Niphadkar M*, Parulekar SV**
(* Third Year Resident, ** Professor and Head, Department of Obstetrics and Gynecology, Seth G S Medical College & KEM Hospital, Mumbai, India.)
Premenstrual syndrome (PMS) is extremely common in all age groups but more common in the age group of 30-45 years. Its prevalence is found to be ranging from 5 to 95%. PMS comprises of a wide spectrum of physical, psychological and psychosomatic symptomatology. Cyclical conjunctivitis is one such rare symptom of PMS. We report a case of a 34 year old patient with cyclical conjunctivitis occurring 7-10 days before menses and then resolving spontaneously after each menstrual cycle.
Premenstrual syndrome (PMS) is extremely common in all age groups but more common in the age group of 30-45 years. PMS includes a wide array of symptoms. The most common physical symptoms are myalgia, abdominal bloating, fatigue, and headache, found in about 50-95% cases of PMS.2 The most commonly found behavioural symptoms in PMS are depressed mood, mood lability causing mood swings, increased irritability, increased appetite, forgetfulness. The more severe form of PMS that may interfere with the normal daily life is called premenstrual dysphoric disorder (PMDD). Many interesting theories have been put forth regarding the pathophysiology of PMS. But the current evidence shows that PMS or PMDD is a result of abnormal or exaggerated cyclical variations in the levels of ovarian steroid hormones on the central neurotransmitter mechanisms. Serotonin particularly plays an important role in its pathophysiology. Ophthalmic conditions associated with PMS include puffy eyes, blurred vision, sensitivity to light, sties, and poor vision and cyclical conjunctivitis. [Cool Press. PMS Symptoms. Available at: http://coolpress.com/what-are-pms-symptoms/] Cyclical conjunctivitis is a very rare form of PMS. We present a case of cyclical conjunctivitis occurring premenstrually.
A 34 year old P1L1 came to the OPD with complaints of pain in lower abdomen and redness of both eyes 7-10 days before every menses for 2 years. The redness and discomfort in the eyes would spontaneously relieve after menses, only to recur before next menses. The patient was examined and on examination was found to have pelvic inflammatory disease. Appropriate antibiotics were prescribed. Thyroid function tests were advised in view of a mild thyroid swelling. The patient was told to follow up when the redness of the eyes occurs. The patient followed up eventually and it was found that both the eyes had redness in the temporal region with features of bilateral conjunctivitis. No other significant history of any allergy was found on detailed history taking. The patient was referred to ophthalmology for further management of the condition. She completed 1 week course of moxifloxacin eyedrops twice a day and a month course of chloramphenicol eye drops. The patient was symptomatically better during the treatment. But after the completion of the treatment, the complaints recurred premenstrually in subsequent menstrual cycles.. The patient was also started on thyroid medication by the endocrinologist as she was found to be hypothyroid on investigations.
Figure 1. Appearance of the eyes just before menses.
Figure 2. Appearance of the eyes after menses.
Cyclical conjunctivitis is a well known clinical form of PMS though its occurrence is rare. [3,4] Various allergic reactions related to menstruation like skin rashes, herpetic eruptions on lip, menstrual asthma, menstrual coryza and cyclical conjunctivitis have been reported.1 Some asthmatics can experience attacks especially premenstrually but that might not always be due to nervous tension. Oestrogen has also been found to induce such attacks. Cyclical conjunctivitis or menstrual red eye is usually accompanied by menstrual coryza. Oestrogen induced swelling of the nasal mucosa may be responsible for both the above symptoms. The treatment of such cyclical allergic conditions is usually not very satisfactory as was seen in our patient.
The ocular surface is also found to be an oestrogen- dependent unit. The lacrimal and meibomian glands functions in the humans, to some extent, are influenced by the sex steroids. This explains the complaints of dry eye and cyclical conjunctivitis premenstrually. The subjective symptoms, dryness of eyes, inflammation are significantly affected by the hormonal variations in the menstrual cycle. The impairment, especially dryness of eyes, was found to be coinciding with the oestrogen peak in the follicular phase of the cycle. Also the chronic inflammation occurring concurrently further strengthens the evidence of oestrogen’s role in upregulating the proinflammatory substances in tears. The treatment is usually symptomatic, lubricant eye drops for dry eye, and antibiotic eye drops in case of conjunctivitis after ruling out all the other causes of conjunctivitis. Antihistaminics and steroids can also be used.
- Kumar P, Jeffcoate N, Malhotra N. Jeffcoate's principles of gynaecology. New Delhi: Butterworths; 2008, 627-634
- Fritz M, Speroff L. Clinical gynecologic endocrinology and infertility. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011, 581
- Versura P, Fresina M, Campos EC. Ocular surface changes over the menstrual cycle in women with and without dry eye. Gynecological endocrinology. 2007;23(7):385-90.
- Bhaduri BN. Recurrent attacks of phlyctenular conjunctivitis synchronizing with menstruation. Br J Ophthalmol. 1927 Aug; 11(8): 387–388.
Niphadkar M, Parulekar SV. Menstrual Red Eye. JPGO 2016. Volume 3 No. 2. Available from: http://www.jpgo.org/2016/01/menstrual-red-eye.html