Premenstrual symptomatology, locus of control, anxiety and depression in women with normal menstrual cycles

What Pre-clinical Rat Models Can Tell Us About Anxiety Across the Menstrual Cycle in Healthy and Clinically Anxious Humans

PURPOSE OF REVIEW

Anxiety symptoms increase during the peri-menstrual phase of the menstrual cycle in people with anxiety disorders. Whether this reflects a heightened variant of normal menstrual-related changes in psychological states experienced by healthy (i.e. non-anxious) people is unknown. Moreover, menstrual-related change in anxiety symptoms is a poorly understood phenomenon, highlighting a need for pre-clinical models to aid mechanistic discovery. Here, we review recent evidence for menstrual effects on anxiety-like features in healthy humans as a counterpart to recent reviews that have focused on clinically anxious populations. We appraise the utility of rodent models to identify mechanisms of menstrual effects on anxiety and offer suggestions to harmonise methodological practices across species to advance knowledge in this field.

RECENT FINDINGS

Consistent with reports in clinical populations, some evidence indicates anxiety symptoms increase during the peri-menstrual period in healthy people, although null results have been reported, and these effects are heterogeneous across studies and individuals. Studies in rats show robust increases in anxiety during analogous phases of the oestrous cycle. Studies in female rats are useful to identify the evolutionarily conserved biological mechanisms of menstrual-related changes in anxiety. Future experimental approaches in rats should model the heterogeneity observed in human studies to increase alignment across species and advance understanding of the individual factors that increase the propensity to experience menstrual-related changes in anxiety.

Unpleasant Pictures Exposure Evokes Different Repercussion on Emotional State and Heart Rate Response in Healthy Women and Men

To evaluate the heart rate response, emotion and changes in anxiety and anger levels after exposure to unpleasant pictures from the International Assessment Pictures System (IAPS) compared with neutral picture exposure in healthy individuals. Forty participants (23 women) visited the laboratory on two occasions. State anger and state anxiety levels were evaluated pre- and post-visualization of a set of IAPS pictures and heart rate was monitored during exposure. Two different picture sets were utilized-one with neutral pictures (that served as the control) and the other with unpleasant pictures. State anxiety and state anger were higher in post-unpleasant session for women than before (p < 0.001). For men, only state anxiety was higher in the post-unpleasant session (p < 0.001). State anxiety (p = 0.004) and state anger (p < 0.001) post-unpleasant session was higher for women than in men. The pleasure and dominance domains were lower in the unpleasant session for both men and women (p < 0.001), and the arousal domain was higher for both men and women (p < 0.001) than in the neutral session. In the unpleasant session, arousal was higher (p = 0.004), and dominance was lower (p < 0.001) among women than among men, but no difference in pleasure was found (p > 0.05). For women, average heart rate was higher on unpleasant session, compared to neutral (p = 0.01), but not for men (p > 0.05). Women are more sensitive and react strongly to unpleasant picture exposure. The IAPS unpleasant session was not able to induce anger levels in men.

Psychiatric Symptoms Across the Menstrual Cycle in Adult Women: A Comprehensive Review

LEARNING OBJECTIVE

After participating in this activity, learners should be better able to:• Discuss and outline the general and overlapping effects of the menstrual cycle on women's mental health.

ABSTRACT

A growing body of research demonstrates menstrual cycle-dependent fluctuations in psychiatric symptoms; these fluctuations can therefore be considered as prevalent phenomena. Possible mechanisms underlying these fluctuations posit behavioral, psychological, and neuroendocrine influences. Recent reviews document cyclic exacerbation of symptoms and explore these mechanisms in the context of specific and often single disorders. The question remains, however, as to whether there are general and overlapping effects of the menstrual cycle on women's mental health. To address this gap, we synthesized the literature examining the exacerbation of a variety of psychiatric symptoms across the menstrual cycle in adult women. Results show that the premenstrual and menstrual phases are most consistently implicated in transdiagnostic symptom exacerbation. Specifically, strong evidence indicates increases in psychosis, mania, depression, suicide/suicide attempts, and alcohol use during these phases. Anxiety, stress, and binge eating appear to be elevated more generally throughout the luteal phase. The subjective effects of smoking and cocaine use are reduced during the luteal phase, but fewer data are available for other substances. Less consistent patterns are demonstrated for panic disorder, symptoms of posttraumatic stress disorder, and borderline personality disorder, and it is difficult to draw conclusions for symptoms of generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, and trichotillomania because of the limited data. Future research should focus on developing standardized approaches to identifying menstrual cycle phases and adapting pharmacological and behavioral interventions for managing fluctuations in psychiatric symptoms across the menstrual cycle.

Stool frequency and form and gastrointestinal symptoms differ by day of the menstrual cycle in healthy adult women taking oral contraceptives: a prospective observational study

Background

Little is known about how the menstrual cycle affects gastrointestinal function and self-reported stress in young, healthy women taking oral contraceptives (OC). This study prospectively characterized gastrointestinal function and symptoms on each day throughout the menstrual cycle.

Methods

Healthy women aged 18–35 years (n = 78) who took OC participated in the 5-week observational study. Stool frequency, self-reported stress, stool form measured by the Bristol Stool Form Scale (BSFS), and gastrointestinal symptoms measured by a modified version of the Gastrointestinal Symptom Rating Scale (GSRS) were assessed daily. GSRS scores were reported (1 = no discomfort at all, 7 = very severe discomfort) and were averaged for individual syndrome scores or summed for the total score. The validated, weekly version of the GSRS was completed at two time points to reflect menstruation and 1 week prior to menstruation (n = 72). Outcomes were analyzed in linear mixed models with the Dunnett’s post hoc test against day 1 of menstrual bleeding or with nonparametric tests.

Results

Daily stress (P = 0.0018), BSFS score (P = 0.0493), stool frequency (P = 0.0241), abdominal pain (P < 0.0001), diarrhea (P = 0.0022), constipation (P = 0.0446), reflux (P = 0.0193), and indigestion (P < 0.0001) all varied significantly by the day of the menstrual cycle. Dunnett’s post hoc tests showed that scores (mean ± SEM) on the first day of bleeding (day 1) for daily abdominal pain (2.6 ± 0.2), diarrhea (1.7 ± 0.1), and indigestion (2.1 ± 0.2) symptoms were higher than scores on all other days of the menstrual cycle (P < 0.05) with scores not on day 1 falling under 1.5, or between no discomfort at all and slight discomfort. Reflux, stool frequency, BSFS, self-reported stress, and constipation were higher on day 1 (P < 0.05) than on 12, 8, 6, 4, and 2 other days of the menstrual cycle, respectively. The median (IQR) GSRS score was higher during the week of menstruation than the week prior to menstruation for diarrhea [1.50 (1.00–2.33) vs 1.33 (1.00–2.00), P = 0.002] and abdominal pain [2.00 (1.33–2.67) vs 1.67 (1.33–2.33), P = 0.011] syndrome scores.

Conclusion

Bowel habits appear to vary across the menstrual cycle and suggest more gastrointestinal discomfort on day 1 of menstrual bleeding in healthy women taking OC. Future interventional studies could identify ways to improve gastrointestinal symptoms in healthy women during menstruation.

A path analysis of stress and premenstrual symptoms in Korean international and Korean domestic students

AIMS

To identify the relationships between perceived stress, acculturative stress and premenstrual symptoms, among other associated factors (e.g. depressive symptoms, coping self-efficacy, perceived social support) of premenstrual symptoms suggested in the literature by testing the conceptual framework of the 'Stress and Premenstrual Experience Model: Women in Cultural Transition'.

BACKGROUND

Level of perceived stress has been cited as a major influencing factor for women's premenstrual symptoms; however, how these two elements are related, including possible mediators and moderators, remains unclear.

DESIGN

A longitudinal causal-comparative web-based study design.

METHODS

Data collection occurred between November, 2014 - February, 2015. The convenience sampling method was used to recruit 98 Korean international students and 89 Korean domestic students. Weekly surveys were conducted for 10 weeks to capture women's levels of perceived stress, acculturative stress and premenstrual symptoms from two menstrual cycles. The survey data collected during the premenstrual phase was analysed using path analyses.

RESULTS/FINDINGS

The hypothesized pathways based on the conceptual model were partially supported in the study. Depressive symptoms were a partial mediator between perceived stress and premenstrual symptoms and between acculturative stress and symptoms in Korean international students. The perceived social support was a moderator between perceived stress and premenstrual symptoms in Korean domestic students.

CONCLUSION

This study proposes a revised conceptual model that will contribute to the understanding of stress and premenstrual symptom severity in women in the acculturation process and concludes with suggestions and implications for future nursing practice and research.

The relationship between food frequency and menstrual distress in high school females

Background:

Nutrition pattern is one of the important factors predicting menstrual distress, which varies among different cultures and countries. The purpose of this study is to determine the relationship between food frequency and menstrual distress in high school girls from Mashhad.

Materials and Methods:

This cross-sectional study was conducted in 2012 using a two-stage sampling method on 407 high school female students from Mashhad who met the inclusion criteria. Subjects completed questionnaires of demographic characteristics, food frequency, and Menstrual Distress Questionnaire (MDQ) during three phases of the menstrual cycle (a week before bleeding, during menstrual bleeding period, and a week after menstruation). The collected data were analyzed by statistical tests such as Pearson correlation coefficient test, independent Student's t-test, and one-way analysis of variance (ANOVA).

Results:

Results showed that 87.7% of the students were at moderate economic status, 82.2% were exposed to cigarette smoke, 94.8% had mothers without university education, and 9.4% had working mothers. About 71% of the students reported minor pre-menstruation distress, 81% reported minor distress during bleeding, and 39% reported minor post-menstruation distress. In addition, the mean (SD) values for sweet–fatty foods, salty–fatty foods, fast foods, and caffeine were 3.6, 3.3, 1.3, and 10.2 per week, respectively. In addition, Pearson correlation coefficient test showed no significant correlation between total menstruation distress and food frequency (P > 0.05).

Conclusions:

With regard to the inappropriate food frequency and high intensity of menstrual distress among high school students and as health care and educational efforts for prevention and health promotion in society are among the duties of health workers, the results of this study can help the officials involved in education to emphasize on nutrition and the menstrual health of students.

The role of perceived control over anxiety in prospective symptom reports across the menstrual cycle

The present investigation tested the role of psychological vulnerabilities to anxiety in reported menstrual symptom severity. Specifically, the current study tested the incremental validity of perceived control over anxiety-related events in predicting menstrual symptom severity, controlling for the effect of anxiety sensitivity, a documented contributor to menstrual distress. It was expected that women with lower perceived control over anxiety-related events would report greater menstrual symptom severity, particularly in the premenstrual phase. A sample of 49 normally menstruating women, aged 18-47 years, each prospectively tracked their menstrual symptoms for one cycle and completed the Anxiety Control Questionnaire (Rapee, Craske, Brown, & Barlow Behav Ther 27:279-293. doi: 10.1016/S0005-7894(96)80018-9 , 1996) in their follicular and premenstrual phases. A mixed model analysis revealed perceived control over anxiety-related events was a more prominent predictor of menstrual symptom severity than anxiety sensitivity, regardless of the current cycle phase. This finding provides preliminary evidence that perceived control over anxiety-related events is associated with the perceived intensity of menstrual symptoms. This finding highlights the role of psychological vulnerabilities in menstrual distress. Future research should examine whether psychological interventions that target cognitive vulnerabilities to anxiety may help reduce severe menstrual distress.

Gastrointestinal symptoms before and during menses in healthy women

Background

Little is known as to the extent gastrointestinal (GI) complaints are reported by women around menses. We aimed to describe GI symptoms that occurred premenstrually and during menses in healthy women, and to specifically assess the relationship of emotional symptoms to GI symptoms around menses.

Methods

We recruited healthy, premenopausal adult women with no indication of GI, gynecologic, or psychiatric disease who were attending an outpatient gynecology clinic for well-woman care. They completed a survey that queried menstrual histories and the presence of GI and emotional symptoms. We compared the prevalence of primary GI symptoms (abdominal pain, diarrhea, constipation, nausea, vomiting), as well as pelvic pain and bloating, in the 5 days preceding menses and during menses, and assessed whether emotional symptoms or other factors were associated with the occurrence of GI symptoms.

Results

Of 156 respondents, 73% experienced at least one of the primary GI symptoms either pre- or during menses, with abdominal pain (58% pre; 55% during) and diarrhea (24% pre; 28% during) being the most common. Those experiencing any emotional symptoms versus those without were more likely to report multiple (2 or more) primary GI symptoms, both premenstrually (depressed p = 0.006; anxiety p = 0.014) and during menses (depressed p < 0.001; anxiety p = 0.008). Fatigue was also very common (53% pre; 49% during), and was significantly associated with multiple GI symptoms in both menstrual cycle phases (pre p < 0.001; during p = 0.01).

Conclusions

Emotional symptoms occurring in conjunction with GI symptoms are common perimenstrually, and as such may reflect shared underlying processes that intersect brain, gut, and hormonal pathways.

Relationships among Premenstrual Syndrome, Perfection and Anxiety among the College Student

PURPOSE

The purpose of this study was to compare the premenstrual syndrome (PMS) and the relationships among PMS, perfection, and anxiety in nursing college students and general college students.

METHODS

The questionnaire survey was carried out with a convenience sample of 215 college students. The MDQ (Menstrual Distress Questionnaire), APS-R (Almost Perfect Scale-Revised), STAI (State and Trait Anxiety Inventory) were used. The data were collected from June to October, 2011. Data analysis included frequency, chi2-test, t-test, and Pearson correlation.

RESULTS

There were significant differences in PMS and perfection but there not in anxiety between nursing college students and general college students. There were significant correlations among PMS, perfection and anxiety in nursing college students, and there were significant correlations among PMS and anxiety in general college students but not significant correlations among PMS and perfection.

CONCLUSION

The findings suggest that to provide effective interventions for PMS in college students, it is necessary to design nursing interventions that consider perfection and anxiety.

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.

The interrelation between premenstrual syndrome and major depression: results from a population-based sample

BACKGROUND

Research about the relationship between premenstrual syndrome (PMS) and major depression is limited. This study examined the relationship between moderate to severe PMS and major depression in a population-based sample of women of reproductive age. The objectives of the study were to assess the association between premenstrual syndrome and major depression, to analyse how PMS and major depression differ and to characterise the group of women who report both PMS and major depression.

METHODS

Data were obtained from the Swiss Health Survey 2007. Included in the analysis was data from women under the age of 55 without hysterectomy and who answered the questions on PMS symptoms. The population-based sample consisted of 3518 women. Weighted prevalence rates were calculated and relative risk ratios for PMS, major depression and women who reported both PMS and major depression, were calculated with logistic multinominal logit regression.

RESULTS

The prevalence of major depression was 11.3% in women screening positive for moderate PMS and 24.6% in women screening positive for severe PMS. Compared to women without any of these conditions, women who reported moderate to severe alcohol consumption had a lower risk for PMS. Women reporting use of antidepressants, and use of oral contraceptives had a higher risk for major depression compared to women without any of these conditions. Women reporting work dissatisfaction had a higher risk for PMS. A higher relative risk to report both PMS and major depression compared to women without PMS or major depression was related to factors such as high psychological distress, low mastery, psychotropic drug consumption, and low self-rated health.

CONCLUSIONS

The results suggested that women who suffer from both PMS and major depression are more impaired compared to women with only one disorder. The results further indicated that PMS and major depression are different disorders that can, however, co-occur.

Anxiety sensitivity, the menstrual cycle, and panic disorder: a putative neuroendocrine and psychological interaction

The 2:1 female-to-male sex difference in the prevalence of panic disorder (PD) suggests that there is a sex-specific vulnerability involved in the etiology and/or maintenance of this disorder. The purpose of this paper is to present a new conceptual model, which emphasizes the interaction between a cognitive vulnerability for PD, anxiety sensitivity, and the effects of progesterone and its metabolite, allopregnanolone, on behavioral and physiological responses to stress during the premenstrual phase. This interaction is proposed to be a potential sex-specific pathway that may initiate and/or maintain panic and anxiety symptoms in women. This review paper presents preliminary evidence from both the human and animal literatures to support this new model. Specific topics reviewed include: psychopathology related to the menstrual cycle, anxiety sensitivity and its relationship to the menstrual cycle, PMS, and PMDD, anxiety-modulating effects of progesterone and its neuroactive metabolite, allopregnanolone, and how results from the neuroendocrine literature relate to psychopathology or symptoms associated with the menstrual cycle.

Fulfillment of the premenstrual dysphoric disorder criteria confirmed using a self-rating questionnaire among Japanese women with depressive disorders

BACKGROUND

Some women with depressive disorders experience severe premenstrual symptoms. However, there have been few studies in which premenstrual symptoms in women suffering from depressive disorders were assessed. In this study, we aimed to investigate premenstrual symptoms in women with depressive disorders using the premenstrual dysphoric disorder (PMDD) scale.

METHODS

We administered questionnaires to 65 Japanese female outpatients who had been diagnosed with a major depressive disorder or dysthymic disorder and to 303 healthy women as control subjects. The questionnaire consisted of items on demographics and the PMDD scale, which was modified from the premenstrual symptoms screening tool (PSST) developed by Steiner et al. (Arch Womens Ment Health 2003, 6:203-209).

RESULTS

Twenty-eight women (43.1%) with depressive disorder fulfilled certain items of the PMDD scale. These women are considered to have coexisting PMDD and a depressive disorder, or to have premenstrual exacerbation (PME) of a depressive disorder. On the other hand, 18 women (5.9%) in the control group were diagnosed as having PMDD. The depressive disorder group who fulfilled the PMDD criteria had more knowledge of the term premenstrual syndrome (PMS) and took more actions to attenuate premenstrual symptoms than the control group with PMDD.

CONCLUSIONS

Our findings demonstrated that the occurrence of severe premenstrual symptoms is much higher in women with depressive disorders than in healthy subjects. This is partially due to this group containing women with PME, but mainly due to it containing women with PMDD. The higher percentage of PMDD suggests similarity between PMDD and other depressive disorders. Furthermore, educating healthy Japanese women and women with depressive disorders about premenstrual symptoms and evidence-based treatment for them is necessary.

Approach to premenstrual dysphoria for the mental health practitioner

As many as 7% of women experience significant social or occupational dysfunction as a result of severe premenstrual mood disturbance. Biological, psychological, and sociocultural factors are implicated in the cause of premenstrual dysphoric disorder, but the interaction between these factors remains to be elucidated. Mental health practitioners can aid women by providing diagnostic clarity and by initiating an integrated step-wise management approach.

Understanding and treating premenstrual dysphoric disorder: an update for the women's health practitioner

Up to 7% of women report premenstrual symptoms severe enough to impair daily function, and are said to suffer from premenstrual dysphoric disorder (PMDD). Although PMDD is predominately regarded as a biologically based condition, sociocultural factors, and particularly life stress, past sexual abuse, and cultural socialization, likely interact with hormonal changes. This integrative model has implications for etiology and treatment of PMDD.

Menstrual-related problems and psychological distress among women in the United States

OBJECTIVE

To examine the associations of menstrual-related problems with mental health and health behaviors in a U.S. population-based study.

METHODS

We analyzed data obtained from women aged 18-55 years (n = 11,648) who participated in the 2002 National Health Interview Survey, an ongoing, computer-assisted personal interview of the noninstitutionalized U.S. population.

RESULTS

Approximately 19% of women aged 18-55 years reported experiencing menstrual-related problems (e.g., heavy bleeding, bothersome cramping, or premenstrual syndrome [PMS]). These women were significantly more likely than those without menstrual-related problems to report frequent anxiety and depression, insomnia, excessive sleepiness, and pain over the past 12 months. Women with menstrual-related problems were also significantly more likely to report feeling sad, nervous, restless, hopeless, or worthless and that everything was an effort all or most of the time during the past 30 days. Cigarette smoking, drinking heavily, and being overweight or obese were also more frequently reported among women with menstrual-related problems than those without.

CONCLUSIONS

Menstrual-related problems pose substantial implications for public health. Healthcare providers should examine mental health concerns in women reporting menstrual-related problems.

Symptoms of depression in late luteal phase dysphoric disorder: a variant of mood disorder?

BACKGROUND

In premenstrual syndrome, depressed mood in the luteal phase of the menstrual cycle is acknowledged, whereas the presence of symptoms of depression during the follicular phase remains in debate.

METHODS

On the basis of prospective daily recording of the presence and severity of symptoms for at least two menstrual cycles, 43 women were diagnosed with Late Luteal Phase Dysphoric Disorder (LLPD) according to the criteria of the third edition revision of the Diagnostic and Statistical Manual of Mental Disorders. They were compared to a group of 85 women who showed no evidence of LLPD for two menstrual cycles. Structured psychiatric interviews were administered during the follicular phase. Only those subjects without Axis I disorders were subsequently included in the study.

RESULTS

Those women with minor/moderate symptoms of depression had an odds of suffering from LLPD of 1.9 (95% CI=1.5-2.4, p<0.001) in relation to increasing severity of symptoms of depression at the total MADRS scale (1-point increase). The ORs of LLPD in relation to each dimension (1-point increase) of the emotional/affective, cognitive, and neurovegetative symptoms were 1.6 (95% CI=1.2-2.3, p=0.003), 2.8 (95% CI=0.9-8.5, p=0.077) and 3.3 (95% CI=1.9-5.9, p<0.001), respectively.

LIMITATIONS

No hormonal changes that may be associated with symptoms of LLPD were determined in this study.

CONCLUSIONS

LLPD is likely to represent a variant of a depressive disorder, where premenstrual psychobiological changes seem to exacerbate mild depressive symptoms and signs to which LLPD women are otherwise predisposed. This hypothesis opens new perspectives for prevention and of even treatment for LLPD. Further longitudinal studies with larger populations and evaluation of hormonal changes are needed to confirm these data.

The menstrual cycle and susceptibility to virtual simulation sickness

Virtual simulation sickness (VSS) is a form of visually induced motion sickness that can result from immersion in a virtual environment (VE). As in their susceptibility to the sickness induced by real motion, women have been reported to be more susceptible than men to VSS, yet the reason for this difference is not known. The aim of the current study was to investigate the influence of the menstrual cycle on susceptibility to VSS in 16 naturally cycling women and to compare the responses of this group with control groups consisting of 1) 16 premenopausal women taking a combined monophasic oral contraceptive and 2) 16 men. All female participants were immersed in a nauseogenic VE on days 5, 12, 19, and 26 of their menstrual/pill cycle. These days were chosen because they fall in line with peaks and troughs of ovarian hormone levels. Menstrual cycle phase was confirmed by salivary estradiol and progesterone levels. A 4-week "pseudo-cycle" was assigned to the male participants. Hormone analysis revealed that 9 participants in the experimental group had been tested at the desired phases of their cycle. These participants exhibited a significant increase in susceptibility to VSS on day 12 of their cycle. The hormone analysis also showed that the cycles of the 7 remaining members of the experimental group had not precisely followed the expected pattern, and so these people had been tested on days that did not coincide with peaks and troughs of ovarian hormone levels. No consistent variation in susceptibility was observed over the cycle in these volunteers. In addition, no change in susceptibility was observed over the pill cycle of the oral contraceptive group nor over the pseudo-cycle applied to the male control group. The authors conclude that susceptibility to VSS varies over the menstrual cycle as a consequence of hormonal variation.