Premenstrual Complaints

(Australia—Australian Family Physician, May 1998, p. 354.) Although most women notice some cyclic variation in mood and physical symptoms, only 12 to 16 percent have significant symptoms associated with the menstrual cycle, and only a small proportion of these seek medical assistance. There are no biochemical tests for premenstrual disorders, but the changing levels of estrogen (a central nervous system stimulant) and progesterone (a central nervous system depressant) are implicated as causes of symptoms. Women who present with premenstrual complaints frequently have complex medical and social problems that require careful screening and diagnosis. Most of these women have identifiable sources of severe social stress. Depression and other psychiatric conditions are reported in 30 percent of cases, gynecologic conditions in 8 percent, medical conditions in 7 percent and iatrogenic conditions in 10 percent. Although progesterone has not been proved to be an effective therapy, clinical trials of this and other remedies have shown placebo effects between 30 and 70 percent. The most commonly used therapies, including evening primrose oil, vitamin B₆, diuretics and progesterone, have not been validated by controlled clinical studies. Estrogen administered transdermally or subcutaneously in dosages sufficient to inhibit ovulation has been reported to relieve symptoms, and several studies have suggested benefit from therapy with fluoxetine or sertraline. More than 75 percent of women presenting with premenstrual symptoms recover without pharmacologic intervention. General health screening and advice concerning nutrition, exercise, smoking cessation and stress reduction are beneficial, but the most powerful interventions appear to be those that enable patients to gain insight into personal and family problems.

Treatment Options for Mastalgia

(Hong Kong—Hong Kong Practitioner, May 1998, p. 260.) Breast pain or mastalgia affects up to 70 percent of women at some point, but only 15 percent of patients experience symptoms severe enough to require treatment. Mastalgia is typically either continuous or cyclic. Cyclic mastalgia usually responds to conservative therapy, including correction of bra size and weight loss. Reduction of caffeine and fat intake, smoking cessation and adjustment in the dose or type of oral contraceptive or other hormone therapy have also been advocated. Several therapies have been suggested for resistant cases of mastalgia, including danazol, bromocriptine, goserelin and tamoxifen, but objective evidence of benefit from studies is very limited. Noncyclic mastalgia may be caused by localized pain of the chest wall, which should respond to injection of local anesthetic or steroid, or both. Nonsteroidal anti-inflammatory drugs are also useful for noncyclic mastalgia.

Otitis Externa

(Great Britain—The Practitioner, June 1998, p. 466.) Acute diffuse otitis externa (“swimmer's ear”) is usually caused by infection with Pseudomonas aeruginosa, Staphylococcus aureus or Proteus species. Thorough cleaning of the ear canal with dry cotton or suction followed by administration of a topical antibiotic and steroid medication usually resolves the infection. Analgesia may be required. Pain on instillation of antibiotic drops may occur as a result of acidity. The more neutral pH of ophthalmic antibiotics may be better tolerated. Severe cases with spreading cellulitis require treatment with systemic antibiotics or insertion of otic wicks, or referral to a subspecialist.

Emergency Contraception

(Australia—Australian Family Physician, May 1998, p. 347.) The traditional form of emergency contraception used within 72 hours of unprotected intercourse is the Yuzpe method, consisting of two doses of 100 μg of ethinyl estradiol and 500 μg of levonorgestrel taken 12 hours apart. Severe nausea is experienced by many patients, and some protocols include extra doses of the medications to replace any lost through vomiting. During the fertile phase of the menstrual cycle, the Yuzpe method is reported to reduce the expected pregnancy rate by 70 to 80 percent. Patients should be reassessed and have a pregnancy test four weeks after undergoing therapy, regardless of menstrual status. Mifepristone is also an effective emergency contraceptive or early abortifacient because of its binding to progesterone receptors. In several countries, the combination of mifepristone and misprostol is used to induce abortion at up to nine weeks of gestation.