Fluctuating serotonergic function in premenstrual dysphoric disorder and premenstrual syndrome: findings from neuroendocrine challenge tests

Higher Circulating Cortisol in the Follicular vs. Luteal Phase of the Menstrual Cycle: A Meta-Analysis

Although results of animal research show that interactions between stress and sex hormones are implicated in the development of affective disorders in women, translation of these findings to patients has been scarce. As a basic step toward advancing this field of research, we analyzed findings of studies which reported circulating cortisol levels in healthy women in the follicular vs. luteal phase of the menstrual cycle. We deemed this analysis critical not only to advance our understanding of basic physiology, but also as an important contrast to the findings of future studies evaluating stress and sex hormones in women with affective disorders. We hypothesized that cortisol levels would be lower in the follicular phase based on the proposition that changes in levels of potent GABAergic neurosteroids, including allopregnanolone, during the menstrual cycle dynamically change in the opposite direction relative to cortisol levels. Implementing strict inclusion criteria, we compiled results of high-quality studies involving 778 study participants to derive a standardized mean difference between circulating cortisol levels in the follicular vs. luteal phase of the menstrual cycle. In line with our hypothesis, our meta-analysis found that women in the follicular phase had higher cortisol levels than women in the luteal phase, with an overall Hedges' g of 0.13 (p < 0.01) for the random effects model. No significant between-study difference was detected, with the level of heterogeneity in the small range. Furthermore, there was no evidence of publication bias. As cortisol regulation is a delicate process, we review some of the basic mechanisms by which progesterone, its potent metabolites, and estradiol regulate cortisol output and circulation to contribute to the net effect of higher cortisol in the follicular phase.

Epidemiological Distribution and Subtype Analysis of Premenstrual Dysphoric Disorder Syndromes and Symptoms Based on TCM Theories

We performed an epidemiological investigation of subjects with premenstrual dysphoric disorder (PMDD) to identify the clinical distribution of the major syndromes and symptoms. The pathogenesis of PMDD mainly involves the dysfunction of liver conveyance and dispersion. Excessive liver conveyance and dispersion are associated with liver-qi invasion syndrome, while insufficient liver conveyance and dispersion are expressed as liver-qi depression syndrome. Additionally, a nonconditional logistic regression was performed to analyze the symptomatic features of liver-qi invasion and liver-qi depression. As a result of this analysis, two subtypes of PMDD are proposed, namely, excessive liver conveyance and dispersion (liver-qi invasion syndrome) and insufficient liver conveyance and dispersion (liver-qi depression syndrome). Our findings provide an epidemiological foundation for the clinical diagnosis and treatment of PMDD based on the identification of different types.

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.

A Comprehensive Review of Treatment Options for Premenstrual Syndrome and Premenstrual Dysphoric Disorder

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome that involves a combination of emotional and physical symptoms that result in significant functional impairment. Because of the debilitating nature of PMDD, multiple treatment options have been considered. This review provides a comprehensive overview of these therapeutic regimens to help health care professionals provide adequate treatment for PMDD and premenstrual syndrome. The treatments that are reviewed are organized into the following categories: psychiatric, anovulatory, supplements, herbal, nonpharmacological, and other. Selective serotonin reuptake inhibitors have been established as the first-line treatment for PMDD. Although luteal phase or continuous dosing can be used, additional research is needed to more thoroughly compare the efficacies and differential symptom response of continuous, semi-intermittent, luteal phase, and symptoms-onset dosing. The psychiatric medications venlafaxine, duloxetine, alprazolam, and buspirone have also been found to be useful treatments for PMDD. Various anovulatory-related treatments have demonstrated efficacy; however, the use of some of these treatments remains limited due to potential side effects and/or the availability of cheaper alternatives. Although a variety of supplement and herbal-related treatments have been proposed, with some warranting further research, at this time only calcium supplementation has demonstrated a consistent therapeutic benefit. In conclusion, serotoninergic antidepressants have been established as the first-line treatment option for PMDD; however, there are a variety of additional treatment options that should be considered if a patient fails to achieve an adequate therapeutic response with a selective serotonin reuptake inhibitor.

Serum brain-derived neurotrophic factor differences between the luteal and follicular phases in premenstrual dysphoric disorder

OBJECTIVE

We hypothesized that comparison of the serum brain-derived neurotrophic factor (BDNF) levels between women with premenstrual dysphoric disorder (PMDD) and women without PMDD in the luteal and follicular phases of their menstrual cycles would reflect the altered neuromodulator responses that compensate the underlying pathogenesis in PMDD.

METHOD

Twenty-nine participants without PMDD and 20 with PMDD were enrolled in the study. The serum BDNF, estrogen and progesterone levels were assessed at the follicular and luteal phases in their two consecutive menstrual cycles.

RESULTS

Participants with PMDD had significantly higher luteal serum BDNF levels than the control subjects. The serum BDNF levels were significantly higher in the luteal phase than in the follicular phase in women with PMDD. The difference in the serum BDNF levels between the luteal and follicular phases were significantly higher in the PMDD patients than in the control.

CONCLUSIONS

The higher serum BDNF levels in the luteal phase in the PMDD patients may reflect compensatory process that results in subsequent improvement of the PMDD-associated depressive symptoms in the follicular phase. The higher difference in the serum BDNF levels between the phases in PMDD patients may reflect an altered neuromodulator response.

Effect of aerobic exercise on premenstrual symptoms, haematological and hormonal parameters in young women

The objective of this study was to investigate the effect of aerobic exercise on premenstrual symptoms, haematological and hormonal parameters in young women. A total of 30 participants aged 16-20 years and complaining of premenstrual syndrome (PMS) were randomly assigned into two groups: a control group received vitamin B6 and Ca supplements once daily and a study group received the same medical treatment and participated in treadmill training three times per week for 3 months. A premenstrual syndrome questionnaire (MSQ), complete blood picture and hormone assays were performed for the assessment of all participants at the start and after the end of the treatment course. The study group showed a significant decrease in all post-treatment subscale symptoms, scores and total score. Haemoglobin, haematocrit, red cell count and platelet count were significantly increased, while mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH), mean corpuscular haemoglobin concentration (MCHC) and white blood cell count showed no significant differences. There was also a significant decrease in prolactin, oestradiol and progesterone levels. In conclusion, aerobic exercise increases haemoglobin, haematocrit, red cell count and platelet count, and decreases levels of prolactin, oestradiol and progesterone, resulting in improvement of fatigue, impaired concentration, confusion and most premenstrual symptoms.

Luteal serum BDNF and HSP70 levels in women with premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome characterized by psychological and somatic symptoms commencing in the luteal phase of the menstrual cycle and concludes with menstrual bleeding. PMDD affects 3-8 % of premenopausal women and represents a significant public health problem especially in young women. Decreased brain-derived neurotrophic factor (BDNF) levels are associated with several mental disorders. Heat-shock protein-70 (HSP70) is an important member of the molecular chaperone system, which provides a molecular defense against proteotoxic stress. We hypothesized that there would be changed levels of BDNF and HSP70 in women with PMDD compared with non-symptomatic women, reflecting impaired and/or activated stress-related responses involved in the underlying pathogenesis of PMDD. Female medical students were screened, and 24 women without premenstrual symptoms and 25 women with PMDD were enrolled in the study. Psychiatric evaluation and the Daily Record of Severity of Problems-Short Form were used for two consecutive menstrual cycles to diagnose PMDD. Serum BDNF and HSP70 levels were assessed in the third luteal phase. Participants with PMDD had significantly higher serum BDNF and HSP70 levels compared with controls, and there was a significant positive correlation between serum BDNF and HSP70 levels. Increased HSP70 levels may reflect cellular distress in PMDD. Increased serum BDNF levels in the luteal phase in subjects with PMDD may reflect a compensation process, which results in subsequent improvement of PMDD-associated depressive symptoms in the follicular phase. Thus, increased serum BDNF levels may be indicative of a compensating capacity in PMDD.

Premenstrual dysphoria and luteal stress in dominant-social-status female macaques

The current study aims to extend our previous work to develop nonhuman primate model for prospectively studying the mechanism underlying premenstrual dysphoric disorder (PMDD). Thirty young dominant-status female monkeys were randomly divided into the control group, the model group, and JQP group. For two consecutive menstrual cycles, from day 18 to 22, monkeys in the model and JQP groups were housed and immobilized singly in specially designed isolation cages for 5-6 hours per day. At the same time, the pharmaceutical interference effect of jingqianping (JQP) granule, a traditional Chinese medicine specifically used to cure PMDD patients, was tested using monkeys in the JQP group. The behavior and facial expressions of monkeys were photographed with an automatic vidicon and were quantitatively analyzed by "the emotion evaluation scale of female experimental macaque." Changes in serum level of progesterone and estradiol were measured with RIA, and serum level of 5-HT, noradrenaline, and dopamine were measured with HPLC. After experiencing mentioned above stress, 70% of monkeys of model group showed PMDD symptoms during three consecutive menstrual cycles. Estradiol and progesterone serum level decreased (P < 0.01). Moreover, the peak value of secreted hormones in their follicular phase did not occur. Serum level of 5-HT and dopamine were significantly lower (P < 0.01), but the serum noradrenaline level was higher (P < 0.01). Moreover, in monkeys administered by JQP granule, both PMDD symptoms and the anormal serum level of neurotransmitters could be obviously reversed. This special luteal-phase treatment on dominant-social-status monkeys might be a feasible way to create models mimicking PMDD.

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.

Premenstrual dysphoric disorder in East Asia: a review of the literature

OBJECTIVE

Fluctuations in ovarian steroids during specific phases of the reproductive cycle, such as pre-menstruation, have been hypothesized to contribute to women's increased vulnerability to depression. This current study's goal is to summarize the literature regarding Premenstrual Dysphoric Disorder (PMDD) in the East Asian countries of Taiwan, China (including Hong Kong and Macau), Japan, and Korea.

METHOD

A Pubmed and Chinese Electronic Periodical Service (CEPS) literature review was conducted using the key words "Premenstrual Dysphoric Disorder" along with "Japan," rea," "Taiwan," "Hong Kong," and "Macau." Using these criteria, 17 articles were found. Three articles were excluded because they did not involve PMDD in the aforementioned countries. In addition to this search, an article found in a review of the research on reproductive mental health disorders in China was utilized. That review contained one article regarding PMDD with an English language abstract, which was utilized in this current article.

RESULTS

The rates of PMDD in East Asia (1.3-2.8%) appear to be lower than that seen in the Western literature (3-8%). Many of the risk factors for PMDD were the same in the Eastern and Western literature, although some key differences were found. The few studies on treatment of PMDD in East Asia have shown positive results.

CONCLUSIONS

The rates of PMDD appear to be lower in East Asia, though reasons for this result are discussed. Few studies have been conducted examining the efficacy of psychotropic medications commonly used to treat PMDD in this population.

Premenstrual symptoms in dysmenorrheic college students: prevalence and relation to vitamin D and parathyroid hormone levels

OBJECTIVES

To determine the prevalence of premenstrual symptoms (PMS) due to primary dysmenorrhea among a sample of university female students, and to explore possible association with vitamin D and parathyroid (PTH) levels, as well as frequency of consumption of dairy products.

DESIGN

A cross-sectional study.

SETTING

One Jordanian university.

SUBJECTS

A total of 177 female students aged between 18 and 24 years who experienced primary dysmenorrhea participated in the study and completed a self administered questionnaire to collect information concerning demographics, menstruation-related information, associated specified premenstrual symptoms, and consumption of dairy products. Plasma 25-hydroxyvitamin vitamin D level and intact parathyroid hormone level were measured.

RESULTS

Of the 177 participants 91.5% had two or more symptoms among which fatigue, mood swings, anxiety, abdominal bloating, and depression were the most prevalent symptoms. There was no evident association between presence of symptoms and vitamin D status, PTH level or dairy products consumption. Headaches and social withdrawal were significantly lower in those women who consumed high amounts of dairy products.

CONCLUSION

Premenstrual symptoms are very common in young women with primary dysmenorrhea. PMS has no relation to levels of vitamin D, parathyroid hormone or dairy products consumption. Headache and social withdrawal may be affected by dairy product consumption.

ACTH and cortisol response to Dex/CRH testing in women with and without premenstrual dysphoria during GnRH agonist-induced hypogonadism and ovarian steroid replacement

CONTEXT

During conditions of ovarian suppression, women with premenstrual dysphoria (PMD) experience abnormal behavioral responses to physiological levels of ovarian steroids. Although hypothalamic-pituitary-adrenal (HPA) axis dysregulation frequently accompanies depression, and ovarian steroids regulate HPA axis responsivity, the role of HPA axis dysregulation in PMD is not known. We hypothesized that women with PMD would show abnormalities of HPA axis function analogous to those reported in depressive illness, and that ovarian steroids would differentially regulate HPA axis function in women with PMD compared with asymptomatic controls (AC).

OBJECTIVE

Our objective was to characterize the HPA axis response to physiological levels of estradiol and progesterone in women with PMD and AC.

DESIGN AND SETTING

We conducted an open-label trial of the GnRH agonist depot Lupron with ovarian steroid replacement administered in a double-blind crossover design in an outpatient clinic.

PARTICIPANTS

Forty-three women (18 with prospectively confirmed PMD and 25 AC) participated.

INTERVENTIONS

Women received Lupron for 6 months. After 3 months of hypogonadism, women received 5 wk each of estradiol (100-μg patch daily) or progesterone (suppositories 200 mg twice daily). During each condition, combined dexamethasone-suppression/CRH-stimulation tests and 24-h urinary free cortisol levels were performed.

MAIN OUTCOME MEASURES

Plasma cortisol and ACTH levels were evaluated.

RESULTS

HPA axis function was similar in PMD compared with AC. In all, progesterone significantly increased the secretion of cortisol compared with estradiol [area under the curve (t(74) = 3.1; P < 0.01)] and urinary free cortisol (t(74) = 3.2; P < 0.01) and ACTH compared with hypogonadism [area under the curve (t(74) = 2.4; P < 0.05)].

CONCLUSIONS

HPA axis regulation is normal in PMD, suggesting that the pathophysiology of PMD differs from major depression. As observed previously, progesterone but not estradiol up-regulates HPA axis function in women.

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.

Biological aspect of hyperthymic temperament: light, sleep, and serotonin

RATIONALE

Hyperthymic temperament is one of several premorbid temperaments putatively associated with bipolar disorder. Several reports suggest that depressive patients with hyperthymic temperament may belong to the proposed soft bipolar spectrum.

OBJECTIVES

To investigate biological aspects of hyperthymic temperament, the present study examined daily activity, sleep time, central serotonergic function, and other relevant variables in relation to hyperthymic temperament in healthy subjects.

METHODS

Fifty six healthy subjects were monitored via the actigraphy system to measure daily total activity, sleep time, and illuminance. A neuroendocrine challenge test was performed to estimate central serotonergic function.

RESULTS

Multiple regression analysis revealed that higher illuminance of daytime, greater fluctuation in sleep time, and lower central serotonergic function significantly and independently predicted hyperthymic temperament scores.

CONCLUSIONS

The present findings suggest that light, sleep, and serotonin are crucial factors in understanding hyperthymic temperament, which may be common to bipolar disorder.

Menstrual cycle-related exacerbation of disease

Exacerbation of common medical and mental health disorders at specific phases of the menstrual cycle is a prevalent phenomenon. Although the precise cause is unclear, studies implicate complex interactions between the immune and neuroendocrine systems. The menstrual cycle also is a trigger for the onset of depressive disorders, including premenstrual dysphoric disorder, a disorder specific to the luteal phase of the menstrual cycle, and depression associated with the transition to menopause. This article discusses common mental health problems exacerbated by the menstrual cycle, with a particular focus on premenstrual dysphoric disorder and perimenopausal depression. Throughout the reproductive lifespan, routine screening and assessment for the presence of common psychiatric disorders are critical for accurate diagnosis and provision of effective treatment. Management options include referral or consultation with a primary care provider or psychiatrist; treatment options for premenstrual dysphoric disorder and perimenopausal depression include pharmacotherapy with antidepressant agents and/or psychotherapy. Hormones may be helpful.

Women and major depressive disorder: clinical perspectives on causal pathways

BACKGROUND AND AIMS

Epidemiological data on the prevalence of mood disorders demonstrate that major depressive disorder (MDD) is approximately twice as common in women as in men and that its first onset peaks during the reproductive years. We aimed to review key social, psychological, and biological factors that seem strongly implicated in the etiology of major depression and to focus on sex-specific aspects of depression, such as the role of a woman's reproductive life cycle in depressive symptomatology.

METHODS

A review of the literature, from 1965 to present, was conducted.

RESULTS

An integrated etiological model best explains gender and sex differences in depression. Social, psychological, and biological variables must be simultaneously taken into account. These vulnerabilities include (but are not limited to) gender-specific roles in society, life stress such as trauma, a tendency toward ruminative coping strategies, and the effects of sex hormones and genetic factors.

CONCLUSIONS

To effectively treat MDD in women and to prevent the recurrence of illness in vulnerable women, clinicians must understand the sex-specific aspects of mood disorders over the longitudinal course of women's reproductive lives. A biopsychosocial approach should, therefore, be the main focus of future research and practice, to eventually result in an integrated etiological model of depression in women. Based on the prevalence of MDD in women, timely screening, diagnosis, and intervention should be public health priorities.

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.

Family caregiver role and premenstrual syndrome as associated factors for postnatal depression

The goal of this study was to identify sociodemographic, psychopathological, and obstetric risk factors associated with postnatal depression (PND) and their relative weight. A cross-sectional two-stage design was used. All consecutive women receiving a routine check-up 6 weeks postpartum at Obstetric Services during a 1-year period were included. In the first stage, women completed the Edinburgh Post-natal Depression Scale (EPDS). In the second stage, mothers with EPDS scores > or =9 and a randomized sample of 16% with EPDS <9 were explored through a structured clinical interview to diagnose DSM-IV PND (major and minor depression). Variables were entered into stepwise regression models. A total of 1,201 women were recruited and did the EPDS; 261 women with EPDS scores > or =9 and 151 with EPDS scores <9 were selected. Three hundred and thirty-four women agreed to be interviewed and 100 were diagnosed with PND. Family caregiver role (defined as women who have to take care of handicapped or ill relatives) was associated with a 4.4-fold increase in risk for major PND (OR: 4.39, 95%CI: 1.10-17.38). Premenstrual syndrome was identified as an independent risk factor for major and minor PND (OR: 1.81, 95%CI: 1.03-3.18). Moreover, previous depression, poor partner relationship, and lower social support were also confirmed as risk factors for PND. Both family caregiver role and premenstrual syndrome should be considered for inclusion in the rating scales of pregnant women at risk for PND.

Selective serotonin reuptake inhibitors for premenstrual syndrome and premenstrual dysphoric disorder: a meta-analysis

OBJECTIVE

To systematically review evidence of the treatment benefits of selective serotonin reuptake inhibitors (SSRIs) for symptoms related to severe premenstrual syndrome (PMS) and premenstrual dysphoric disorder.

DATA SOURCES

We conducted electronic database searches of MEDLINE, Web of Science, Cochrane Library, Embase, PsycINFO, and Cinahl through March 2007, and hand-searched reference lists and pertinent journals.

METHODS OF STUDY SELECTION

Studies included in the review were double-blind, randomized, controlled trials comparing an SSRI with placebo that reported a change in a validated score of premenstrual symptomatology. Studies had to report follow-up for any duration longer than one menstrual cycle among premenopausal women who met clinical diagnostic criteria for PMS or premenstrual dysphoric disorder. From 2,132 citations identified, we pooled results from 29 studies (in 19 citations) using random-effects meta-analyses and present results as odds ratios (ORs).

TABULATION, INTEGRATION, AND RESULTS

Our meta- analysis, which included 2,964 women, demonstrates that SSRIs are effective for treating PMS and premenstrual dysphoric disorder (OR 0.40, 95% confidence interval [CI] 0.31-0.51). Intermittent dosing regimens were found to be less effective (OR 0.55, 95% CI 0.45-0.68) than continuous dosing regimens (OR 0.28, 95% CI 0.18-0.42). No SSRI was demonstrably better than another. The choice of outcome measurement instrument was associated with effect size estimates. The overall effect size is smaller than reported previously.

CONCLUSION

Selective serotonin reuptake inhibitors were found to be effective in treating premenstrual symptoms, with continuous dosing regimens favored for effectiveness.

Symptoms related to the menstrual cycle: diagnosis, prevalence, and treatment

Menstrual cycle-related symptoms are associated with the intrinsic hormonal fluctuations of the menstrual cycle. These symptoms can be physical, behavioral, or emotional and include problems such as dysmenorrhea, premenstrual syndrome (PMS), and premenstrual dysphoric disorder (PMDD). Because of the emotional and behavioral aspects of menstrual cycle-related symptoms, it is likely that clinical psychiatrists will encounter these symptoms in their daily practice and should therefore be familiar with their diagnosis, prevalence, etiology, and treatment. As many as 2.5 million women are affected by menstrual disorders each year, which can have a profound impact on their quality of life. Although a definitive etiology has yet to be established, fluctuations in estrogen and progesterone as well as genetic factors are thought to contribute to the occurrence of menstrual disorders. Current treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs) (for dysmenorrhea), lifestyle changes, selective serotonin reuptake inhibitors (SSRIs), and ovulation suppression (e.g., with oral contraceptives). Treatment with oral contraceptives (OCs), particularly extended or continuous use, may significantly reduce the incidence of menstrual cycle-related symptoms.