Fluoxetine in the treatment of premenstrual dysphoria. Canadian Fluoxetine/Premenstrual Dysphoria Collaborative Study Group

[Premenstrual syndrome and premenstrual dysphoric disorder-Overview on pathophysiology, diagnostics and treatment]

Premenstrual syndrome and premenstrual dysphoric disorder become episodically manifest during the second half of the female menstrual cycle and are characterized by psychological and physical symptoms causing relevant functional and social impairments. Mood swings, depression and dysphoria are associated depressive symptoms. Therefore, affective disorders should be considered as a differential diagnosis. Of women in reproductive age 3-8% suffer from premenstrual syndrome and 2% of women are affected by premenstrual dysphoric disorder. Genetic and sociobiographical risk factors are discussed. Furthermore, genetic polymorphisms of specific hormone receptors are considered to be genetic risk factors. From a pathophysiological perspective premenstrual syndrome and premenstrual dysphoric disorder are caused by a complex interaction between cyclic changes of ovarian steroids and central neurotransmitters. An imbalance of estrogen and progesterone in the luteal phase is believed to cause the symptoms. Therefore, the first treatment approach consists of regulation of the menstrual cycle or luteal support with progesterone or synthetic progestins even if their effectiveness has not yet been proven in randomized controlled studies and meta-analyses. The administration of combined oral contraceptives is also an option. Especially treatment with selective serotonin reuptake inhibitors (SSRI) represent an evidence-based approach. In severe cases the administration of gonadotropin releasing hormone (GnRH) agonists with add back treatment can also be considered. In the field of affective disorders premenstrual syndromes represent clinically relevant differential diagnoses and comorbidities, which confront the treating physician with particular clinical challenges. Therefore, this literature review gives the readership a clinical orientation for dealing with these disorders.

Management of Premenstrual Dysphoric Disorder: A Scoping Review

Premenstrual dysphoric disorder (PMDD) and premenstrual syndrome (PMS) refer to physical, cognitive, or affective symptoms that arise in the late luteal phase and remit with menses. The present work is a clinically focused scoping review of the last twenty years of research on treatment for these disorders. A search of key terms using the PubMed/Medline, the Cochrane Library, Embase, and Web of Science databases was performed, and 194 studies of adult women met initial inclusion criteria for review. Research studies concerning medications, pharmacological and non-pharmacological complementary and alternative medicine treatments, and surgical interventions with the most available evidence were appraised and summarized. The most high-quality evidence can be found for the use of selective serotonin reuptake inhibitors (SSRIs) and combined oral contraceptives (COCs), with gonadotropin releasing hormone (GnRH) agonists and surgical interventions showing efficacy for refractory cases. While there is some evidence of the efficacy of alternative and complementary medicine treatments such as nutraceuticals, acupuncture, and yoga, variability in quality and methods of studies must be taken into account. Reprinted from Int J Womens Health 2022; 14:1783-1801, with permission from Dove Medical Press Ltd. Copyright © 2022.

Drug repurposing: A novel strategy to target cancer stem cells and therapeutic resistance

Chemotherapy is an effortless and frequently used approach in cancer therapy. However, in most cases, it can only prolong life expectancy and does not guarantee a complete cure. Furthermore, chemotherapy is associated with severe adverse effects, one of the major complications of effective cancer therapy. In addition, newly published research outputs show that cancer stem cells are involved in cancer disease progression, drug resistance, metastasis, and recurrence and that they are functional in the trans-differentiation capacity of cancer stem cells to cancer cells in response to treatments. Novel strategies are therefore required for better management of cancer therapy. The prime approach would be to synthesize and develop novel drugs that need extensive resources, time, and endurance to be brought into therapeutic use. The subsequent approach would be to screen the anti-cancer activity of available non-cancerous drugs. This concept of repurposing non-cancer drugs as an alternative to current cancer therapy has become popular in recent years because using existing anticancer drugs has several adverse effects. Micronutrients have also been investigated for cancer therapy due to their significant anti-cancer effects with negligible or no side effects and availability in food sources. In this paper, we discuss an ideal hypothesis for screening available non-cancerous drugs with anticancer activity, with a focus on cancer stem cells and their clinical application for cancer treatment. Further, drug repurposing and the combination of micronutrients that can target both cancers and cancer stem cells may result in a better therapeutic approach leading to maximum tumor growth control.

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.

Management of Premenstrual Dysphoric Disorder: A Scoping Review

Premenstrual dysphoric disorder (PMDD) and premenstrual syndrome (PMS) refer to physical, cognitive, or affective symptoms that arise in the late luteal phase and remit with menses. The present work is a clinically focused scoping review of the last twenty years of research on treatment for these disorders. A search of key terms using the PubMed/Medline, the Cochrane Library, Embase, and Web of Science databases was performed, and 194 studies of adult women met initial inclusion criteria for review. Research studies concerning medications, pharmacological and non-pharmacological complementary and alternative medicine treatments, and surgical interventions with the most available evidence were appraised and summarized. The most high-quality evidence can be found for the use of selective serotonin reuptake inhibitors (SSRIs) and combined oral contraceptives (COCs), with gonadotropin releasing hormone (GnRH) agonists and surgical interventions showing efficacy for refractory cases. While there is some evidence of the efficacy of alternative and complementary medicine treatments such as nutraceuticals, acupuncture, and yoga, variability in quality and methods of studies must be taken into account.

Use of hormonal contraceptives and antidepressants and risks of suicidal behavior and accidents among women with premenstrual disorders: a nationwide cohort study

BACKGROUND

Women with premenstrual disorders (PMDs) are at increased risks of suicidal behavior and accidents. However, the effect of PMD first-line treatment on such risks have not been assessed.

METHODS

To study the association between use of hormonal contraceptives or antidepressants and subsequent risks of suicidal behavior and accidents among women with PMDs. We conducted a nationwide register-based cohort study with between- and within-individual analyses in Sweden. All women with a clinical diagnosis/indication of PMDs recorded in the Patient Register and the Prescribed Drug Register during 1987-2011 were included (n = 23 029, age 15-52 years). Information on hormonal contraceptives and antidepressants prescribed for these women was obtained from the Prescribed Drug Register. Events of suicidal behavior (complete suicide and suicide attempt) and accidents were separately identified through the Patient and the Causes of Death Registers. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) of suicidal behavior and accidents after use of hormonal contraceptives or antidepressants were estimated in between-individual and within-individual analyses (i.e., comparing the risk between use and no use in the same individual) using Poisson regression.

RESULTS

Women with PMDs were followed for a median of 6.2 years. Compared to no use of hormonal contraceptives, use of hormonal contraceptives was associated with a lower risk of suicidal behavior in both between-individual (IRR 0.76, 0.43-1.34) and within-individual analyses (IRR 0.65, 0.51-0.83). These risk reductions were primarily restricted to combined products (IRR 0.18, 0.07-0.47 and 0.19, 0.08-0.42 in between- and within-individual analyses) and observed among women with/without psychiatric comorbidities (p for interaction 0.830 and 0.043 in between- and within-individual analyses). Yet, the use of hormonal contraceptives was not consistently associated with risk of accidents between between-individual (IRR 1.13, 1.01-1.27) and within-individual analyses (IRR 1.01, 0.92-1.11). Use of antidepressants was associated with a higher risk of suicidal behavior and accidents in both between- and within-individual analyses.

CONCLUSIONS

Our findings suggest that use of hormonal contraceptives, particularly combined products, is associated with reduced rates of suicidal behaviors, but not accidents, among women with PMDs. The estimates for antidepressants may be biased by indication.

Drug Repurposing for Influenza Virus Polymerase Acidic (PA) Endonuclease Inhibitor

Drug repurposing can quickly and effectively identify novel drug repurposing opportunities. The PA endonuclease catalytic site has recently become regarded as an attractive target for the screening of anti-influenza drugs. PA N-terminal (PAN) inhibitor can inhibit the entire PA endonuclease activity. In this study, we screened the effectivity of PAN inhibitors from the FDA database through in silico methods and in vitro experiments. PAN and mutant PAN-I38T were chosen as virtual screening targets for overcoming drug resistance. Gel-based PA endonuclease analysis determined that the drug lifitegrast can effectively inhibit PAN and PAN-I38T, when the IC50 is 32.82 ± 1.34 μM and 26.81 ± 1.2 μM, respectively. Molecular docking calculation showed that lifitegrast interacted with the residues around PA or PA-I38 T's active site, occupying the catalytic site pocket. Both PAN/PAN-I38T and lifitegrast can acquire good equilibrium in 100 ns molecular dynamic simulation. Because of these properties, lifitegrast, which can effectively inhibit PA endonuclease activity, was screened through in silico and in vitro research. This new research will be of significance in developing more effective and selective drugs for anti-influenza therapy.

Clinical indications of premenstrual disorders and subsequent risk of injury: a population-based cohort study in Sweden

BACKGROUND

Premenstrual disorders, including premenstrual syndrome and premenstrual dysphoric disorder, are suggested to be correlated with suicidal behavior and accidents in cross-sectional and retrospective studies. However, prospective data are still lacking.

METHODS

We performed a population-based cohort study including 1,472,379 Swedish women of reproductive age who were followed from 2001 to 2012. Within the cohort, we also performed a sibling analysis where we compared the rates of injury between full sisters. By linking to the Patient and the Prescribed Drug Registers, we identified 18,628 women with any clinical indications for premenstrual disorders in the cohort (population analysis) and 7674 women in the sibling analysis. Any injury, primarily suicidal behavior (completed suicide and suicide attempt) or accidents (e.g., fall and transportation accidents), was identified through the Patient and Causes of Death Registers as the primary outcome. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) of these outcomes among women with premenstrual disorders in both population and sibling analyses using multivariable Cox proportional hazards regression.

RESULTS

During a maximal follow-up of 12 years (mean 9.55 years), we identified 2390 women with premenstrual disorders with any injury; 216 through suicidal behavior and 2191 through accidents. Compared to women without premenstrual disorders, women with premenstrual disorders were at increased risk of any injury (HR 1.37, 95% CI 1.31-1.42), particularly suicidal behavior (HR 2.26, 95% CI 1.97-2.59) and accidents (HR 1.32, 95% CI 1.27-1.38). Such associations somewhat attenuated yet remained significant in the sibling analysis (HRs: 1.31 for any injury, 1.86 for suicidal behavior, and 1.29 for accidents). Additional adjustment for psychiatric comorbidities minimally altered the associations with any injury and accidents in both population and sibling analyses, whereas the association with suicidal behavior was considerably attenuated to non-significance in the sibling analysis. Such risks were particularly strong within 2 years after receiving the diagnosis of premenstrual disorders and were evident among women with premenstrual disorders with and without psychiatric comorbidities.

CONCLUSIONS

Our findings suggest that women with a clinical indication of premenstrual disorders are at increased subsequent risk of injury, particularly accidents within the first 2 years after diagnosis.

Trends in Research Related to Premenstrual Syndrome and Premenstrual Dysphoric Disorder From 1945 to 2018: A Bibliometric Analysis

Background: The global incidence of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) is increasing, with increasing suicide reports. However, the bibliometric analysis of global research on PMS and PMDD is rare. We aimed to evaluate the global scientific output of research on PMS and PMDD and to explore their research hotspots and frontiers from 1945 to 2018 using a bibliometric analysis methodology.

Methods: Articles with research on PMS and PMDD between 1945 and 2018 were retrieved from the Web of Science Core Collection (WoSCC). We used the bibliometric method, CiteSpace V and VOSviewer to analyze publication years, journals, countries, institutions, authors, research hotspots, and trends. We plotted the reference co-citation network, and we used keywords to analyze the research hotspots and trends.

Results: We identified 2,833 publications on PMS and PMDD research from 1945 to 2018, and the annual publication number increased with time, with fluctuations. Psychoneuroendocrinology published the highest number of articles. The USA ranked the highest among the countries with the most publications, and the leading institute was UNIV PENN. Keyword and reference analysis indicated that the menstrual cycle, depression and ovarian hormones were the research hotspots, whereas prevalence, systematic review, anxiety and depression and young women were the research frontiers.

Conclusions: We depicted overall research on PMS and PMDD by a bibliometric analysis methodology. Prevalence and impact in young women, systematic review evaluations of risk factors, and the association of anxiety and depression with menstrual cycle phases are the latest research frontiers that will pioneer the direction of research in the next few years.

Cognitive Behavioral Therapy for Insomnia and Women's Health: Sex as a Biological Variable

Differences in sleep for men and women begin at a very early age, with women reporting poorer sleep and having a higher risk for insomnia compared with men. Women are particularly vulnerable to developing insomnia during times of reproductive hormonal change. Sleep across the woman's lifespan and special treatment considerations for using cognitive behavioral therapy for insomnia (CBT-I) in women will be addressed in this review.

In silico study on identification of novel MALT1 allosteric inhibitors

Mucosa-associated lymphoid tissue lymphoma translocation protein 1 (MALT1), which plays a crucial role in the nuclear factor-kappa B (NF-κB) activation signaling pathway as a paracaspase, is a new target for immunomodulatory and antitumor drugs. Here, novel inhibitors that target MALT1 allosteric sites were identified by virtual screening FDA-approved drug databases. Paliperidone, a compound that binds to the allosteric site of MALT1, is investigated. An in vitro study found that the proteolytic activity of MALT1 substrate cleavage was blocked by paliperidone. Meanwhile, the MALT1 proteolytic activity was reversible, as demonstrated by the partial recovery of the MALT1 substrate cleavage following compound wash out. The docking analysis of the interaction of MALT1 and paliperidone suggested that two hydrogen bonds formed in the allosteric pocket of MALT1. MALT1 and paliperidone achieved a good equilibrium, as demonstrated by 100 ns molecular dynamic (MD) simulations conducted with the program Gromacs. However, the catalytically active site of the MALT1 complex with paliperidone remained in an inactive conformation. Thus, paliperidone, a noncompetitive and allosteric inhibitor, was screened through in silico and in vitro methods. This study will be of significance for the development of effective and selective drugs that can treat MALT1-driven cancer or autoimmune diseases.

Paliperidone was screened as an effective and selective drug that can treat MALT1-driven cancer or autoimmune diseases.

Fluoxetine exposure in adolescent and adult female mice decreases cocaine and sucrose preference later in life

BACKGROUND

Preclinical evidence from male subjects indicates that exposure to psychotropic medications, during early development, results in long-lasting altered responses to reward-related stimuli. However, it is not known if exposure to the antidepressant fluoxetine, in female subjects specifically, changes sensitivity to natural and drug rewards, later in life.

AIMS

The aim of this work was to investigate if exposure to fluoxetine mediates enduring changes in sensitivity to the rewarding properties of cocaine and sucrose, using female mice as a model system.

METHODS

We exposed C57BL/6 female mice to fluoxetine (250 mg/L in their drinking water) for 15 consecutive days, either during adolescence (postnatal day 35-49) or adulthood (postnatal day 70-84). Twenty-one days later, mice were examined on their behavioral reactivity to cocaine (0, 2.5, 5, 7.5 mg/kg) using the conditioned place preference paradigm, or assessed on the two-bottle sucrose (1%) test.

RESULTS

We found that regardless of age of antidepressant exposure, female mice pre-exposed to fluoxetine displayed reliable conditioning to the cocaine-paired compartment. However, when compared to respective age-matched controls, antidepressant pre-exposure decreased the magnitude of conditioning at the 5 and 7.5 mg/kg cocaine doses. Furthermore, fluoxetine pre-exposure reduced sucrose preference without altering total liquid intake.

CONCLUSIONS

The data suggest that pre-exposure to fluoxetine, during adolescence or adulthood, results in a prolonged decrease in sensitivity to the rewarding properties of both natural and drug rewards in female C57BL/6 mice.

Treatment of Premenstrual Breakthrough of Depression With Adjunctive Oral Contraceptive Pills Compared With Placebo

PURPOSE/BACKGROUND

Two-thirds of women with depressive disorders report reemergence of depression premenstrually, or premenstrual exacerbation (PME), despite effective treatment of the underlying mood disorder during the remainder of the cycle. There is a paucity of studies that rigorously assess treatments targeting PME. Open-label data suggest that augmentation of antidepressants with the oral contraceptive pill (OCP) drospirenone and ethinyl estradiol (DRSP/EE) improves depressive symptoms that break through treatment premenstrually. We now report results of a randomized placebo-controlled OCP augmentation trial.

METHODS

Women with unipolar depressive disorders in remission on stable antidepressant doses with a 30% increase in Montgomery-Åsberg Depression Rating Scale (MADRS) scores from the follicular to luteal phase were randomized to double-blind augmentation of antidepressant with either DRSP/EE or placebo for 2 months. The MADRS and Daily Record of Severity of Problems (DRSP) measures were anchored to the menstrual cycle phase.

FINDINGS/RESULTS

Of 32 women randomized, 25 (n = 12 DRSP/EE, n = 13 placebo) completed the trial. Premenstrual MADRS scores declined by a median of 43.6% and 38.9% (P = 0.59), and premenstrual DRSP scores declined by a median of 23.5% and 20.9% (P = 0.62) in the DRSP/EE and placebo groups, respectively. There was a trend toward greater improvement in premenstrual DRSP scores for women with fewer lifetime depressive episodes (r = -0.40, P = 0.06).

IMPLICATIONS/CONCLUSIONS

Findings from this small randomized trial suggest that OCP augmentation of antidepressants may not be effective for treating premenstrual breakthrough of depression. Future studies should target women established to have hormonal sensitivity prior to antidepressant therapy and those with fewer lifetime depressive episodes.

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 Guide to Medications Inducing Salivary Gland Dysfunction, Xerostomia, and Subjective Sialorrhea: A Systematic Review Sponsored by the World Workshop on Oral Medicine VI

BACKGROUND

Medication-induced salivary gland dysfunction (MISGD), xerostomia (sensation of oral dryness), and subjective sialorrhea cause significant morbidity and impair quality of life. However, no evidence-based lists of the medications that cause these disorders exist.

OBJECTIVE

Our objective was to compile a list of medications affecting salivary gland function and inducing xerostomia or subjective sialorrhea.

DATA SOURCES

Electronic databases were searched for relevant articles published until June 2013. Of 3867 screened records, 269 had an acceptable degree of relevance, quality of methodology, and strength of evidence. We found 56 chemical substances with a higher level of evidence and 50 with a moderate level of evidence of causing the above-mentioned disorders. At the first level of the Anatomical Therapeutic Chemical (ATC) classification system, 9 of 14 anatomical groups were represented, mainly the alimentary, cardiovascular, genitourinary, nervous, and respiratory systems. Management strategies include substitution or discontinuation of medications whenever possible, oral or systemic therapy with sialogogues, administration of saliva substitutes, and use of electro-stimulating devices.

LIMITATIONS

While xerostomia was a commonly reported outcome, objectively measured salivary flow rate was rarely reported. Moreover, xerostomia was mostly assessed as an adverse effect rather than the primary outcome of medication use. This study may not include some medications that could cause xerostomia when administered in conjunction with others or for which xerostomia as an adverse reaction has not been reported in the literature or was not detected in our search.

CONCLUSIONS

We compiled a comprehensive list of medications with documented effects on salivary gland function or symptoms that may assist practitioners in assessing patients who complain of dry mouth while taking medications. The list may also prove useful in helping practitioners anticipate adverse effects and consider alternative medications.

Daily symptom ratings for studying premenstrual dysphoric disorder: A review

BACKGROUND

To review how daily symptom ratings have been used in research into premenstrual dysphoric disorder (PMDD), and to discuss opportunities for the future.

METHODS

PsycINFO and Medline were systematically searched, resulting in the inclusion of 75 studies in which (1) participants met the diagnostic criteria for late luteal phase dysphoric disorder (LLPDD) or PMDD and (2) diaries were used to study LLPDD/PMDD.

RESULTS

To date, diaries have been used to gain insight into the aetiology and phenomenology of PMDD, to examine associated biological factors, and to assess treatment efficacy. We found low consistency among the diaries used, and often only part of the menstrual cycle was analysed instead of the whole menstrual cycle. We also observed that there was substantial variability in diagnostic procedures and criteria.

LIMITATIONS

This review excluded diary studies conducted in women with premenstrual syndrome, women seeking help for premenstrual complaints without a clear diagnosis, and women without premenstrual complaints.

CONCLUSIONS

Prospective daily ratings of symptoms and related variables provide a valuable and important tool in the study of PMDD. This paper addresses some options for improving the use of diaries and proposes the use of experience sampling and ecological momentary assessment to investigate within-person variability in symptoms in more detail.

Beta-Arrestin1 Levels in Mononuclear Leukocytes Support Depression Scores for Women with Premenstrual Dysphoric Disorder

Depression is very common in reproductive women particularly with premenstrual dysphoric disorder (PMDD), which is a severe form of premenstrual syndrome (PMS). Beta-arrestins were previously implicated in the pathophysiology, diagnosis and treatment for mood disorders. This study examined whether a measurement for beta-arrestin1 levels in peripheral blood mononuclear leukocytes (PBMC), could aid to distinguish between PMDD and PMS. Study participants (n = 25) were non-pregnant women between 18-42 years of age with the symptoms of PMS/PMDD, but not taking any antidepressants/therapy and at the luteal phase of menstruation. The levels of beta-arrestin1 protein in the PBMCs were determined by ELISA using human beta-arrestin1 kit. The beta-arrestin1 levels were compared with the Hamilton Depression Rating Scale scores among these women. The magnitude of the different parameters for Axis 1 mental disorders were significantly higher and beta arrestin1 protein levels in PBMCs were significantly lower in women with PMDD as compared to PMS women. The reduction in beta arrestin1 protein levels was significantly correlated with the severity of depressive symptoms. Beta-arrestin1 measurements in women may potentially serve for biochemical diagnostic purposes for PMDD and might be useful as evidence-based support for questionnaires.

Fluoxetine elevates allopregnanolone in female rat brain but inhibits a steroid microsomal dehydrogenase rather than activating an aldo-keto reductase

Background and Purpose

Fluoxetine, a selective serotonin reuptake inhibitor, elevates brain concentrations of the neuroactive progesterone metabolite allopregnanolone, an effect suggested to underlie its use in the treatment of premenstrual dysphoria. One report showed fluoxetine to activate the aldo-keto reductase (AKR) component of 3α-hydroxysteroid dehydrogenase (3α-HSD), which catalyses production of allopregnanolone from 5α-dihydroprogesterone. However, this action was not observed by others. The present study sought to clarify the site of action for fluoxetine in elevating brain allopregnanolone.

Experimental Approach

Adult male rats and female rats in dioestrus were treated with fluoxetine and their brains assayed for allopregnanolone and its precursors, progesterone and 5α-dihydroprogesterone. Subcellular fractions of rat brain were also used to investigate the actions of fluoxetine on 3α-HSD activity in both the reductive direction, producing allopregnanolone from 5α-dihydroprogesterone, and the reverse oxidative direction. Fluoxetine was also tested on these recombinant enzyme activities expressed in HEK cells.

Key Results

Short-term treatment with fluoxetine increased brain allopregnanolone concentrations in female, but not male, rats. Enzyme assays on native rat brain fractions and on activities expressed in HEK cells showed fluoxetine did not affect the AKR producing allopregnanolone from 5α-dihydroprogesterone but did inhibit the microsomal dehydrogenase oxidizing allopregnanolone to 5α-dihydroprogesterone.

Conclusions and Implications

Fluoxetine elevated allopregnanolone in female rat brain by inhibiting its oxidation to 5α-dihydroprogesterone by a microsomal dehydrogenase. This is a novel site of action for fluoxetine, with implications for the development of new agents and/or dosing regimens to raise brain allopregnanolone.

Treatment of premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) is comprised of a cluster of affective, behavioral and somatic symptoms recurring monthly during the luteal phase of the menstrual cycle. The disorder affects 3-8% of menstruating women and represents the more severe and disabling end of the spectrum of premenstrual disorders, which includes premenstrual syndrome and premenstrual aggravation of underlying affective disorder. Rigorous and specific diagnostic criteria for PMDD were specified in the Diagnostic and Statistical Manual of Mental Disorders IV (1994) and reaffirmed in the Diagnostic and Statistical Manual of Mental Disorders V (2013) and, consequently, there has been a marked increase in well-designed, placebo-controlled studies evaluating treatment modalities. Although the exact pathogenesis of PMDD is still elusive, treatment of PMDD and severe premenstrual syndrome has centered on neuromodulation via serotonin reuptake inhibitor antidepressants, and ovulation suppression utilizing various contraceptive and hormonal preparations. Unlike the approach to the treatment of depression, serotonergic antidepressants need not be given daily, but can be effective when used cyclically, only in the luteal phase or even limited to the duration of the monthly symptoms. Less, well-substantiated alternative treatments, such as calcium supplementation, agnus castus (chasteberry), Hypericum perforatum (St John's wort) and cognitive/behavioral/relaxation therapies, may be useful adjuncts in the treatment of PMDD. This review provides an overview of current information on the treatment of PMDD.

A pilot study to compare fluoxetine, calcium, and placebo in the treatment of premenstrual syndrome

Serotonin reuptake inhibitors and calcium supplements ameliorate symptoms of premenstrual syndrome. A comparison of these agents to placebo may guide treatment selection. The goal of this pilot study was to compare fluoxetine and calcium to placebo.We enrolled 39 women with at least 3 moderate to severe premenstrual symptoms and functional impairment. The trial compared fluoxetine (10 mg twice daily), calcium carbonate (600 mg twice daily), and placebo over the course of 4 menstrual cycles. The Inventory of Depressive Symptomatology, Premenstrual Tension Scale, Clinical Global Impression-Severity and -Improvement scales, and Daily Record of Severity of Problems were used to measure symptoms.Symptom improvement was greatest for the fluoxetine group, although significance was achieved only for the Daily Record of Severity of Problems (β = -0.28; 95% confidence interval, -1.70 to -0.35; P = 0.02) and the Clinical Global Impression-Improvement (β = -1.03; 95% confidence interval= -1.70 to -0.35; P = 0.04). The Cohen d effect sizes for fluoxetine relative to placebo were between 0.80 and 2.08, whereas the effect sizes for calcium were only between 0.10 and 0.44.Fluoxetine had clear therapeutic benefit for premenstrual syndrome, whereas the effect of calcium was much smaller. Results of this pilot do not support the need for a larger study that would compare these compounds.

Luteal phase and symptom-onset dosing of SSRIs/SNRIs in the treatment of premenstrual dysphoria: clinical evidence and rationale

Premenstrual dysphoria (PMD) affects 3-8 % of women in their reproductive years worldwide. This paper summarizes the studies establishing the efficacy of continuous, luteal phase, and symptom-onset dosing of selective serotonin reuptake inhibitors (SSRIs) and dual serotonin and norepinephrine reuptake inhibitors (SNRIs) in treating women with PMD. The evidence indicates that for some women, symptom-onset dosing with escitalopram, fluoxetine, and paroxetine controlled release (CR) is as effective as continuous or luteal phase dosing. The wide range of clinical efficacy of SSRIs/SNRIs suggests that they exert their therapeutic effect through multiple pathways. This paper offers a few alternative mechanisms of action to explain the rapid response to SSRIs/SNRIs in women with PMD.

Missing and Possible Link between Neuroendocrine Factors, Neuropsychiatric Disorders, and Microglia

Endocrine systems have long been suggested to be one of the important factors in neuropsychiatric disorders, while the underlying mechanisms have not been well understood. Traditionally, neuropsychiatric disorders have been mainly considered the consequence of abnormal conditions in neural circuitry. Beyond the neuronal doctrine, microglia, one of the glial cells with inflammatory/immunological functions in the central nervous system (CNS), have recently been suggested to play important roles in neuropsychiatric disorders. However, the crosstalk between neuroendocrine factors, neuropsychiatric disorders, and microglia has been unsolved. Therefore, we herein introduce and discuss a missing and possible link between these three factors; especially highlighting the following hormones; (1) Hypothalamic-Pituitary-Adrenal (HPA) axis-related hormones such as corticotropin-releasing hormone (CRH) and glucocorticoids, (2) sex-related hormones such as estrogen and progesterone, and (3) oxytocin. A growing body of evidence has suggested that these hormones have a direct effect on microglia. We hypothesize that hormone-induced microglial activation and the following microglia-derived mediators may lead to maladaptive neuronal networks including synaptic dysfunctions, causing neuropsychiatric disorders. Future investigations to clarify the correlation between neuroendocrine factors and microglia may contribute to a novel understanding of the pathophysiology of neuropsychiatric disorders.

Sleep and Women's Health

Sex differences in sleep begin at a very early age and women report poorer sleep quality and have higher risk for insomnia than do men. Sleep may be affected by variation in reproductive hormones, stress, depression, aging, life/role transitions, and other factors. The menstrual cycle is associated with changes in circadian rhythms and sleep architecture. Menstruating women (even without significant menstrual-related complaints) often report poorer sleep quality and greater sleep disturbance during the premenstrual week compared to other times of her menstrual cycle. In addition to these sleep disturbances, women with severe premenstrual syndrome often report more disturbing dreams, sleepiness, fatigue, decreased alertness and concentration during the premenstrual phase. Sleep disturbances are also commonly reported during pregnancy and increase in frequency and duration as the pregnancy progresses. The precipitous decline in hormones and unpredictable sleep patterns of the newborn contribute to and/or exacerbate poor sleep and daytime sleepiness during the early postpartum period. Insomnia is also among the most common health complaints that are reported by perimenopausal women. Women are particularly vulnerable to developing insomnia disorder during these times of reproductive hormonal change. In this review, we present a discussion on the most relevant and recent publications on sleep across the woman's lifespan, including changes in sleep related to menstruation, pregnancy, postpartum, and the menopausal transition. Treatment for sleep disturbances and insomnia disorder and special considerations for treating women will also be discussed.

Selective serotonin reuptake inhibitors for premenstrual syndrome

BACKGROUND

Premenstrual syndrome (PMS) is a common cause of physical, psychological and social problems in women of reproductive age. The key characteristic of PMS is the timing of symptoms, which occur only during the two weeks leading up to menstruation (the luteal phase of the menstrual cycle). Selective serotonin reuptake inhibitors (SSRIs) are increasingly used as first line therapy for PMS. SSRIs can be taken either in the luteal phase or else continuously (every day). SSRIs are generally considered to be effective for reducing premenstrual symptoms but they can cause adverse effects.

OBJECTIVES

The objective of this review was to evaluate the effectiveness and safety of SSRIs for treating premenstrual syndrome.

SEARCH METHODS

Electronic searches for relevant randomised controlled trials (RCTs) were undertaken in the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, and CINAHL (February 2013). Where insufficient data were presented in a report, attempts were made to contact the original authors for further details.

SELECTION CRITERIA

Studies were considered in which women with a prospective diagnosis of PMS, PMDD or late luteal phase dysphoric disorder (LPDD) were randomised to receive SSRIs or placebo for the treatment of premenstrual syndrome.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies, assessed eligible studies for risk of bias, and extracted data on premenstrual symptoms and adverse effects. Studies were pooled using random-effects models. Standardised mean differences (SMDs) with 95% confidence intervals (CIs) were calculated for premenstrual symptom scores, using separate analyses for different types of continuous data (that is end scores and change scores). Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for dichotomous outcomes. Analyses were stratified by type of drug administration (luteal or continuous) and by drug dose (low, medium, or high). We calculated the number of women who would need to be taking a moderate dose of SSRI in order to cause one additional adverse event (number needed to harm: NNH). The overall quality of the evidence for the main findings was assessed using the GRADE working group methods.

MAIN RESULTS

Thirty-one RCTs were included in the review. They compared fluoxetine, paroxetine, sertraline, escitalopram and citalopram versus placebo. SSRIs reduced overall self-rated symptoms significantly more effectively than placebo. The effect size was moderate when studies reporting end scores were pooled (for moderate dose SSRIs: SMD -0.65, 95% CI -0.46 to -0.84, nine studies, 1276 women; moderate heterogeneity (I(2) = 58%), low quality evidence). The effect size was small when studies reporting change scores were pooled (for moderate dose SSRIs: SMD -0.36, 95% CI -0.20 to -0.51, four studies, 657 women; low heterogeneity (I(2)=29%), moderate quality evidence).SSRIs were effective for symptom relief whether taken only in the luteal phase or continuously, with no clear evidence of a difference in effectiveness between these modes of administration. However, few studies directly compared luteal and continuous regimens and more evidence is needed on this question.Withdrawals due to adverse effects were significantly more likely to occur in the SSRI group (moderate dose: OR 2.55, 95% CI 1.84 to 3.53, 15 studies, 2447 women; no heterogeneity (I(2) = 0%), moderate quality evidence). The most common side effects associated with a moderate dose of SSRIs were nausea (NNH = 7), asthenia or decreased energy (NNH = 9), somnolence (NNH = 13), fatigue (NNH = 14), decreased libido (NNH = 14) and sweating (NNH = 14). In secondary analyses, SSRIs were effective for treating specific types of symptoms (that is psychological, physical and functional symptoms, and irritability). Adverse effects were dose-related.The overall quality of the evidence was low to moderate, the main weakness in the included studies being poor reporting of methods. Heterogeneity was low or absent for most outcomes, though (as noted above) there was moderate heterogeneity for one of the primary analyses.

AUTHORS' CONCLUSIONS

SSRIs are effective in reducing the symptoms of PMS, whether taken in the luteal phase only or continuously. Adverse effects are relatively frequent, the most common being nausea and asthenia. Adverse effects are dose-dependent.

Premenstrual dysphoric disorder and severe premenstrual syndrome in adolescents

Numerous epidemiologic studies have demonstrated that premenstrual disorders (PMDs) begin during the teenage years. At least 20 % of adolescents experience moderate-to-severe premenstrual symptoms associated with functional impairment. Premenstrual syndrome (PMS) consists of physical and/or psychological premenstrual symptoms that interfere with functioning. Symptoms are triggered by ovulation and resolve within the first few days of menses. The prevalence of premenstrual dysphoric disorder (PMDD), a severe form of PMS accompanied by affective symptoms, is likely equal to or higher than in adults. The diagnosis of a PMD requires a medical and psychological history and physical examination but it is the daily prospective charting of bothersome symptoms for two menstrual cycles that will clearly determine if the symptoms are related to a PMD or to another underlying medical or psychiatric diagnosis. The number and type of symptoms are less important than the timing. Randomized controlled trials of pharmacologic treatments in teens with moderate-to-severe PMS and PMDD have yet to be performed. However, clinical experience suggests that treatments that are effective for adults can be used in adolescents. PMS can be ameliorated by education about the nature of the disorder, improving calcium intake, performing exercise and reducing stress, but to treat severe PMS or PMDD pharmacologic therapy is usually required. Eliminating ovulation with certain hormonal contraceptive formulations or gonadotropin-releasing hormone agonists will be discussed. Serotonergic agonists are a first-line therapy for adults, and some serotonin reuptake inhibitors such as fluoxetine and escitalopram can be administered safely to teens.

Cognitive-behavioral and pharmacological interventions for premenstrual syndrome or premenstrual dysphoric disorder: a meta-analysis

The current meta-analysis investigates the efficacy of psychotherapeutic interventions and psychopharmacotherapy for premenstrual syndrome (PMS) and premenstrual dysphoric disorder. Based on a multiple-phase literature search, controlled trials were selected according to a priori defined inclusion criteria. Data were extracted on the basis of a standardized coding scheme. The standardized weighted mean difference (random effects model) was used as effect size index. Dependent on outcome, 22 included studies obtained small to medium effect sizes for cognitive-behavioral interventions (range: d(+) = 0.24-0.70) and for serotonergic antidepressants (range: d(+) = 0.29-0.58), at post-assessment. Follow-ups were performed only in studies of cognitive-behavioral interventions (range: d(+) = 0.46-0.74). There was no evidence of a publication bias. For both cognitive-behavioral interventions and serotonergic antidepressants, efficacy in treatment of PMS was found to not be satisfactory. Future research should possibly focus more on a combination of both approaches.

Pilot investigation of the circadian plasma melatonin rhythm across the menstrual cycle in a small group of women with premenstrual dysphoric disorder

Women with premenstrual dysphoric disorder (PMDD) experience mood deterioration and altered circadian rhythms during the luteal phase (LP) of their menstrual cycles. Disturbed circadian rhythms may be involved in the development of clinical mood states, though this relationship is not fully characterized in PMDD. We therefore conducted an extensive chronobiological characterization of the melatonin rhythm in a small group of PMDD women and female controls. In this pilot study, participants included five women with PMDD and five age-matched controls with no evidence of menstrual-related mood disorders. Participants underwent two 24-hour laboratory visits, during the follicular phase (FP) and LP of the menstrual cycle, consisting of intensive physiological monitoring under “unmasked”, time-isolation conditions. Measures included visual analogue scale for mood, ovarian hormones, and 24-hour plasma melatonin. Mood significantly (P≤.03) worsened during LP in PMDD compared to FP and controls. Progesterone was significantly (P = .025) increased during LP compared to FP, with no between-group differences. Compared to controls, PMDD women had significantly (P<.05) decreased melatonin at circadian phases spanning the biological night during both menstrual phases and reduced amplitude of its circadian rhythm during LP. PMDD women also had reduced area under the curve of melatonin during LP compared to FP. PMDD women showed affected circadian melatonin rhythms, with reduced nocturnal secretion and amplitude during the symptomatic phase compared to controls. Despite our small sample size, these pilot findings support a role for disturbed circadian rhythms in affective disorders. Possible associations with disrupted serotonergic transmission are proposed.

Psychotropic medications and other non-hormonal treatments for premenstrual disorders

Selective serotonin re-uptake inhibitors have well-established efficacy for severe premenstrual syndrome and premenstrual dysphoric disorder. Efficacy has been reported with both continuous dosing (all cycle) and intermittent or luteal phase dosing (from ovulation to menses). Efficacy may be less with intermittent dosing, particularly for premenstrual physical symptoms. The efficacy of symptom-onset dosing (medication taken only on luteal days when symptoms occur) needs further systematic study. Women going through the menopausal transition may need to adjust their antidepressant dosing regimen due to the change in frequency of menstruation. Anxiolytics, calcium, chasteberry and cognitive-behaviour therapy may also have a role in the treatment of premenstrual symptoms.

Reproductive hormonal treatments for mood disorders in women

There has been a century-long view in medicine that reproductive function in both men and women is intimately involved with mood regulation. The 19th century witnessed a proliferation of medical reports documenting beneficial effects on mood and behavior after medical or surgical manipulations of women's reproductive functíon. More recently, the results of several studies suggest that gonadal steroids do regulate mood in some women. Thus, there is considerable interest in the potential role of reproductive therapies in the management of depressive illness, including both classical and reproductive endocrine-related mood disorders. Future studies need to determine the predictors of response to hormonal therapies compared with traditional antidepressant agents, and to characterize the long-term safety and benefits of these therapies.

Treatment of depression associated with the menstrual cycle: premenstrual dysphoria, postpartum depression, and the perimenopause

Several forms of depression are unique to women because of their apparent association with changes in gonadal hormones, which in turn modulate neuroregulatory systems associated with mood and behavior. This review examines the evaluation and treatment of depression that occurs premenstrually, postpartum, or in the perimenopause on the basis of current literature. The serotonergic antidepressants consistently show efficacy for severe premenstrual syndromes (PMSs) and premenstrual dysphoric disorder (PMDD), and are the first-line treatment for these disorders. The use of antidepressants for postpartum depression is compromised by concerns for effects in the infants of breast-feeding mothers, but increasing evidence suggests the relative safety of the antidepressant medications, and the risk calculation should be made on an individual basis. Estradiol may be effective for postpartum depression and for moderate-to-severe major depression in the perimenopause. In spite of its frequent use, progesterone is not effective for the mood and behavioral symptoms of PMS/PMDD, postpartum depression, or perimenopausal depressive symptoms.

Nocturnal polysomnographic sleep across the menstrual cycle in premenstrual dysphoric disorder

OBJECTIVES

Women with premenstrual dysphoric disorder (PMDD) experience disturbed mood, altered melatonin circadian rhythms, and frequent reports of insomnia during the luteal phase (LP) of their menstrual cycle. In this study we aimed to investigate nocturnal polysomnographic (PSG) sleep across the menstrual cycle in PMDD women and controls.

METHODS

Seven PMDD women who indicated insomnia during LP, and five controls, spent every third night throughout a complete menstrual cycle sleeping in the laboratory.

RESULTS

In PMDD and controls progesterone and core body temperature (BT(core)) were elevated during LP compared to the follicular phase (FP). Stage 2 sleep showed a significant main effect of menstrual phase and was significantly increased during mid-LP compared to early-FP in both groups. Rapid eye movement (REM) sleep for both groups was decreased during early-LP compared to early-FP. Slow wave sleep (SWS) was significantly increased, and melatonin significantly decreased, in PMDD women compared to controls.

CONCLUSIONS

PMDD women who experience insomnia during LP had decreased melatonin secretion and increased SWS compared to controls. The sleep and melatonin findings in PMDD women may be functionally linked. Results also suggest an altered homeostatic regulation of the sleep-wake cycle in PMDD, perhaps implicating melatonin in the homeostatic process of sleep-wake regulation.

Chinese version of Daily Record of Severity of Problems: reliability and validity

AIM

To report a study of the psychometric properties of the Chinese version of the Daily Record of Severity of Problems form.

BACKGROUND

In China, the prevalence of premenstrual syndrome is not confirmed due to lack of prospective daily tools. Daily Record of Severity of Problems was a validated daily symptom chart widely used for the diagnosis of premenstrual syndrome. There is no such an instrument for Chinese women.

METHODS

The convenience sample included 126 female students in a school of nursing from September 2010-March 2011 in China. All of them completed daily ratings for two menstrual cycles, Premenstrual Tension Syndrome Self-Rating scale and Zung Self-Rating Depression scale at the first day of menses in two cycles.

RESULTS

The internal consistency coefficients of reliability for total score and the correlations of each item with the total score in two cycles were all high. The majority of the cycle to cycle test-retest reliability for total scores and the individual items for the two phases of the cycle were high. Factor analysis yielded four factors describing mood, behaviour, pain, and physical symptoms. There were moderate correlations of the total Daily Record of Severity of Problems during the late-luteal phase of both cycles with Premenstrual Tension Syndrome Self-Rating scale and Zung Self-Rating Depression scale.

CONCLUSIONS

The Daily Record of Severity of Problems Chinese version provides reliable and valid measures of premenstrual symptoms in Chinese women. It has satisfactory psychometric properties and is suitable for nursing implication.

When should surgical treatment be considered for premenstrual dysphoric disorder?

Premenstrual mood disorders afflict a substantial number of women of reproductive age. Medical treatments provide excellent symptomatic relief to many women but at times a poor therapeutic response or adverse effects attributable to these therapies lead women to seek alternative solutions. Oophorectomy (with concomitant hysterectomy) followed by low-dose estrogen therapy has been shown to be an effective alternative for such cases of menstrual-cycle-related mood disorder.

Rapid response to fluoxetine in women with premenstrual dysphoric disorder

BACKGROUND

Selective serotonin reuptake inhibitors (SRIs) relieve irritability within days in women with premenstrual dysphoric disorder (PMDD); however, the effects on other affective symptoms in PMDD remain to be demonstrated.

METHODS

We performed hourly ratings in women with PMDD to test the specificity of the therapeutic effects of SRIs and to determine whether the kinetics of these effects differ from those of the symptom offset accompanying menses. Twelve women with PMDD received fluoxetine (20 mg daily) during the luteal phase of the menstrual cycle. Twelve other women with PMDD received no treatment. Outcome measures included a visual analogue scale completed hourly before and after either the start of SRIs or at menses-onset in the untreated women and the premenstrual tension syndrome (PMTS) scale completed daily. Data were analyzed by ANOVA-R.

RESULTS

Hourly VAS scores significantly improved after SRI in irritability as well as sadness, anxiety, and mood swings. Compared with the symptomatic pretreatment baseline, PMTS scores significantly improved on the second day after the start of SRI (p < .01). An identical time course of symptom improvement occurred after both SRI and menses-onset.

CONCLUSION AND DISCUSSION

These data document that the rapid response to SRI was not limited to irritability. The similar kinetics in the remission of PMDD after SRIs and after menses-onset suggest both a phenotype reflecting the relative capacity to rapidly change affective state, and a possible therapeutic mechanism by which SRIs recruit this endogenous capacity to change state, normally expressed around menses-onset in women with PMDD.

Criteria for premenstrual dysphoric disorder: secondary analyses of relevant data sets

CONTEXT

There is substantial information that premenstrual dysphoric disorder (PMDD) is a clinically significant disorder with biological underpinnings that differ from other psychiatric disorders. However, data regarding the symptoms noted in DSM-IV and timing of their expression in the menstrual cycle have had little empirical support.

OBJECTIVE

To provide evidence informing the definitional criteria for PMDD.

DESIGN

Prospective surveys.

SETTING

General community and clinical settings.

PARTICIPANTS

Two cohorts that included a representative sample and a self-identified treatment-seeking cohort. Main Outcome Measure  Daily ratings of perimenstrual symptoms and functioning.

RESULTS

Mood and physical symptoms were most severe and were accompanied by impairment in the 4 days before through the first 2 days of menses for the self-identified group and in the 3 days before through the first 3 days of menses in the community sample. The most problematic symptoms endorsed were those listed in DSM-IV, but depressed mood was less frequent than other affective symptoms. In the combined sample, 4 or more symptoms was the optimal cutoff point for maximizing both sensitivity and specificity when predicting impairment.

CONCLUSIONS

This is informative for DSM-5 in that the most symptomatic period typically includes the few days before through the first 3 days of menses rather than only the premenstrual phase. Further, we validated the salience of PMDD symptoms included in DSM-IV. Although the number of symptoms most associated with distress and impairment differed between the 2 cohorts, results from the combined cohort suggest that 4 symptoms are linked with impairment from PMDD symptoms.

Neuropsychological performance and menstrual cycle: a literature review

Approximately 80% of all women of reproductive age experience psychological and physical changes associated with the premenstrual phase. Cognitive alterations are among the most common complaints. In this context, studies have assessed cognitive performance across the menstrual cycle in healthy women and also in women with premenstrual syndrome (PMS). The main objective of the present study was to review the literature on cognitive function in different phases of the menstrual cycle in women of reproductive age, both healthy and with PMS, in particular premenstrual dysphoric disorder (PMDD). We searched MEDLINE and LILACS databases. A total of 27 studies were selected. The studies used heterogeneous methodologies. Most studies suggested that healthy women show small fluctuations in cognitive performance across the menstrual cycle, with low performance scores in the luteal phase for visuospatial and motor skills, attention and concentration, verbal memory, visual memory, working memory, and reaction time. Among women with PMS or PMDD, low performance scores for visuospatial and motor skills, attention and concentration, verbal memory, working memory, reaction time and impulsivity were also detected in the luteal phase. Symptoms observed in PMS/PMDD patients showed low intensity, but greater when compared with healthy women. Evidence indicates fluctuations in cognitive performance in the different phases of the menstrual cycle in healthy and PMS women, with worse performance for women with PMS/PMDD in the luteal phase. However, methodological limitations prevent us from drawing solid conclusions. Further studies are needed to investigate the impact of these cognitive fluctuations on patients' daily activities.

The premenstrual tension syndrome rating scales: an updated version

BACKGROUND

The Premenstrual Tension Syndrome (PMTS) Rating Scales have been widely used as inclusion criteria and/or outcome measures in clinical trials of treatment of Premenstrual Syndromes (PMS). However, both the PMTS Observer Rating Scale (PMTS-O) and the PMTS Self Rating Scale (PMTS-SR) are outdated. We propose to bring them in line with the DSM-IV criteria for Premenstrual Dysphoric Disorder (PMDD) by updating the PMTS-O and replacing the PMTS-SR with a Multiple Visual Analogue Scale (PMTS-VAS).

METHODS

A convenience sample of 23 Caucasian, English-speaking women in their reproductive years with regular menstrual cycles was recruited. Participants were administered the revised PMTS-O (PMTS-OR) by a trained clinician and then instructed to complete the PMTS-SR and the new PMTS-VAS, both of which were timed. The participants were also asked which of the instruments they preferred.

RESULTS

The PMTS-OR and the new PMTS-VAS were sensitive to the variation in severity of premenstrual symptoms among the study participants. All 3 questionnaires showed very high inter-correlations. The PMTS-VAS took less time to complete, and most women preferred the PMTS-VAS to the original PMTS-SR, especially those with PMDD and severe PMS.

CONCLUSIONS

By making minor modifications to the PMTS-O we have ensured that all criteria for the DSM-IV definition of PMDD are now represented in the PMTS-OR. The new PMTS-VAS mirrors the PMTS-OR but now also captures the severity of self rated symptoms. These scales are simple to complete for both clinicians and clients, and are reliable, valid and sensitive to change.

Myo-inositol in the treatment of premenstrual dysphoric disorder

OBJECTIVE

Premenstrual dysphoric disorder (PMDD) is a mood disorder disrupting social and/or occupational life of affected women. Premenstrual dysphoric disorder etiology is unknown, although a pivotal role is played by the serotoninergic system. Indeed, one of the most effective treatments is selective serotonin reuptake inhibitors. Several studies have proposed a selective serotonin reuptake inhibitor-like role for myo-inositol, likely due to the fact that myo-inositol is the second messenger of serotonin. In the present study, we aimed to investigate the effect of myo-inositol in the treatment of PMDD.

METHODS

We used a two-phase clinical trial approach (phase I: placebo washout; phase II: comparisons between treatment and placebo) and treated PMMD patients with two different myo-inositol formulations: powder or soft gel capsules. We decided to test these two formulations because according to the manufacturer, 0.6 g of myo-inositol in soft gel capsule has a pharmacokinetic equivalent to 2 g of myo-inositol in powder.

RESULTS

Our results showed a significant improvement of three different scales: a reduction in the Daily Symptoms Records scale and an improvement of the Hamilton Depression Rating and Clinical Global Impression-Severity of Illness scales. Results were similar for both formulations.

CONCLUSIONS

In the present study, by using a new pharmaceutical formulation, we were able to clearly prove the efficacy of myo-inositol in PMDD.

Menstrual effects on mood symptoms in treated women with bipolar disorder

OBJECTIVES

Reports suggest women with bipolar disorder (BD) have high rates of perimenstrual mood worsening. In this prospective study, the authors compared healthy controls and depressed and euthymic BD patients on medications on mood levels, psychosocial function, and physical symptoms in the late luteal versus the early follicular phase.

METHODS

At baseline, the lifetime diagnosis of bipolar I disorder or bipolar II disorder, current mood episode, and absence of premenstrual dysphoric disorder in controls were confirmed with the Structured Clinical Interview for DSM-IV Disorders. Subjects were assessed across three menstrual cycles during the late luteal and early follicular phases. Clinicians administered the Structured Interview Guide for the Hamilton Depression Rating Scale and the Mania Rating Scale to assess levels of depression and hypomania/mania, respectively. Subjects completed self-report ratings on psychosocial function and perceived stress and tracked daily mood and physical symptoms on the National Institute of Mental Health LifeChart and the Daily Rating Form. Ovulation was verified objectively with mid-cycle luteinizing hormone urine dipsticks and serum progesterone levels.

RESULTS

The sample characteristics were similar among the three patient groups of healthy controls (n = 10), BD-euthymic (n = 6), and BD-depressed (n = 5). The two-way analysis of variance indicated a significant difference among the diagnostic groups on depression scores, psychosocial functioning, and levels of perceived stress. There was no significant difference for menstrual phase or the interaction of menstrual phase by diagnostic group.

CONCLUSIONS

Mood symptom level, psychosocial functioning, perceived stress, and physical discomfort were unrelated to menstrual phase in patients with BD. Appropriate maintenance treatment may prevent menstrual related mood symptoms. Use of an objective marker of ovulation is critical for research involving menstrual related outcomes.

Neurosteroids as neuromodulators in the treatment of anxiety disorders

Anxiety disorders are the most common psychiatric disorders. They are frequently treated with benzodiazepines, which are fast acting highly effective anxiolytic agents. However, their long-term use is impaired by tolerance development and abuse liability. In contrast, antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are considered as first-line treatment but have a slow onset of action. Neurosteroids are powerful allosteric modulators of GABA(A) and glutamate receptors. However, they also modulate sigma receptors and they are modulated themselves by SSRIs. Both pre-clinical and clinical studies have shown that neurosteroid homeostasis is altered in depression and anxiety disorders and antidepressants may act in part through restoring neurosteroid disbalance. Moreover, novel drugs interfering with neurosteroidogenesis such as ligands of the translocator protein (18 kDa) may represent an attractive pharmacological option for novel anxiolytics which lack the unwarranted side effects of benzodiazepines. Thus, neurosteroids are important endogenous neuromodulators for the physiology and pathophysiology of anxiety and they may constitute a novel therapeutic approach in the treatment of these disorders.

Prefrontal brain asymmetry and pre-menstrual dysphoric disorder symptomatology

BACKGROUND

Pre-menstrual dysphoric disorder (PMDD), a dysphoric form of pre-menstrual syndrome, is included as a diagnosis for further study in the DSM-IV-TR (APA, 2000). The present study investigated whether a marker of risk for major depressive disorder (MDD), prefrontal brain asymmetry, also characterizes women with PMDD.

METHODS

In a sample of 25 college women with PMDD symptomatology and 25 matched controls, resting frontal electroencephalographic (EEG) activity was assessed on four occasions within a two-week span.

RESULTS

Across several frontal sites women with PMDD had relatively less left than right prefrontal brain activity, consistent with a diathesis-stress model for menstrual-related dysphoria.

CONCLUSIONS

The findings suggest an overlap in the risk profile for MDD and PMDD.

Safety, efficacy, actions, and patient acceptability of drospirenone/ethinyl estradiol contraceptive pills in the treatment of premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) is estimated to affect 3%–8% of reproductive age women. Multiple therapeutic modalities have been evaluated with varying efficacy for the associated somatic and mood symptoms. The majority of older studies had shown that oral contraceptive pills (OCs) were most effective for the physical symptoms. However, newer OCs containing a novel progestin, drospirenone, have shown promise in alleviating both the somatic and affective/behavioral symptoms. This progestin, which is a derivative of spironolactone, has both antimineralocorticoid and antiandrogenic activity. A 24/4 formulation containing 20 μg of ethinyl estradiol has been found effective in randomized double-blind placebo-controlled trials utilizing established scales documenting symptoms associated with PMDD. Multiple studies have shown that drospirenone-containing OCs are safe without evidence of clinically adverse effects on carbohydrate metabolism, lipids, blood pressure, weight, serum potassium or increased thrombotic events compared to other low dose OCs. In addition, significant improvements have been demonstrated in acne, hirsutism, and fluid retention symptoms. Several open label studies demonstrated good patient compliance and reported satisfaction with the method. Because of the significant placebo effect demonstrated in the blinded placebo-controlled trials, additional large randomized placebo-controlled trials are needed to confirm the efficacy of the drospirenone OCs in the treatment of PMDD. However, this OC formulation appears to be a promising therapeutic modality.