Does a disconnect occur between research and practice for premenstrual dysphoric disorder (PMDD) diagnostic procedures?

Practical diagnosis and treatment of premenstrual syndrome and premenstrual dysphoric disorder by psychiatrists and obstetricians/gynecologists in Japan

Aim

To investigate and compare the diagnoses and treatment of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) from the perspectives of psychiatrists and obstetricians/gynecologists (OB/GYNs) in Japan.

Methods

Between December 2021 and February 2022, a web-based survey was conducted among the members of the Japanese Association of Neuro-Psychiatric Clinics. Data from 262 psychiatrists who responded to the aforementioned survey were compared with data from 409 OB/GYNs from a survey conducted in 2021 among members of the Japanese Society of Obstetrics and Gynecology.

Results

Overall, 79.8% of psychiatrists and 97.3% of OB/GYNs were involved in practicing PMS/PMDD diagnosis and treatment. Most psychiatrists believed that PMS should be treated by OB/GYNs (74.4%) and PMDD by psychiatrists (75.6%). Only vague medical interviews were conducted by 86.6% of psychiatrists, and only 9.7% maintained a two-cycle symptom diary. Psychiatrists mostly prescribed selective serotonin/serotonin and noradrenaline reuptake inhibitor (SSRI/SNRI) continuous dosing (91.1%), followed by Kampo medicines, especially Kamishoyosan (73.3%); only 2.8% chose oral contraceptive pills, unlike OB/GYNs, while SSRI continuous (32.8%) and luteal phase dosing (20.6%) and Kampo medicine (42.1%) were the most common first-line treatments. Lifestyle guidance was prescribed by 63.6% of psychiatrists, followed by cognitive behavioral therapy (13.8%) and the symptom diary observation method (11.1%), which were similar to OB/GYNs' choices.

Conclusions

Many Japanese psychiatrists and OB/GYNs do not base PMS/PMDD diagnoses on prospective monitoring methods using specific diagnostic criteria and therefore do not provide evidence-based treatment. Moreover, a tendency of being biased toward treatments in which the department specialized was observed.

Premenstrual disorders and PMDD - a review

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

Women's Health Care Committee, Japan Society of Obstetrics and Gynecology: Annual report-2023

The Women's Health Care Committee was established in 2010 with the goal of improving women's health. In the current academic year, there are six subcommittees focusing on conducting the following surveys: (1) the current status of pregnancy-associated breast cancer in Japan; (2) surgery for disorders of sex development; (3) diagnosis and treatment of premenstrual syndrome and premenstrual dysphoric disorder; (4) obstetrics and gynecology-based treatment for patients with eating disorders in Japan; (5) multi-drug-resistant bacterial infections in the field of obstetrics and gynecology; and (6) changing the methodology of the treatment of dysmenorrhea and continuing medical education. The activities of each subcommittee are described below. This report is based on the Japanese version of the annual report (Acta Obst Gynaec Jpn 2023;75(6):662-86).

Gender Differences in Premenstrual Syndrome and Premenstrual Dysphoric Disorder Diagnosis and Treatment among Japanese Obstetricians and Gynecologists: A Cross-Sectional Study

Premenstrual symptoms are characterized by unpleasant psychophysical symptoms that appear during the luteal phase before menstruation and interfere with a woman's quality of life. Premenstrual syndrome (PMS) is a pathological condition with premenstrual symptoms, of which premenstrual dysphoric disorder (PMDD) is a particularly severe psychological symptom. This study aimed to examine the gender differences in the diagnosis and treatment of PMS and PMDD among obstetricians and gynecologists (OB/GYNs) in Japan. Data were obtained from the survey conducted by the Japanese Society of Obstetrics and Gynecology. We used data from 1,257 of the 1,265 OB/GYNs who are engaged in PMS/PMDD practice and reported their gender. Multivariate regression analysis adjusted for propensity scores was performed. Female OB/GYNs were more frequently engaged in treating patients with PMS/PMDD than males [odds ratio (OR) 1.74; 95% confidence interval (CI) 1.36-2.21]. With regard to the diagnostic methods, more female OB/GYNs selected the two-cycle symptom diary than males (OR 2.88; 95% CI 1.80-4.60). Regarding treatment, fewer female OB/GYNs selected selective serotonin reuptake inhibitors as their first-line drug (OR 0.39; 95% CI 0.17-0.89). Gender differences were found in the selection of PMS/PMDD diagnosis and treatment methods among Japanese OB/GYNs.

A scoping review of hormonal clinical trials in menstrual cycle-related brain disorders: Studies in premenstrual mood disorder, menstrual migraine, and catamenial epilepsy

Cyclic variations in hormones during the normal menstrual cycle underlie multiple central nervous system (CNS)-linked disorders, including premenstrual mood disorder (PMD), menstrual migraine (MM), and catamenial epilepsy (CE). Despite this foundational mechanistic link, these three fields operate independently of each other. In this scoping review (N = 85 studies), we survey existing human research studies in PMD, MM, and CE to outline the exogenous experimental hormone manipulation trials conducted in these fields. We examine a broad range of literature across these disorders in order to summarize existing diagnostic practices and research methods, highlight gaps in the experimental human literature, and elucidate future research opportunities within each field. While no individual treatment or study design can fit every disease, there is immense overlap in study design and established neuroendocrine-based hormone sensitivity among the menstrual cycle-related disorders PMD, MM, and CE.

SCOPING REVIEW STRUCTURED SUMMARY

Background. The menstrual cycle can be a biological trigger of symptoms in certain brain disorders, leading to specific, menstrual cycle-linked phenomena such as premenstrual mood disorders (PMD), menstrual migraine (MM), and catamenial epilepsy (CE). Despite the overlap in chronicity and hormonal provocation, these fields have historically operated independently, without any systematic communication about methods or mechanisms.

OBJECTIVE

Online databases were used to identify articles published between 1950 and 2021 that studied hormonal manipulations in reproductive-aged females with either PMD, MM, or CE. We selected N = 85 studies that met the following criteria: 1) included a study population of females with natural menstrual cycles (e.g., not perimenopausal, pregnant, or using hormonal medications that were not the primary study variable); 2) involved an exogenous hormone manipulation; 3) involved a repeated measurement across at least two cycle phases as the primary outcome variable.

CHARTING METHODS

After exporting online database query results, authors extracted sample size, clinical diagnosis of sample population, study design, experimental hormone manipulation, cyclical outcome measure, and results from each trial. Charting was completed manually, with two authors reviewing each trial.

RESULTS

Exogenous hormone manipulations have been tested as treatment options for PMD (N = 56 trials) more frequently than MM (N = 21) or CE (N = 8). Combined oral contraceptive (COC) trials, specifically those containing drospirenone as the progestin, are a well-studied area with promising results for treating both PMDD and MM. We found no trials of COCs in CE. Many trials test ovulation suppression using gonadotropin-releasing hormone agonists (GnRHa), and a meta-analysis supports their efficacy in PMD; GnRHa have been tested in two MM-related trials, and one CE open-label case series. Finally, we found that non-contraceptive hormone manipulations, including but not limited to short-term transdermal estradiol, progesterone supplementation, and progesterone antagonism, have been used across all three disorders.

CONCLUSIONS

Research in PMD, MM, and CE commonly have overlapping study design and research methods, and similar effects of some interventions suggest the possibility of overlapping mechanisms contributing to their cyclical symptom presentation. Our scoping review is the first to summarize existing clinical trials in these three brain disorders, specifically focusing on hormonal treatment trials. We find that PMD has a stronger body of literature for ovulation-suppressing COC and GnRHa trials; the field of MM consists of extensive estrogen-based studies; and current consensus in CE focuses on progesterone supplementation during the luteal phase, with limited estrogen manipulations due to concerns about seizure provocation. We argue that researchers in any of these respective disciplines would benefit from greater communication regarding methods for assessment, diagnosis, subtyping, and experimental manipulation. With this scoping review, we hope to increase collaboration and communication among researchers to ultimately improve diagnosis and treatment for menstrual-cycle-linked brain disorders.

Current status and problems in the diagnosis and treatment of premenstrual syndrome and premenstrual dysphoric disorder from the perspective of obstetricians and gynecologists in Japan

AIM

To investigate the current status and problems in the diagnosis and treatment of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) from the perspective of obstetricians and gynecologists (OB/GYNs) in Japan, the Japanese Society of Obstetrics and Gynecology (JSOG) conducted a national-wide survey.

METHODS

An email survey was sent to all JSOG members (16 732) and a web-based survey was conducted using a Google form between September and November 2021. The current status and problems in PMS/PMDD diagnosis and treatment were surveyed in this cross-sectional study.

RESULTS

In total, 1312 respondents (7.8% of all JSOG members) completed the questionnaire. In terms of diagnoses and treatment, OB/GYN was preferred over psychiatrist for PMS (91.4% vs. 45%); however, no differences were noted for PMDD (76.1% vs. 73.7%). A total of 1267 (96.6%) respondents engaged in routine PMS/PMDD treatment. Regarding the general diagnosis procedure, 84.4% respondents answered "only a vague medical interview," 8.4% kept a two-cycle symptom diary, and 10.3% used a screening questionnaire. The most commonly used medication was oral contraceptive pills (OCPs) (98.1%), followed by the Kampo, traditional Japanese herbal medicines, Kamishoyosan (73.6%). Concerning first-line drugs for treatment, OCPs were the most common (76.8%), followed by Kampo medicine (19.5%); selective serotonin reuptake inhibitors (SSRIs) were less frequently used (2.6%). Regarding first-line drugs among OCPs, 65.1% respondents reported drospirenone-ethinylestradriol use.

CONCLUSIONS

This study indicates that only a few OB/GYNs practicing PMS/PMDD in Japan use a prospective diary, which is an essential diagnostic criterion for PMS/PMDD. Regarding treatment, SSRIs were used less frequently.

Premenstrual disorders: Premenstrual syndrome and premenstrual dysphoric disorder

Recently, the term premenstrual disorders (PMDs), which includes premenstrual syndrome and premenstrual dysphoric disorder as a continuum, has been proposed. Although the precise etiology of PMDs remains unknown, the involvement of hormonal fluctuations is clear. The brain transmitters, serotonin and γ-amino butyric acid, also seem to be involved. Serotonin reuptake inhibitors and oral contraceptives are the current mainstay of treatment, but these are insufficient. Even the currently used prospective two-period symptom diary is not widely used in actual clinical practice, creating a major problem of discrepancy between research and clinical practice. In this review, I would like to outline the latest information and problems in the etiology, diagnosis, and treatment of PMDs, with an emphasis on promising new therapies.

Characteristics of the gut microbiota in women with premenstrual symptoms: A cross-sectional study

Purpose

Premenstrual symptoms can negatively impact the quality of life of women through a range of mood, behavioral, and physical symptoms. The association between the microbiota and brain function has been extensively studied. Here, we examined the characteristics of the microbiota in women with premenstrual disorders (PMDs) and the association between premenstrual symptoms and the microbiota.

Materials and methods

In this single center cross-sectional pilot study, we recruited 27 women reporting premenstrual symptoms and 29 women with no serious premenstrual symptoms. Among them, we further selected 21 women experiencing premenstrual symptoms resulting in interference to their social life (PMDs group) and 22 women with no serious premenstrual symptoms and thereby no interference to their social life (control group). The severity of symptoms was evaluated by a premenstrual symptoms questionnaire (PSQ). Inflammatory markers were analyzed in blood samples, including C reactive protein, soluble CD14, and lipopolysaccharide binding protein. Sequencing of 16S ribosomal ribonucleic acid genes was performed on stool samples.

Results

Inflammatory markers in blood samples did not differ significantly between the PMDs and control groups. A difference in beta, but not alpha diversity, was detected for the gut microbiotas of the PMDs and control groups. The relative abundance of the Bacteroidetes phylum was lower in the PMDs group. At the genus level, the prevalence was decreased for Butyricicoccus, Extibacter, Megasphaera, and Parabacteroides and increased for Anaerotaenia in the PMDs group, but after false discovery rate correction, these differences were no longer significant. Linear discriminant effect size analysis revealed a decrease in Extibacter, Butyricicoccus, Megasphaera, and Parabacteroides and an increase in Anaerotaenia in the PMDs group. The PSQ total score correlated with Anaerotaenia, Extibacter, and Parabacteroides. Multiple regression analysis showed that Parabacteroides and Megasphaera negatively predicted the PSQ total score.

Conclusion

The properties of the gut microbiota are associated with premenstrual symptoms.

A DSM-5-based tool to monitor concurrent mood and premenstrual symptoms: the McMaster Premenstrual and Mood Symptom Scale (MAC-PMSS)

Background

Despite high co-morbidity between premenstrual dysphoric disorder and mood disorders, there is a gap of research-based tools to monitor concurrent premenstrual and mood symptoms. In this study, we developed a new DSM-5-based questionnaire to prospectively monitor concurrent premenstrual and mood symptoms.

Methods

Fifty-two females with bipolar or major depressive disorder, ages 16–45, were enrolled in the study. Participants completed two months of prospective symptom charting including the McMaster Premenstrual and Mood Symptom Scale (MAC-PMSS) and the Daily Record of Severity of Problems (DRSP). At the end of the prospective charting, participants also completed the Montgomery-Åsberg Depression Rating Scale (MADRS), Hamilton Depression Rating Scale (HDRS) and the Young Mania Rating Scale (YMRS). The MAC-PMSS was correlated with the DRSP, MADRS, HDRS and YMRS.

Results

All individual items of the MAC-PMSS correlated strongly with the individual DRSP scores (all p < 0.001). The mood section of the MAC-PMSS also significantly correlated with MADRS (r = 0.572; p < 0.01), HDRS (r = 0.555; p < 0.01) and YMRS scores (r = 0.456; p < 0.01).

Conclusions

The MAC-PMSS is a reliable to tool to measure concurrent mood and premenstrual symptoms in women with mood disorders.

Prevalence of lifetime self-injurious thoughts and behaviors in a global sample of 599 patients reporting prospectively confirmed diagnosis with premenstrual dysphoric disorder

BACKGROUND

Suicide is the second leading cause of death among Americans ages 10 to 34, with alarming recent increases in suicide rates among those assigned female at birth. A large body of evidence points to menstrual cycle influences on self-injurious thoughts and behaviors (STBs), suggesting that neurobiological hormone sensitivities, such as in premenstrual dysphoric disorder (PMDD), may drive suicide risk in females. However, existing studies of STBs in PMDD use cross-sectional self-report measures of PMDD with poor validity. As a first step to establish accurate prevalence rates of STBs in PMDD, we examined the lifetime prevalence of STBs in a large global survey of patients reporting a diagnosis of PMDD based on daily ratings.

METHOD

Individuals with self-reported PMDD symptoms were invited to an online survey through online support groups for PMDD and social media posts from PMDD awareness accounts. Participants reported demographics, whether they had been diagnosed with PMDD by a healthcare provider using daily ratings, STBs using the Columbia Suicide Severity Rating Scale, and history of lifetime comorbid psychiatric diagnoses.

RESULTS

Of 2,689 survey completers, 599 (23%) reported a diagnosis with PMDD based on two months of daily ratings and were included in analyses. We observed high rates of lifetime active suicidal ideation (72%), planning (49%), intent (42%), preparing for an attempt (40%), and attempt (34%), as well as non-suicidal self-injury (51%). The majority (70%) of the sample reported at least one lifetime comorbid psychiatric diagnosis. Predictors of lifetime active suicidal ideation included nulliparity, low-to-moderate (vs. high) income, and history of diagnosis with major depression or post-traumatic stress disorder. Predictors of lifetime attempts among those reporting lifetime active ideation included older age, nulliparity, lower income, and history of diagnosis with post-traumatic stress disorder or borderline personality disorder.

CONCLUSIONS

These data indicate high rates of STBs among those reporting prospective diagnosis of PMDD and highlight the need for prospective research on mechanisms and prevention of STBs in PMDD. Clinical practice guidelines for PMDD should accommodate comorbidities and recommend frequent screenings for STB risk. STBs should be considered for inclusion in future iterations of the DSM PMDD diagnostic criteria.

Patient Experiences of Health Care Providers in Premenstrual Dysphoric Disorder: Examining the Role of Provider Specialty

Background: Premenstrual dysphoric disorder (PMDD) is a severe mood disorder that affects ∼5% of menstruating individuals. Although symptoms are limited to the luteal phase of the menstrual cycle, PMDD causes significant distress and impairment across a range of activities. PMDD is under-recognized by health care providers, can be difficult to diagnose, and lies at the intersection of gynecology and psychiatry. Thus, many patients are misdiagnosed, or encounter challenges in seeking care. The aim of this study was to examine patients' experiences with different health care specialties when seeking care for PMDD symptoms. Methods: We examined data from the 2018 Global Survey of Premenstrual Disorders conducted by the International Association for Premenstrual Disorders (IAPMD). Patients rated their health care providers (general practitioners, psychiatrists, gynecologists, psychotherapists) in three key areas related to treatment of premenstrual mood complaints: interpersonal factors, awareness and knowledge of PMDD, and whether the patient was asked to track symptoms daily. Intraclass correlations examined between- and within-person variance. Multilevel regression models predicted ratings on each provider competency item, with ratings nested within individuals to examine the within-patient effect of provider type on outcomes. Results: The sample included 2,512 patients who reported seeking care for PMDD symptoms. Regarding interpersonal factors, psychotherapists were generally rated the highest. On awareness and knowledge of PMDD, gynecologists and psychiatrists were generally rated the highest. Gynecologists were more likely than other providers to ask patients to track symptoms daily. Conclusions: These findings suggest that different providers have different strengths in assessing and treating PMDD. Further, graduate and medical training programs may benefit from increased curricular development regarding evidence-based evaluation and treatment of PMDD.

The impact of depressed mood and coping motives on cannabis use quantity across the menstrual cycle in those with and without pre-menstrual dysphoric disorder

BACKGROUND AND AIMS

Reported rates of cannabis use among Canadian females are increasing. Female cannabis users progress to cannabis use disorder more rapidly than males (telescoping) and have higher rates of emotional disorder comorbidity. Addictive behaviors may change, along with mood and motivations, across the menstrual cycle (MC), particularly for females with pre-menstrual dysphoric disorder (PMDD). This study aimed to determine whether increases in depressed mood and coping motives would predict increased cannabis use pre-menstrually/menstrually, particularly among females with PMDD. We also assessed positive mood and enhancement motive ratings to establish specificity of predicted depressed mood and coping motive results.

DESIGN

Observational study using data collected across 32 days using electronic daily diary methods.

SETTING

Nova Scotia, Canada.

PARTICIPANTS

Sixty-nine naturally cycling female cannabis users (Mean (M) age = 29.25, Standard Deviation  (SD) = 5.66) with and without retrospectively identified PMDD (via structured clinical interview) and prospectively identified PMDD (via elevated pre-menstrual depressed mood). Self-reported MC phase was validated using salivary progesterone concentrations.

MEASUREMENTS

Depressed/positive mood, coping-/enhancement-motivated cannabis use, and cannabis use quantity.

FINDINGS

Coping motives explained heightened cannabis use pre-menstrually/menstrually in those with retrospectively identified PMDD. Depressed mood explained increased cannabis use menstrually in those with retrospectively/prospectively identified PMDD. Moreover, prospectively identified PMDD significantly moderated the relationship between depressed mood and cannabis use quantity menstrually. In those with prospectively identified PMDD, positive mood and enhancement motives were associated with decreased cannabis use during the follicular/ovulatory phases. Females with versus without retrospectively identified PMDD also displayed greater overall cannabis use quantity (M [SD] = 3.44[2.84] standard joint equivalents versus 1.85[1.82], respectively; U = 277.50, P = 0.008).

CONCLUSIONS

Depressed mood may explain heightened cannabis use menstrually in females with pre-menstrual dysphoric disorder. Coping motives may explain heightened cannabis use pre-menstrually/menstrually in females with retrospectively identified with pre-menstrual dysphoric disorder.

Toward the Reliable Diagnosis of DSM-5 Premenstrual Dysphoric Disorder: The Carolina Premenstrual Assessment Scoring System (C-PASS)

OBJECTIVE

Despite evidence for the validity of premenstrual dysphoric disorder (PMDD) and the inclusion of the disorder in DSM-5, variable diagnostic practices compromise the construct validity of the diagnosis and threaten the clarity of efforts to understand and treat its underlying pathophysiology. In an effort to hasten and streamline the translation of the DSM-5 criteria for PMDD into terms compatible with existing research practices, the authors present the development and initial validation of the Carolina Premenstrual Assessment Scoring System (C-PASS). The C-PASS (available as a worksheet, Excel macro, and SAS macro) is a standardized scoring system for making DSM-5 PMDD diagnoses using two or more months of daily symptom ratings with the Daily Record of Severity of Problems (DRSP).

METHOD

Two hundred women recruited for retrospectively reported premenstrual emotional symptoms provided two to four months of daily symptom ratings on the DRSP. Diagnoses made by expert clinician and by the C-PASS were compared.

RESULTS

Agreement of C-PASS diagnosis with expert clinical diagnosis was excellent; overall correct classification by the C-PASS was estimated at 98%. Consistent with previous evidence, retrospective reports of premenstrual symptom increases were a poor predictor of prospective C-PASS diagnosis.

CONCLUSIONS

The C-PASS is a reliable and valid companion protocol to the DRSP that standardizes and streamlines the complex, multilevel diagnosis of DSM-5 PMDD. Consistent use of this robust diagnostic method would result in more clearly defined, homogeneous samples of women with PMDD, thereby improving the clarity of studies seeking to characterize and treat the underlying pathophysiology of the disorder.

A symptom diary to assess severe premenstrual syndrome and premenstrual dysphoric disorder

The differentiation between premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) has been widely discussed. PMDD is listed as a mental disorder in the DSM-5, whereas PMS is not considered as a mental disorder in any diagnostic manual. Consequently, PMS is operationalized in different ways. Keeping a symptom diary is required to diagnose PMDD but is also recommended for PMS. The aim of our study was, therefore, to operationalize PMS and PMDD within a DSM-5-based symptom diary. We developed a symptom-intensity-score (SI-score) and an interference-score (INT-score) to evaluate the symptom diary. Ninety-eight women (aged 20-45 years) completed a symptom diary over two menstrual cycles, a retrospective screening for premenstrual symptoms, and answered additional impairment questionnaires from August 2013 to August 2015. The scores revealed moderate to good reliability (Cronbach's α = 0.83-0.96). Convergent validity was shown by significant correlations with a retrospective screening, the Pain Disability Index, and the German PMS-Impact Questionnaire. Discriminant validity was indicated by low correlations with the Big Five Inventory-10. These scores may facilitate the evaluation of prospective symptom ratings in research and clinical practice. Future research should focus on continuing to validate the scores (e.g., in an ambulatory setting).

How to measure the impact of premenstrual symptoms? Development and validation of the German PMS-Impact Questionnaire

With 75% of women of reproductive age affected, premenstrual symptoms are very common, ranging from emotional and cognitive to physical symptoms. Premenstrual Syndrome and Premenstrual Dysphoric Disorder can lead to substantial functional interference and psychological distress comparable to that of dysthymic disorders. The assessment of this impact is required as a part of the diagnostic procedure in the DSM-5. In the absence of a specific measure, the authors developed the PMS-Impact Questionnaire. A sample of 101 women reporting severe premenstrual complaints was assessed with the twenty-two items in the questionnaire during their premenstrual phase in an ongoing intervention study at the Philipps-University Marburg from August 2013 until January 2015. An exploratory factor analysis revealed a two-factor solution (labeled Psychological Impact and Functional Impact) with 18 items. A Cronbach's alpha of 0.90 for Psychological Impact and of 0.90 for Functional Impact indicated good reliability. Convergent construct validity was demonstrated by moderate to high correlations with the Pain Disability Index. Low correlations with the Big Five Inventory-10 indicated good divergent validity. The PMS-Impact Questionnaire was found to be a valid, reliable, and an economic measure to assess the impact of premenstrual symptoms. In future research, cross validations and confirmatory factor analyses should be conducted.