New Pharmacological Approaches to the Management of Premenstrual Dysphoric Disorder

ShuYu capsule alleviates emotional and physical symptoms of premenstrual dysphoric disorder: Impact on ALLO decline and GABAA receptor δ subunit in the PAG area

Premenstrual dysphoric disorder (PMDD) is a severe subtype of premenstrual syndrome in women of reproductive age, with its pathogenesis linked to the heightened sensitivity of type A γ -aminobutyric acid receptors (GABAAR) to neuroactive steroid hormone changes, particularly allopregnanolone (ALLO). While a low dose of fluoxetine, a classic selective serotonin reuptake inhibitor, is commonly used as a first-line drug to alleviate emotional disorders in PMDD in clinical settings, its mechanism of action is related to ALLO-GABAA receptor function. However, treating PMDD requires attention to both emotional and physical symptoms, such as pain sensitivity. This study aims to investigate the efficacy of ShuYu capsules, a traditional Chinese medicine, in simultaneously treating emotional and physical symptoms in a rat model of PMDD. Specifically, our focus centres on the midbrain periaqueductal grey (PAG), a region associated with emotion regulation and susceptibility to hyperalgesia. Considering the underlying mechanisms of ALLO-GABAA receptor function in the PAG region, we conducted a series of experiments to evaluate and define the effects of ShuYu capsules and uncover the relationship between the drug's efficacy and ALLO concentration fluctuations on GABAA receptor function in the PAG region. Our findings demonstrate that ShuYu capsules significantly improved oestrous cycle-dependant depression-like behaviour and reduced stress-induced hyperalgesia in rats with PMDD. Similar to the low dose of fluoxetine, ShuYu capsules targeted and mitigated the sharp decline in ALLO, rescued the upregulation of GABAAR subunit function, and activated PAG neurons in PMDD rats. The observed effects of ShuYu capsules suggest a central mechanism underlying PMDD symptoms, involving ALLO_GABAA receptor function in the PAG region. This study highlights the potential of traditional Chinese medicine in addressing both emotional and physical symptoms associated with PMDD, shedding light on novel therapeutic approaches for this condition.

White matter volume and treatment with selective progesterone receptor modulator in patients with premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) is a mood disorder for which selective progesterone receptor modulator (SPRM) treatment has been demonstrated to be beneficial. The neural signatures of this treatment have been so far identified as greater fronto-cingulate reactivity during aggressive response to provocation, but no changes in terms of gray matter structure. White matter has recently been found to differ between patients with PMDD and healthy controls. The present study thus sought to investigate the relationship between white matter volume and SPRM treatment in patients with PMDD. A pharmaco-neuroimaging study was conducted on patients with PMDD participating in a randomized controlled trial. Participants underwent magnetic resonance imaging before and after treatment randomization to ulipristal acetate (an SPRM), or placebo, for three months. The interaction effect of treatment by time on white matter volume (WMV) was assessed. Voxel based morphometry analyses were performed on both a whole brain exploratory level and on regions of interest. No treatment effect was observed on WMV in any region, including the anterior thalamic radiations, cingulum, forceps minor, fornix, inferior fronto-occipital fasciculus, superior cerebellar peduncle, superior longitudinal fasciculus, and uncinate fasciculus. This is the first finding to indicate that no white matter volume alterations follow three-month progesterone antagonism, suggesting that white matter volume does not participate in symptom relief upon SPRM treatment for PMDD.

Premenstrual disorders and PMDD - a review

Defining, diagnosing and managing premenstrual disorders (PMDs) remains a challenge both for general practitioners and specialists. Yet these disorders are common and can have an enormous impact on women. PMDD (premenstrual dysphoric disorder), one severe form of PMD, has a functional impact similar to major depression yet remains under-recognised and poorly treated. The aim of this chapter is to give some clarity to this area, provide a framework for non-specialists to work towards, and to stress the importance of MDT care for severe PMDs, including PMDD.

Childhood adversity predicts stronger premenstrual mood worsening, stress appraisal and cortisol decrease in women with Premenstrual Dysphoric Disorder

Background

Lifetime traumatic events are prevalent in women with Premenstrual Dysphoric Disorder (PMDD) and predict stronger premenstrual symptom intensities. Less is known about the unique effects of childhood adversity on PMDD. This study aims to investigate the menstrual cycle related course of mood, stress appraisal and cortisol activity over time and the effects of childhood adversity - by controlling for recent stressful life events - on the cyclicity of these outcomes.

Methods

Fifty-two women with PMDD completed questionnaires on childhood adversity and stressful life events during the past 12 months. Momentary negative and positive affect, stress appraisal, and saliva-cortisol were assessed within an Ambulatory Assessment (AA) design over four consecutive days during both the follicular and the late luteal phase. This AA was repeated after five months, resulting in two measurement bursts.

Results

Women with PMDD showed expected cycle related variations in mood and stress appraisal, whereby these effects weakened over time. No cortisol cyclicity was identified. Higher childhood adversity was linked to stronger increases in negative affect and stress appraisal, and stronger decreases in positive affect from the follicular toward the late luteal phase. Women with higher childhood adversity exhibited lower cortisol levels during the late luteal phase compared to the follicular phase whereas no such cyclicity was found in women with lower childhood adversity.

Conclusion

Childhood adversity appears to show independent deteriorating effects on premenstrual mood worsening and stress appraisal in women with PMDD. The observed cortisol cyclicity in women with higher childhood adversity may point to different neuroendocrine subtypes of PMDD in relation to childhood trauma and requires further systematic research.

GABA-ergic Modulators: New Therapeutic Approaches to Premenstrual Dysphoric Disorder

Premenstrual dysphoric disorder (PMDD) is characterized by the predictable onset of mood and physical symptoms secondary to gonadal steroid fluctuation during the luteal phase of the menstrual cycle. Although menstrual-related affective dysfunction is responsible for considerable functional impairment and reduction in quality of life worldwide, currently approved treatments for PMDD are suboptimal in their effectiveness. Research over the past two decades has suggested that the interaction between allopregnanolone, a neurosteroid derivative of progesterone, and the gamma-aminobutyric acid (GABA) system represents an important relationship underlying symptom genesis in reproductive-related mood disorders, including PMDD. The objective of this narrative review is to discuss the plausible link between changes in GABAergic transmission secondary to the fluctuation of allopregnanolone during the luteal phase and mood impairment in susceptible individuals. As part of this discussion, we explore promising findings from early clinical trials of several compounds that stabilize allopregnanolone signaling during the luteal phase, including dutasteride, a 5-alpha reductase inhibitor; isoallopregnanolone, a GABA-A modulating steroid antagonist; and ulipristal acetate, a selective progesterone receptor modulator. We then reflect on the implications of these therapeutic advances, including how they may promote our knowledge of affective regulation more generally. We conclude that these and other studies of PMDD may yield critical insight into the etiopathogenesis of affective disorders, considering that (1) symptoms in PMDD have a predictable onset and offset, allowing for examination of affective state kinetics, and (2) GABAergic interventions in PMDD can be used to better understand the relationship between mood states, network regulation, and the balance between excitatory and inhibitory signaling in the brain.