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プロゲステロンのステロイド作用のスペクトル

参考文献:
日本産科婦人科学会編・監:OC・LEPガイドライン2015年度版を参考に作表
出典
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1: 著者提供

月経前症候群(PMS)の診断基準

診断は原則として米国産科婦人科学会の診断基準を用いる。
出典
imgimg
1: Diagnosis of premenstrual syndrome by a simple, prospective, and reliable instrument: the calendar of premenstrual experiences.
著者: J F Mortola, L Girton, L Beck, S S Yen
雑誌名: Obstet Gynecol. 1990 Aug;76(2):302-7.
Abstract/Text: To establish a quantitative method for the diagnosis of premenstrual syndrome (PMS), a simple prospective inventory, the calendar of premenstrual experiences, was constructed. The validity and reliability of this instrument were assessed by administering it throughout two consecutive ovulatory cycles to 36 rigidly screened women with PMS and to 18 controls. To establish concurrent validity, scores on behavioral items were correlated with simultaneously obtained scores on lengthier, well-validated psychiatric inventories designed to measure depression rather than PMS, the Beck Depression Inventory and the Profile of Mood States. The results showed that the calendar of premenstrual experiences luteal phase score distinguished PMS women from controls correctly in 104 of 108 cycles, with a 2.8% false-negative rate and no false positives when used for two consecutive cycles. An upper limit follicular phase score was observed beneath which all PMS and normal control subjects fell, suggesting that a higher score is not consistent with PMS. Correlation coefficients of calendar item scores with Profile of Mood States scale scores were 0.58 for tension, 0.51 for depression, 0.46 for anger, 0.61 for fatigue, and 0.57 for confusion (P less than .0001 for all correlations). The correlation of the calendar depression item with the Beck Depression Inventory score was 0.56 (P less than .0001). The test-retest reliability of the calendar given in the same phase of two consecutive menstrual cycles was high (r = 0.78, P less than .0001). We conclude that this instrument is a valid, reliable, and practical PMS inventory, applicable to clinical and some research settings.
Obstet Gynecol. 1990 Aug;76(2):302-7.
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2: AmericanCollege of Obstetricians and Gynecologists: ACOG practice bulletin No. 15Premenstrual syndrome. Obstet Gynecol2000; 95: 1-9

月経前不快気分障害(PMDD)の診断基準

米国精神医学会のマニュアル「DSM-5 精神疾患の診断・統計マニュアル」では、PMS/PMDDを月経前に繰り返す気分変調として1つの疾患として取り扱っている。
出典
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1: DSM-5 精神疾患の診断・統計マニュアル. 医学書院, 2014;171-172

PMS/PMDD質問用紙

PSM/PMDDの重症度はSteiner et al.の質問紙(PSST)を用いて評価する。
出典
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1: The premenstrual symptoms screening tool (PSST) for clinicians.
著者: M Steiner, M Macdougall, E Brown
雑誌名: Arch Womens Ment Health. 2003 Aug;6(3):203-9. doi: 10.1007/s00737-003-0018-4.
Abstract/Text: A variety of instruments have been used in an attempt to operationalize DSM-IV criteria for premenstrual dysphoric disorder (PMDD) and to understand clinically significant premenstrual syndrome (PMS). The objectives of this research were to devise a simple user friendly screening tool to identify women who suffer from severe PMS/PMDD and who are likely to benefit from treatment. Five hundred and nineteen women, between the ages of 18 and 55 yrs, who were seen at a primary care facility completed "The Premenstrual Symptoms Screening tool" (PSST). The PSST reflects and 'translates' categorical DSM-IV criteria into a rating scale with degrees of severity. The results are in line with reported prevalence rates from several recent large prospective studies. We believe that the PSST applies a necessary degree of measure of severity and impact of premenstrual symptoms, establishes quickly if women qualify for PMDD, and is less time consuming and more practical than two cycles of prospective charting. This fast simple tool is an effective screening tool and an important starting point for further assessment.
Arch Womens Ment Health. 2003 Aug;6(3):203-9. doi: 10.1007/s00737-003-...

月経前症候群の症状の出現様式

症状の発現する時期は月経開始前ではあるが多様性がある。
出典
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1: 武谷雄二. 性器・生殖機能に関連する症候、女性医学体系、金原出版、2002; p35-37

PMS/PMDDにおける身体症状と精神症状

精神症状が主体で強い場合、症状がきわめて重症で日常生活に支障を来す場合はPMDDを考える。
出典
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1: 武谷雄二. 性器・生殖機能に関連する症候、女性医学体系、金原出版、2002; p35-37

月経前不快気分障害自己診断表

参考文献:
  1. 日本産科婦人科学会編:産婦人科診療ガイドライン―婦人科外来編2014、p226表3、日本産科婦人科学会、2014
出典
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1: 著者提供

PMSをどのように治療するのか-治療法決定のアルゴリズム

  1. First line:
  1. 運動療法、認知行動療法、ビタミンB6(ピドキサール錠10mg 1日3回経口 [㊜ビタミンB6欠乏症])新世代の低用量エストロゲン・プロゲスチン配合薬(周期的あるいは持続的)と併用する
  1. 持続的あるいは黄体期(15日ー28日)の低用量SSRI、citalopram(本邦では未承認)/escitalopram (レクサプロⓇ)10 mg [㊜うつ状態]など
 
  1. Second line:
  1. エストラジオールパッチ(100 micrograms)[ ㊜更年期障害、閉経後骨粗鬆症など]+マイクロナイズドプロゲステロン(100 mg または 200 mg [月経周期 17–28日],経口または経腟) [㊜生殖補助医療における黄体補充]またはLNG-IUS 52 mg(ミレーナⓇ)[㊜過多月経、月経困難症]
  1. 高用量SSRI持続的あるいは黄体期、citalopram(本邦では未承認)/escitalopram (レクサプロⓇ)20–40 mg [㊜うつ状態]など
 
  1. Third line:
  1. GnRH アナログ:GnRHアゴニスト(リュープリン注射⽤1.88mgⓇ 4週に1回 ⽪下注 [㊜子宮筋腫、⼦宮内膜症])・GnRHアンタゴニスト(レルミナ錠40mgⓇ1日1回経口 [㊜子宮筋腫])+ add-back HRT (持続併用療法 エストロゲン(50–100 micrograms エストラジオールパッチ [㊜更年期障害、閉経後骨粗鬆症など]または 2–4回塗布 エストラジオールゲル [㊜更年期障害、閉経後骨粗鬆症など])+ プロゲステロン(100 mg/dayマイクロナイズドプロゲステロン [㊜生殖補助医療における黄体補充], あるいはチボロン2.5 mg(本邦では未承認)
 
  1. Fourth line
  1. 外科的治療± HRT
 
※[ ]内は本邦での保険適用病名を示し、ここに記載する薬剤はすべてPMSの適用はない。
出典
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1: [https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.14260 英国王立産婦人科医協会(Green-top Guideline No. 48)2017年]

月経前症候群診断のアルゴリズム

PMSの診療は第一に月経周期が正順であることを確認する。次に症状が出現する時期が月経周期の何日目からか、消失する時期と月経発来との関係を評価する。最終に類似する症状が繰り返し出現することを確かめる。
出典
img
1: 著者提供

プロゲステロンのステロイド作用のスペクトル

参考文献:
日本産科婦人科学会編・監:OC・LEPガイドライン2015年度版を参考に作表
出典
img
1: 著者提供

月経前症候群(PMS)の診断基準

診断は原則として米国産科婦人科学会の診断基準を用いる。
出典
imgimg
1: Diagnosis of premenstrual syndrome by a simple, prospective, and reliable instrument: the calendar of premenstrual experiences.
著者: J F Mortola, L Girton, L Beck, S S Yen
雑誌名: Obstet Gynecol. 1990 Aug;76(2):302-7.
Abstract/Text: To establish a quantitative method for the diagnosis of premenstrual syndrome (PMS), a simple prospective inventory, the calendar of premenstrual experiences, was constructed. The validity and reliability of this instrument were assessed by administering it throughout two consecutive ovulatory cycles to 36 rigidly screened women with PMS and to 18 controls. To establish concurrent validity, scores on behavioral items were correlated with simultaneously obtained scores on lengthier, well-validated psychiatric inventories designed to measure depression rather than PMS, the Beck Depression Inventory and the Profile of Mood States. The results showed that the calendar of premenstrual experiences luteal phase score distinguished PMS women from controls correctly in 104 of 108 cycles, with a 2.8% false-negative rate and no false positives when used for two consecutive cycles. An upper limit follicular phase score was observed beneath which all PMS and normal control subjects fell, suggesting that a higher score is not consistent with PMS. Correlation coefficients of calendar item scores with Profile of Mood States scale scores were 0.58 for tension, 0.51 for depression, 0.46 for anger, 0.61 for fatigue, and 0.57 for confusion (P less than .0001 for all correlations). The correlation of the calendar depression item with the Beck Depression Inventory score was 0.56 (P less than .0001). The test-retest reliability of the calendar given in the same phase of two consecutive menstrual cycles was high (r = 0.78, P less than .0001). We conclude that this instrument is a valid, reliable, and practical PMS inventory, applicable to clinical and some research settings.
Obstet Gynecol. 1990 Aug;76(2):302-7.
img
2: AmericanCollege of Obstetricians and Gynecologists: ACOG practice bulletin No. 15Premenstrual syndrome. Obstet Gynecol2000; 95: 1-9