TENSÃO PRÉ-MENSTRUAL Adriana Wagner.

Apresentação em tema: "TENSÃO PRÉ-MENSTRUAL Adriana Wagner."— Transcrição da apresentação:

1 TENSÃO PRÉ-MENSTRUAL Adriana Wagner

2 O que você quer dizer com “aqueles” dias do mês?
Ação Ovariana... O que você quer dizer com “aqueles” dias do mês?

3 SPM: histórico Semonides (2600 a.C.) : Essay on Women
Hipócrates (600 a.C.): tratado A doença das virgens “ as alterações de comportamento, as idéias de morte, as alucinações e os delírios resultantes da retenção do fluxo menstrual”

4 Tipos de desordens menstruais
Molime Pré-Menstrual=90% Desconfortos menstruais “não-incapacitantes”. Síndrome ou Tensão Pré-menstrual(TPM)= 20-40% Sintomas físicos e somáticos durante a fase lútea do ciclo menstrual. Distúrbio Disfórico Pré-Menstrual (DDPM): 3-5% Forma mais severa de TPM, predomínio de sintomas psicológicos (DSM-IV). Types of Premenstrual Disorders The adverse symptoms of premenstrual disorders occur only during the luteal phase of the ovulatory cycle and disappear soon after the onset of menses, thus indicating that ovulation is necessary for these symptoms to occur. The premenstrual symptoms a woman may experience differ in type and severity. Premenstrual molimina refers to the premenstrual discomfort that most women experience before menstruation as a sign of the ovulatory cycle. The symptoms, which may include breast tenderness, food cravings and pelvic heaviness or bloating, are normal, not distressing, and do not interfere with a woman’s normal functioning. Premenstrual syndrome (PMS) encompasses the bothersome mild-to-moderate emotional and physical symptoms that occur during the luteal phase of the ovulatory cycle and subside within three days of the onset of menses. Premenstrual dysphoric disorder (PMDD) is the most severe type of premenstrual disorder and causes significant impairment. References: Ginsburg KA, Dinsay R. Premenstrual syndrome. In: Ransom SB, ed. Practical Strategies in Obstetrics and Gynecology. Philadelphia: W.B. Saunders Company, 2000: Kessel B. Premenstrual syndrome. Advances in diagnosis and treatment. Obstet Gynecol Clin North Am. 2000;27: Ginsburg KA, Dinsay R. In: Ransom SB, ed. Practical Strategies in Obstetrics and Gynecology. Philadelphia: W.B. Saunders Company; 2000: ; Kessel B. Obstet Gynecol Clin North Am. 2000;27:

5 Etiologia das Desordens Menstruais
Os hormônios reguladores controlam o lobo anterior e posterior da hipófise

6 Provável Etiologia das Desordens Menstruais
Sensibilidade aumentada mudanças hormonais Predisposição genética Vulnerabilidade Sintemas Neurotransmissores e Neurohormônios* SPM Interagem com Alteram as respostas para as mudanças hormonais Proposed Etiology of Premenstrual Disorders The etiology of premenstrual disorders is multidimensional; several biological mechanisms have been proposed as underlying menstrual-related symptoms. Some women are more vulnerable to these changes because of a genetic predisposition. An increased sensitivity to the cyclic changes in gonadal hormones contributes to premenstrual symptoms. Neurotransmitters and neurohormonal systems, such as serotonin, the renin-angiotensin-aldosterone system, -aminobutyric acid (GABA), and cholecystokinin, normally interact with gonadal hormones and their metabolites. Women with altered responses to these changes in gonadal hormone levels may experience premenstrual symptoms. Reference: Halbreich U. The etiology, biology, and evolving pathology of premenstrual syndromes. Psychoneuroendocrinology. 2003;28(Suppl 3):55-99. Hormônios gonadais e metabólitos *Serotonina, renina-angiotensina-aldosterona sistema, -aminobutirico ácido (GABA) e catecolaminas. Halbreich U. Psychoneuroendocrinology. 2003;28(Suppl 3):55-99.

7 Hormônios Esteróides e o Sistema Renina-Angiotensina e Aldosterona
Estrógenos Progestágenos efeitos mineralocorticóides ( aldosterona) efeitos anti-mineralocorticóides ( aldosterona) Sistema Renina-Angiotensina-Aldosterona Retenção de sódio e água / excreção de potássio Steroid Hormones and the Renin-Angiotensin-Aldosterone System Interactions between estrogen and progesterone and the renin-angiotensin-aldosterone system (RAAS) are one of the mechanisms believed to be involved in the etiology of premenstrual symptoms. Estrogen has a mineralocorticoid effect by inducing the synthesis of angiotensinogen in the liver, which in turn increases aldosterone and stimulates the RAAS to increase water retention, bloating and breast tenderness, all of which are premenstrual syndrome-related symptoms. Progesterone has antimineralocorticoid activity by competing with aldosterone at the aldosterone receptor. The end result is to encourage water excretion and to reduce the bloating and breast tenderness characteristic of the late luteal phase of the cycle. Reference: Halbreich U, Monacelli E. Some clues to the etiology of premenstrual syndrome/premenstrual dysphoric disorder. Prim Psychiatry. 2004;11:33-40. Retenção de líquidos Distensão abdominal Sensibilidade mamária Excreção de líquidos Redução da distensão abdominal Redução da sensibilidade mamária Halbreich U, Monacelli E. Prim Psychiatry. 2004;11:33-40.

8 SPM: critérios diagnósticos do ACOG

9 SPM: Critérios Diagnósticos do ACOG
exclusão de doenças clínicas ou psiquiátricas disfunção social e performance física Sintomas Afetivos Sintomas Somáticos Irritabilidade† Depressão Crises de raiva Ansiedade Confusão mental Isolamento social Dolorimento e tumefação das mamas (mastalgia) Distensão abdominal Cefaléia Edema das extremidades ACOG Diagnostic Criteria for Premenstrual Syndrome The American College of Obstetrics and Gynecology (ACOG) diagnostic criteria for premenstrual syndrome include affective and somatic symptoms. Irritability is considered to be the hallmark affective symptom for this syndrome. Other affective symptoms include depression, angry outbursts, anxiety, confusion and social withdrawal. The somatic symptoms include breast tenderness, abdominal bloating, headache and swelling of the extremities. According to these criteria, a diagnosis must be based on prospective diaries that have been kept for two or three consecutive months. The ACOG diagnostic criteria for premenstrual syndrome also stipulate that: 1) other disorders must be excluded as the cause of symptoms; 2) women experiencing these symptoms must suffer from dysfunction in social or economic performance; and 3) the symptoms must be present in the absence of any pharmacologic therapy and use of illicit drugs or alcohol. Reference: ACOG Practice Bulletin No. 15. Premenstrual syndrome. Obstet Gynecol. 2000;95(4): supplemental material at end of issue. ACOG=American College of Obstetricians and Gynecologists Adapted from ACOG Practice Bulletin No. 15. Obstet Gynecol.2000;95(4): supplemental material at end of issue.

10 Distúrbio Disfórico Pré-Menstrual (DDPM): critérios diagnósticos

11 Distúrbio Disfórico Pré-Menstrual (DDPM): critérios diagnósticos
4 grupos de sintomas, isolados ou em combinação variável de pessoa-a-pessoa: 1.Predomínio de ansiedade e agressividade; 2.Predomínio de alterações afetivas, notadamente com sintomas depressivos; 3.Predomínio de queixas físicas resultantes de acúmulo e retenção de líquidos; 4.Predomínio de alterações alimentares anorexia ou bulimia alteração seletiva do apetite

12 Distúrbio Disfórico Pré-Menstrual (DDPM): critérios diagnósticos
2 ou 3 ciclos menstruais = 5 ou mais sintomas na última semana do ciclo, devendo tais sintomas estar ausentes na pós-menstruação. Marcante humor depressivo, sentimentos de desesperança ou autodepreciativos. Marcante ansiedade e tensão. Marcante labilidade afetiva. Irritabilidade e/ou agressividade marcantes ou dificuldades de relacionamento pessoal. Diminuição do interesse para atividades usuais. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association, 2000.

13 Distúrbio Disfórico Pré-Menstrual (DDPM): critérios diagnósticos
Dificuldades de pensamento, memória e concentração. Cansaço, fadiga e perda de energia. Alterações do apetite e/ou da aceitação de determinados alimentos. Alterações do sono (insônia ou hipersonia). Sensação subjetiva de opressão ou perder o controle. Outros sintomas físicos tais como turgência nos seios, cefaléia, dor muscular, inchaço, ganho de peso. O distúrbio deve interferir marcantemente com a ocupação, atividades sociais e de relacionamento. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association, 2000.

14 Terapias para a SPM Mudanças no estilo de vida exercícios aeróbicos
modificação da dieta Terapia cognitiva-comportamental Fármacos Inibidores seletivos da recaptação da serotonina(SSRIs) Aprovados pelo FDA para SPM e TDPM Fluoxetina Sertralina Paroxetina Espirolactona Ansiolíticos Agonistas do GnRH Contraceptivos hormonais (Aprovados pelo FDA para SPM e TDPM) YAZ Therapies for Premenstrual Syndrome ACOG Practice Bulletin No. 15, published in 2000, outlines treatments commonly used for premenstrual symptoms. These include lifestyle changes (e.g., exercise and dietary modifications), cognitive-behavioral therapy, and pharmacologic agents. The selective serotonin reuptake inhibitors—fluoxetine hydrochloride, sertraline hydrochloride and paroxetine hydrochloride—are currently the only pharmacologic agents with an FDA-approved indication for treating PMDD. Other therapies used in the treatment of PMS and PMDD include spironolactone, anxiolytic agents, gonadotropin-releasing hormone agonists and hormonal contraceptives. Reference: ACOG Practice Bulletin No Premenstrual syndrome. Obstet Gynecol. 2000;95(4): supplemental material at end of issue.

15 SPM: mudanças no estilo de vida
Exercícios Aeróbicos = aumento de endorfinas Recomenda-se: 20–30 minutes/dia, 3 x/semana. Dieta Ingesta de cálcio Redução de sal, acúcar, álcool e cafeína= sem impacto nos estudos controlados. Lifestyle Changes to Alleviate Symptoms of Premenstrual Syndrome Many women find that regular aerobic exercise eases the symptoms of premenstrual syndrome. The decline in endorphin levels that normally occurs in the late luteal phase of the menstrual cycle has been suggested as an underlying mechanism for premenstrual symptoms in some women. Regular aerobic exercise leads to the release of endorphins in the central nervous system. The recommendation is that women engage in at least 20–30 minutes of aerobic exercise per day at least three days each week. Several studies indicate that calcium supplements have modest effects on premenstrual symptoms. Limited data indicate a possible benefit for a beverage containing complex and simple carbohydrates. Other recommendations such as reductions in salt, sugar, alcohol and caffeine intake have not been investigated in controlled studies. References: Ginsburg KA, Dinsay R. Premenstrual syndrome. In: Ransom SB, ed. Practical Strategies In Obstetrics and Gynecology. Philadelphia: W.B. Saunders Company, 2000: Thys-Jacobs S, Starkey P, Bernstein D, Tian J. Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Premenstrual Syndrome Study Group. Am J Obstet Gynecol. 1998;179: Freeman EW, Stout AL, Endicott J, Spiers P. Treatment of premenstrual syndrome with a carbohydrate-rich beverage. Int J Gynaecol Obstet. 2002;77: Sayegh R, Schiff I, Wurtman J, Spiers P, McDermott J, Wurtman R. The effect of a carbohydrate-rich beverage on mood, appetite, and cognitive function in women with premenstrual syndrome. Obstet Gynecol. 1995;86: Ginsburg KA, Dinsay R. Premenstrual syndrome. In: Ransom SB, ed. Practical Strategies in Obstetrics and Gynecology. Philadelphia: W.B. Saunders Company, 2000: ; Thys-Jacobs S, et al. Am J Obstet Gynecol. 1998;179: ; Sayegh R, et al. Obstet Gynecol. 1995; 86: ; Freeman EW, et al. Int J Gynaecol Obstet. 2002;77:

16 SPM: diuréticos= espironolactona, 100mg/dia
*P<0.01 vs. baseline †P<0.01 vs. placebo * Baseline * Spironolactone Placebo *† Visual Analogue Scale *† Spironolactone for Premenstrual Syndrome Spironolactone, an aldosterone receptor agonist derived from 17-spirolactone, acts as a potassium-sparing diuretic. Spironolactone treats premenstrual fluid retention and is also beneficial for relieving other premenstrual symptoms. Thirty-five women with premenstrual syndrome participated in this double-blind, crossover, randomized trial. Participants were randomized to two 3-month treatment periods of spironolactone (100 mg/day) or placebo from day 14 of their cycle until onset of menses. The primary outcome measure was prospective recording of symptoms using a daily Visual Analogue Scale. Women receiving placebo experienced a significant improvement in negative and positive symptoms when compared with baseline values (P<0.01). During active treatment: The negative symptoms, which included anxiety and tension, irritability, fatigue and depression, were significantly improved when compared with baseline and placebo (P<0.01) The positive symptoms, which included cheerfulness, well-being, friendliness and an energetic feeling, were significantly improved when compared with baseline (P<0.01) The somatic symptoms, which included headache, a feeling of swelling, sweet craving and breast tenderness, were significantly improved compared with baseline and placebo (P<0.01) Reference: Wang M, Hammarback S, Lindhe BA, Backstrom T. Treatment of premenstrual syndrome by spironolactone: a double-blind, placebo-controlled study. Acta Obstet Gynecol Scand. 1995;74: ansiedade, tensão, irritabilidade, fadiga, depressão Bem-estar, maior energia, sociabilidade Dor de cabeça, crises de raiva, desejo por doces, mastalgia Wang M, et al. Acta Obstet Gynecol Scand. 1995;74:

17 SPM: ansiolítico = alprazolam
agente ansiolítico 0.25 mg, 1 ou 2x/dia na fase lútea do ciclo; resultados não satisfatórios contra-indicado em mulheres com história de dependência ou abuso de drogas sedação Alprazolam for Premenstrual Syndrome The American College of Obstetricians and Gynecologists (ACOG) noted that the anxiolytic agent alprazolam is sometimes used to treat premenstrual symptoms. The typical dose is 0.25 mg once or twice daily during the luteal phase; the dose should be tapered at menses. Studies of alprazolam in women with premenstrual symptoms have had inconsistent results. Use of this drug is contraindicated in women with a history of drug abuse or dependence; alprazolam also causes problems with sedation in some women. For example, Evans et al. conducted a study in which women with premenstrual symptoms were given either alprazolam (0.25, 0.50, or 0.75 mg) or placebo during both the luteal and follicular phases of the cycle under controlled laboratory conditions and found that acute doses of alprazolam did not improve negative premenstrual mood and actually increased negative mood during the follicular phase. Alprazolam also impaired task performance in both phases of the cycle and was not clinically useful in the treatment of premenstrual symptoms. References: ACOG Practice Bulletin No Premenstrual syndrome. Obstet Gynecol. 2000;95(4): supplemental material at end of issue. Evans SM, Haney M, Levin FR, Foltin RW, Fischman MW. Mood and performance changes in women with premenstrual dysphoric disorder: acute effects of alprazolam. Neuropsychopharmacology. 1998;19: ACOG Practice Bulletin No. 15. Obstet Gynecol. 2000;95(4): supplemental material at end of issue.

18 Reduziram os sintomas físicos e comportamentais.
SPM: agonistas do GnRH Inibem o FSH/LH Reduziram os sintomas físicos e comportamentais. Menopausa química = osteoporose Indicado somente em casos severos com falha em outras terapêuticas. Gonadotropin-Releasing Hormone Agonists for Premenstrual Syndrome Gonadotropin-releasing hormone (GnRH) agonists inhibit follicle-stimulating hormone and luteinizing hormone, suppress ovarian steroid hormone production, and prevent ovulation, in effect inducing medical oophorectomy. These agents have been shown to be effective in reducing a number of premenstrual symptoms. For example, Mortola et al. conducted a study in which eight women with severe premenstrual syndrome used a GnRH agonist for two months before entering a four-month double-blind, crossover phase in which they were randomized to receive conjugated equine estrogen (CEE) on days 1 through 25, 10 mg of medroxyprogesterone acetate (MPA) on days 16 through 25, CEE (days 1–25) plus MPA (days 16–25), or placebo for one month each. They found that GnRH monotherapy was associated with at least 75% improvement from baseline in the Calendar of Premenstrual Experiences scores for behavioral (P<0.01), physical (P<0.05), and total (P<0.01) symptoms. Since GnRH agonists induce medical menopause, either estrogen and progestin must be added back or other bone-sparing therapy, such as a bisphosphonate, must be used to preserve bone density. GnRH agonists are indicated only for patients with severe premenstrual symptoms who are unresponsive to other treatments. These agents are also expensive. References: Ginsburg KA, Dinsay R. Premenstrual syndrome. In: Ransom SB, ed. Practical Strategies in Obstetrics and Gynecology. Philadelphia: W.B. Saunders Company, 2000: Mortola JF, Girton L, Fischer U. Successful treatment of severe premenstrual syndrome by combined use of gonadotropin-releasing hormone agonist and estrogen/progestin. J Clin Endocrinol Metab. 1991;72:252A-252F. Ripps BA, Van Gilder K, Minhas B, Welford M, Mamish Z. Alendronate for the prevention of bone mineral density loss during gonadotropin-releasing hormone agonist therapy. J Reprod Med. 2003;48: Ginsburg KA, Dinsay R. Premenstrual syndrome. In: Ransom SB, ed. Practical Strategies in Obstetrics and Gynecology. Philadelphia: W.B. Saunders Company, 2000: ; Mortola JF et al. J Clin Endocrinol Metab. 1991;72:252A-252F.; Ripps BA et al. J Reprod Med. 2003;48:

19 SPM: fluoxetina na fase lútea
* † † *P<0.01; †P<0.05 Mean Change from Baseline in Daily Record of Severity of Symptoms * * Fluoxetine 10 mg Fluoxetine 20 mg Daily Fluoxetine During the Luteal Phase Improves Symptoms of Premenstrual Dysphoric Disorder Several selective serotonin reuptake inhibitors, including fluoxetine, sertraline and paroxetine, have an FDA-approved indication for treating premenstrual dysphoric disorder (PMDD). It is believed that these agents improve the symptoms of PMDD by restoring the balance of serotonin in the brain. These agents can be used continuously or intermittently, particularly during the luteal phase of the cycle. Cohen et al. conducted a double-blind, parallel-group study of fluoxetine in women with PMDD (N=260). Participants were randomized to receive 10 mg of fluoxetine, 20 mg of fluoxetine, or placebo during the luteal phase of the cycle (i.e., 14 days before the expected date of menses until the first day of active bleeding). The 10-mg and 20-mg doses of fluoxetine were significantly superior to placebo in reducing mood symptoms (P<0.01) and problems with social functioning (P<0.05), as measured by the Daily Record of Severity of Problems (DRSP). In addition, the 20-mg dose of fluoxetine was significantly superior to placebo in reducing physical symptoms of breast tenderness (P<0.001), bloating (P<0.001), and joint/muscle pain (P=0.037) and in reducing the total DRSP score (P<0.01). The investigators concluded that 20-mg fluoxetine, given daily during the luteal phase of the cycle, was superior to placebo and that 20-mg fluoxetine had better efficacy than 10-mg fluoxetine with comparable tolerability. Reference: Cohen LS, Miner C, Brown EW, Freeman E, Halbreich U, Sundell K, McCray S. Premenstrual daily fluoxetine for premenstrual dysphoric disorder: a placebo-controlled, clinical trial using computerized diaries. Obstet Gynecol. 2002;100: Placebo * DRSP=Daily Record of Severity of Problems Cohen LS, et al. Obstet Gynecol. 2002;100:

20 SPM: ACO regime 21/7 ACO combinados, regime tradicional 21/7 não melhoraram os sintomas da SPM; Declínio do estradiol endógeno na última semana do ciclo pode ser o responsável pela exacerbação dos sintomas durante o intervalo livre de hormônios Experience with Hormonal Contraceptives for Managing Premenstrual Syndrome Symptoms Estrogen and progestin combinations (e.g., vaginal ring, patch, oral contraceptives [OCs]) mimic spontaneous menstrual flow using a traditional regimen of 21 days of hormone delivery followed by a 7-day hormone-free interval. The hormone-free period of these regimens is associated with withdrawal symptoms such as pelvic pain, headaches, breast tenderness and bloating/swelling. Studies in oral contraceptives have assessed the effects of standard 21 day/7 day contraceptive regimens on premenstrual symptoms with inconsistent results, often showing no or minimal improvement. Studies have documented an increase in premenstrual symptoms during the last week of active oral contraceptive pills extending into the 7-day hormone free interval (HFI). Lack of ovarian suppression during the standard 7-day HFI leads to endogenous estradiol production. Endogenous estradiol levels have been documented to rise at the end of the 7-day HFI, peak in the first half of the of active pill taking and then decline during the last week of active pills. This decline in endogenous estradiol levels during the last week of active pills may be responsible for the estrogen-withdrawal symptoms that appear during the last week of active pills, further exacerbating premenstrual-type symptoms during the subsequent 7-day HFI. References: Backstrom T, Hansson-Malmstrom Y, Lindhe BA, Cavalli-Bjorkman B, Nordenstrom S. Oral contraceptives in premenstrual syndrome: a randomized comparison of triphasic and monophasic preparations. Contraception. 1992;46: Graham CA, Sherwin BB. A prospective treatment study of premenstrual symptoms using a triphasic oral contraceptive. J Psychosom Res. 1992;36: Joffe H, Cohen LS, Harlow BL. Impact of oral contraceptive pill use on premenstrual mood: predictors of improvement and deterioration. Am J Obstet Gynecol. 2003;189: Sulak PJ, Scow RD, Preece C, Riggs MW, Kuehl TJ. Hormone withdrawal symptoms in oral contraceptive users. Obstet Gynecol. 2000;95: Joffe H, Cohen LS, Harlow BL. Impact of oral contraceptive pill use on premenstrual mood: predictors of improvement and deterioration. Am J Obstet Gynecol. 2003;189:

21 Cycle-Related Symptom
Traditional 21/7 Oral Contraceptive Regimen Associated with Premenstrual Symptoms Cycle-Related Symptom N=262 P Value 21 Active Days 7 Hormone-Free Days Pelvic pain = dor pélvica 21% 70% <0.001 Headache= cefaléia 53% Breast tenderness = sensibilidade mamária 19% 58% Bloating/swelling = inchaço/edema 16% 38% Needing pain meds = uso de analgésicos 43% 69% Traditional 21/7 Oral Contraceptive Regimen Associated with Premenstrual Symptoms This study conducted by Sulak et al. compared hormone-related symptoms during the active-pill and hormone-free intervals in 262 women taking oral contraceptives (OCs). Women had either no prior OC use, were restarting OC use, or had been taking OCs continuously for 12 months or longer. Participants used a daily diary to record symptoms. Pelvic pain, headaches, breast tenderness and bloating/swelling were all statistically significantly worse during the 7-day hormone-free interval when compared with the 21-day active-pill interval. The use of pain medications was also significantly increased during the hormone-free interval. Accumulating data suggest that eliminating the 7-day placebo interval decreases cycle-related symptoms. By doing so, renewed ovarian activity is avoided. Reference: Sulak PJ, Scow RD, Preece C, Riggs MW, Kuehl TJ. Hormone withdrawal symptoms in oral contraceptive users. Obstet Gynecol. 2000;95: 21/7=21 days of an active hormone followed by a 7-day hormone-free interval Sulak PJ, et al. Obstet Gynecol. 2000;95:

22 SPM: Drospirenona: progestágeno com efeito antimineralocorticóide
Aldosterone Aldosterone receptor Kidney Drospirenone Drospirenona: derivada da 17-espirolactona, ocupa os receptores da aldosterona e bloqueia a ação da mesma no rim. Aumentando: excreção de sódio e água retenção do potássio Drospirenone: A Novel Progestin with Antimineralocorticoid Effects The ethinyl estradiol in oral contraceptives causes an increase in serum aldosterone levels, which results in the retention of sodium and water and can contribute to bloating and breast tenderness. Data indicate that progestins derived from 19-nortestosterone do not improve premenstrual symptoms. Drospirenone is currently the only progestin not derived from 19-nortestosterone being used in oral contraceptive formulations in the United States. Drospirenone is a novel progestin derived from 17-spirolactone. It is an analogue of spironolactone and has antimineralocorticoid activity and antiandrogenic activity. Drospirenone blocks aldosterone at its receptor, thereby increasing sodium and water excretion and some potassium retention. Reference: Krattenmacher R. Drospirenone: pharmacology and pharmacokinetics of a unique progestogen. Contraception. 2000;62:29-38. Krattenmacher R. Contraception. 2000;62:29-38.

23 Swelling, Bloating, Weight Gain
Drospirenone-Estrogen in an Extended Cycle (168-day) Regimen: Improvement in Premenstrual Symptoms 28-day cycle 168-day cycle † † † Average Score on DSR17* Item † † Drospirenone-Estrogen in an Extended Cycle (168-day) Regimen: Improvement in Premenstrual Symptoms This trial compared the incidence and severity of premenstrual-like symptoms during a traditional 21/7 regimen with an extended-cycle regimen using a validated instrument, the first study of this type. Women ages 18 to 48 years who had been taking oral contraceptives for a minimum of three months (N=114) completed two 21/7 cycles before entering into an extended regimen of 168 days of 3 mg of drospirenone plus 30 µg of ethinyl estradiol (Yasmin, Berlex Labs, Montville, NJ). Symptoms were assessed using the 17-item Penn State Daily Symptom Report of physical and emotional problems. There was significant improvement on 16 of 17 items (P≤0.0001) on the DSR17 in the extended-cycle phase of the study compared with the 21/7 regimen; decreased interest in usual activities was the only item on the DSR17 that did not improve significantly during the extended-cycle phase. Reference: Coffee AL, et al. Oral contraceptives and premenstrual symptoms: comparison of a 21/7 and extended regimen. Am J Obstet Gynecol. 2006;195: Headache Swelling, Bloating, Weight Gain Anxiety Irritability Mood Swings Depression *DSR17=Penn State Daily Symptom Report; †P<0.0001; §P= Coffee AL, et al. Am J Obstet Gynecol. 2006;195:

24 Maioria das mulheres no menacme experimentam SPM:
SPM: Resumo Maioria das mulheres no menacme experimentam SPM: Impacto negativo sobre a qualidade de vida Repercussões sociais negativas, produtividade diminuída e custos elevados. Summary Most reproductive-age women experience some cyclic menstruation-related symptoms that vary widely in severity. These premenstrual symptoms have a negative impact on a woman’s quality of life and productivity, cause functional impairment and increase direct and indirect medical costs. The proposed etiology of premenstrual disorders includes a genetic predisposition that makes women more vulnerable to altered responses of neurotransmitters and reproductive hormonal systems. Many nonpharmacologic and pharmacologic therapies are used to treat premenstrual symptoms; many of these treatment options are not based on clinical evidence of efficacy. Currently, three selective serotonin reuptake inhibitors have an FDA-approved indication to treat premenstrual dysphoric disorder. Oral contraceptives are often used to treat premenstrual syndrome even though most formulations have not been studied. New formulations and altered regimens (i.e., increasing the number of consecutive days of hormone use) of hormonal contraceptives have been shown to reduce the severity of premenstrual symptoms when compared to placebo. A new oral contraceptive formulation that contains 3 mg of drospirenone plus 20 µg of ethinyl estradiol reduces the severity of premenstrual symptoms administered for 24 days in a 28-day cycle.

25 Inibidores seletivos da recaptação
SPM: Resumo Muitas terapias não farmacológicas e farmacológicas são usadas: Aprovados pelo FDA + Inibidores seletivos da recaptação da serotonina(SSRIs)

26 Regimes ACO 21/7 não demonstraram melhora na SPM.
SPM: Resumo Novo contraceptivo regime 24/4 Cartela de 24 pílulas: 3 mg de drosperinona + 0,02 mg de etinilestradiol. A maneira correta de tomar é uma pílula por dia durante 24 dias e 4 dias de repouso. Aprovada pelo FDA (2006) Regimes ACO 21/7 não demonstraram melhora na SPM.

27 SPM: Resumo

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