Premenstrual fall of plasma beta-endorphin in patients with premenstrual syndrome

Relationship Between Steroid Hormone Profile and Premenstrual Syndrome in Women Consulting for Infertility or Recurrent Miscarriage

To determine the relationships between luteal-phase steroidal hormonal profile and PMS for a large number of women attending a dedicated fertility clinic. This was a retrospective cross-sectional study on women attending a hospital-based clinic for fertility concerns and/or recurrent miscarriage. All participants were assessed with a women's health questionnaire which also included evaluation of premenstrual symptoms. Day of ovulation was identified based on the peak mucus symptom assessed by the woman after instruction in a fertility awareness-based method (FABM). This enabled reliable timing of luteal-phase serum hormone levels to be taken and analysed. Between 2011 and 2021, 894 of the 2666 women undertaking the women's health assessment had at least one evaluable serum luteal hormone test. Serum progesterone levels were up to 10 nmol/L lower for symptomatic women compared with asymptomatic women. This difference was statistically significant (p < 0.05) for the majority of PMS symptoms at ≥ 9 days after the peak mucus symptom. A similar trend was observed for oestradiol but differences were generally not statistically significant. ROC curves demonstrated that steroid levels during the luteal phase were not discriminating in identifying the presence of PMS symptoms. Blood levels for progesterone were lower throughout the luteal phase in women with PMS, with the greatest effect seen late in the luteal phase.

HPA axis activity across the menstrual cycle - a systematic review and meta-analysis of longitudinal studies

Differential HPA axis function has been proposed to underlie sex-differences in mental disorders; however, the impact of fluctuating sex hormones across the menstrual cycle on HPA axis activity is still unclear. This meta-analysis investigated basal cortisol concentrations as a marker for HPA axis activity across the menstrual cycle. Through a systematic literature search of five databases, 121 longitudinal studies were included, summarizing data of 2641 healthy, cycling participants between the ages of 18 and 45. The meta-analysis showed higher cortisol concentrations in the follicular vs. luteal phase (d_SMC = 0.12, p =.004, [0.04 - 0.20]). Comparisons between more precise cycle phases were mostly insignificant, aside from higher concentrations in the menstrual vs. premenstrual phase (d_SMC = 0.17, [0.02 - 0.33], p =.03). In all included studies, nine samples used established cortisol parameters to indicate HPA axis function, specifically diurnal profiles (k = 4) and the cortisol awakening response (CAR) (k = 5). Therefore, the meta-analysis highlights the need for more rigorous investigation of HPA axis activity and menstrual cycle phase.

Premenstrual Syndrome and Premenstrual Dysphoric Disorder as Centrally Based Disorders

Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) encompass a variety of symptoms that occur during the luteal phase of the menstrual cycle and impair daily life activities and relationships. Depending on the type and severity of physical, emotional or behavioral symptoms, women of reproductive age followed for at least two prospective menstrual cycles may receive one of the two diagnoses. PMDD is the most severe form of PMS, predominantly characterized by emotional and behavioral symptoms not due to another psychiatric disorder. PMS and PMDD are common neuro-hormonal gynecological disorders with a multifaceted etiology. Gonadal steroid hormones and their metabolites influence a plethora of biological systems involved in the occurrence of specific symptoms, but there is no doubt that PMS/PMDD are centrally based disorders. A more sensitive neuroendocrine threshold to cyclical variations of estrogens and progesterone under physiological and hormonal therapies is present. Moreover, altered brain sensitivity to allopregnanolone, a metabolite of progesterone produced after ovulation potentiating GABA activity, along with an impairment of opioid and serotoninergic systems, may justify the occurrence of emotional and behavioral symptoms. Even neuro-inflammation expressed via the GABAergic system is under investigation as an etiological factor of PMS/PMDD. Pharmacological management aims to stabilize hormonal fluctuations and to restore the neuroendocrine balance. The rationale of suppressing ovulation supports prescription of combined hormonal contraception (CHC). Its effect on mood is highly variable and depends on biochemical characteristics of exogenous steroids and on type and severity of symptoms. Hormonal regimens reducing the estrogen-free interval or suppressing menstruation seem better choices. Psychoactive agents, such as serotonin reuptake inhibitors (SSRIs), are effective in reducing the symptoms of PMS/PMDD and may be prescribed continuously or only during the luteal phase. Novel therapeutic approaches include inhibition of progesterone receptors in the brain, i.e., with ulipristal acetate, reduced conversion of progesterone with dutasteride, and modulation of the action of allopregnanolone on the brain GABAergic system with sepranolone.

Premenstrual syndrome and fibromyalgia: the frequency of the coexistence and their effects on quality of life

OBJECTIVE

We aimed to investigate the association between Premenstrual syndrome (PMS) and fibromyalgia syndrome (FMS), to assess common symptoms and quality of life (QOL) of them.

METHODS

Patients with PMS formed the PMS group and age-matched healthy normal controls were included in the control group. The diagnosis of the FMS and PMS were based on new American College of Rheumatology FMS criteria and DSM-IV PMS criteria. FMS-related symptoms assessed by visual analog scale and number of tender points (TePs) were analyzed. QOL, PMS severity and FMS severity were assessed with SF-36, fibromyalgia impact questionnaire (FIQ) and premenstrual assessment form (PAF), respectively. Patients with PMS were divided into two subgroups according to coexistence of FMS or not.

RESULTS

The frequency of FMS in PMS and control group were 20 and 0%, respectively (p = 0.002). FMS-related symptoms, number of TePs in the PMS group were higher than those in the control group. The mean mental component summary (MCS) score of SF-36 was low in the PMS group. The mean PAF score in PMS with FMS subgroup was higher than those in without FMS subgroup. The mean physical component summary of SF-36 was low in the PMS patient with FMS. There was correlation between PAF score and FIQ score (r = 0.476, p < 0.001).

CONCLUSION

FMS was common among the patients with PMS and frequently seen in the PMS patients having severe premenstrual complaints. Mental QOL was distressed in the patients with PMS but while FMS accompanied to PMS, the physical QOL was decreased.

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.

Vitex agnus-castus (Chaste-Tree/Berry) in the treatment of menopause-related complaints

BACKGROUND

The origin of the current practice of administering Vitex agnus-castus in menopause-related complaints is uncertain, but appears to be relatively recent. Here we review the evidence for this application of Vitex based on evidence from pharmacological studies and clinical research.

METHODS

The mechanisms of potential relevance in the context of menopause are explored with reference to the current understanding of the endocrinology and neuroendocrinology of menopause and associated symptoms.

CONCLUSIONS

We conclude that, while evidence from rigorous randomized controlled trials is lacking for the individual herb in this context, emerging pharmacological evidence supports a role for V. agnus-castus in the alleviation of menopausal symptoms and suggests that further investigation may be appropriate.

The premenstrual syndrome revisited

More women - and their families - are affected by the physical and psychological irregularities due to premenstrual symptoms than by any other condition. Up to 90% of women of childbearing age report perceiving one or more symptoms during the days before menstruation, symptoms which can alter their behaviour and wellbeing and which, therefore, can affect their family, social and work circle. However, and notwithstanding this general prevalence, the clinical entity that in a large number of cases results from these symptoms, commonly known as the premenstrual syndrome, still lacks defined and validated contents so that recommendations of treatments backed by adequate experimental and clinical evidence are only slowly appearing. In the present paper, we review recent experimental data as to a possible aetiology of the premenstrual problem. We propose a Premenstrual Profile, i.e. a new register of symptoms, to be used for the differential diagnosis of the three forms of the premenstrual alteration. Finally, we review the evidence-based recommendations from reliable sources as regards the treatment of "normal" and "abnormal" premenstrual symptoms.

Premenstrual dysphoric disorder: prevalence, diagnostic considerations, and controversies

Premenstrual dysphoric disorder (PMDD) has been included as a formal diagnosis of a mood disorder in the appendix of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition in 1994. The ensuing, critical attention has resulted in increased research productivity and clinical recognition of this neglected women's health problem. A decade later, this paper will review the current literature on PMDD focusing on prevalence, biopsychosocial etiological correlates, history of the development of a formal DSM diagnosis, and the controversies surrounding the current classification of PMDD. The authors conclude that PMDD presents a distinct diagnostic entity and that recognition through formal diagnostic criteria serves the important minority of women who suffer from this cyclical mood disorder distinct from premenstrual symptoms and major depression.

The etiology, biology, and evolving pathology of premenstrual syndromes

Menstrually related symptoms and disorders are multidimensional and affect diverse physiologic systems. Elucidation of the pathophysiologic mechanisms of these disorders should allow for a more precise diagnosis, and provide direction for targeted therapeutic interventions. Several biologic mechanisms that underlie menstrually related symptoms have been proposed. They focus mostly on gonadal hormones, their metabolites and interactions with neurotransmitters and neurohormonal systems, such as serotonin, GABA, cholecystokinin, and the renin-angiotensin-aldosterone system. Altered responses of these systems to gonadal hormone's fluctuations during the menstrual cycle, as well as an increased sensitivity to changes in gonadal hormones may contribute to menstrually related symptoms in vulnerable women. Disrupted homeostasis and deficient adaptation may be core underlying mechanisms. Future directions for clinically-relevant progress include identification of specific subgroups of menstrually-related syndromes, assessment of the genetic vulnerability and changes in vulnerability along the life cycle, the diversified mechanisms by which vulnerability is translated into pathophysiology and symptoms, the normalization process as well as syndromes-based and etiology-based clinical trials.

Endocrine withdrawal syndromes

Hypersecretion of endogenous hormones or chronic administration of high doses of the same hormones induces varying degrees of tolerance and dependence. Elimination of hormone hypersecretion or discontinuation of hormone therapy may result in a mixed picture of two syndromes: a typical hormone deficiency syndrome and a generic withdrawal syndrome. Thus, hormones with completely different physiological effects may produce similar withdrawal syndromes, with symptoms and signs reminiscent of those observed with drugs of abuse, suggesting shared mechanisms. This review postulates a unified endocrine withdrawal syndrome, with changes in the hypothalamic-pituitary-adrenal axis and the central opioid peptide, in which noradrenergic and dopaminergic systems of the brain act as common links in its pathogenesis. Long-term adaptations to hormones may involve relatively persistent changes in molecular switches, including common intracellular signaling systems, from membrane receptors to transcription factors. The goals of therapy are to ease withdrawal symptoms and to expedite weaning of the patient from the hormonal excess state. Clinicians should resort to the fundamentals of tapering hormones down over time, even in the case of abrupt removal of a hormone-producing tumor. In addition, the prevention of stress and concurrent administration of antidepressants may ameliorate symptoms and signs of an endocrine withdrawal syndrome.

Pituitary-adrenal hormones and testosterone across the menstrual cycle in women with premenstrual syndrome and controls

BACKGROUND

Premenstrual syndrome (PMS) is a cyclic mood disorder, widely believed, yet not conclusively shown, to be of endocrine etiology. This study examines basal levels of several hormones reported, albeit inconsistently, to differ in women with PMS compared with controls.

METHODS

Subjects (10 PMS patients and 10 controls) had their blood drawn for one full menstrual cycle. Subjects' mood and behavioral symptoms were assessed by daily self-ratings and objective ratings. Plasma was assayed for total and free testosterone (T), beta-endorphin (beta-EP), adrenocorticotropic hormone (ACTH), and cortisol.

RESULTS

No differences were observed between the PMS and control groups for beta-EP, ACTH, or cortisol. PMS subjects had significantly lower total and free T plasma levels with a blunting of the normal periovulatory peak, a finding that may be epiphenomenal to age.

CONCLUSIONS

This study does not confirm previous reports of abnormalities in plasma levels of either ACTH or beta-EP in women with PMS; it also fails to replicate a previous observation of high free T levels in women with PMS. These results are not supportive of a primary endocrine abnormality in PMS patients.

Diagnosis and treatment of premenstrual dysphoric disorder

Premenstrual syndrome (PMS) is a common problem and patients with PMS are encountered by obstetricians, gynecologists, family practitioners, internists (general physicians) and psychiatrists. Despite several decades of biological research, the etiology of the disorder is still elusive. The introduction of a psychiatric category called premenstrual dysphoric disorder (PMDD), describing women with severe emotional premenstrual symptoms, has advanced biological treatment research by identifying a more homogeneous patient population. This paper aims to review our current understanding of the clinical presentation, underlying psycho-biology, and essentials of treatment for premenstrual dysphoric disorder.

Late luteal phase dysphoric disorder: a scientific puzzle

Late luteal phase dysphoric disorder is described as a classic biopsychosocial disorder resulting from complex interactions of biological, psychological, socioeconomic and cultural forces on women. To understand women suffering from the disorder, one must understand how the genetically designed female brain and body influence and are influenced by experience and learning. Each perspective of understanding constitutes one piece of a scientific puzzle. These perspectives are delineated and the conceptual problem of how to measure the outcome of the interactions is described.

The premenstrual syndrome: a twin study

Data are presented from 157 monozygotic and 143 dizygotic female twin pairs of reproductive age who completed a self-report questionnaire on the premenstrual syndrome (PMS). For global PMS scores, the correlation coefficient for the monozygotic twins (0.55) was double that of the dizygotic ones (0.28). The results are consistent with the hypothesis that aggregation for global PMS scores is determined by genetic factors acting additively over a number of loci. Two alternative explanations are suggested: that monozygotic twins share greater environmental similarities than dizygotic ones; or that PMS scores may be a reflection of some other underlying characteristic (such as neuroticism), which is itself genetically determined.

Relationships between self-reported symptoms of infection, menstrual-cycle-related distress, and cycle phase

This study examined the relationships between symptoms of common infectious illnesses, menstrual cycle phase, and cycle-related distress. Sixty-five women who had regular menstrual cycles and were not taking birth control pills were the convenience sample for this research. Subjects completed the Menstrual Distress Questionnaire (MDQ), the Perceived Stress Scale (PSS), and an investigator-developed symptom checklist (SCL) that inventoried symptoms of common respiratory, skin, gastrointestinal, and genitourinary infections. The subjects completed all questionnaires three times during the menstrual cycle (during menstruation, midcycle, and premenstruum). The results of the study indicated a highly significant clustering of infectious illness symptoms during the perimenstrual period compared with midcycle. There were significant relationships between scores on the MDQ and PSS and the frequency and intensity of infection symptoms throughout the cycle. Analysis of covariance (ANCOVA) of the effects of phase, PSS, MDQ, and SCL scores revealed that phasic influences were not significant when MDQ scores were controlled. PSS and MDQ scores significantly influenced symptom scores when phase was controlled, suggesting a general relationship between distress and infectious symptoms during the menstrual cycle.

Buserelin in premenstrual syndrome

Buserelin, a luteinizing hormone releasing hormone agonist was administered nasally in doses of 900 micrograms daily to inhibit the ovarian cycle. Of 16 patients recruited, ten completed the treatment. Daily symptoms were measured on the Visual Analogue Scale and Trigg's trend analysis utilized for the analysis. The peak severity of symptoms (ESAmax) and the maximum global scores (Gmax) reduced on buserelin treatment. The minimum global scores (Gmin) and the minimum score for each symptom (ESAmin) increased, suggesting worsening of underlying symptoms. The difference between ESAmax and ESAmin (ESAdelta) and Gmax and Gmin (Gdelta) were calculated to determine the degree of symptom change. The delta scores for symptoms of depression, bloatedness and breast symptoms, and Gdelta were significantly reduced (p less than 0.05) on buserelin, whilst the latter significantly worsened in the follow-up months. Side-effects may limit the place of buserelin in the long-term treatment of premenstrual syndrome, although combination of additional hormonal treatment may facilitate long-term treatment.

Effect of ovariectomy and estrogen replacement on hypothalamic, pituitary and peripheral blood beta-endorphin levels in the rat

This study was initiated to detect possible changes in beta-endorphin (beta-EP) levels of the hypothalamus, anterior pituitary gland, and peripheral blood of rats after ovariectomy and estrogen administration. Attempts were also made to determine the correlation between peripheral and central levels of beta-EP. Twenty-six Sprague-Dawley rats were decapitated. Nine had intact ovaries (Gr. INT), and 17 were ovariectomized 3 weeks before they were killed. Nine of the ovariectomized rats received estradiol benzoate (EB) (Gr. EB) and the other 8 received peanut oil (Gr. OVX) prior to the decapitation. A beta-EP radioimmunoassay was used to analyze homogenates of the hypothalamus and anterior pituitary, and peripheral blood. In the hypothalamus, beta-EP levels were significantly lower in Gr. INT and Gr. EB than in Gr. OVX. In the pituitary gland and peripheral blood, beta-EP levels were significantly higher in Gr. INT than in Gr. OVX. Pituitary beta-EP levels did not vary between Gr. OVX and Gr. EB, although beta-EP levels in peripheral blood were significantly higher in Gr. EB than in Gr. OVX. No significant correlations were noted in beta-EP levels between the hypothalamus, pituitary gland, and peripheral blood in either Gr. INT, Gr. OVX, or Gr. EB. It appears that EB exerts different effects on beta-EP levels in the hypothalamus, anterior pituitary gland, and peripheral blood, and that beta-EP levels in these regions may be independent of one another.

Current concepts of beta-endorphin physiology in female reproductive dysfunction

beta-Endorphin has a role in the regulation of the normal menstrual cycle and possibly in the onset of puberty. We have reviewed the evidence pointing to an alteration in this neuropeptide that may contribute to the pathogenesis of various reproductive dysfunctions. Elevated or high levels of beta-endorphin have been associated with exercise-associated amenorrhea, stress-associated amenorrhea, and polycystic ovarian syndrome. Depressed or low levels of beta-endorphin have been associated with PMS and menopause. Alterations in the levels of beta-endorphin may change the pulsatile release of GnRH via noradrenergic and/or dopaminergic pathways. We have primarily focused on beta-endorphin as representative of the endogenous opioid peptides, but other opioid peptides may also contribute to the pathogenesis of various types of reproductive dysfunction. Perhaps it will become possible to characterize and hone our understanding of the function of beta-endorphin and the other substances composing the endogenous opioid peptides. A better understanding of their role in physiological as well as pathophysiological processes may allow for the development of rational approaches to the treatment of specific disorders pertaining to reproduction. Many questions remain unanswered. Among the most relevant are: what is the precise mechanism of action by which beta-endorphin exerts its influence on pulsatile GnRH release? Is there a functional relationship between CNS and peripheral (serum) levels of beta-endorphin? Are the detected changes in beta-endorphin levels merely associated, or are they a cause of a particular disorder? Since it took almost 40 years between the time prostaglandins were first discovered and eventual realization of their clinical application, it may take some time before the beta-endorphin story is complete.

Recent developments in the toxicology of anabolic steroids

Anabolic steroids are extensively abused as ergogenic aids by athletes (and others). A number of features of anabolic steroid use and toxicology have been recently reviewed in the Journal, and a large body of data has accumulated concerning their toxic nature. The lipoprotein profile induced by anabolic steroids carries a markedly adverse cardiovascular risk. Glucose metabolism is significantly altered and includes peripheral insulin resistance, hyperinsulinaemia and attenuated responses to glucagon. Hypertension has been noted. Psychiatric and psychological alterations are major toxicities of anabolic steroids, and probably constitute the major mechanism of their action. Hepatic neoplasia occurs in the setting of abuse of this class of drugs, and may be related to their use, although there is no convincing evidence that other malignancies are induced in athletes who abuse them. Gross disturbance of reproductive function occurs in both sexes: hypogonadal states are common and prolonged. The anabolic steroids are toxic drugs with both long and short term effects. Their abuse by athletes is to be decried, particularly in view of the frequent and prolonged use by the young.

Opioid control of the hypothalamus-pituitary-adrenal axis cyclically fails in menstrual migraine

To assess the biological correlates of the precipitation of migraine attacks in the perimenstrual period, plasma beta-endorphin (beta-EP) and cortisol responses to naloxone (8 mg iv) and corticotropin releasing hormone (100 micrograms iv) were evaluated in both the follicular phase and the premenstrual period in 7 patients suffering from menstrual migraine and in 7 healthy, asymptomatic control volunteers. In the controls, naloxone evoked a significant release of both beta-EP (F = 5.86, p less than 0.002) and cortisol (F = 4.43, p less than 0.008), independently of the menstrual cycle phase (F = 0.31 and 1.04, for beta-EP and cortisol, respectively). Menstrual migraine patients, on the other hand, showed a significant hormone response only in the follicular phase, not in the premenstrual period. Corticotropin releasing hormone significantly increased beta-EP and cortisol in both the controls and the menstrual migraine patients, independently of the menstrual cycle phase. In both the naloxone and corticotropin releasing hormone testings, the basal beta-EP levels measured in the premenstrual period were lower than those observed in the follicular phase (p less than 0.02). These data demonstrate a cyclical, premenstrual dysfunction of the hypothalamic control exerted by opioids on the hypothalamus-pituitary-adrenal axis. Impairment of this fundamental adaptive mechanism (involved in stress responses and in pain control) could establish a causal relationship between menstrual-related migraine attacks and premenstrual opioid hyposensitivity.

The endocrine effects of visual erotic stimuli in normal men

Endocrine responses to erotic stimulation in the laboratory were assessed in eight normal subjects. Each subject was tested on two occasions. On one occasion only neutral stimuli were involved. After 15 min baseline, 30 min of films were shown. For the erotic condition on the other occasion, two 10-min erotic films were interspersed with 10 min of neutral film. Fifteen-minute blood samples were taken from the start of each test and continued for 5 hr after the films. Plasma was assayed for testosterone, LH, prolactin, cortisol, ACTH and beta-endorphin. Urine was collected for 4 hr before and 4 hr after the films; this was assayed for adrenaline, noradrenaline and dopamine. Sexual arousal occurred in response to the erotic films in all subjects, as shown by erectile and subjective responses. There were no significant changes in hormone or catecholamine levels following either the erotic or the neutral stimuli, except for a rise in cortisol during the neutral but not the erotic film. These results indicate that in the laboratory, substantial sexual response can occur without accompanying endocrine or biochemical changes.

Beta-endorphin decline in late luteal phase dysphoric disorder

The beta-endorphin hypothesis of late luteal phase dysphoric disorder (premenstrual syndrome or L2D2) was tested. Twenty-two PMS patients were compared to twenty-two controls. Levels of beta-endorphin, ACTH, FSH, LH, cortisol, prolactin and TRH were measured on the first and twentieth days after menses. PMS subjects exhibited a significantly greater drop in the opiate, beta-endorphin, (p less than .001) than controls. No relationship or significant e was seen with the other hormones/transmitters tested. The symptoms of PMS may be due to noradrenergic rebound following beta-endorphin decline. Symptomatic and pharmacological morphine withdrawal and manic phase of bipolar disorder are discussed as possible models for L2D2.

Neuroendocrine correlates of premenstrual syndrome: changes in the pulsatile pattern of plasma LH

Some studies suggest that patients suffering from premenstrual syndrome (PMS) may be affected by an endogenous opioid dysfunction. Since opioids are the main modulators of the pulsatile LH secretion, we evaluated plasma LH pulsatility in 13 patients with PMS (aged 33.1 yr) and in six asymptomatic control volunteers (aged 31.5 yr), in the late luteal phase (-7, -5 days before their next menses). The patients were prospectively evaluated for two menstrual cycles with the Menstrual Distress Questionnaire; the main symptoms which worsened during the premenstrual period were mood swings and water retention. The pulsatility of plasma LH secretion was studied by collecting blood samples every 10 min for 12 hr, starting at 0800h. The presence of LH pulses was estimated using the program DETECT on the raw data. This program also allows the computation of the instantaneous secretory rate (ISR). Ovulation was ascertained in all the controls and in nine PMS patients by means of urinary LH assay and luteal progesterone (P) determination. The remaining four patients did not ovulate. Both the ovulatory and the anovulatory PMS patients had an increased number of LH pulses/12 hr (10.3 +/- 2.4 and 11.5 +/- 4.4, mean +/- SD, respectively) in comparison with the controls (7.0 +/- 1.3 pulses, p less than 0.01), together with a reduced amplitude and duration. Similar findings were obtained with the ISR computation. Plasma P levels were similar in both the ovulatory patients and controls. The increased frequency and reduced amplitude of LH pulses in the PMS patients most likely reflect a dysfunction of hypothalamic Gn-RH release, possibly linked to a reduction of opioid inhibition.

The premenstrual syndrome--diagnosis and management

Premenstrual syndrome is an extremely common disorder. Prospective documentation of symptoms and their temporal relationship to menstruation establishes the diagnosis of PMS. Because the pathophysiologic mechanisms causing PMS are still undetermined, therapy for PMS is largely empiric. A number of pharmacologic agents may be used to reduce PMS symptomatology, and therapeutic decisions should be tailored to the individual's symptom complex. Many women will be able to lead more productive lives if PMS is properly diagnosed and intelligently treated.

Clinical relevance of endorphins in psychiatry

1. 13 years after the discovery of endorphins, the relationships between these peptides and mental illness remain unclear. 2. Current concepts are controversial and convincing hypotheses have not been elaborated yet. 3. Endorphin measurements in CSF or serum of psychiatric patients did not strongly support that schizophrenia or depression is related to a deficit or an excess of these peptides. Moreover, treatment with endorphins or opiate antagonists did not result in a distinct change of psychiatric symptoms. Recently, research focused on the relationship between endorphins and addictive behavior, but substantial evidence for clinical relevance is still missing. 4. The physiological relevance of many newly discovered endorphins is barely known and several subtypes of the opiate receptor have been found. Thus, it will still require a substantial effort in basic and clinical studies before, if at all, endorphins turn out to be helpful in the treatment of mental illness.