WHAT ARE NURSES DOING TO HELP PMS PATIENTS?

Abstract

Premenstrual syndrome (PMS) is a hot topic these days but the disorder remains an enigma. Many women suffer, to some degree, the cyclic signs of PMS-irritability, depression, anxiety, impaired concentration, breast swelling and tenderness, headache, binge eating and/or craving for sweet or salty foods. But why? Is the cause hormonal and/or biochemical imbalance, poor nutrition, underlying psychiatric disorder, or some other unknown factor(1-3)? The syndrome is defined as a complex of symptoms-somatic, behavioral, and emotional-occurring in the luteal phase. This phase usually begins in midcycle with ovulation, when the follicle is changed into corpus luteum, and ends at (or shortly after) menstruation(l). In many ways, PMS mimics dysmenorrhea; the key differences are in the timing of symptoms and in pelvic cramping. Although headache, nausea, edema, and fatigue are common to both, pelvic cramping is specific to, and the principal sign of, dysmenorrhea, which generally begins a day or two before menses and peaks in severity on the first or second day of flow. PMS has a wider variety of symptoms (150 having been identified in the literature)(4). The syndrome also begins earlier in the cycle than does dysmenorrhea, and PMS is abruptly relieved at menses. An estimated 20 to 40 percent of women of childbearing age suffer some premenstrual symptoms. However, it is also believed that only 5 to 15 percent have very severe symptoms(5). Many theories have been proposed on specific etiology. An estrogen/progesterone imbalance, excessive prostaglandins, abnormal magnesium metabolism, vitamin deficiencies, reactive hypoglycemia, and neuroendocrine changes in the hypothalmic-pituitary axis are among them, but no theory has been conclusively proved(1-8). Theories on effective treatment also abound. AJN asked nurses, physicians, and researchers involved in the treatment and study of PMS what methods they used, and to what effect. It became clear that nurses are playing the key role in the management of patients with PMS, and that they can back up their advice on methods with solid evidence. Michelle Harrison, MD, of Cambridge, Massachusetts, author of Self-Help for Premenstrual Syndrome, advises physicians that nurses are ideally qualified to handle patients with PMS(9). Guy E. Abraham, MD, a California PMS specialist known for significant research on nutritional and vitamin treatment for the disorder, agrees: "The predominant model in PMS treatment is that the patient has most of her contact with a nurse. Total nurse management is not unusual, unless a medical evaluation is necessary to rule out possible disease." The "predominant model" might describe Mary Ann Wilson, RN, C, a nurse practitioner who has seen over 100 PMS patients in the obstetrics and gynecology department of the Kaiser Foundation Health Plan, a health maintenance organization (HMO) in East Hartford, Connecticut. The department is staffed by five nurse practitioners, four physicians, and two RNs who do phone follow-up. Wilson says PMS patients are referred to the nurse practitioners. "We do all the screening and counseling, unless a medical problem is indicated, or the patient requests an MD," she reports. The initial PMS consult is scheduled during the patient's asymptomatic follicular phase (which runs from menses to ovulation), Wilson explained, "since a PMS patient is then under less stress and she'll have much more energy to do what you suggest." Some women, says Wilson, will first call during an emergency. "We'll do a 'validating' visit; we will talk and calm them and advise a visit when they don't feel so bad. If the patient seems in crisis, particularly if she is suicidal, we will send her immediately to the mental health department for counseling." Most HMO patients have had a thorough physical within six to 12 months of seeking help for PMS. The nurse reviews the patient's chart for health problems that could be contributing to, or confused with, PMS. A nutritional history is taken, with particular attention to excessive alcohol, salt, and caffeine intake. Patients with a very poor Ellen Perley Frank,former editor of Clinical Aspects of High-Risk Pregnancy writes on health and science topics. cr 0