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

Illicit drug use, early age at first use and risk of premenstrual syndrome: A longitudinal study

BACKGROUND

Premenstrual syndrome (PMS) is common among women of reproductive age. Limited studies have investigated the long-term association between illicit drug use and PMS.

METHODS

The 1973-1978 cohort from the Australian Longitudinal Study on Women's Health, a prospective cohort study, was followed up for 13-year from 2000 to 2012. Data were collected through self-reported questionnaires on all variables, including PMS, illicit drug use and a range of sociodemographic, lifestyle, reproductive and psychological factors.

RESULTS

When the women were 22-27 years of age, over 40% use illicit drug in the last 12 months, 9% first used drug before age 15 years and approximately 35% reported PMS. Over the study period, the prevalence of drug use in the last 12 months declined whereas that of PMS remained fairly stable except an increase when they were 34-39 years old. Generalised estimating equations analysis showed that, compared to never drug users, significantly higher odds of reporting PMS were detected for illicit drug use in the last 12 months: multiple drugs (odds ratio (OR) 1.31, 95% confidence interval (CI) 1.21, 1.43), exclusive marijuana (OR 1.23, 95% CI 1.08, 1.40). A higher odds of PMS was identified for age at first drug use before 15 years (OR 1.20, 95% CI 1.03, 1.40).

CONCLUSIONS

Illicit drug use in the last 12 months, especially early age at first use and multiple drug use, is associated with increased risk of PMS. However current study is unable to prove causality.

Effect of Melissa officinalis Capsule on the Intensity of Premenstrual Syndrome Symptoms in High School Girl Students

BACKGROUND

Several studies are conducted on Premenstrual Syndrome (PMS). However, a few herbal surveys exist on the treatment of PMS in Iran. Due to the sedative effects of Melissa officinalis (M. officinalis), this question comes to mind that "can it be used in the treatment of PMS symptoms?"

OBJECTIVES

The current study aimed to assess the effect of M. officinalis capsule on the intensity of PMS in high-school girls.

MATERIALS AND METHODS

A double-blind randomized, placebo-controlled trial was performed on 100 high school girls from 2013 to 2014. The intervention group (n = 50) received 1200 mg of M. officinalis essence daily from the first to the last day of their menstrual cycle for three consecutive cycles. The second group (n = 50) received the placebo. The premenstrual symptoms screening tool was used to assess the intensity of PMS symptoms in the two groups before and one, two, and three months after the intervention. The data were analyzed using paired t-test and repeated measures analysis of variance.

RESULTS

The results of repeated measures test revealed a significant reduction (P < 0.001) in PMS symptoms. Overall, the mean score of PMS intensity in the intervention group was 42.56 + 15.73 before the intervention and changed to 32.72 ± 13.24, 30.02 ± 12.08, and 13.90 ± 10.22 at the three consecutive months after the intervention, respectively (P = 0.001).

CONCLUSIONS

M. officinalis capsules were effective in reduction of the PMS symptoms. Yet, application of this medication requires further investigations.

Psychiatric symptoms and disorders associated with reproductive cyclicity in women: advances in screening tools

Female-specific psychiatric illness including premenstrual dysphoria, perinatal depression, and psychopathology related to the perimenopausal period are often underdiagnosed and treated. These conditions can negatively affect the quality of life for women and their families. The development of screening tools has helped guide our understanding of these conditions. There is a wide disparity in the methods, definitions, and tools used in studies relevant to female-specific psychiatric illness. As a result, there is no consensus on one tool that is most appropriate for use in a research or clinical setting. In reviewing this topic, we hope to highlight the evolution of various tools as they have built on preexisting instruments and to identify the psychometric properties and clinical applicability of available tools. It would be valuable for researchers to reach a consensus on a core set of screening instruments specific to female psychopathology to gain consistency within and between clinical settings.

Menstrual cycle influence on cognitive function and emotion processing-from a reproductive perspective

The menstrual cycle has attracted research interest ever since the 1930s. For many researchers the menstrual cycle is an excellent model of ovarian steroid influence on emotion, behavior, and cognition. Over the past years methodological improvements in menstrual cycle studies have been noted, and this review summarizes the findings of methodologically sound menstrual cycle studies in healthy women. Whereas the predominant hypotheses of the cognitive field state that sexually dimorphic cognitive skills that favor men are improved during menstrual cycle phases with low estrogen and that cognitive skills that favor women are improved during cycle phases with increased estrogen and/or progesterone, this review has not found sufficient evidence to support any of these hypotheses. Mental rotation has gained specific interest in this aspect, but a meta-analysis yielded a standardized mean difference in error rate of 1.61 (95% CI -0.35 to 3.57), suggesting, at present, no favor of an early follicular phase improvement in mental rotation performance. Besides the sexually dimorphic cognitive skills, studies exploring menstrual cycle effects on tasks that probe prefrontal cortex function, for instance verbal or spatial working memory, have also been reviewed. While studies thus far are few, results at hand suggest improved performance at times of high estradiol levels. Menstrual cycle studies on emotional processing, on the other hand, tap into the emotional disorders of the luteal phase, and may be of relevance for women with premenstrual disorders. Although evidence at present is limited, it is suggested that emotion recognition, consolidation of emotional memories, and fear extinction is modulated by the menstrual cycle in women. With the use of functional magnetic resonance imaging, several studies report changes in brain reactivity across the menstrual cycle, most notably increased amygdala reactivity in the luteal phase. Thus, to the extent that behavioral changes have been demonstrated over the course of the menstrual cycle, the best evidence suggests that differences in sexually dimorphic tasks are small and difficult to replicate. However, emotion-related changes are more consistently found, and are better associated with progesterone than with estradiol such that high progesterone levels are associated with increased amygdala reactivity and increased emotional memory.

Hormone therapy for reproductive depression in women

An email survey of patients attending a PMS and Menopause Centre produced 238 patients whose principal presenting symptom was depression. Seventy-seven percent claimed to have had severe or moderate depression, 17% had had at least one psychotic episode and 14% had attempted suicide. Fifty-eight percent had seen a psychiatrist. Seventy-one percent had received antidepressants and 17% had received mood stabilising drugs. Twelve percent had been admitted to a psychiatric hospital and 3.8% had received electroconvulsive therapy. Sixty-eight percent had premenstrual syndrome as a teenager and 145 women (89%) out of 165 women who had been pregnant had no depression during pregnancy but 110 (66%) developed postnatal depression. Ninety-seven women (58%) who had been pregnant had suffered both premenstrual depression and postnatal depression. All were treated with transdermal estrogens and 93% also had transdermal testosterone. One hundred and seventy-one patients had a uterus and received cyclical progestogen to protect the endometrium and 63% of these developed the premenstrual syndrome-type symptoms of progesterone intolerance during the progestogen days. Thirty-five percent of patients claimed to be cured and 55% had a considerable improvement with estrogen therapy. Only 3.7% reported that there was no improvement. For 94%, the hormone therapy was a life-changing event for the better. None were worse. Forty patients had hysterectomy and bilateral oophorectomy for progesterone intolerance or heavy uterine bleeding and 38 replied that it was life changing for the better with less or no depression. It is concluded that premenstrual and postnatal depressions appear in the same vulnerable women. These women are typically well during pregnancy and are a sub group of reproductive depression which also develops climacteric depression in the transition phase. These types of depression are the product of hormonal changes and respond well to transdermal hormone therapy.

Were there evolutionary advantages to premenstrual syndrome?

Premenstrual syndrome (PMS) affects up to 80% of women, often leading to significant personal, social and economic costs. When apparently maladaptive states are widespread, they sometimes confer a hidden advantage, or did so in our evolutionary past. We suggest that PMS had a selective advantage because it increased the chance that infertile pair bonds would dissolve, thus improving the reproductive outcomes of women in such partnerships. We confirm predictions arising from the hypothesis: PMS has high heritability; gene variants associated with PMS can be identified; animosity exhibited during PMS is preferentially directed at current partners; and behaviours exhibited during PMS may increase the chance of finding a new partner. Under this view, the prevalence of PMS might result from genes and behaviours that are adaptive in some societies, but are potentially less appropriate in modern cultures. Understanding this evolutionary mismatch might help depathologize PMS, and suggests solutions, including the choice to use cycle-stopping contraception.

Premenstrual syndrome in Turkish medical students and their quality of life

This study aimed to analyse the frequency and symptoms of premenstrual syndrome (PMS) and its effect on quality of life in medical students. Sociodemographic data, a symptom calendar for the following consecutive two menstrual periods and SF-36 quality of life questionnaire were collected. A total of 228 students joined the survey. The average age of the students was 20.77 ± 1.90. The frequency of PMS was 91.8%. The most frequent symptoms were abdominal bloating (89.5%), irritability (88.3%) and breast tenderness (82.6%). Quality of life scores ranged from 17.00 to 97.00 and were lowest in the severe PMS group. Alcohol consumption, stress events and fat rich diets increased the severity of PMS. Family history significantly affected the severity of PMS and quality of life scores. Premenstrual syndrome was found to be a frequent entity among medical students and seemed to affect quality of life in a moderate way.

Serum oxidative stress, visfatin and apelin in healthy women and those with premenstrual syndrome

The aim of this study was to investigate whether there is a relationship between premenstrual syndrome and oxidative stress, visfatin and apelin. The study included 40 women with premenstrual syndrome and 40 healthy women. In all subjects, serum visfatin, apelin and oxidative stress parameters were studied in venous blood samples. The oxidative stress parameters were higher in the premenstrual syndrome group than among the controls, but this difference did not reach statistical significance (p > 0.05). It was found that total antioxidant capacity was similar in both groups. For the insulin-serotonin cycle markers, no significant difference was found between groups in terms of visfatin level (p = 0.893), although apelin was found to be significantly higher in the premenstrual syndrome group when compared with the controls (p < 0.001). According to our results, apelin can be used as an ancillary laboratory test in the diagnosis of premenstrual syndrome.

A comparison of second and third generations combined oral contraceptive pills' effect on mood

Background:

Most women taking combined oral contraceptives (COCs) are satisfied with their contraceptive method. However, one of the most common reasons reported for discontinuation of combined oral contraceptives (COCs) is mood deterioration.

Objectives:

This study aimed to compare effects of the second and third generation oral contraceptive pills on the mood of reproductive women.

Materials and Methods:

This randomized, double-blind, controlled clinical trial was conducted in reproductive women at health centers in Tehran, Iran. Participants were randomized into the second and third generation oral contraceptive groups. Positive and negative moods were recorded using positive affect, negative affect scale (PANAS) tools at the end the second and fourth months of the study. Data analysis was carried out using ANOVA and P Values < 0.05 was considered significant.

Results:

Statistically significant difference was seen in positive and negative mood changes in women receiving contraceptive pills. The second generation oral contraceptive pills resulted in a decrease in positive mood (95% CI: 43.39 to 38.32 in second month and 43.39 to 26.05 in four month) and increase in negative mood (95% CI: 14.23 to 22.04 in second month and 14.23 to 32.26 in four month - P < 0.001), but the third generation led to an increase in positive mood (95% CI: 22.42 to 25.60 in second month and 22.42 to 33.87 in four month) and decrease in negative mood (95% CI: 36.78 to 31.97 in second month and 36.78 to 22.65 in four month - P < 0.001).

Conclusions:

Third generation combined oral contraceptive pills have a better effect on mood in women in reproductive ages than the second generation pills. It can be recommended as a proper combined oral contraceptive in Iran.

Is catechol-o-methyltransferase gene polymorphism a risk factor in the development of premenstrual syndrome?

Objective

The objective of this study was to investigate whether there was a correlation between catechol-o-methyltransferase (COMT) gene polymorphism, which is believed to play a role in the etiology of psychotic disorders, and premenstrual syndrome (PMS).

Methods

Fifty-three women with regular menstrual cycles, aged between 18 and 46 years and diagnosed with PMS according to the American Congress of Obstetrics and Gynecology criteria were included in this study as the study group, and 53 healthy women having no health problems were selected as the controls. Venous blood was collected from all patients included in the study and kept at -18℃ prior to analysis.

Results

There was no significant difference between the groups in terms of demographic features such as age, body mass index, number of pregnancies, parity, and number of children. No statistically significant difference was observed in terms of COMT gene polymorphism (p=0.61) between women in the PMS and the control groups. However, a significant difference was found between arthralgia, which is an indicator of PMS, and low-enzyme activity COMT gene (Met/Met) polymorphism (p=0.04).

Conclusion

These results suggested that there was no significant relationship between PMS and COMT gene polymorphism. Since we could not find a direct correlation between the COMT gene polymorphism and PMS, further studies including alternative neurotransmitter pathways are needed to find an effective treatment for this disease.

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.

Does a disconnect occur between research and practice for premenstrual dysphoric disorder (PMDD) diagnostic procedures?

Diagnostic assessment recommendations for premenstrual dysphoric disorder (PMDD) include the use of daily symptom monitoring for two consecutive menstrual cycles; however, it is unclear whether medical providers use this established procedure in practice. This study explored typical diagnostic procedures for PMDD among a sample of physicians (N = 87) who were recruited by mail and completed questions about current practices. Results indicated that only 11.5% of physicians in this sample reported routinely using 60-day symptom monitoring, and only 18.4% of physicians reported regular use of any type of daily symptom monitoring. No differences were observed in these procedures based on frequency of contact with patients with PMDD or physician type (obstetrics and gynecology [OB/GYN] or family medicine). Overall, these results indicated that it is important to establish standard assessment methods for PMDD that have clinical utility for physicians, as well as increase awareness of research-based practice in diagnosing PMDD.

Plasma 25-hydroxyvitamin D and risk of premenstrual syndrome in a prospective cohort study

Background

Moderate to severe premenstrual syndrome (PMS) affects 8–20 percent of premenopausal women. Previous studies suggest that high dietary vitamin D intake may reduce risk. However, vitamin D status is influenced by both dietary vitamin D intake and sunlight exposure and the association of vitamin D status with PMS remains unclear.

Methods

We assessed the relation of plasma 25-hydroxyvitamin D (25OHD), total calcium and parathyroid hormone levels with risk of PMS and specific menstrual symptoms in a case–control study nested within the prospective Nurses’ Health Study II. Cases were 401 women free from PMS at baseline who developed PMS during follow-up (1991–2005). Controls were women not experiencing PMS (1991–2005), matched 1:1 with cases on age and other factors. Timed luteal phase blood samples were collected between 1996 and 1999 from cases and controls. We used conditional logistic regression to model the relation of 25OHD levels with risk of PMS and individual menstrual symptoms.

Results

In analyses of all cases and controls, 25OHD levels were not associated with risk of PMS. However, results differed when the timing of blood collection vs. PMS diagnosis was considered. Among cases who had already been diagnosed with PMS at the time of blood collection (n = 279), 25OHD levels were positively associated with PMS, with each 10 nmol/L change in 25OHD associated with a 13% higher risk. Among cases who developed PMS after blood collection (n = 123), 25OHD levels were unrelated to risk of PMS overall, but inversely related to risk of specific menstrual symptoms. For example, each 10 nmol/L increase was associated with a significant 21% lower risk of breast tenderness (P = 0.02). Total calcium or parathyroid hormone levels were unrelated to PMS.

Conclusions

25OHD levels were not associated with overall risk of PMS. The positive association observed among women already experiencing PMS at the time of 25OHD measurement is likely due to confounding by indication related to use of dietary supplements to treat menstrual symptoms. Results from prospective analyses, which were less likely influenced by this bias, suggest that higher 25OHD levels may be inversely related to the development of specific menstrual 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.

Physiological Correlates of Premenstrual Dysphoric Disorder (PMDD)

Premenstrual dysphoric disorder (PMDD) is a mood disorder with onset of functionally impairing or distressing mood symptoms in the late luteal phase of the menstrual cycle. Psychophysiologic findings in PMDD broadly fall into two categories: vulnerability trait findings, thus categorized because they are present in the asymptomatic phases of the menstrual cycle, and state findings, which are only present in the symptomatic late luteal phase and which are potentially representative of the hormonal events and biological mechanisms that lead to PMDD. Trait vulnerability markers in PMDD include diminished cardiovascular stress responses, lower heart rate variability (reflecting increased vagal tone), and lower P300 amplitude, eventually suggesting that women with PMDD share a number of physiological correlates with related anxiety and mood disorders. State findings in PMDD include lower luteal phase prepulse inhibition and altered luteal phase emotion processing. Lower prepulse inhibition in the late luteal phase may be an important ovarian steroid-influenced indicative of altered serotonergic neurotransmission, of relevance for women with PMDD. Attempts to determine the neural correlates of emotion processing in the late luteal phase are thus far inconsistent, but promising.

The Cerebellum and Premenstrual Dysphoric Disorder

The cerebellum constitutes ten percent of brain volume and contains the majority of brain neurons. Although it was historically viewed primarily as processing motoric computations, current evidence supports a more comprehensive role, where cerebro-cerebellar feedback loops also modulate various forms of cognitive and affective processing. Here we present evidence for a role of the cerebellum in premenstrual dysphoric disorder (PMDD), which is characterized by severe negative mood symptoms during the luteal phase of the menstrual cycle. Although a link between menstruation and cyclical dysphoria has long been recognized, neuroscientific investigations of this common disorder have only recently been explored. This article reviews functional and structural brain imaging studies of PMDD and the similar but less well defined condition of premenstrual syndrome (PMS). The most consistent findings are that women with premenstrual dysphoria exhibit greater relative activity than other women in the dorsolateral prefrontal cortex and posterior lobules VI and VII of the neocerebellum. Since both brain areas have been implicated in emotional processing and mood disorders, working memory and executive functions, this greater activity probably represents coactivation within a cerebro-cerebellar feedback loop regulating emotional and cognitive processing. Some of the evidence suggests that increased activity within this circuit may preserve cerebellar structure during aging, and possible mechanisms and implications of this finding are discussed.

Perceptions of health and somatic sensations in women reporting premenstrual syndrome and premenstrual dysphoric disorder

Focus on bodily sensations may be involved in the etiology of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). This study investigated the relationship between two types of somatic self-focus (i.e., health anxiety and anxiety sensitivity) and health-related quality of life (QOL) in women with provision diagnoses of PMS and PMDD. On the basis of responses to a screening measure, 731 college women were divided into three groups: PMDD, Moderate/Severe PMS, and Mild/No PMS. Measures included health-related QOL, health anxiety, anxiety sensitivity, and trait anxiety. Women with provisional diagnoses of PMDD and moderate/severe PMS reported higher levels of health anxiety and anxiety sensitivity. These relationships were not accounted for by trait anxiety. Furthermore, women in the PMDD and Moderate/Severe PMS groups reported lower health-related QOL. There is a significant health-related QOL burden for college women with PMDD and PMS. Health anxiety and anxiety sensitivity may contribute to the etiology of premenstrual disorders.

ISPMD consensus on the management of premenstrual disorders

The second consensus meeting of the International Society for Premenstrual Disorders (ISPMD) took place in London during March 2011. The primary goal was to evaluate the published evidence and consider the expert opinions of the ISPMD members to reach a consensus on advice for the management of premenstrual disorders. Gynaecologists, psychiatrists, psychologists and pharmacologists each formally presented the evidence within their area of expertise; this was followed by an in-depth discussion leading to consensus recommendations. This article provides a comprehensive review of the outcomes from the meeting. The group discussed and agreed that careful diagnosis based on the recommendations and classification derived from the first ISPMD consensus conference is essential and should underlie the appropriate management strategy. Options for the management of premenstrual disorders fall under two broad categories, (a) those influencing central nervous activity, particularly the modulation of the neurotransmitter serotonin and (b) those that suppress ovulation. Psychotropic medication, such as selective serotonin reuptake inhibitors, probably acts by dampening the influence of sex steroids on the brain. Oral contraceptives, gonadotropin-releasing hormone agonists, danazol and estradiol all most likely function by ovulation suppression. The role of oophorectomy was also considered in this respect. Alternative therapies are also addressed, with, e.g. cognitive behavioural therapy, calcium supplements and Vitex agnus castus warranting further exploration.

Luteal phase and symptom-onset dosing of SSRIs/SNRIs in the treatment of premenstrual dysphoria: clinical evidence and rationale

Premenstrual dysphoria (PMD) affects 3-8 % of women in their reproductive years worldwide. This paper summarizes the studies establishing the efficacy of continuous, luteal phase, and symptom-onset dosing of selective serotonin reuptake inhibitors (SSRIs) and dual serotonin and norepinephrine reuptake inhibitors (SNRIs) in treating women with PMD. The evidence indicates that for some women, symptom-onset dosing with escitalopram, fluoxetine, and paroxetine controlled release (CR) is as effective as continuous or luteal phase dosing. The wide range of clinical efficacy of SSRIs/SNRIs suggests that they exert their therapeutic effect through multiple pathways. This paper offers a few alternative mechanisms of action to explain the rapid response to SSRIs/SNRIs in women with PMD.

A review of treatment and management modalities for premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) affects 5 to 8 percent of women and can significantly decrease their quality of life. Symptoms generally present during the late luteal phase of the menstrual cycle and can affect women emotionally, behaviorally, cognitively and physiologically. This article reviews the clinical literature on PMDD and the evidence behind various methods of symptom management. Evidence suggests that a holistic approach, including lifestyle modifications, pharmacotherapy and cognitive behavioral therapy, is most beneficial for symptom reduction and improvement in daily functioning and quality of life.

Selective serotonin reuptake inhibitors for premenstrual syndrome

BACKGROUND

Premenstrual syndrome (PMS) is a common cause of physical, psychological and social problems in women of reproductive age. The key characteristic of PMS is the timing of symptoms, which occur only during the two weeks leading up to menstruation (the luteal phase of the menstrual cycle). Selective serotonin reuptake inhibitors (SSRIs) are increasingly used as first line therapy for PMS. SSRIs can be taken either in the luteal phase or else continuously (every day). SSRIs are generally considered to be effective for reducing premenstrual symptoms but they can cause adverse effects.

OBJECTIVES

The objective of this review was to evaluate the effectiveness and safety of SSRIs for treating premenstrual syndrome.

SEARCH METHODS

Electronic searches for relevant randomised controlled trials (RCTs) were undertaken in the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, and CINAHL (February 2013). Where insufficient data were presented in a report, attempts were made to contact the original authors for further details.

SELECTION CRITERIA

Studies were considered in which women with a prospective diagnosis of PMS, PMDD or late luteal phase dysphoric disorder (LPDD) were randomised to receive SSRIs or placebo for the treatment of premenstrual syndrome.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies, assessed eligible studies for risk of bias, and extracted data on premenstrual symptoms and adverse effects. Studies were pooled using random-effects models. Standardised mean differences (SMDs) with 95% confidence intervals (CIs) were calculated for premenstrual symptom scores, using separate analyses for different types of continuous data (that is end scores and change scores). Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for dichotomous outcomes. Analyses were stratified by type of drug administration (luteal or continuous) and by drug dose (low, medium, or high). We calculated the number of women who would need to be taking a moderate dose of SSRI in order to cause one additional adverse event (number needed to harm: NNH). The overall quality of the evidence for the main findings was assessed using the GRADE working group methods.

MAIN RESULTS

Thirty-one RCTs were included in the review. They compared fluoxetine, paroxetine, sertraline, escitalopram and citalopram versus placebo. SSRIs reduced overall self-rated symptoms significantly more effectively than placebo. The effect size was moderate when studies reporting end scores were pooled (for moderate dose SSRIs: SMD -0.65, 95% CI -0.46 to -0.84, nine studies, 1276 women; moderate heterogeneity (I(2) = 58%), low quality evidence). The effect size was small when studies reporting change scores were pooled (for moderate dose SSRIs: SMD -0.36, 95% CI -0.20 to -0.51, four studies, 657 women; low heterogeneity (I(2)=29%), moderate quality evidence).SSRIs were effective for symptom relief whether taken only in the luteal phase or continuously, with no clear evidence of a difference in effectiveness between these modes of administration. However, few studies directly compared luteal and continuous regimens and more evidence is needed on this question.Withdrawals due to adverse effects were significantly more likely to occur in the SSRI group (moderate dose: OR 2.55, 95% CI 1.84 to 3.53, 15 studies, 2447 women; no heterogeneity (I(2) = 0%), moderate quality evidence). The most common side effects associated with a moderate dose of SSRIs were nausea (NNH = 7), asthenia or decreased energy (NNH = 9), somnolence (NNH = 13), fatigue (NNH = 14), decreased libido (NNH = 14) and sweating (NNH = 14). In secondary analyses, SSRIs were effective for treating specific types of symptoms (that is psychological, physical and functional symptoms, and irritability). Adverse effects were dose-related.The overall quality of the evidence was low to moderate, the main weakness in the included studies being poor reporting of methods. Heterogeneity was low or absent for most outcomes, though (as noted above) there was moderate heterogeneity for one of the primary analyses.

AUTHORS' CONCLUSIONS

SSRIs are effective in reducing the symptoms of PMS, whether taken in the luteal phase only or continuously. Adverse effects are relatively frequent, the most common being nausea and asthenia. Adverse effects are dose-dependent.

Clinical subtypes of core premenstrual disorders: a Delphi survey

The purpose of this study was to classify the clinical subtypes of core premenstrual disorders during the International Society for Premenstrual Disorders' second consensus meeting. Multiple iterations were used to achieve consensus between a group of experts; these iterations included a two-generational Delphi technique that was preceded and followed by open group discussions. The first round was to generate a list of all potential clinical subtypes, which were subsequently prioritized using a Delphi methodology and then finalised in a final round of open discussion. On a six-point scale, 4 of the 12 potential clinical subtypes had a mean score of ≥5.0 following the second iteration and only 3 of the 4 still had a mean score of ≥5.0 after the third iteration. The final list consisted of these three subtypes and an additional subtype, which was introduced and agreed upon, in the final iteration. There is consensus amongst experts that core premenstrual disorder is divided into three symptom-based subtypes: predominantly physical, predominantly psychological and mixed. A proportion of psychological and mixed subtypes may meet the DSM-IV diagnostic criteria for premenstrual dysphoric disorder.

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.

Does lavender aromatherapy alleviate premenstrual emotional symptoms?: a randomized crossover trial

Background

A majority of reproductive-age women experience a constellation of various symptoms in the premenstrual phase, commonly known as premenstrual syndrome (PMS). Despite its prevalence, however, no single treatment is universally recognized as effective, and many women turn to alternative approaches, including aromatherapy, a holistic mind and body treatment. The present study investigated the soothing effects of aromatherapy on premenstrual symptoms using lavender (Lavandula angustifolia), a relaxing essential oil, from the perspective of autonomic nervous system function.

Methods

Seventeen women (20.6 ± 0.2 years) with mild to moderate subjective premenstrual symptoms participated in a randomized crossover study. Subjects were examined on two separate occasions (aroma and control trials) in the late-luteal phases. Two kinds of aromatic stimulation (lavender and water as a control) were used. This experiment measured heart rate variability (HRV) reflecting autonomic nerve activity and the Profile of Mood States (POMS) as a psychological index before and after the aromatic stimulation.

Results

Only a 10-min inhalation of the lavender scent significantly increased the high frequency (HF) power reflecting parasympathetic nervous system activity in comparison with water (aroma effect: F = 4.50, p = 0.050; time effect: F = 5.59, p = 0.017; aroma x time effect: F = 3.17, p = 0.047). The rate of increase in HF power was greater at 10–15 min (p = 0.051) and 20–25 min (p = 0.023) in the lavender trial than in the control trial with water. In addition, POMS tests revealed that inhalation of the aromatic lavender oil significantly decreased two POMS subscales—depression–dejection (p = 0.045) and confusion (p = 0.049)—common premenstrual symptoms, in the late-luteal phase, as long as 35 min after the aroma stimulation.

Conclusions

The present study indicated that lavender aromatherapy as a potential therapeutic modality could alleviate premenstrual emotional symptoms, which, at least in part, is attributable to the improvement of parasympathetic nervous system activity. This study further implies that HRV could evaluate the efficacy of aromatherapy using various fragrances to relieve premenstrual symptoms, and ultimately, support the mind and body health of women.

A comparative efficacy of low-dose combined oral contraceptives containing desogestrel and drospirenone in premenstrual symptoms

Objective. To compare the efficacy of low-dose COC containing desogestrel (DSG) with drospirenone (DRSP) in the changes of premenstrual symptoms. Methods. In an open-label randomized controlled trial, 90 women with premenstrual syndrome who required COC were randomly recruited and allocated equally to receive either 6 cycles of 20 micrograms ethinyl estradiol (EE)/150 micrograms DSG (DSG group) or 20 micrograms EE/3 mg DRSP (DRSP group) in 24/4 extended regimen. Analysis of covariance and repeated analysis of variance were used to determine the difference of mean Women's Health Assessment Questionnaire (WHAQ) scores changes between groups, within group, and in premenstrual, menstrual, and postmenstrual phases. Results. Baseline characteristics and WHAQ scores were comparable. At the ends of the 3rd and the 6th cycles, mean WHAQ scores of all the 3 phases in DRSP group showed significant reduction and were significantly lower than those in DSG group. DSG group showed significant reduction in both premenstrual and menstrual phases after the 6th cycle. Adverse effects were comparable in both groups. In conclusion, low-dose COC containing either DSG or DRSP reduced premenstrual symptoms, but the latter showed greater efficacy and earlier reduction.

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.

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.

Treatment of premenstrual syndrome: a decision-making algorithm

The aim of this short paper will be to guide the clinician through the plethora of possible interventions to help them to individualize treatment for their patients with PMS. The discussion will highlight management principles rather than evidence per se. It uses as its basis an updated version of the treatment algorithm published by the RCOG in its Green Top Guideline no. 48 on the management of PMS.

Psychotropic medications and other non-hormonal treatments for premenstrual disorders

Selective serotonin re-uptake inhibitors have well-established efficacy for severe premenstrual syndrome and premenstrual dysphoric disorder. Efficacy has been reported with both continuous dosing (all cycle) and intermittent or luteal phase dosing (from ovulation to menses). Efficacy may be less with intermittent dosing, particularly for premenstrual physical symptoms. The efficacy of symptom-onset dosing (medication taken only on luteal days when symptoms occur) needs further systematic study. Women going through the menopausal transition may need to adjust their antidepressant dosing regimen due to the change in frequency of menstruation. Anxiolytics, calcium, chasteberry and cognitive-behaviour therapy may also have a role in the treatment of premenstrual symptoms.

Potential strategies to avoid progestogen-induced premenstrual disorders

Non-hormonal approaches to premenstrual syndrome (PMS) treatment such as selective serotonin reuptake inhibitors are by no means effective for all women and frequently we must resort to endocrine therapy. During many of the hormonal approaches, PMS-like symptoms can be introduced or re-introduced during the necessary cyclical or continuous progestogen component of the therapy. This is seen with combined oral contraception, progestogen only contraception, progestogen therapy for heavy menstrual bleeding and endometriosis, sequential hormone replacement therapy and any therapeutic strategy for premenstrual syndrome where it is necessary to provide endometrial protection, including estrogen suppression of ovulation or add-back during gonadotrophin releasing hormone suppression. The link to progestogen is very often missed by health professionals. When the pattern of symptoms mimics the cyclicity of PMS, it is termed progestogen-induced premenstrual disorder. The need to use progestogen to protect the endometrium from the proliferative actions of estrogen can pose insurmountable difficulties in managing premenstrual disorders. In the absence of any really useful evidence, nearly all practice in this area depends on clinician experience. We cannot afford to wait for adequate research evidence to be produced - it never will - and so we must rely on empirical findings, clinical experience, theoretical strategies and common sense.

Epidemiology of premenstrual symptoms and disorders

The aim of this paper is to review published literature on the types and prevalences of premenstrual disorders and symptoms, and effects of these on activities of daily life and other parameters of burden of illness. The method involved review of the pertinent published literature. Premenstrual disorders vary in prevalence according to the definition or categorization. The most severe disorder being premenstrual dysphoric disorder (PMDD) affects 3-8% of women of reproductive age. This disorder focuses on psychological symptoms whereas global studies show that the most prevalent premenstrual symptoms are physical. Both psychological and physical symptoms affect women's activities of daily life. A considerable burden of illness has been shown to be associated with moderate to severe premenstrual disorders. In conclusion, premenstrual symptoms are a frequent source of concern to women during their reproductive lives and moderate to severe symptoms impact on their quality of lives.

Clinical subtypes of premenstrual syndrome and responses to sertraline treatment

OBJECTIVE

To estimate response of diagnosis and symptom-based subtypes to sertraline treatment.

METHODS

This was a secondary data analysis for women who were diagnosed with premenstrual syndrome (PMS) or premenstrual dysphoric disorder and treated in three National Institutes of Health-supported clinical trials (N=447). Three PMS subtypes were identified based on predominance of psychological, physical, or both symptom types. Scores for each symptom and a total premenstrual score at baseline and endpoint were calculated from daily symptom diaries. Change from baseline after three treated menstrual cycles (or endpoint if sooner) was estimated using linear regression models adjusted for baseline severity.

RESULTS

The PMS and premenstrual dysphoric disorder diagnoses improved similarly with sertraline relative to placebo, whereas symptom-based subtypes had differential responses to treatment. The mixed symptom subtype had the strongest response to sertraline relative to placebo (Daily Symptom Rating difference 33.80; 95% confidence interval [CI] 17.16-50.44; P<.001), and the physical symptom subtype had the poorest response to sertraline (Daily Symptom Rating difference 9.50; 95% CI -16.29 to 35.28; P=.470). Results based on clinical improvement (50% decrease from baseline) indicated that 8.3 participants in the mixed symptom subtype, 3.9 in the psychological subtype, and 7.1 in the physical subtype are needed to observe one woman in the subtype who would achieve clinical improvement.

CONCLUSION

The PMS and premenstrual dysphoric disorder diagnoses have similar response to sertraline treatment, but symptom-based subtypes have significantly different responses to this treatment. Mixed and psychological symptom subtypes improved whereas the physical symptom subtype did not improve significantly. Identifying the patient's predominant symptoms and their severity is important for individualized treatment and a possible response to a selective serotonin reuptake inhibitor.

LEVEL OF EVIDENCE

II.

Premenstrual syndrome and attitudes toward menstruation in a sample of nursing students

OBJECTIVE

The aim of this study was to evaluate baccalaureate nursing students' attitudes toward menstruation, and to analyze the frequency of premenstrual syndrome (PMS) symptoms, as well as the relationship between attitudes toward menstruation and PMS symptoms.

METHODS

This cross-sectional study was carried out between February 15 and March 10, 2009, in Ankara Turkey. The study participants were 250 undergraduate nursing student volunteers. Data were collected using a demographic questionnaire, the validated Turkish version of the Menstrual Attitude Questionnaire (MAQ), and the validated Turkish Premenstrual Syndrome (PMS) Scale. Obtained data were analyzed using SPSS version 15.0.

FINDINGS

The average age of participants was 19.89 ± 1.43. The MAQ's five subscales' mean scores ranged from 2.67 ± 0.58 to 3.37 ± 0.52, indicating natural to moderate attitudes toward menstruation. The mean PMS score was 114.86 ± 35.15, indicating moderate PMS symptoms. PMS symptoms were detected in 36.4% of the nursing students. Thirty one percent of the students reported having dysmenorrhoea during every menstrual cycle. Students who had PMS symptoms scored significantly higher on the debilitation subscale and scored significantly lower on the denial subscale of the MAQ (p < 0.05).

CONCLUSIONS

The findings of this research showed that menstruation was considered to be a natural event by most of the nursing students. In addition, dysmenorrhea was found to be the most common menstrual problem and the rate of PMS was found lower than that found in previous researches conducted in Turkey.

When should surgical treatment be considered for premenstrual dysphoric disorder?

Premenstrual mood disorders afflict a substantial number of women of reproductive age. Medical treatments provide excellent symptomatic relief to many women but at times a poor therapeutic response or adverse effects attributable to these therapies lead women to seek alternative solutions. Oophorectomy (with concomitant hysterectomy) followed by low-dose estrogen therapy has been shown to be an effective alternative for such cases of menstrual-cycle-related mood disorder.

Classification of premenstrual disorders as proposed by the International Society for Premenstrual Disorders

Premenstrual disorders have been recognized as affecting innumerable women for decades but unlike most other medical conditions universally accepted criteria for definition and diagnosis are not established. Although premenstrual syndrome (PMS) occurs throughout reproductive life, there are some women who become particularly troubled. Those approaching the menopause may also have a mixture of PMS and menopause symptoms, not to mention heavy periods. Furthermore, some of the symptoms are similar in nature and so it is a challenge to identify which set of symptoms belongs to which spectrum. This is an area that has not been explored well. Various classifications have been proposed over the last few decades. A further effort towards the classification was made by an international multidisciplinary group of experts established as the International Society for Premenstrual Disorders (ISPMD) in Montreal in September 2008. Their deliberations resulted in a unified diagnosis, classification of premenstrual disorders (PMD) along with their quantification and guidelines on clinical trial design. This classification of PMS is far more comprehensive and inclusive than previous attempts. PMD in the ISPMD Montreal consensus are divided into two categories: Core and Variant PMD. Core PMD are typical, pure or reference disorders associated with spontaneous ovulatory menstrual cycles while Variant PMD exist where more complex features are present. Further, the consensus group considered that PMD may be subdivided into three subgroups predominantly physical, predominantly psychological and mixed. Variant PMD encompass primarily four different types; premenstrual exacerbation, PMD with anovulatory ovarian activity, PMD with absent menstruation and progestogen-induced PMD.

Pathophysiology of premenstrual syndrome and premenstrual dysphoric disorder

Premenstrual syndrome (PMS) and premenstrual dysphoric disorder are triggered by hormonal events ensuing after ovulation. The symptoms can begin in the early, mid or late luteal phase and are not associated with defined concentrations of any specific gonadal or non-gonadal hormone. Although evidence for a hormonal abnormality has not been established, the symptoms of the premenstrual disorders are related to the production of progesterone by the ovary. The two best-studied and relevant neurotransmitter systems implicated in the genesis of the symptoms are the GABArgic and the serotonergic systems. Metabolites of progesterone formed by the corpus luteum of the ovary and in the brain bind to a neurosteroid-binding site on the membrane of the gamma-aminobutyric acid (GABA) receptor, changing its configuration, rendering it resistant to further activation and finally decreasing central GABA-mediated inhibition. By a similar mechanism, the progestogens in some hormonal contraceptives are also thought to adversely affect the GABAergic system. The lowering of serotonin can give rise to PMS-like symptoms and serotonergic functioning seems to be deficient by some methods of estimating serotonergic activity in the brain; agents that augment serotonin are efficacious and are as effective even if administered only in the luteal phase. However, similar to the affective disorders, PMS is ultimately not likely to be related to the dysregulation of individual neurotransmitters. Brain imaging studies have begun to shed light on the complex brain circuitry underlying affect and behaviour and may help to explicate the intricate neurophysiological foundation of the syndrome.

Premenstrual dysphoric disorder: evidence for a new category for DSM-5

Premenstrual dysphoric disorder, which affects 2%–5% of premenopausal women, was included in Appendix B of DSMIV, "Criterion Sets and Axes Provided for Further Study." Since then, aided by the inclusion of specific and rigorous criteria in DSM-IV, there has been an explosion of research on the epidemiology, phenomenology, pathogenesis, and treatment of the disorder. In 2009, the Mood Disorders Work Group for DSM-5 convened a group of experts to examine the literature on premenstrual dysphoric disorder and provide recommendations regarding the appropriate criteria and placement for the disorder in DSM-5. Based on thorough review and lengthy discussion, the work group proposed that the information on the diagnosis, treatment, and validation of the disorder has matured sufficiently for it to qualify as a full category in DSM-5. A move to the position of category, rather than a criterion set in need of further study, will provide greater legitimacy for the disorder and encourage the growth of evidence-based research, ultimately leading to new treatments.

Premenstrual syndrome (PMS): a peri-menopausal perspective

PMS (premenstrual syndrome) affects 30-40% of the reproductive female population and hence creates significant impairment amongst women of working age [1]. Having such an economical and financial impact makes it an important disorder to know more about in terms of diagnosis and treatment. In this article, as well as addressing diagnosis and treatments, we focus mainly on peri-menopausal women who are equally (if not more) affected by this disorder and who are subjected to PMS via a host of widely used hormonal treatments. We describe the vicious cycle that exists between exogenous progestogen stimulating PMS-like symptoms and the progestogen that is required for endometrial protection and ways of avoiding this. The treatment should address all concerns of the individual, namely contraceptive requirements, control of PMS and menopausal symptoms. The main theory behind treatment of PMS is to suppress ovulation along the hypothalamo-pituitary-ovarian axis, however neurotransmitters are also implicated in reducing sensitivity to progesterone via receptors, and therefore selective serotonin reuptake inhibitors are also useful. Surgical methods are strongly discouraged and are a last resort. With so many pitfalls, this article aims to tackle the issues commonly encountered with diagnosis and treatment of PMS in the peri-menopause.