there are: stress, obesity, age (most often women aged 25 to 39 years old face the most severe manifestations of the syndrome), genetic predisposition, the presence of certain concomitant diseases (kidney disease, heart disease, consequences head injuries, etc.).

Diagnostics of a woman’s health with PMS

Diagnosis of premenstrual syndrome is based on the analysis of symptoms. But sometimes you need to make sure that a woman’s poor health is not the result of any diseases and other pathological conditions (thyroid dysfunction, depression, heart or kidney disease). Tests for hormones, assessment of daily urine output, mammography or ultrasound, CT, consultation of a neurologist, endocrinologist, psychiatrist, cardiologist may be required.

Treatment of premenstrual syndrome

Treatment for PMS is complex and symptomatic. This may include taking diuretics, NSAIDs, birth control pills, dopamine agonists, herbal medicines, antidepressants, vitamins, and dietary supplements. Diet and lifestyle are being adjusted. At the “Family” medical center for a patient suffering from premenstrual syndrome, after examination, experienced gynecologists will select a set of necessary medications (only those that are really needed) and develop individual recommendations.Our specialists will provide assistance, thanks to which the patient’s quality of life will be stable, regardless of the menstrual cycle.

90,000 Premenstrual Syndrome. Outdated problem? uMEDp

According to various sources, from 50 to 80% of women of reproductive age note some kind of premenstrual symptoms, in about 8% of them the presence of extremely severe manifestations makes it possible to diagnose “premenstrual dysphoric disorder”. Combined oral contraceptives are an effective treatment for these disorders.The article discusses the benefits of using drugs containing drospirenone in premenstrual syndrome / premenstrual dysphoric disorder.

Introduction

Premenstrual syndrome (PMS) was first described by the American psychiatrist A.F. Frank in 1931, who drew attention to a clear connection between pronounced emotional, mental and behavioral changes in women with the second phase of the menstrual cycle and their complete disappearance after the onset of menstruation [1].The scientist proposed a definition according to which “premenstrual illness is a feeling of indescribable tension that begins seven to ten days before menstruation and continues until the onset of menstrual bleeding. A woman finds relief in committing stupid and senseless actions, but unlike mental patients, she experiences remorse towards her family and realizes the intolerance of her behavior and deeds ”[2].

Approximately 50–80% of women of reproductive age report some type of premenstrual symptoms (physical, emotional, behavioral, and cognitive).In 20% of them, the manifestations can be quite serious and significantly worsen the general well-being and quality of life, which makes it possible to diagnose PMS [3]. The most severe manifestations, as a rule, are emotional and behavioral: irritability, mood lability, depression or, conversely, anxiety, impulsivity, aggression, feeling of “loss of control over oneself”, increased fatigue, inability to concentrate and decreased concentration. Physical manifestations (bloating, pain in the mammary glands, muscles, joints) and changes in eating behavior (increased appetite and special taste preferences) complete the clinical picture of PMS.A particular woman may have one symptom or a combination of several symptoms, but their nature is usually stable during most menstrual cycles.

Up to 8% of women in the general population suffer from extremely severe PMS symptoms [4]. In the case of a sharp violation of the usual way of life, a negative impact on performance, general well-being and social activity, we can talk about the so-called premenstrual dysphoric disorder (PMDD).However, the clinical picture may not fully meet the diagnostic criteria of the American Psychiatric Association, formulated in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (1994) [3].

Epidemiology and clinical presentation

Patients with PMS are almost nine times more likely to report significant deterioration in family relationships, lack of enjoyment from hobbies, and a sharp decline in productivity on the premenstrual days.European studies have convincingly demonstrated that the economic and social burden of PMS / PMDD, according to the value of the indicator representing the years of life with disability (Disability Adjusted Life Years), is comparable to the negative impact of well-known mood disorders and only slightly lags behind that in endogenous depression [5, 6]. In the United States, PMS leads to significant costs, both direct (cost of medical care) and indirect (loss of productivity), amounting to approximately $ 4,333 per patient per year [7].

Difficulties in accurately assessing the prevalence of PMS / PMDD and their negative impact on the well-being of women in the general population arise mainly from the low prevalence of women, as well as the lack of routine diagnostic criteria for these disorders. In any case, the cyclicality of symptoms should be confirmed by daily monitoring of clinical manifestations in the dynamics of the menstrual cycle (in women after hysterectomy, the connection with the menstrual cycle is detected using additional examination methods) for at least two menstrual cycles.A key characteristic of PMS is that symptoms appear clearly in the luteal phase of the cycle and regress during menstruation. The “light gap” in the patient’s condition is an important criterion for PMS, which makes it possible to exclude premenstrual exacerbation of a psychiatric illness or any disorder not related to the menstrual cycle.

Pathogenesis

Hormonal theory

The main manifestations of PMS / PMDD are emotional and behavioral symptoms.The underlying mechanisms of these disorders cannot but affect the central nervous system. Sex hormones easily penetrate the blood-brain barrier, and their receptors are widely represented in many parts of the brain, including those that regulate emotions and behavior (amygdala and hypothalamus).

The decisive role in the genesis of PMS symptoms belongs not to the level of sex hormones, which does not differ from that in healthy women, but to hormonal fluctuations during the menstrual cycle and increased sensitivity to progesterone, which is caused by dysfunction of the most important neurotransmitters, especially gamma-aminobutyric acid (GABA) and serotonin.Mood changes reported by some peri- and early postmenopausal women on cyclic hormone replacement therapy suggest that it is progesterone, not estrogen, that is responsible for inducing dysphoria.

The level of serotonin or the expression of its receptors in the brain changes during the menstrual cycle under the modulating effect of sex hormones. The relief of many PMS / PMDD symptoms with the help of selective serotonin reuptake inhibitors (SSRIs) indicates the participation of the serotonergic system of the brain in the genesis of these disorders.GABA controls the activity of neurons in the central nervous system through an inhibitory effect. In this case, the progesterone metabolite allopregnanolone acts as an agonist of GABA _A receptors, and usually its level in patients with PMS decreases. The proven close interaction of the serotonergic and GABAergic systems serves as an argument in favor of their combined participation in the pathogenesis of premenstrual disorders, while the change in the level of sex steroids plays the role of a trigger mechanism for their development.

Interestingly, neuroimaging studies of the brain using functional magnetic resonance imaging in women with PMDD found a decrease in amygdala reactivity in the premenstrual period, which leads to a lengthening of the processing time for negative emotions and a shortening of the processing time of positive emotions, as well as a decrease in control from the limbic system. for the severity of emotions [8].

The above hypothesis for the development of PMS is quite convincing, since symptoms are absent during anovulatory cycles, after oophorectomy or treatment with ovulation inhibitors, and, conversely, may recur after the administration of exogenous hormones.However, it is not clear to what extent premenstrual somatic symptoms, especially those associated with pain, are due to changes in hormone-dependent tissues, since dysphoric disorders can reduce the threshold for perception of pain.

Theory of violation of water-salt metabolism

PMS is a multifactorial disease that includes changes in many biological parameters in the dynamics of the menstrual cycle. Along with the hormonal theory, an important place in explaining the pathogenesis of PMS is occupied by a violation of water-salt metabolism, which, in particular, is regulated by the renin-angiotensin-aldosterone system.In the middle luteal phase, when the symptoms are most pronounced, there is a fairly high level of both estrogens and progesterone, which have a significant modulating effect on this system. Endogenous estrogens stimulate the synthesis of angiotensinogen in the liver, as a result of which the level of angiotensin II increases, which in turn increases the production of aldosterone in the adrenal cortex, which means sodium reabsorption in the kidneys, potassium loss and, as a result, water retention in women predisposed to such disorders.However, due to the negative feedback mechanism in healthy young women, this leads to a decrease in renin secretion in the kidneys, therefore, the increase in angiotensin II and aldosterone is negligible. In addition, endogenous progesterone normally acts as an antagonist of aldosterone receptors in the kidney and thereby reduces the mineralocorticoid effect of endogenous estrogens. Dysregulation of these processes in patients with PMS leads to the appearance of symptoms in the middle of the luteal phase due to fluid retention:

• swelling of the face, hands, legs and feet, the latter sometimes necessitates wearing shoes one size larger;

90,089 bloating (flatulence), constipation;

• engorgement and soreness of the mammary glands;
• a slight increase in blood pressure due to an increase in the volume of circulating blood.

The aldosterone antagonist spironolactone has been shown to be effective in abdominal distention and mastalgia [9, 10]. However, not all studies have clearly traced that the somatic symptoms of PMS are associated with fluid retention, possibly, its redistribution occurs.

Basic principles of treatment

First, a thorough history should be taken before initiating drug treatment for patients with PMS / PMDD, with particular attention to disorders such as depression, a history of dysthymic / anxiety disorders, and hypothyroidism.Keep in mind that premenstrual disorders can be associated with alcohol abuse (as women with anxiety and depression struggle to cope with their condition, which only worsens their symptoms), as well as domestic violence and post-traumatic stress disorder. These difficult questions in a delicate form must be asked to the patient. As noted, it is key to confirm that symptoms are cycling over at least two menstrual cycles and to rule out other disorders / illnesses that may be exacerbated in the premenstrual days.

Secondly, you need to find time and slowly talk with the patient, explaining to her that her symptoms have a biological explanation, and are not the result of her personal and / or characterological characteristics. This is important because many patients feel guilty about violent behavior, especially against children, and do not believe in effective treatment, taking cyclical mood / behavior disorders for granted.

Third, the clinical symptoms and the degree of their influence on the patient’s general well-being should be analyzed in order to prescribe treatment, depending on their severity.

Non-pharmacological (behavioral) therapy

For mild / moderate premenstrual disorders, dietary changes – reducing the intake of high-glycemic carbohydrates, salt, caffeine and alcohol – can help, although evidence is lacking. It is important that the diet is complete, balanced and includes all the necessary vitamins and nutrients. Folates play a significant role in the functioning of the nervous system, participating in important mechanisms of transmethylation in the central nervous system (in the monocarboxylic acid cycle), and hence in the metabolism of the most important neurotransmitters (serotonin, dopamine, and norepinephrine) [11].In addition, they take part in the exchange of fatty acids in the membranes of neurons and neuroglia cells.

Many studies of the last 30 years have shown a tendency of people with folate deficiency to psychological disorders, especially depression, combined with apathy, fatigue, insomnia, irritability and decreased concentration [12]. According to various sources, 15–38% of patients with severe depression have borderline / low levels of folate in serum and erythrocytes [13, 14]. Rapid relief of these manifestations after taking folate seems to be convincing evidence of the relationship between mood disorders and metabolism of these substances [15].

The main sources of folate in food are fresh fruits and vegetables, but the body can only absorb 50% of the folate found in natural foods. Up to 90% of these important substances are lost during heat treatment. Unfortunately, in a significant part of women of reproductive age, even consuming foods fortified with folic acid, the level of folate in erythrocytes (most importantly!) Is below the recommended level [16]. In addition, for many modern women, nutrition is not complete due to the desire to lose weight even with normal body weight, which may require additional folate intake.

Various methods of stress relief and relaxation (aerobic exercise for 20-30 minutes at least three times a week, yoga, etc.) can reduce the severity of PMS manifestations, it is believed, by increasing the level of endorphins, decreasing in the luteal phase of the cycle.

Drug treatment

Medication for PMS includes herbal preparations, vitamins and minerals, psychotropic and hormonal agents.Vitex vulgaris extract ( Vitex agnus castus ) is the only herbal remedy that has shown positive effects on symptoms such as irritability and mood lability in placebo-controlled studies [17]. Additional methods of therapy include the appointment of vitamin B ₆ (pyridoxine) at a dose of 20 to 40 mg per day [18]. It is also recommended to take magnesium in the form of magnesium oxide, 200 mg per day or a complex preparation Magne B6 (four to six tablets per day).It should be emphasized that these drugs are used only for minor manifestations of PMS and there is no evidence of their effectiveness.

In moderate / severe forms of PMS / PMDD, more effective methods of pharmacological action are used [4]. Few of the proposed regimens for the treatment of premenstrual disorders have a clear biological rationale, and their effectiveness has been confirmed in randomized placebo-controlled clinical trials.The two main treatments for moderate / severe PMS include targeting the serotonergic system in the brain and the hypothalamic-pituitary-ovarian axis.

Antidepressants

Recently, modern antidepressants have been widely used for the treatment of PMS and especially PMDD, which include selective serotonin reuptake inhibitors (SSRIs), which have a thymoanaleptic effect (relieving anxiety, tension, improving mood and general mental well-being) [19, 20].It is recommended to take SSRIs continuously. In the intermittent mode – 7-14 days before the expected menstruation – taking drugs of this series does not make sense, since the “entry period” into therapy takes two weeks. Among the most common adverse effects when using SSRIs are anxiety, excessive sedation, insomnia, nausea, sexual dysfunction and weight gain, that is, extremely undesirable manifestations for patients with premenstrual disorders [19].

Four drugs are approved by the US Food and Drug Administration for the treatment of PMS / PMDD.These are three SSRIs – fluoxetine (Prozac®), paroxetine (Paxil ™), sertraline (Zoloft®) and the combined oral contraceptive Jess® (ethinyl estradiol 20 mcg + drospirenone 3 mg 24/4). To date, in the Russian Federation, none of the above SSRIs have been approved for the treatment of these disorders, in contrast to the drug Jess®.

Hormonal preparations

Due to the previously widespread attitude towards premenstrual disorders as a consequence of progesterone deficiency, some doctors tried to prescribe progesterone drugs in a cyclic mode, which only worsened the patients’ condition.The goal of hormone therapy for PMS / PMDD is not to correct hormonal disturbances, but to interrupt the normal cyclic activity of the hypothalamic-pituitary-ovarian system, which is the trigger for these symptoms. Therefore, danazol, gonadotropin-releasing hormone agonists and combined oral contraceptives can be successfully used in therapy [3]. Danazol is prescribed at a dose of 200-400 mg per day for six to seven months, gonadotropin-releasing hormone agonists – three to six injections per course (always with add-back therapy) [21].Treatment should be long-term, and therefore, against the background of these classes of drugs, it is impossible to avoid serious side effects. In this regard, the most widespread for the treatment of premenstrual disorders of various kinds are combined oral contraceptives.

Prior to the development of combined oral contraceptives containing the progestogen drospirenone, there was conflicting evidence to support their use in the treatment of PMS / PMDD. In some studies, a tendency was noted for an improvement in the condition of patients in the pre-menstrual period, while in others there was no effect or even an increase in the severity of symptoms, probably as a result of the influence of progestogens as derivatives of 19-nortestosterone (mastalgia, headaches, bloating, etc.) and progesterone derivatives (depression, anxiety, irritability, impaired concentration, etc.). Drospirenone, being a derivative of 17-alpha-spironolactone, is pharmacologically close to endogenous progesterone, a natural antagonist of mineralocorticoid receptors. However, the affinity of this progestogen for these receptors is about five times higher than that of aldosterone, and two to four times higher than that of progesterone.

Many studies have shown that while taking the combination “ethinylestradiol 30 μg + drospirenone 3 mg” in the 21/7 regimen, body weight remained stable or even slightly decreased [22].This could be caused by a significant decrease in the amount of fluid in the body in general and extracellular fluid in the luteal phase of the cycle in particular. In fact, these indicators did not differ from those in the folliculin phase [23]. In patients with PMS, by the sixth month of treatment with ethinyl estradiol 30 μg + drospirenone 3 mg 24/4, there was a significant improvement in symptoms such as labile mood, fluid retention and changes in appetite [24]. All combined oral contraceptives have the ability to inhibit the hypothalamic-pituitary-ovarian system.However, when comparing the combination of “ethinyl estradiol 30 mcg + drospirenone 3 mg” and “ethinyl estradiol 30 mcg + levonorgestrel 150 mcg” over six treatment cycles, a more significant improvement in symptoms such as anxiety, irritability, depression and fluid retention was found against the background of containing drospirenone preparation [25]. This certainly confirms the importance of the characteristics of the progestin in combined oral contraceptives. According to experimental studies, drospirenone, in addition to having antimineralocorticoid effect, is also able to influence the content of beta-endorphin and the neurosteroid allopregnanolone in certain structures of the central nervous system [26].

It is important to emphasize that drospirenone does not have androgenic properties that are undesirable for patients with PMS / PMDD (on the contrary, there is a moderate antiandrogenic effect) and glucocorticoid properties (for example, in medroxyprogesterone acetate). Many women consider aggression (anger) and irritability as the most severe symptoms. These manifestations may be due to the fact that in patients with PMS / PMDD at the time of the “flowering” of the corpus luteum in the middle of the luteal phase of the cycle, the level of free testosterone is higher than in healthy women.Drospirenone, having an antiandrogenic effect, helps to improve the condition of patients, relieving irritability and aggressiveness [27].

Another additional beneficial effect of drospirenone is the relief of the cyclical appearance of acne. In many studies, when taking Jess®, a statistically significant decrease in the percentage of inflammatory and non-inflammatory skin lesions, as well as the total number of skin lesions on average, was observed compared with the placebo group [28].

Jess® is the first oral contraceptive drug with a registered therapeutic indication for contraception and treatment of severe PMS. In addition to the fact that the drug contains drospirenone with unique properties and a long half-life, it is taken 24/4. Unlike other low-dose combined oral contraceptives with a traditional 21/7 regimen, when PMS symptoms recur during a break, Jess®, thanks to a 24/4 regimen, contributes to a more significant suppression of ovarian function and a decrease in endogenous fluctuations in hormone levels [29].The efficacy of the drug for the treatment of PMS / PMDD has been confirmed in fairly large, double-blind, placebo-controlled, randomized trials [30, 31].

For a number of reasons, combined oral contraceptives are unique carriers of folate that allow you to achieve adequate folate status, and therefore Jess® Plus was developed for 24/4 intake, which, in addition to ethinyl estradiol 20 μg and drospirenone 3 mg, also includes metafoline® (calcium levomefolate).Metafolin® is a stable form of natural folate, which is immediately broken down in the body into a biologically active substance and calcium, in contrast to folic acid, which requires a series of stepwise transformations with the participation of several enzymes. When using a combined oral contraceptive with folate, the woman receives the recommended daily dose of this vitamin. Based on the extremely negative effect of folate deficiency on emotions and mood, which can aggravate the condition of women with premenstrual disorders, the importance of the appearance of such a drug can hardly be overestimated.In a US multicenter study in women of reproductive age who took Jess® Plus, there was a statistically significant increase in folate status compared with women who received hormones in the same regimen and in the same combination, but without metafoline [32].

Additional non-contraceptive benefits of combined oral contraceptives containing drospirenone are important factors influencing adherence and satisfaction with treatment in patients with premenstrual disorders (both psychological and somatic) of varying severity.