PMS after 40: persistence of a stress-related symptom pattern

Menstrual cycle phase, menopausal transition stage, self-reports of premenstrual syndrome and symptom severity: observations from the Seattle Midlife Women's Health Study

OBJECTIVE

The aim of this study was to determine the effects of menstrual cycle phases (postmenses and premenses), self-report of premenstrual syndrome (PMS), late reproductive stages (LRS1 and LRS2), and early menopausal transition (EMT) stage (Stages of Reproductive Aging Workshop [STRAW]) on severity of five symptom groups.

METHODS

A subset of Seattle Midlife Women's Health Study participants (n = 290) in either LRS1 or LRS2 or EMT (STRAW+10 criteria) provided daily symptom data for at least one full menstrual cycle during the first year of the study and reported current PMS. Symptom severity was rated (1-4, least to most severe) in the daily diary for five symptom groups (dysphoric mood, neuromuscular, somatic, vasomotor, and insomnia) identified earlier with the same sample ( Maturitas 1996;25:1-10). A three-way analysis of variance was used to test for within- and between-participants effects on symptom severity.

RESULTS

Stage had no effect on severity for any of the five symptom groups. Dysphoric mood and neuromuscular and somatic symptom severity (but not vasomotor or insomnia severity) differed significantly across menstrual cycle phases, increasing from postmenses to premenses. Current PMS and premenses cycle phase had significant interactive effects on dysphoric mood and neuromuscular symptoms, but there were no significant interaction effects on somatic, vasomotor, or insomnia symptom severity.

CONCLUSIONS

Dysphoric mood, neuromuscular, and somatic symptoms exhibit cyclicity and are influenced by current PMS. Late reproductive stages and EMT stage do not have significant effects on the five symptom groups. Vasomotor or insomnia symptoms do not exhibit significant cyclicity from postmenses to premenses and are not affected by current PMS. Future studies of symptom cyclicity and reproductive aging including daily symptom data across an entire menstrual cycle in samples including women in late menopausal transition stage are essential to capture the effects of both cyclicity and self-reported PMS to capture symptom severity reports at their peak.

The Seattle Midlife Women's Health Study: a longitudinal prospective study of women during the menopausal transition and early postmenopause

Background

The need for longitudinal, population-based studies to illuminate women’s experiences of symptoms during the menopausal transition motivated the development of the Seattle Midlife Women’s Health Study.

Methods

Longitudinal, population-based study of symptoms women experienced between the Late Reproductive stage of reproductive aging and the early postmenopause. Data collection began in 1990 with 508 women ages 35–55 and continued to 2013. Entry criteria included age, at least one period in past 12 months, uterus intact and at least 1 ovary. Women were studied up to 5 years postmenopause. Data collection included yearly health questionnaires, health diaries, urinary hormonal assays, menstrual calendars and buccal cell smears.

Results

Contributions of the study included development of a method for staging the menopausal transition; development of bleeding criteria to differentiate bleeding episodes from intermenstrual bleeding from menstrual calendars; identification of hormonal changes associated with menopausal transition stages; assessment of the effects of menopausal transition factors, aging, stress-related factors, health factors, social factors on symptoms, particularly hot flashes, depressed mood, pain, cognitive, sexual desire, and sleep disruption symptoms, and urinary incontinence symptoms; identification of naturally occurring clusters of symptoms women experienced during the menopausal transition and early postmenopause; and assessment of gene polymorphisms associated with events such as onset of the early and late menopausal transition stages and symptoms.

Conclusions

Over the course of the longitudinal Seattle Midlife Women's Health Study, investigators contributed to understanding of symptoms women experience during the menopausal transition and early postmenopause as well as methods of staging reproductive aging.

Electronic supplementary material

The online version of this article (doi:10.1186/s40695-016-0019-x) contains supplementary material, which is available to authorized users.

A lack of consistent evidence for cortisol dysregulation in premenstrual syndrome/premenstrual dysphoric disorder

Although decades of research has examined the association between cortisol regulation and premenstrual syndrome/premenstrual dysphoric disorder (PMS/PMDD), no review exists to provide a general set of conclusions from the extant research. In the present review we summarize and interpret research that has tested for associations between PMS/PMDD and cortisol levels and reactivity (n=38 original research articles). Three types of studies are examined: correlational studies, environmental-challenge studies, and pharmacological-challenge studies. Overall, there was very little evidence that women with and without PMS/PMDD demonstrate systematic and predictable mean-level differences in cortisol, or differences in cortisol response/reactivity to challenges. Methodological differences in sample size, the types of symptoms used for diagnosis (physical and psychological vs. only affective), or the type of cortisol measure used (serum vs. salivary), did not account for differences between studies that did and did not find significant effects. Caution is recommended before accepting the conclusion of null effects, and recommendations are made that more rigorous research be conducted, considering symptom-specificity, within-person analyses, and multiple parameters of cortisol regulation, before final conclusions are drawn.

The influence of early life sexual abuse on oxytocin concentrations and premenstrual symptomatology in women with a menstrually related mood disorder

Oxytocin (OT), associated with affiliation and social bonding, social salience, and stress/pain regulation, may play a role in the pathophysiology of stress-related disorders, including menstrually-related mood disorders (MRMD's). Adverse impacts of early life sexual abuse (ESA) on adult attachment, affective regulation, and pain sensitivity suggest ESA-related OT dysregulation in MRMD pathophysiology. We investigated the influence of ESA on plasma OT, and the relationship of OT to the clinical phenomenology of MRMD's. Compared to MRMD women without ESA (n=40), those with ESA (n=20) displayed significantly greater OT [5.39pg/mL (SD, 2.4) vs. 4.36pg/mL (SD, 1.1); t (58)=-2.26, p=0.03]. In women with ESA, OT was significantly, inversely correlated with premenstrual psychological and somatic symptoms (r's=-0.45 to -0.64, p's<0.05). The relationship between OT and premenstrual symptomatology was uniformly low and non-significant in women without ESA. In women with ESA, OT may positively modulate MRMD symptomatology.

Neurosteroid, GABAergic and hypothalamic pituitary adrenal (HPA) axis regulation: what is the current state of knowledge in humans?

RATIONALE

A robust epidemiological literature suggests an association between chronic stress and the development of affective disorders. However, the precise biological underpinnings of this relationship remain elusive. Central to the human response and adaptation to stress, activation and inhibition of the hypothalamic pituitary adrenal (HPA) axis involves a multi-level, multi-system, neurobiological stress response which is as comprehensive in its complexity as it is precarious. Dysregulation in this complex system has implications for human stress related illness.

OBJECTIVES

The pioneering research of Robert Purdy and colleagues has laid the groundwork for advancing our understanding of HPA axis regulation by stress-derived steroid hormones and their neuroactive metabolites (termed neurosteroids), which are potent allosteric modulators of GABAA receptor function in the central nervous system. This review will describe what is known about neurosteroid modulation of the HPA axis in response to both acute and chronic stress, particularly with respect to the current state of our knowledge of this process in humans.

RESULTS

Implications of this research to the development of human stress-related illness are discussed in the context of two human stress-related psychiatric disorders - major depressive disorder and premenstrual dysphoric disorder.

CONCLUSIONS

Neurosteroid-mediated HPA axis dysregulation is a potential pathophysiologic mechanism which may cross traditional psychiatric diagnostic classifications. Future research directions are identified.

Ovarian steroids and premenstrual symptoms: a comparison of group differences and intra-individual patterns

To examine the relationship of gonadal hormone and symptom patterns across the menstrual cycle, women screened for 2-3 cycles completed an intensive study cycle; 26 had a low-severity symptoms (LS), 20, a premenstrual syndrome (PMS), and 26, a premenstrual magnification pattern (PMM). All completed daily symptom diaries and collected late afternoon urine samples which were assayed for pregnanediol and estradiol for that cycle. The PMS and PMM groups had significantly more positive cross-correlations of pregnanediol and symptoms than the LS group. Women in all groups had similar levels of estradiol and pregnanediol. Women with PMS and PMM patterns responded to progesterone differently than women with LS patterns: thus the former groups may not benefit from hormone therapies.

Neurosteroids in the context of stress: implications for depressive disorders

Animal models indicate that the neuroactive steroids 3alpha,5alpha-THP (allopregnanolone) and 3alpha,5alpha-THDOC (allotetrahydroDOC) are stress responsive, serving as homeostatic mechanisms in restoring normal GABAergic and hypothalamic-pituitary-adrenal (HPA) function following stress. While neurosteroid increases to stress are adaptive in the short term, animal models of chronic stress and depression find lower brain and plasma neurosteroid concentrations and alterations in neurosteroid responses to acute stressors. It has been suggested that disruption in this homeostatic mechanism may play a pathogenic role in some psychiatric disorders related to stress. In humans, neurosteroid depletion is consistently documented in patients with current depression and may reflect their greater chronic stress. Women with the depressive disorder, premenstrual dysphoric disorder (PMDD), have greater daily stress and a greater rate of traumatic stress. While results on baseline concentrations of neuroactive steroids in PMDD are mixed, PMDD women have diminished functional sensitivity of GABA(A) receptors and our laboratory has found blunted allopregnanolone responses to mental stress relative to non-PMDD controls. Similarly, euthymic women with histories of clinical depression, which may represent a large proportion of PMDD women, show more severe dysphoric mood symptoms and blunted allopregnanolone responses to stress versus never-depressed women. It is suggested that failure to mount an appropriate allopregnanolone response to stress may reflect the price of repeated biological adaptations to the increased life stress that is well documented in depressive disorders and altered allopregnanolone stress responsivity may also contribute to the dysregulation seen in HPA axis function in depression.

Lack of beneficial effects of clonidine in the treatment of premenstrual dysphoric disorder: results of a double-blind, randomized study

OBJECTIVES

To test the effects of clonidine in comparison with active placebo on premenstrual symptoms, mood scores and norepinephrine (NE) concentration, in women with premenstrual dysphoric disorder (PMDD).

METHODS

Twelve women with prospectively confirmed PMDD were randomly assigned to oral 0.3 mg/day clonidine, as an active treatment, or 10 mg/day loratadine, as an active placebo, for 2 months each using a double-blind, cross-over design. NE concentration, premenstrual symptom ratings and mood scales were measured on three occasions: at pretreatment, after clonidine treatment and after placebo treatment. All patients were free of current psychiatric co-morbidity and medication use.

RESULTS

There were no significant differences between clonidine and placebo for mood scales or premenstrual symptom ratings, though clonidine significantly suppressed NE concentration and produced more side effects in comparison with placebo.

CONCLUSION

Compared with an active placebo clonidine demonstrated no beneficial changes in mood and premenstrual symptoms in women with PMDD.

Association between psychological stress and menstrual cycle characteristics in perimenopausal women

In previous studies of the relationship between stress and menstrual cycles, stress has been found to be associated with longer cycles, to be associated with shorter cycles, and to have no association with cycle length. Some of the menstrual cycle changes that have been attributed to stress are similar to those experienced by women during perimenopause. In an effort to see whether an association between psychological stress and menstrual cycle characteristics can be detected in women approaching menopause, this study examines this relationship in perimenopausal women who are participants in the Tremin Research Program on Women's Health. The analyses used prospectively recorded bleeding data and retrospectively captured life-event data. A single-year cross-sectional analysis of data from 206 women shows no correlation between stress level, as measured by total number and severity of stressful life events, and cycle characteristics, including interval length, duration of bleed, and variability in both of these factors, nor are there significant differences in cycle characteristics between subgroups of women with different overall levels of stress. In analyzing stress levels and cycle characteristics across 2 years, however, women with marked increases in their level of stress (n = 30) are shown to have decreased length (-0.2 days/cycle) of menstrual cycle intervals and decreased duration of bleed (-0.1 day/cycle) compared with increases in these measures (+2.9 days/cycle for cycle interval; +0.3 days/cycle for duration of bleed) among women with no marked change in stress level (n = 103); t-tests indicate that these differences are significant (p < .05).

Dysregulation of cardiovascular and neuroendocrine responses to stress in premenstrual dysphoric disorder

Twelve women with prospectively confirmed premenstrual dysphoric disorder (PMDD or PDD) were compared with 12 healthy control subjects for cardiovascular and neuroendocrine responses to speech and mental arithmetic (Paced Auditory Serial Addition Task) stressors during both the follicular and luteal phases of the menstrual cycle. Structured clinical interview was used to assess psychiatric and abuse histories, and standardized questionnaires were administered to assess current life stress. Results revealed that PMDD women had significantly lower stroke volume, cardiac output and cortisol levels but significantly elevated norepinephrine and total peripheral resistance at rest and also during mental stressors compared with control subjects. These effects were evident in both cycle phases. Significantly more women with PMDD had histories of sexual abuse, and they also reported greater current life stress than control subjects. Consistent with a history of trauma, the PMDD women exhibited significantly greater ratios of norepinephrine to cortisol at rest and during stress. These results are interpreted as reflecting dysregulation of the stress response and may be related to histories of severe and/or chronic exposure to stress for a subgroup of PMDD women.