Premenstrual Changes: Impaired Hormonal Homeostasis

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.

Role of estrogen in the aetiology and treatment of mood disorders

Worldwide, the prevalence of depression in women is significantly greater than in men. Available data suggest that estrogen, or its absence, is strongly implicated in the regulation of mood and behaviour, as well as in the pathobiology of mood disorders. The multiple effects of estrogens and their complex interactions with the CNS and endocrine system have been well documented, although the specific, multifaceted role of estrogen in each dysphoric state has yet to be elucidated. Several facts suggest that estrogen plays a vital role in the precipitation and course of mood disorders in women. Gender differences in the prevalence of depression first appear after menarche, continue through reproductive age, and dissipate after perimenopause. Periods of hormonal fluctuations or estrogen instability (i.e. premenstrually, postpartum, perimenopausally) have been associated with increased vulnerability to depression among susceptible women. It is plausible that the phenotype of these depressions is distinguishable from those that are not associated with reproductive events or that occur in men. Based on current knowledge, estrogen treatment for affective disorders may be efficacious in two situations: (i) to stabilise and restore disrupted homeostasis - as occurs in premenstrual, postpartum or perimenopausal conditions; and (ii) to act as a psychomodulator during periods of decreased estrogen levels and increased vulnerability to dysphoric mood, as occurs in postmenopausal women. There is growing evidence suggesting that estrogen may be efficacious as a sole antidepressant for depressed perimenopausal women. It is still unclear whether estrogen is efficacious as an adjunct to selective serotonin reuptake inhibitors or as one of the paradigms to manage treatment-resistance depression in menopausal women, but such efficacy is plausible.

Differences in cortisol, a stress hormone, in women with turmoil-type premenstrual symptoms

BACKGROUND

A significant number of American women of childbearing age are troubled by premenstrual symptoms, but the underlying cause is not understood, resulting in inadequate therapy.

OBJECTIVES

To use basal levels of cortisol to differentiate women with low symptom (LS) patterns of turmoil-type premenstrual symptoms from women with premenstrual symptom (PMS) patterns and from women with premenstrual magnification (PMM) patterns of turmoil-type premenstrual symptoms.

METHOD

Symptom and cortisol patterns of women were monitored for three consecutive menstrual cycles. Three distinct groups of women were identified based on symptom patterns and types.

RESULTS

Significant differences in symptom severity among groups were observed during the follicular (F = 203; df= 2, 24; p < .0001) and luteal phases (F= 51.3; df= 2, 24; p< .0001) of the cycle. There were no statistically significant differences in cortisol among groups for the follicular phase, but there were during the luteal phase (F= 4.0; df= 2, 24; p= .03).

CONCLUSIONS

Altered regulation of the stress axis may be involved in mediating turmoil-type PMS.

A clinical review of the adaptive role of vasopressin in migraine

Vasopressin is a naturally available neuropeptide that subserves important vasomotor, antinociceptive, behavior control, fluid and electrolyte balance, platelet aggregation and blood coagulation functions. This review focuses on the clinical phenomena of migraine that are likely to influence vasopressin bioavailability or efficacy as well as the modulating influence of vasopressin itself. As part of a complex homeostatic adjustment to stress and pain, the intricacies of vasopressin metabolism may have particular relevance to the pathophysiology of migraine.

Lack of ovarian steroid hormone regulation of norepinephrine transporter mRNA expression in the non-human primate locus coeruleus

Decreases in ovarian steroids can negatively affect mood, and drugs which block the norepinephrine transporter (NET) or the serotonin transporter (SERT) alleviate depression. However, the respective contribution of the noradrenergic and serotonergic systems may vary depending upon the etiology of the depression. We previously demonstrated that E and P alter gene expression for tryptophan hydroxylase (TPH) and for the serotonin reuptake transporter (SERT) in raphe neurons of the rhesus monkey. In this study, we questioned whether the noradrenergic system contributes to depression related to the reproductive function in women, using a non-human primate model of the menstrual cycle. The effect of estrogen (E) or E plus progesterone (P) on the expression of the NET gene in the locus coeruleus (LC) was examined with in situ hybridization for NET mRNA. In addition, we questioned whether the neurons of the LC contain nuclear E or P receptors (ER/PR). Hence, immunocytochemistry for ER and PR were performed on adjacent sections. Treatment groups consisted of monkeys (n = 4 per treatment) which were ovariectomized/hysterectomized (spayed), E-treated (28 days) and E+P-treated (14 days E, +14 days E+P). Expression of mRNA for NET was unchanged at any level of the LC due to steroid treatment (p > .05). Neither ER nor PR were detected in the LC of any treatment group. Therefore, E and P in a treatment paradigm which mimics the menstrual cycle do not directly regulate NET mRNA expression in the non-human primate LC. In addition, the noradrenergic neurons of the primate LC lack nuclear receptors for ovarian steroids. These data suggest that the noradrenergic system may not contribute significantly to depression related to changes in ovarian hormones.

Premenstrual exacerbation of symptoms in multiple sclerosis is attenuated by treatment with weak electromagnetic fields

It has been suspected that hormonal factors contribute to the etiology and pathogenesis of multiple sclerosis (MS). A direct relationship between MS and endocrine functions is suggested by changes in disease activity during the phases of the menstrual cycle. A subset of women with MS experience premenstrual worsening of symptoms which improve dramatically with the onset of menstruation. The biological mechanisms underlying these changes in disease activity are unexplained but may be related to cyclical fluctuations in gonadal sex steroid hormones, abrupt changes in the activity of the endogenous opioid peptides and fluctuations in plasma melatonin levels which affect neuronal excitability and immune functions. Extracerebral application of weak electromagnetic fields (EMFs) in the picotesla range intensity has been reported efficacious in the treatment of MS with patients experiencing sustained improvement in motor, sensory, autonomic, affective and cognitive functions. The present report concerns two women with chronic progressive stage MS who experienced, coincident with increasing functional disability, regular worsening of their symptoms beginning about a week before menstruation and abating with the onset of menstruation. These symptoms resolved two months after the initiation of treatment with EMFs. The report supports the association between the endocrine system and MS and indicates that brief, extracranial applications of these magnetic fields modifies the activity of neuroendocrine systems which precipitate worsening of MS symptoms premenstrually.

Social pathways to premenstrual symptoms

The purpose of this study was to explore feminine and menstrual socialization, expectations about experiencing symptoms, and the stressful nature of women's lives among women with three perimenstrual symptom patterns. Social learning and stress theory provided a theoretical framework for understanding why some menstruating women experience premenstrual syndrome or premenstrual magnification symptom patterns. Data about socialization, stressful life context, expectations about symptoms, depressed mood, and other health-related and demographic indicators were obtained from an interview. Subsequent daily recordings in a health diary for two or more menstrual cycles provided data with which to classify women's symptoms across the menstrual cycle as a low severity symptom (LS, n = 73), premenstrual syndrome (PMS, n = 36), or premenstrual magnification (PMM, n = 62) pattern. Stepwise discriminant function analysis demonstrated that stressful life context, menstrual socialization, and expectations about symptoms related to menstruation differentiated women with an LS from those with a PMS or PMM symptom pattern. In addition, depressed mood differentiated the three groups.

Menstrual migraine is not pathogenetically related to premenstrual syndrome

Facchinetti and colleagues present epidemiological evidence regarding comorbidity between menstrual migraine and premenstrual syndrome, and suggest that premenstural symptoms should be incorporated in the diagnostic criteria for menstrual migraine (1). The crux of the matter, however, should be the concern regarding the nature or biological significance of the common neuroendocrine link of transient and cyclic failure of endogenous opioid activity in both premenstrual syndrome and menstrual migraine patients. Is this a primary event of pathogenetic importance (which would merit inclusion in the definition) or the concomitant side effect of a carefully orchestrated adaptive mechanism?

Premenstrual experiences: the four profiles and factorial patterns

Premenstrual experiences were studied in 112 non-complaining women using the Premenstrual Assessment Forms I (for positive experiences), II (for distressing experiences) and the bi-directional Visual Analog Scale. Overall, 27% of women reported no or minimal changes, 20% reported predominantly negative experiences, and 18% predominantly positive feelings. However, the commonest experience was a mixed picture with coexisting positive and negative feelings in 35% of the subjects. Severe premenstrual changes were noted in only nine (8%) of the women. None had a late luteal phase dysphoric disorder. The 26 items of the Premenstrual Assessment Forms I and II were factor analyzed by the principal components method using a varimax rotation. Four factors were derived. Factor I had 12 items indicating negative experiences. Factor II had seven items indicating positive feelings. The other two factors have vegetative features (like sleep and bowel changes) and sexual feelings. The findings also indicated that research needs to be directed towards understanding the mixed group of symptoms rather than the excessive emphasis on negative feelings.

Non-migraine headache across the menstrual cycle in women with and without premenstrual syndrome

Fluctuation of estrogen levels across the menstrual cycle influences migraine headache. In this study, 53 women documented prospectively the incidence and severity of headache daily for an average of three menstrual cycles. Seven of the women met the criteria established by the International Headache Society for migraine with or without aura, while the remaining 46 women failed to do so. Chi-square analysis revealed that, overall, the incidence of non-migraine headache was dependent on day of the cycle (chi 2 [1,66] = 247.7, p < 0.001), with more headaches occurring during the perimenstrual phase. The 46 women without migraine were further classified according to NIMH criteria into PMS (n = 26) and non-PMS groups (n = 20). An association between headache and menstrual cycle phase was noted for both groups (p < 0.001), although the incidence of severe headache was greater for the PMS women, during both the perimenstrual and intermenstrual phases. Both groups experienced an increase in severe headaches during the perimenstrual phase. The PMS women peaked on the day prior to menstruation, while the non-PMS women peaked on the first day of menstruation. There did not appear to be an overall difference in the reporting of mild headache across the cycle between women with or without PMS.(ABSTRACT TRUNCATED AT 250 WORDS)

Retrospective assessment of premenstrual changes in Icelandic women

The purpose of this study was to increase our knowledge of the condition of Icelandic women aged 29 to 40 years during the premenstrual phase of the menstrual cycle. Premenstrual symptoms were measured by a retrospective instrument adapted from Halbreich and colleagues' Premenstrual Assessment Form. Our findings showed that Icelandic women experience premenstrual changes as do their peers in other countries. The most common symptoms were bloating, mood swings, irritability, abdominal discomfort-pain, and intolerance-impatience. Women who were symptomatic in the week before menses tended to manifest more symptoms at other times as well. In general, women responded to their symptoms by taking some time to relax, take pain medication, or seek support. Women experiencing more severe symptoms were more likely to seek support from a partner, relative, or friend. More than 40% of the sample reported that they perceived the symptoms as having negative effects on their relationships with their partners and children, and those experiencing more severe symptoms were more likely to report these perceptions.

Symptom patterns in women with premenstrual syndrome complaints: a prospective assessment using a marker for ovulation and screening criteria for adequate ovarian function

This study examined the symtom patterns of women seeking help for Premenstrual Syndrome (PMS) complaints. Seven women who were less than 35 yrs, within 10% of ideal body weight and who had experienced a full-term pregnancy, completed a daily health diary during an ovulatory menstrual cycle. In the luteal phase, symptom summary scores of the PMS group increased (P less than 0.05) and were markedly higher (P less than 0.5) from baseline acyclic scores of four ovulatory women who denied menstrual-related distress. To examine severity changes in individual symptoms, a total of 399 cases representing 57 symptoms from the seven 45-day diaries were evaluated for menstrual cycle entrainment. Of the 246 symptoms that met the criteria for a cycle phase change (62%), the classic PMS pattern of low/high severity was the most common (40%). Seven different subtypes of the PMS pattern were identified; four of these subtypes demonstrated a severity score elevation at ovulation as well as during the premenstruum. For individual women, the majority of symptoms (65%) displayed only two pattern types, suggesting a common rhythmic entrainment of symptom intensity.