Clinical diagnostic criteria for premenstrual syndrome and guidelines for their quantification for research studies

Menstrual Cycle and the Prevalence of Premenstrual Syndrome/Premenstrual Dysphoric Disorder in Adolescent Athletes

STUDY OBJECTIVE

The purpose of this study was to assess the menstrual cycle, menstrual disorders and premenstrual syndrome/premenstrual dysphoric disorder (PMS/PMDD) in girls and young women participating in competitive sports. The impact of PMS/PMDD symptoms on the quality of life was also analyzed.

DESIGN

The prospective study encompassed 125 girls and young women with the aim to determine the presence of menstrual disorders and the prevalence of PMS/PMDD.

PARTICIPANTS

The studied group was composed of 75 female athletes aged 16 to 22 years. The control group included 50 healthy girls and young women who did not practice competitive sports.

SETTING

The studied athletes and the controls prospectively evaluated their 2 consecutive menstrual cycles by using a questionnaire.

INTERVENTIONS

The research tools were a purpose-built questionnaire, a daily log of PMS symptoms according to the American College of Obstetricians and Gynecologists' guidelines, and a daily log of PMDD symptoms based on the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria.

MAIN OUTCOME MEASURES

To determine the impact of competitive sports on the menstrual cycle, menstrual disorders, and the prevalence of PMS/PMDD in girls and young women.

RESULTS

Intensive physical exercise delayed menarche. PMDD was diagnosed in 8% and PMS in 42.4% of all respondents. The prevalence of PMDD did not differ significantly between the groups (9.33% versus 6.00%). PMS was significantly more frequent among athletes than among controls (49.33% versus 32%, P = .045). The prevalence of PMS correlated significantly with mean age (P = .00001) and age at menarche (P = .03) in athletes. PMS was more frequent in older athletes and in girls with older age at menarche.

CONCLUSION

Competitive sports, older mean age, older age at menarche, length of sporting career, and intensity of training are conducive to PMS. The prevalence of PMS increases with the duration and intensification of competitive exercises.

How to measure the impact of premenstrual symptoms? Development and validation of the German PMS-Impact Questionnaire

With 75% of women of reproductive age affected, premenstrual symptoms are very common, ranging from emotional and cognitive to physical symptoms. Premenstrual Syndrome and Premenstrual Dysphoric Disorder can lead to substantial functional interference and psychological distress comparable to that of dysthymic disorders. The assessment of this impact is required as a part of the diagnostic procedure in the DSM-5. In the absence of a specific measure, the authors developed the PMS-Impact Questionnaire. A sample of 101 women reporting severe premenstrual complaints was assessed with the twenty-two items in the questionnaire during their premenstrual phase in an ongoing intervention study at the Philipps-University Marburg from August 2013 until January 2015. An exploratory factor analysis revealed a two-factor solution (labeled Psychological Impact and Functional Impact) with 18 items. A Cronbach's alpha of 0.90 for Psychological Impact and of 0.90 for Functional Impact indicated good reliability. Convergent construct validity was demonstrated by moderate to high correlations with the Pain Disability Index. Low correlations with the Big Five Inventory-10 indicated good divergent validity. The PMS-Impact Questionnaire was found to be a valid, reliable, and an economic measure to assess the impact of premenstrual symptoms. In future research, cross validations and confirmatory factor analyses should be conducted.

Premenstrual Distress Among Japanese High School Students: Self-Care Strategies and Associated Physical and Psychosocial Factors

This study aimed to identify self-care strategies and assess physical and psychosocial factors associated with premenstrual distress among high school students. A cross-sectional survey of 217 adolescent girls aged 15 to 18 years was conducted in October 2009. Most (84.3 percent) had at least one or more symptoms of premenstrual distress. Premenstrual distress interfered with normal school activity in 51.2 percent. Most participants (57.1 percent) did not perform any self-care strategies for premenstrual distress. A hierarchical multiple linear regression analysis was conducted. Comprehension of one's own physical and mental states during premenstrual phases mediated the relationship between neuroticism and premenstrual distress. Activity restrictions due to menstrual distress mediated the relationship between the family's understanding of one's behavior during premenstrual phases and premenstrual distress. Findings suggest that, even if girls have neuroticism, it will be important to teach them to address the comprehension of one's own physical and mental states so that perceptions of both premenstruation and menstruation become more positive. Findings also suggest that the family's understanding was associated with alleviation of premenstrual distress. This study suggests the need for education to help adolescent girls and their families manage premenstrual distress and increase awareness of the benefit of managing its associated symptoms.

Sex hormones affect neurotransmitters and shape the adult female brain during hormonal transition periods

Sex hormones have been implicated in neurite outgrowth, synaptogenesis, dendritic branching, myelination and other important mechanisms of neural plasticity. Here we review the evidence from animal experiments and human studies reporting interactions between sex hormones and the dominant neurotransmitters, such as serotonin, dopamine, GABA and glutamate. We provide an overview of accumulating data during physiological and pathological conditions and discuss currently conceptualized theories on how sex hormones potentially trigger neuroplasticity changes through these four neurochemical systems. Many brain regions have been demonstrated to express high densities for estrogen- and progesterone receptors, such as the amygdala, the hypothalamus, and the hippocampus. As the hippocampus is of particular relevance in the context of mediating structural plasticity in the adult brain, we put particular emphasis on what evidence could be gathered thus far that links differences in behavior, neurochemical patterns and hippocampal structure to a changing hormonal environment. Finally, we discuss how physiologically occurring hormonal transition periods in humans can be used to model how changes in sex hormones influence functional connectivity, neurotransmission and brain structure in vivo.

Is objective and accurate cognitive assessment across the menstrual cycle possible? A feasibility study

Objectives:

Variation in plasma hormone levels influences the neurobiology of brain regions involved in cognition and emotion processing. Fluctuations in hormone levels across the menstrual cycle could therefore alter cognitive performance and wellbeing; reports have provided conflicting results, however. The aim of this study was to assess whether objective assessment of cognitive performance and self-reported wellbeing during the follicular and luteal phases of the menstrual cycle is feasible and investigate the possible reasons for variation in effects previously reported.

Methods:

The Cambridge Neuropsychological Test Automated Battery and Edinburgh Postnatal Depression Scale were used to assess the cognitive performance and wellbeing of 12 women. Data were analysed by self-reported and hormone-estimated phases of the menstrual cycle.

Results:

Recruitment to the study and assessment of cognition and wellbeing was without issue. Plasma hormone and peptide estimation showed substantial individual variation and suggests inaccuracy in self-reported menstrual phase estimation.

Conclusion:

Objective assessment of cognitive performance and self-assessed wellbeing across the menstrual cycle is feasible. Grouping data by hormonal profile rather by self-reported phase estimation may influence phase-mediated results. Future studies should use plasma hormone and peptide profiles to estimate cycle phase and group data for analyses.

Internet-based cognitive behavioural self-help for premenstrual syndrome: study protocol for a randomised controlled trial

BACKGROUND

With a prevalence of 3 to 8% among women of reproductive age, severe premenstrual symptoms are very common. Symptoms range from emotional and cognitive to physical changes. Severe symptoms (that is, premenstrual syndrome) can have a strong impact on everyday functioning and quality of life. Impairment can be as serious as that of dysthymic disorders. Many affected women receive either no treatment at all or are unsatisfied with their treatment. Although there is some evidence for the reduction of distress through cognitive behavioural therapy, there are only a small number of randomised controlled trials carefully investigating the efficacy of this psychotherapeutic approach. Thus, this study aims to evaluate the efficacy of a cognitive behavioural self-help treatment for women suffering from premenstrual syndrome.

METHODS/DESIGN

The study is conducted as a randomised controlled trial. The complex diagnostic assessment includes the completion of a symptom diary over two consecutive cycles and a telephone interview. Eligible women are randomly assigned to either a treatment or a wait-list control group. The intervention is based on cognitive behavioural therapy principles and is provided via the internet. It consists of 14 different modules on which participants work over 8 consecutive weeks. In addition to written information, participants receive email feedback from a clinical psychologist on a weekly basis. Participants assigned to the wait-list receive the treatment after the end of the waiting period (8 weeks). The primary outcome measure is the Premenstrual Syndrome Impairment Measure. Secondary outcomes include the Premenstrual Syndrome Coping Measure, the Short-Form Social Support Questionnaire, the Questionnaire for the Assessment of Relationship Quality, and the Perceived Stress Scale. Data is collected during the premenstrual (luteal) phase at pre-treatment, post-treatment, and 6-month follow-up.

DISCUSSION

So far, there is no study investigating internet-based cognitive behavioural therapy for premenstrual syndrome. The programme approaches the problem of high prevalence in combination with severe impairment and insufficient treatment options.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01961479, 9 October 2013.

Premenstrual syndrome and premenstrual dysphoric disorder in perimenopausal women

OBJECTIVES

To evaluate the prevalence of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) of perimenopausal women at a university hospital along with their menstrual characters.

METHODS

A questionnaire survey regarding premenstrual symptoms was carried out in 100 perimenopausal women (43 to 53, years). The pattern of menstruation and, the intensity of dysmenorrhea were assessed; and further, the symptoms were classified according to their number, intensity, and persistence. The PMS criteria of American College of Obstetrics and Gynecology (ACOG) and PMDD criteria by American Psychiatric Association (APA) were evaluated.

RESULTS

The approximate prevalence of PMS criteria was 95% and that of PMDD criteria was 23%. The most dominant symptoms were 'breast tenderness', 'abdominal bloating', 'and headache'. PMDD was significantly associated with the severity of dysmenorrhea (P = 0.020). There was no significant relation with age, height, weight, body mass index and the cycle of menstruation.

CONCLUSION

Most women experience PMS and PMDD, which and have a significant impact on the activity of perimenopause women. However in most women that do not know well about PMS and PMDD. We should educate and inform women of PMS and PMDD, thus helping them increase their quality of life.

Treatment of premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) is comprised of a cluster of affective, behavioral and somatic symptoms recurring monthly during the luteal phase of the menstrual cycle. The disorder affects 3-8% of menstruating women and represents the more severe and disabling end of the spectrum of premenstrual disorders, which includes premenstrual syndrome and premenstrual aggravation of underlying affective disorder. Rigorous and specific diagnostic criteria for PMDD were specified in the Diagnostic and Statistical Manual of Mental Disorders IV (1994) and reaffirmed in the Diagnostic and Statistical Manual of Mental Disorders V (2013) and, consequently, there has been a marked increase in well-designed, placebo-controlled studies evaluating treatment modalities. Although the exact pathogenesis of PMDD is still elusive, treatment of PMDD and severe premenstrual syndrome has centered on neuromodulation via serotonin reuptake inhibitor antidepressants, and ovulation suppression utilizing various contraceptive and hormonal preparations. Unlike the approach to the treatment of depression, serotonergic antidepressants need not be given daily, but can be effective when used cyclically, only in the luteal phase or even limited to the duration of the monthly symptoms. Less, well-substantiated alternative treatments, such as calcium supplementation, agnus castus (chasteberry), Hypericum perforatum (St John's wort) and cognitive/behavioral/relaxation therapies, may be useful adjuncts in the treatment of PMDD. This review provides an overview of current information on the treatment of PMDD.

Survey of premenstrual symptom severity and impairment in Korean adolescents: premenstrual dysphoric disorder, subthreshold premenstrual dysphoric disorder and premenstrual syndrome

INTRODUCTION

The aims of the study were to examine the prevalence of premenstrual dysphoric disorder (PMDD), subthreshold PMDD and premenstrual syndrome (PMS) among adolescents, and to assess the nature of symptoms and the impact on daily life functions, especially for PMDD and subthreshold PMDD.

METHODS

A cross-sectional survey was conducted among adolescents from an urban area. Participants included 984 girls divided into the following four groups, using a premenstrual symptoms screening tool: PMDD, subthreshold PMDD, moderate/severe PMS and no/mild PMS. An Adolescent Mental Problem Questionnaire, Center for Epidemiological Studies-Depression Scale, revised Children's Manifest Anxiety Scale, and a menstrual information questionnaire were also used.

RESULTS

Sixty-three (6.76%) of the subjects met the criteria for PMDD and 58 (6.2%) were subthreshold PMDD. The subthreshold PMDD group included 79.3% who met the symptom criteria for PMDD, but their impairment was moderate, and 21.7% who were falling short by the number of symptoms for PMDD diagnosis, though reporting severe impairment. The symptom intensity and frequency of the subthreshold PMDD subjects were similar to those in subjects with PMDD. In these two groups, 69% had moderate to severe physical symptoms. Psychiatric problems, including depression and anxiety, were higher in the PMDD and subthreshold PMDD groups than in the moderate/severe PMS and no/mild PMS group.

DISCUSSION

In total, 20% of adolescents reported suffering from distressing premenstrual symptoms, and girls with PMDD and subthreshold PMDD were very similar in their symptom severity and characteristics. Prospective daily charting is needed to confirm the accurate diagnosis and management of PMDD.

Ecological validity and clinical utility of Patient-Reported Outcomes Measurement Information System (PROMIS®) instruments for detecting premenstrual symptoms of depression, anger, and fatigue

OBJECTIVE

This study examined the ecological validity and clinical utility of NIH Patient Reported-Outcomes Measurement Information System (PROMIS®) instruments for anger, depression, and fatigue in women with premenstrual symptoms.

METHODS

One-hundred women completed daily diaries and weekly PROMIS assessments over 4weeks. Weekly assessments were administered through Computerized Adaptive Testing (CAT). Weekly CATs and corresponding daily scores were compared to evaluate ecological validity. To test clinical utility, we examined if CATs could detect changes in symptom levels, if these changes mirrored those obtained from daily scores, and if CATs could identify clinically meaningful premenstrual symptom change.

RESULTS

PROMIS CAT scores were higher in the pre-menstrual than the baseline (ps<.0001) and post-menstrual (ps<.0001) weeks. The correlations between CATs and aggregated daily scores ranged from .73 to .88 supporting ecological validity. Mean CAT scores showed systematic changes in accordance with the menstrual cycle and the magnitudes of the changes were similar to those obtained from the daily scores. Finally, Receiver Operating Characteristic (ROC) analyses demonstrated the ability of the CATs to discriminate between women with and without clinically meaningful premenstrual symptom change.

CONCLUSIONS

PROMIS CAT instruments for anger, depression, and fatigue demonstrated validity and utility in premenstrual symptom assessment. The results provide encouraging initial evidence of the utility of PROMIS instruments for the measurement of affective premenstrual symptoms.

Low-dose acetazolamide in the treatment of premenstrual dysphoric disorder: a case series

The treatment of premenstrual dysphoric disorder (PMDD) is far from satisfactory, as there is a high proportion of patients who do not respond to conventional treatment. The antidiuretic sulfonamide, acetazolamide, inhibits carbonic anhydrase and potentiates GABAergic transmission; the latter is putatively involved in PMDD. We therefore tried acetazolamide in a series of women with intractable PMDD. Here, we describe a series of eight women diagnosed with DSM-IV-TR PMDD, five of whom had comorbidity with a mood disorder and one with an anxiety disorder, who were resistant to treatment and responded with symptom disappearance after being added-on 125 mg/day acetazolamide for 7-10 days prior to menses each month. Patients were free from premenstrual symptoms at the 12-month follow-up. We suggest that acetazolamide may be used to improve symptoms of PMDD in cases not responding to other treatments. GABAergic mechanisms may be involved in counteracting PMDD symptoms.

Sleep and Women's Health

Sex differences in sleep begin at a very early age and women report poorer sleep quality and have higher risk for insomnia than do men. Sleep may be affected by variation in reproductive hormones, stress, depression, aging, life/role transitions, and other factors. The menstrual cycle is associated with changes in circadian rhythms and sleep architecture. Menstruating women (even without significant menstrual-related complaints) often report poorer sleep quality and greater sleep disturbance during the premenstrual week compared to other times of her menstrual cycle. In addition to these sleep disturbances, women with severe premenstrual syndrome often report more disturbing dreams, sleepiness, fatigue, decreased alertness and concentration during the premenstrual phase. Sleep disturbances are also commonly reported during pregnancy and increase in frequency and duration as the pregnancy progresses. The precipitous decline in hormones and unpredictable sleep patterns of the newborn contribute to and/or exacerbate poor sleep and daytime sleepiness during the early postpartum period. Insomnia is also among the most common health complaints that are reported by perimenopausal women. Women are particularly vulnerable to developing insomnia disorder during these times of reproductive hormonal change. In this review, we present a discussion on the most relevant and recent publications on sleep across the woman's lifespan, including changes in sleep related to menstruation, pregnancy, postpartum, and the menopausal transition. Treatment for sleep disturbances and insomnia disorder and special considerations for treating women will also be discussed.

Premenstrual dysphoric disorder and severe premenstrual syndrome in adolescents

Numerous epidemiologic studies have demonstrated that premenstrual disorders (PMDs) begin during the teenage years. At least 20 % of adolescents experience moderate-to-severe premenstrual symptoms associated with functional impairment. Premenstrual syndrome (PMS) consists of physical and/or psychological premenstrual symptoms that interfere with functioning. Symptoms are triggered by ovulation and resolve within the first few days of menses. The prevalence of premenstrual dysphoric disorder (PMDD), a severe form of PMS accompanied by affective symptoms, is likely equal to or higher than in adults. The diagnosis of a PMD requires a medical and psychological history and physical examination but it is the daily prospective charting of bothersome symptoms for two menstrual cycles that will clearly determine if the symptoms are related to a PMD or to another underlying medical or psychiatric diagnosis. The number and type of symptoms are less important than the timing. Randomized controlled trials of pharmacologic treatments in teens with moderate-to-severe PMS and PMDD have yet to be performed. However, clinical experience suggests that treatments that are effective for adults can be used in adolescents. PMS can be ameliorated by education about the nature of the disorder, improving calcium intake, performing exercise and reducing stress, but to treat severe PMS or PMDD pharmacologic therapy is usually required. Eliminating ovulation with certain hormonal contraceptive formulations or gonadotropin-releasing hormone agonists will be discussed. Serotonergic agonists are a first-line therapy for adults, and some serotonin reuptake inhibitors such as fluoxetine and escitalopram can be administered safely to teens.

Premenstrual syndrome and migraine

Premenstrual syndrome (PMS) includes a wide variety of physical, psychological, and cognitive symptoms that occur recurrently and cyclically during the luteal phase of the menstrual cycle and disappear soon after the onset of menstruation. Headache, often of migrainous type, is one of physical symptoms often reported in the diagnostic criteria for PMS. Menstrual migraine (MM) is a particular subtype of migraine occurring within the 2 days before and the 3 days after the onset of menses. According to this definition, therefore, some attacks of MM certainly occur in conjunction with the period of maximum exacerbation of PMS symptoms. The relationship between MM and PMS has been investigated through diary-based studies which have confirmed the possible correlation between these two conditions. In this paper we provide indications for the treatment of MM, making particular reference to those therapies that may be useful in the treatment of PMS symptoms. Even if triptans are the gold standard for the acute treatment, if symptomatic treatment is not sufficient one can resort to a short-term perimenstrual prophylaxis. Non-steroidal anti-inflammatory drugs have been demonstrated effective in MM prophylaxis. Among natural products there is some evidence of efficacy for magnesium, phytoestrogens, and ginkgolide B. Finally, also a combined oral contraceptive containing drospirenone, taken continuously for 168 days, has shown promising results.

Advances in the diagnosis of premenstrual syndrome and premenstrual dysphoric disorder

Premenstrual disorders negatively impact the quality of life and functional ability of millions of women. The two generally recognized premenstrual disorders are premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). These disorders are characterized by a wide variety of nonspecific mood, somatic and behavioral symptoms that occur only during the late luteal phase of a woman's cycle and disappear soon after the onset of menstruation. This paper reviews the diagnostic criteria for PMS and PMDD, describes some of the more common symptom diaries and other tools used to diagnose premenstrual disorders, and discusses the challenges inherent in diagnosing PMS and PMDD. A survey of peer-reviewed articles and relevant texts provided diagnostic criteria, descriptions of diagnostic tools and information about diagnostic challenges. The many nonspecific symptoms associated with premenstrual disorders complicate the diagnostic process. The use of proven symptom diaries and other diagnostic tools should aid in the differential diagnosis of premenstrual disorders. Patients need to report bothersome premenstrual symptoms, and clinicians should become more proficient in the diagnostic process in order to prevent underdiagnosis of these disorders.

Intradermal sex hormone desensitization for relief of premenstrual symptoms may improve the obstetric outcome of women with recurrent pregnancy loss

The aim of this study was to determine whether women with recurrent pregnancy loss (RPL) and concurrent premenstrual syndrome (PMS) who underwent desensitization with sex hormones had an improved obstetric outcome. This manuscript summarizes a 10 year open label prospective follow up study of 26 women with RPL, aged 25-42 with 3-8 previous miscarriages and PMS, who had hormone hypersensitivity on skin testing. Skin testing was positive to estradiol in 23 women, progesterone in 20 women and to both estrogen and progesterone in 17 women. Amelioration of the symptoms of PMS (according to the VAS) was seen in 21 of 26 patients after desensitization with small doses of sex hormones intradermally. There was long term and stable reduction of severe PMS in 21 of 26 patients after desensitization. Five women conceived after skin testing, prior to desensitization. Sixteen of 26 women (61%) had subsequent live births. Five women had two subsequent live births in the subsequent pregnancy. There were no obstetric complications. Five women had two subsequent pregnancies with live births. It seems that correction of sex hormone hypersensitivity was accompanied by relief of persistent PMS, may have a positive effect on the chances of a successful pregnancy.

Cognitive-behavioral and pharmacological interventions for premenstrual syndrome or premenstrual dysphoric disorder: a meta-analysis

The current meta-analysis investigates the efficacy of psychotherapeutic interventions and psychopharmacotherapy for premenstrual syndrome (PMS) and premenstrual dysphoric disorder. Based on a multiple-phase literature search, controlled trials were selected according to a priori defined inclusion criteria. Data were extracted on the basis of a standardized coding scheme. The standardized weighted mean difference (random effects model) was used as effect size index. Dependent on outcome, 22 included studies obtained small to medium effect sizes for cognitive-behavioral interventions (range: d(+) = 0.24-0.70) and for serotonergic antidepressants (range: d(+) = 0.29-0.58), at post-assessment. Follow-ups were performed only in studies of cognitive-behavioral interventions (range: d(+) = 0.46-0.74). There was no evidence of a publication bias. For both cognitive-behavioral interventions and serotonergic antidepressants, efficacy in treatment of PMS was found to not be satisfactory. Future research should possibly focus more on a combination of both approaches.

Homeopathic treatment of premenstrual syndrome: a case series

OBJECTIVE

Observational, prospective study to describe the homeopathic management of premenstrual syndrome (PMS) by a group of French physicians.

METHOD

Women with PMS for >3 months were prescribed individualized homeopathic treatment. The intensity of 10 clinical symptoms of PMS was scored individually at inclusion and at a 3-6 month follow-up visit: absent = 0, mild = 1, moderate = 2, severe = 3. Total symptom score (range: 0-30) was calculated and compared for each patient at inclusion and at follow-up. PMS impact on daily activities (quality of life, QoL) was compared at inclusion and follow-up as: none, mild, moderate, severe, very severe.

RESULTS

Twenty-three women were prescribed homeopathic treatment only (mean age: 39.7 years). Folliculinum (87%) was the most frequently prescribed homeopathic medicine followed by Lachesis mutus (52.2%). The most common PMS symptoms (moderate or severe) at inclusion were: irritability, aggression and tension (87%), mastodynia (78.2%) and weight gain and abdominal bloating (73.9%); and the most common symptoms at follow-up were: irritability, aggression and tension (39.1%), weight gain and abdominal bloating (26.1%) and mastodynia (17.4%). Mean global score for symptom intensity was 13.7 at inclusion and 6.3 at follow-up. The mean decrease in score (7.4) was statistically significant (p < 0.0001). Twenty-one women reported that their QoL also improved significantly (91.3%; p < 0.0001).

CONCLUSIONS

Homeopathic treatment was well tolerated and seemed to have a positive impact on PMS symptoms. Folliculinum was the most frequent homeopathic medicine prescribed. There appears to be scope for a properly designed, randomized, placebo-controlled trial to investigate the efficacy of individual homeopathic medicines in PMS.

Biopsychosocial aspects of premenstrual syndrome and premenstrual dysphoric disorder

A majority of women in their reproductive years experience a variety of symptoms premenstrually that can alter behavior and well-being and affect family, friends, and working relationships. Notwithstanding its prevalence, however, research has not yet clarified this inscrutable condition, commonly known as premenstrual syndrome (PMS) or more severe PMS, premenstrual dysphoric disorder (PMDD). This comprehensive review discusses the diagnosis, epidemiology, symptoms, etiology, and the complex web of biopsychosocial factors that attends PMS.

Increased salivary chromogranin A in women with severe negative mood states in the premenstrual phase

The present study investigated whether salivary chromogranin A (CgA), a psychological stress marker associated with sympathetic nervous system activity, changes during the menstrual cycle in women with different degrees of premenstrual psychoemotional symptoms. Forty-five women (28.6 ± 1.3 years) with regular menstrual cycles participated in this study. Salivary CgA and cortisol were measured during the follicular and late-luteal phases. The authors used the Profile of Mood State (POMS) to assess current mood states of subjects in each menstrual phase and divided the subjects into three groups depending on increase of total mood disturbance (TMD), a global measure of affective states of POMS from the follicular to the late-luteal phase: Low (4.1 ± 0.7%), Middle (18.7 ± 1.2%) and High (51.7 ± 7.4%). Results showed no intramenstrual cycle differences in salivary CgA in the Low and Middle groups. Women in the High group, in contrast, had a significantly higher level of salivary CgA in the late-luteal phase compared to that of the follicular phase. Additionally, salivary CgA level significantly and positively correlated with TMD and four emotional subscales: tension-anxiety, depression-dejection, anger-hostility and confusion in the late-luteal phase. No intergroup or menstrual-cycle difference occurred in the salivary cortisol. This study indicates a significant late-luteal increase in salivary CgA, reflecting an increase of sympathetic nerve activity in women who experience a substantial increase (>30%) in a cluster of negative psychoemotional symptoms premenstrually. Furthermore, salivary CgA, as opposed to salivary cortisol, could serve as a reliable noninvasive biomarker to more sensitively evaluate neuropsychophysiological fluctuations during the menstrual cycle.

Menstrual cycle effects on amygdala reactivity to emotional stimulation in premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) with luteal phase related anxiety and mood swings compromise quality of life in around 4% of reproductive women. While anxiety is related to amygdala function, prior studies on amygdala reactivity both in healthy controls and women with PMDD are inconsistent with respect to menstrual cycle effects. Here women with PMDD and healthy controls were exposed to emotional faces during the mid-follicular and late luteal phase, and mean blood-oxygen-level dependence (BOLD) signal changes in the amygdala were determined with functional magnetic resonance imaging (fMRI). Women with PMDD had enhanced bilateral amygdala reactivity in the follicular phase in comparison with healthy controls, but there was no difference between groups during the luteal phase. In contrast, healthy controls displayed higher left amygdala reactivity in the luteal than in their follicular phase. However, among women with PMDD follicular phase progesterone serum concentrations were positively correlated with bilateral amygdala reactivity while depression scores were positively correlated with right amygdala reactivity in the luteal phase. In addition, women with PMDD and high scores on trait anxiety had increased right amygdala reactivity in the luteal as compared to the follicular phase. Finally, amygdala reactivity was more prone to habituation in women with PMDD, as they had enhanced amygdala reactivity in comparison with controls at the first, but not the second scanning session. Thus, while the study failed to indicate increased luteal phase amygdala reactivity in women with PMDD, our findings suggest that anxiety proneness and progesterone levels modulate menstrual cycle related amygdala reactivity in women with PMDD.

Higher luteal progesterone is associated with low levels of premenstrual aggressive behavior and fatigue

Contradictory findings show both positive and negative effect of progesterone on the premenstrual mood changes in women. Here we present the study investigating this relationship on the large sample of premenstrual women. 122 healthy, reproductive age women collected daily morning saliva samples and recorded intensity scores for the mood symptoms: irritability, anger, sadness, tearfulness, insomnia, and fatigue. Saliva samples were assayed for progesterone concentrations and mood intensity scores were used to calculate behavioral indices. Women with low Aggression/Irritability and Fatigue had consistently higher progesterone levels during the luteal phase than women with high Aggression/Irritability and Fatigue. Additionally, Aggression/Irritability and Fatigue correlated negatively with maximal progesterone value during the luteal phase. Our results demonstrated a negative effect of low progesterone level on the premenstrual mood symptoms such as aggressive behavior and fatigue in healthy reproductive age women. This supports a previously proposed model of biphasic action of progesterone metabolites on mood.

Perceived stress and severity of perimenstrual symptoms: the BioCycle Study

OBJECTIVE

To examine the longitudinal relation between perceived stress in the previous month and perimenstrual symptom severity across two cycles among regularly menstruating, healthy women (n = 259).

METHODS

At baseline (11 days before the first cycle), participants completed the 4-item Perceived Stress Scale (PSS) for the previous month (first cycle exposure) and questionnaires on lifestyle factors. On cycle day 22 of a standardized 28-day cycle, participants again completed the PSS for the previous week (second cycle exposure) and each week rated the severity (none, mild, moderate, severe) of 17 psychological and physical symptoms (e.g., crying, cramping, pain). Mixed models estimated the association between perceived stress scores and number of moderate/severe symptoms and symptom severity scores, allowing both stress and perimenstrual symptoms to vary by cycle.

RESULTS

Adjusting for age, education, passive and active smoking, and waist/height ratio (WHtR), high stress (fourth quartile PSS) was associated with an increased risk of reporting >or=8 or more (OR 7.2, 3.3-15.8) and >or=5 (OR 2.5, 1.6-4.1) symptoms as moderate/severe during the perimenstrual period compared with lower stress (quartiles one, two, and three). Stress scores were positively (p < 0.0001) associated with increased symptom severity scores for total, psychological, and physical symptoms.

CONCLUSIONS

These analyses show that higher perceived stress precedes an increased severity of perimenstrual symptoms. Stress reduction programs may be an effective, nonpharmaceutical treatment for physical and psychological symptom relief.

Progesterone for premenstrual syndrome

BACKGROUND

About 5% of women experience severe symptoms called premenstrual syndrome (PMS), only in the two weeks before their menstrual periods. Treatment with progesterone may restore a deficiency, balance menstrual hormone levels or reduce effects of falling progesterone levels on the brain or on electrolytes in the blood.

OBJECTIVES

The objectives were to determine if progesterone has been found to be an effective treatment for all or some premenstrual symptoms and if adverse events associated with this treatment have been reported.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and PsycINFO to February 2011. We contacted pharmaceutical companies for information about unpublished trials, for the first version of this review.The search strings are in Appendix 2.

SELECTION CRITERIA

We included randomised double-blind, placebo-controlled trials of progesterone on women with PMS diagnosed by at least two prospective cycles, without current psychiatric disorder.

DATA COLLECTION AND ANALYSIS

Two reviewers (BM and OF) extracted data independently and decided which trials to include. OF wrote to trial investigators for missing data.

MAIN RESULTS

From 17 studies, only two met our inclusion criteria. Together they had 280 participants aged between 18 and 45 years. One hundred and fifteen yielded analysable results. Both studies measured symptom severity using subjective scales. Differing in design, participants, dose of progesterone and how delivered, the studies could not be combined in meta-analysis.Adverse events which may or may not have been side effects of the treatment were described as mild.Both trials had defects. They intended to exclude women whose symptoms continued after their periods. When data from ineligible women were excluded from analysis in one trial, the other women were found to have benefited more from progesterone than placebo. The smaller study found no statistically significant difference between oral progesterone, vaginally absorbed progesterone and placebo, but reported outcomes incompletely.

AUTHORS' CONCLUSIONS

The trials did not show that progesterone is an effective treatment for PMS nor that it is not. Neither trial distinguished a subgroup of women who benefited, nor examined claimed success with high doses.

Reliability and component structure of the modified Daily Symptom Report (DSR-20)

OBJECTIVES

The purpose of the present study was to modify Freeman et al.'s (1996) Daily Symptom Report (DSR) for premenstrual syndrome (PMS) by adding items depicting aggressive and impulsive symptoms, to explore the component structure of this revised measure (DSR-20) in a sample of PMS sufferers, and to compare their scores with those from controls during the follicular and luteal cycle phases.

METHODS

The DSR-20 was administered to 140 PMS sufferers who were seeking treatment for PMS and 54 controls who considered themselves to be free from premenstrual complaints daily for three menstrual cycles.

RESULTS

Cronbach's α was 0.95 for the luteal DSR-20 scores of the PMS sufferers, indicating very high internal consistency of the 20 items. Exploratory Principal Components Analysis (PCA) of the luteal ratings of the PMS sufferers identified two components with high internal consistency (>0.90), describing psychological and physical premenstrual symptoms. PMS sufferers scored significantly higher than the controls on each of these components during the luteal, but not follicular, phase.

CONCLUSIONS

The DSR-20 total scale score is an internally consistent global measure of the intensity of PMS. The division of PMS symptoms into psychological and physical components, both of which significantly differentiated PMS sufferers from controls during the luteal phase, sheds further light on the description of PMS and provides a clinically relevant and practical means by which to summarise and interpret daily symptom ratings, necessary for the identification and investigation of the syndrome.

Mood instability in women with premenstrual syndrome

OBJECTIVE

Most women of reproductive age experience premenstrual symptoms. Mood swings within a day and from day to day are a common complaint of people with mood problems (mood instability). We investigated whether mood instability was higher in women with premenstrual syndrome (PMS) than in a control group with no PMS.

METHODS

We prospectively studied mood and physical symptoms over two menstrual periods in 29 women with self-identified PMS and 31 women without PMS. We excluded women on hormonal birth control or with a history of past or current diagnoses of depression. We used the mean square successive difference derived from twice daily visual analogue scale ratings of mood as the measure of mood instability.

RESULTS

The women with PMS showed more irritable and depressed mood instability than the women without PMS. These differences were present whether or not the late luteal phase (seven days before the start of menstruation) was included in the data. On visual inspection of mood ratings, typically irritable and depressed moods increased in the late luteal phase. However, women with self-identified PMS showed a variety of mood patterns throughout the cycle.

CONCLUSION

Women with PMS have increased mood instability within the seven day premenstrual phase and at other times as well. This supports the premise that PMS may represent a manifestation of an underlying problem of mood dysregulation in common with other mood disorders.

Premenstrual symptoms in young adults born preterm at very low birth weight - from the Helsinki Study of Very Low Birth Weight Adults

Background

Clinically significant premenstrual symptoms are common among young women. Premenstrual syndrome (PMS) is characterized by emotional, behavioural and physical symptoms that consistently occur during the luteal phase of the menstrual cycle. Premenstrual dysphoric disorder (PMDD) is a severe form of PMS. Individual variation in stress responsiveness may be involved in the pathophysiology of premenstrual symptoms. Preterm birth at very low birth weight (VLBW, < 1500g) has a multitude of consequences that extend to adult life, including altered stress responsiveness which could affect the prevalence of premenstrual symptoms.

Methods

In this cohort study, we compared 75 VLBW women with 95 women born at term (mean age 22.5). We used a standardized retrospective questionnaire assessing the presence and severity of a variety of symptoms before and after menses. The symptom scores were used both as continuous and as dichotomized variables, with cutoffs based on DSM-IV criteria for PMDD and ACOG criteria for PMS, except prospective daily ratings could not be used. We used multiple linear and logistic regression to adjust for confounders.

Results

There was no difference in the continuous symptom score before menses (mean difference VLBW-term -18.3%, 95% confidence interval -37.9 to 7.5%) or after menses. The prevalence of premenstrual symptoms causing severe impairment to daily life was 13.3% for VLBW women and 14.7% for control women. For PMDD, it was 8.0% and 4.2%, and for PMS, 12.0% and 11.6%, respectively. These differences were not statistically significant (p > 0.1).

Conclusion

Our findings suggest that the severity of premenstrual symptoms and the prevalence of PMDD and PMS among young women born preterm at VLBW is not higher than among those born at term.

ESPECTRA: searching the bipolar spectrum in eating disorder patients

BACKGROUND

Bipolar Disorder (BD) is a chronic, recurrent and highly prevalent illness. Despite the need for correct diagnosis to allow proper treatment, studies have shown that reaching a diagnosis can take up to ten years due to the lack of recognition of the broader presentations of BD. Frequent comorbidities with other psychiatric disorders are a major cause of misdiagnosis and warrant thorough evaluation.

METHODS/DESIGN

ESPECTRA (Occurrence of Bipolar Spectrum Disorders in Eating Disorder Patients) is a single-site cross-sectional study involving a comparison group, designed to evaluate the prevalence of bipolar spectrum in an eating disorder sample. Women aged 18-45 years will be evaluated using the SCID-P and Zurich criteria for diagnosis and the HAM-D, YOUNG, SCI-MOODS, HCL-32, BIS-11, BSQ, WHOQoL and EAS instruments for rating symptoms and measuring clinical correlates.

DISCUSSION

The classificatory systems in psychiatry are based on categorical models that have been criticized for simplifying the diagnosis and leading to an increase in comorbidities. Some dimensional approaches have been proposed aimed at improving the validity and reliability of psychiatric disorder assessments, especially in conditions with high rates of comorbidity such as BD and Eating Disorder (ED). The Bipolar Spectrum (BS) remains under-recognized in clinical practice and its definition is not well established in current diagnostic guidelines. Broader evaluation of psychiatric disorders combining categorical and dimensional views could contribute to a more realistic understanding of comorbidities and help toward establishing a prognosis.

Towards a consensus on diagnostic criteria, measurement and trial design of the premenstrual disorders: the ISPMD Montreal consensus

Premenstrual disorders (PMD) are characterised by a cluster of somatic and psychological symptoms of varying severity that occur during the luteal phase of the menstrual cycle and resolve during menses (Freeman and Sondheimer, Prim Care Companion J Clin Psychiatry 5:30-39, 2003; Halbreich, Gynecol Endocrinol 19:320-334, 2004). Although PMD have been widely recognised for many decades, their precise cause is still unknown and there are no definitive, universally accepted diagnostic criteria. To consider this issue, an international multidisciplinary group of experts met at a face-to-face consensus meeting to review current definitions and diagnostic criteria for PMD. This was followed by extensive correspondence. The consensus group formally became established as the International Society for Premenstrual Disorders (ISPMD). The inaugural meeting of the ISPMD was held in Montreal in September 2008. The primary aim was to provide a unified approach for the diagnostic criteria of PMD, their quantification and guidelines on clinical trial design. This report summarises their recommendations. It is hoped that the criteria proposed here will inform discussions of the next edition of the World Health Organisation's International Classification of Diseases (ICD-11), and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) criteria that are currently under consideration. It is also hoped that the proposed definitions and guidelines could be used by all clinicians and investigators to provide a consistent approach to the diagnosis and treatment of PMD and to aid scientific and clinical research in this field.

Prevalence of premenstrual syndrome and premenstrual dysphoric disorder in a representative cohort of Spanish women of fertile age

OBJECTIVE

To assess the prevalence of premenstrual symptoms, premenstrual syndrome and premenstrual dysphoric disorder in a cohort of women of fertile age representative of the general Spanish population.

STUDY DESIGN

During the period between November 27th and December 22nd, 2008, a cross-sectional nationwide survey was conducted among a cohort of Spanish women aged between 15 and 49 years. Participants were personally interviewed at home and completed the premenstrual symptoms screening tool.

RESULTS

Of the 2108 participants, 1554 women (73.7%) complained of some of the premenstrual symptoms during the last 12 menstrual cycles. A total of 1415 (91%) women presented isolated symptoms and 139 (8.9%) a moderate/severe premenstrual syndrome. Twenty-four (1.1%) women fulfilled criteria for a diagnosis of premenstrual dysphoric disorder.

CONCLUSION

The prevalence of premenstrual symptoms (73.7%) and premenstrual dysphoric disorder (1.1%) in Spanish women aged between 15 and 49 years is similar to that reported in other Western countries. Only women with moderate or severe premenstrual syndrome or premenstrual dysphoric disorder, however, had daily life activities significantly impaired by premenstrual symptoms.

Core symptoms that discriminate premenstrual syndrome

OBJECTIVE

To identify core symptoms that discriminate premenstrual syndrome (PMS) in prospective daily diary ratings and determine the association of these symptoms with functional impairment.

METHODS

The study analyzed prospective daily symptom ratings and functional impairment data provided by 1081 women who requested PMS treatment at an academic medical center. The data were obtained before any treatment procedures. A random-split sample design provided separate developmental and validation datasets. Logistic regression was used to identify a reduced set of symptoms that best discriminated PMS. The results were validated in a separate dataset. Optimal cutoff points in the symptom scores were identified for clinical use.

RESULTS

Statistical modeling identified 6 symptoms that discriminated PMS and not PMS as well as 17 symptoms in daily diary ratings. The identified core symptoms included anxiety/tension, mood swings, aches, appetite/food cravings, cramps, and decreased interest in activities. The area under the curve (AUC) was 0.84 in both models. The sums of the premenstrual symptom scores also discriminated PMS and not PMS and correctly classified 84%-86% of the cases.

CONCLUSIONS

Six symptoms rated in daily diaries discriminate between PMS and not PMS among women seeking treatment and are significantly associated with functional impairment. The findings suggest that the burden of daily diaries to confirm PMS can be reduced to a smaller number of symptoms that distinguish the patients who meet this requirement. Results also support the concept that a clinical diagnosis of PMS can be developed around a core symptom group.

The complexity of premenstrual dysphoric disorder--risk factors in the population of Polish women

BACKGROUND

Premenstrual dysphoric disorder has multiple determinants in the biological, psychological and socio-cultural domains. The aim of the study was to evaluate the risk factors for premenstrual dysphoric disorder in Polish women, considering their reproductive history, socio-economic factors, as well as lifestyle and health-related factors.

METHODS

2,500 females, aged 18 to 45, from the Upper Silesian region of Poland were eligible for the prospective population study. The final study sample was 1,540 individuals. The research was based on a questionnaire containing socio-economic status, general health, lifestyle, medical and reproductive history, premenstrual symptoms based on the American Psychiatric Association's criteria for diagnosing premenstrual dysphoric disorder, and patient prospective daily ratings of symptoms. The Statistica 8.0 computer software was used for statistical analysis. The value of p < 0.05 was adopted as the level of statistical significance.

RESULTS

The mean age of the studied population was 31.9 +/- 7.3 years. The majority of the studied women were married (57.9%), lived in large cities (42.0%) and had tertiary education (43.2%). The results of the study indicated that the prevalence of premenstrual dysphoric disorder was 2.1%. The final statistical analysis revealed that only tertiary education decreased the risk of premenstrual dysphoric disorder (OR = 0.08; p < 0.05).

CONCLUSIONS

Our research showed that women with tertiary education are less vulnerable to premenstrual dysphoric disorder than women with a lower level of education. Reproductive and lifestyle factors seem to be play a lesser role.

The possible protective role of personality dimensions against premenstrual syndrome

Previous studies suggest that women with premenstrual syndrome (PMS) differ from those without PMS in personality dimensions, but it is not clear what role personality plays in the background of premenstrual symptomatology. Our purpose was to examine personality dimensions measured by the Tridimensional Character Inventory (TCI) in psychiatrically healthy women not suffering from premenstrual dysphoric disorder (PMDD) in relation to the severity of distressing and impairing mental and physical symptoms experienced in the late luteal phase of the menstrual cycle. Forty healthy women completed the prospective record of the Impact and Severity of Menstrual Symptoms (PRISM) calendar every evening through three consecutive menstrual cycles and were assigned into LPS (luteal phase symptom) vs. non-LPS groups. Our grouping did not reflect categorization according to the presence of PMS, since we investigated healthy women. Personality characteristics were evaluated using the TCI. LPS subjects scored significantly higher in subscales associated with novelty seeking (NS), self-directedness (S), cooperation (C) and self-transcendence (ST), and lower in the harm avoidance (HA) scale. Elevated scores of women with higher symptom severity in the late luteal phase in NS, S, ST and C scales and lower HA scores are in contrast with previous results on personality traits associated with PMS. However, we investigated psychiatrically healthy women. Therefore, our results suggest that this personality profile is a protective factor against developing serious psychiatric symptoms when experiencing a distressing and more marked symptomatology associated with the late luteal phase of the reproductive cycle.

Lifestyle factors, hormonal contraception, and premenstrual symptoms: the United Kingdom Southampton Women's Survey

OBJECTIVE

To estimate the prevalence of premenstrual symptoms in women from the general population in Southampton, U.K., and examine their association with lifestyle factors and contraceptive use.

METHODS

This was a cross-sectional survey in the city of Southampton, U.K., of 974 women aged 20-34 years (53% of the 1841 women invited to participate). The survey consisted of interviews, questionnaires, and completion of a prospective 6-week menstrual symptom diary recording on a daily basis the presence and severity of 11 common premenstrual symptoms. Premenstrual symptoms were identified from the diaries by two clinicians who reviewed them independently using a predefined algorithm to assess the onset and decline of symptoms in relation to the start of menstruation.

RESULTS

Of the women surveyed, 24% were considered to have premenstrual symptoms (95% confidence interval [CI] 21-27). Women were less likely to have symptoms if they had higher levels of educational attainment and suffered less from stress. No associations were found between premenstrual symptoms and diet, alcohol, or strenuous exercise nor after adjustment for other factors, with age, smoking, or body mass index (BMI). Use of any form of hormonal contraceptives was associated with a lower prevalence of premenstrual symptoms (prevalence ratio 0.66, 95% CI 0.52-0.84).

CONCLUSIONS

Premenstrual symptoms were common in this cohort. Use of hormonal contraceptive methods was associated with a lower prevalence of these symptoms.

The efficacy of Hypericum perforatum (St John's wort) for the treatment of premenstrual syndrome: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Premenstrual syndrome (PMS) is a common condition. Some of the most widely prescribed medications are selective serotonin reuptake inhibitors (SSRIs), based on the hypothesized role of serotonin in the production of PMS symptoms. PMS sufferers, especially those experiencing mild to moderate symptoms, are often reluctant to take this form of medication and instead buy over-the-counter preparations to treat their symptoms, for which the evidence base with regard to efficacy is limited. Hypericum perforatum (St John's wort) influences the serotonergic system. As such, this widely available herbal remedy deserves attention as a PMS treatment.

OBJECTIVE

To investigate the effectiveness of Hypericum perforatum on symptoms of PMS.

STUDY DESIGN

This randomized, double-blind, placebo-controlled, crossover study was conducted between November 2005 and June 2007.

SETTING

Institute of Psychological Sciences, University of Leeds, Leeds, UK.

PARTICIPATION

36 women aged 18-45 years with regular menstrual cycles (25-35 days), who were prospectively diagnosed with mild PMS.

INTERVENTION

Women who remained eligible after three screening cycles (n = 36) underwent a two-cycle placebo run-in phase. They were then randomly assigned to receive Hypericum perforatum tablets 900 mg/day (standardized to 0.18% hypericin; 3.38% hyperforin) or identical placebo tablets for two menstrual cycles. After a placebo-treated washout cycle, the women crossed over to receive placebo or Hypericum perforatum for two additional cycles.

MAIN OUTCOME MEASURES

Symptoms were rated daily throughout the trial using the Daily Symptom Report. Secondary outcome measures were the State Anxiety Inventory, Beck Depression Inventory, Aggression Questionnaire and Barratt Impulsiveness Scale. Plasma hormone (follicle-stimulating hormone [FSH], luteinizing hormone [LH], estradiol, progesterone, prolactin and testosterone) and cytokine (interleukin [IL]-1beta, IL-6, IL-8, interferon [IFN]-gamma and tumour necrosis factor [TNF]-alpha) levels were measured in the follicular and luteal phases during Hypericum perforatum and placebo treatment.

RESULTS

Hypericum perforatum was statistically superior to placebo in improving physical and behavioural symptoms of PMS (p < 0.05). There were no significant effects of Hypericum perforatum compared with placebo treatment for mood- and pain-related PMS symptoms (p > 0.05). Plasma hormone (FSH, LH, estradiol, progesterone, prolactin and testosterone) and cytokine (IL-1beta, IL-6, IL-8, IFNgamma and TNFalpha) levels, and weekly reports of anxiety, depression, aggression and impulsivity, also did not differ significantly during the Hypericum perforatum and placebo cycles (p > 0.05).

CONCLUSION

Daily treatment with Hypericum perforatum was more effective than placebo treatment for the most common physical and behavioural symptoms associated with PMS. As proinflammatory cytokine levels did not differ significantly between Hypericum perforatum and placebo treatment, these beneficial effects are unlikely to be produced through this mechanism of action alone. Further work is needed to determine whether pain- and mood-related PMS symptoms benefit from longer treatment duration. Trial registration number (International Standard Randomised Controlled Trial Number Register) ISRCTN31487459.

Effectiveness of manual therapies: the UK evidence report

BACKGROUND

The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions.

METHODS

The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories. The strength/quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs.

RESULTS

By September 2009, 26 categories of conditions were located containing RCT evidence for the use of manual therapy: 13 musculoskeletal conditions, four types of chronic headache and nine non-musculoskeletal conditions. We identified 49 recent relevant systematic reviews and 16 evidence-based clinical guidelines plus an additional 46 RCTs not yet included in systematic reviews and guidelines.Additionally, brief references are made to other effective non-pharmacological, non-invasive physical treatments.

CONCLUSIONS

Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic.

Puberty, steroids and GABA(A) receptor plasticity

GABA(A) receptors (GABAR) mediate most inhibition in the CNS and are also a target for neuroactive steroids such as 3alpha,5[alpha]beta-THP (3alphaOH-5[alpha]beta-OH-pregnan-20-one or [allo]pregnanolone). Although these steroids robustly enhance current gated by alpha1beta2delta GABAR, we have shown that 3alpha,5[alpha]beta-THP effects at recombinant alpha4beta2delta GABAR depend on the direction of Cl(-) flux, where the steroid increases outward flux, but decreases inward flux through the receptor. This polarity-dependent inhibition of alpha4beta2delta GABAR resulted from an increase in the rate and extent of rapid desensitization of the receptor, recorded from recombinant receptors expressed in HEK-293 cells with whole cell voltage clamp techniques. This inhibitory effect of 3alpha,5[alpha]beta-THP was not observed at other receptor subtypes, suggesting it was selective for alpha4beta2delta GABAR. Furthermore, it was prevented by a selective mutation of basic residue arginine 353 in the intracellular loop of the receptor, suggesting that this might be a putative chloride modulatory site. Expression of alpha4betadelta GABAR increases markedly at extrasynaptic sites at the onset of puberty in female mice. At this time, 3alpha,5[alpha]beta-THP decreased the inhibitory tonic current, recorded with perforated patch techniques to maintain the physiological Cl(-) gradient. By decreasing this shunting inhibition, 3alpha,5[alpha]beta-THP increased the excitability of CA1 hippocampal pyramidal cells at puberty. These effects of the steroid were opposite to those observed before puberty when 3alpha,5[alpha]beta-THP reduced neuronal excitability as a pre-synaptic effect. Behaviorally, the excitatory effect of 3alpha,5[alpha]beta-THP was reflected as an increase in anxiety at the onset of puberty in female mice. Taken together, these findings suggest that the emergence of alpha4beta2delta GABAR at the onset of puberty reverses the effect of a stress steroid. These findings may be relevant for the mood swings and increased response to stressful events reported in adolescence.

Progesterone for premenstrual syndrome

BACKGROUND

About 5% of women experience severe symptoms called premenstrual syndrome (PMS), only in the two weeks before their menstrual periods. Treatment with progesterone may restore a deficiency, balance menstrual hormone levels or reduce effects of falling progesterone levels on the brain or on electrolytes in the blood.

OBJECTIVES

The objectives were to determine if progesterone has been found to be an effective treatment for all or some premenstrual symptoms and if adverse events associated with this treatment have been reported.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2005), MEDLINE (1966 to 2005) and EMBASE (1980 to 2005) in March 2005, and PsycINFO (1806 to 2006) in April 2006. We contacted pharmaceutical companies for information about unpublished trials.The Trials Search Co-ordinator searched MEDLINE, EMBASE and PsycLIT on October 16 2000. MEDLINE and EMBASE were searched again on March 1 2005 and all again on March 3 2008. CINAHL was searched on March 3 2008. The search strings are in Appendix 2.

SELECTION CRITERIA

We included randomised double-blind, placebo-controlled trials of progesterone on women with PMS diagnosed by at least two prospective cycles, without current psychiatric disorder.

DATA COLLECTION AND ANALYSIS

Two reviewers (BM and OF) extracted data independently and decided which trials to include. OF wrote to trial investigators for missing data.

MAIN RESULTS

From 17 studies, only two met our inclusion criteria. Together they had 280 participants aged between 18 and 45 years. One hundred and fifteen yielded analysable results. Both studies measured symptom severity using subjective scales. Differing in design, participants, dose of progesterone and how delivered, the studies could not be combined in meta-analysis.Adverse events which may or may not have been side effects of the treatment were described as mild.Both trials had defects. They intended to exclude women whose symptoms continued after their periods. When data from ineligible women were excluded from analysis in one trial, the other women were found to have benefited more from progesterone than placebo. The smaller study found no statistically significant difference between oral progesterone, vaginally absorbed progesterone and placebo, but reported outcomes incompletely.

AUTHORS' CONCLUSIONS

The trials did not show that progesterone is an effective treatment for PMS nor that it is not. Neither trial distinguished a subgroup of women who benefited, nor examined claimed success with high doses.

Premenstrual syndrome and premenstrual dysphoric disorder in adolescents

PURPOSE OF REVIEW

To review the current knowledge about the prevalence, diagnosis, and management of premenstrual syndromes in adolescents.

RECENT FINDINGS

Large epidemiologic studies addressing adolescent premenstrual disorders, clinical presentation, and comorbidity with other disorders have yet to be performed. Randomized controlled treatment trials for teens with moderate-to-severe premenstrual syndrome or the more severe affective predominant, premenstrual dysphoric disorder still are sorely lacking. This review will present an updated review of the published studies with respect to premenstrual syndrome and premenstrual dysphoric disorder in adolescents in the context of the large body of literature regarding presentation, diagnosis, and treatment in adult women.

SUMMARY

Premenstrual disorders likely start in the teen years. At least 20% of adolescents may experience moderate-to-severe premenstrual symptoms associated with functional impairment. Current treatment includes lifestyle recommendations and pharmacologic agents that suppress the rise and fall of ovarian steroids or augment serotonin.

Update on research and treatment of premenstrual dysphoric disorder

Many women in their reproductive years experience some mood, behavioral. or physical symptoms in the week prior to menses. Variability exists in the level of symptom burden in that some women experience mild symptoms, whereas a small minority experience severe and debilitating symptoms. For an estimated 5%-8% of premenopausal women, work or social functioning are affected by severe premenstrual syndrome. Many women in this group meet diagnostic criteria for premenstrual dysphoric disorder (PMDD). Among women who suffer from PMDD, mood and behavioral symptoms such as irritability, depressed mood, tension, and labile mood dominate. Somatic complaints, including breast tenderness and bloating, also can prove disruptive to women's overall functioning and quality of life. Recent evidence suggests that individual sensitivity to cyclical variations in levels of gonadal hormones may predispose certain women to experience these mood, behavioral, and somatic symptoms. Treatments include: antidepressants of the serotonin reuptake inhibitor class, taken intermittently or throughout the menstrual cycle; medications that suppress ovarian cyclicity; and newer oral contraceptives with novel progestins.

Patterns of mood changes throughout the reproductive cycle in healthy women without premenstrual dysphoric disorders

OBJECTIVE

The cyclic nature of female reproductive function is a natural part of life accompanied by changes in several physical and psychological phenomena. The aim of our study was to investigate the fluctuation of psychological symptoms throughout the female reproductive cycle in healthy, non-PMDD (premenstrual dysphoric disorder) women.

METHOD

63 psychiatrically healthy, non-PMDD women with normal regular menstrual cycles and not using hormonal contraceptive methods participated in the study. Participants completed the PRISM (Prospective Record of the Impact and Severity of Menstrual Symptoms) calendar every night for three cycles and in addition they completed several other psychometric measures (Symptom Distress Checklist-SCL-51, State Trait Anxiety Inventory-STAI, Zung Self-rating Depression Scale-ZSDS, Eating Attitude Test-EAT, Mind and Body Cathexis Scale) at three predefined days of the first cycle. Based on an at least 66% increase in physical symptoms from the late follicular to the late luteal phase on the PRISM, subjects were assigned to luteal phase physical symptoms (LPPS) and no luteal phase physical symptoms (nonLPPS) groups. The association of psychometric scores with timing within the cycle and with physical symptoms was analysed.

RESULTS

Significant changes in psychometric scores over time were observed for STAI state anxiety, SCL anxiety, SCL somatization, SCL depression, SCL obsessive-compulsive, SCL interpersonal sensitivity, SCL total, and ZSDS. A significant timexLPPS grouping interaction emerged in case of the SCL somatization subscale and the ZSDS. LPPS grouping was associated with only the interpersonal sensitivity subscale of the SCL51.

CONCLUSION

Our results indicate that there is a significant increase in psychological symptoms related to neuroticism and depression from the late follicular to the late luteal phase in a healthy, non-PMDD female population. Although our results may not have direct clinical significance, since the statistically significant increases in psychometric scores are still small, it is an important finding that there is a consistent pattern observable in the fluctuation of psychological symptoms accompanying the female reproductive cycle.