Clinical diagnostic criteria for premenstrual syndrome and guidelines for their quantification for research studies

Correlation of White Matter Microstructure MRI and Inflammatory Cytokine Alterations With Symptom Severity in Premenstrual Syndrome

BACKGROUND

Women with premenstrual syndrome (PMS) are at increased risk for depression throughout their lives. White matter (WM) microstructure and inflammatory cytokine alterations have been proposed in its etiology.

PURPOSE

To investigate whether WM, assessed using diffusion tensor imaging (DTI), and inflammatory cytokine levels are altered in PMS, and to examine the relationships between WM microstructure, inflammatory cytokines, and symptom severity.

STUDY TYPE

Prospective.

SUBJECTS

Forty-two PMS patients and 58 healthy controls (HCs), categorized according to the daily record of severity of problems (DRSP).

FIELD STRENGTH/SEQUENCE

3-T, echo planar imaging DTI.

ASSESSMENT

Fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) were measured by using tract-based spatial statistics (TBSS). Venous blood was collected to measure cytokines, including interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α). Symptoms were assessed by using the DRSP.

STATISTICAL TESTS

Two-sample t test or Mann-Whitney U test were used to compare the DRSP and cytokines. Abnormal DTI metrics in WM were extracted and the differences between groups were analyzed by using two sample t-tests. Spearman's correlation (r) was used to assess the relationship between DTI metrics, cytokines, and DRSP. A P-value <0.05 with FDR correction was considered statistically significant.

RESULTS

Compared with HCs, PMS patients showed significantly lower FA in the corpus callosum and corona radiata, and significantly higher MD, AD, and RD in the corticospinal tract (CST), and significantly higher MD and RD in the anterior thalamic radiation (ATR). These differential metrics were significantly correlated with DRSP. Patients showed significantly higher IL-1β and TNF-α than HCs. Moreover, TNF-α correlated positively with MD, AD, and RD in both groups (r range, 0.256-0.315).

DATA CONCLUSION

Alterations of WM microstructure and IL-1β and TNF-α may be associated with PMS symptom severity, and TNF-α may correlate with DTI metrics of CST and ATR pathways.

EVIDENCE LEVEL

1 TECHNICAL EFFICACY: Stage 2.

Impact of Menstrual cycle-based Periodized training on Aerobic performance, a Clinical Trial study protocol-the IMPACT study

BACKGROUND

The menstrual cycle and its impact on training and performance are of growing interest. However, evidence is lacking whether periodized exercise based on the menstrual cycle is beneficial. The primary purpose of this proposed randomized, controlled trial, the IMPACT study, is to evaluate the effect of exercise periodization during different phases of the menstrual cycle, i.e., comparing follicular phase-based and luteal phase-based training with regular training during the menstrual cycle on physical performance in well-trained women.

METHODS

Healthy, well-trained, eumenorrheic women between 18 and 35 years (n = 120) will be recruited and first assessed for physical performance during a run-in menstrual cycle at different cycle phases and then randomized to three different interventions: follicular phase-based training, luteal phase-based training, or regular training during three menstrual cycles. The training intervention will consist of high-intensity spinning classes followed by strength training. The menstrual cycle phases will be determined by serum hormone analysis throughout the intervention period. Assessment of aerobic performance (primary outcome) and muscle strength, body composition, and blood markers will be performed at baseline and at the end of the intervention.

DISCUSSION

With a robust methodology, this study has the potential to provide evidence of the differential effects of exercise periodization during different phases of the menstrual cycle in female athletes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05697263 . Registered on 25 January 2023.

Management of Premenstrual Disorders: ACOG Clinical Practice Guideline No. 7

PURPOSE

To provide recommendations for the management of premenstrual syndrome and premenstrual dysphoric disorder, collectively referred to as premenstrual disorders, based on assessment of the evidence regarding the safety and efficacy of available treatment options. An overview of the epidemiology, pathophysiology, and diagnosis of premenstrual disorders also is included to provide readers with relevant background information and context for the clinical recommendations.

TARGET POPULATION

Reproductive-aged adults and adolescents with premenstrual symptoms.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Gynecology and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development and Evaluations) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes recommendations on the following evidence-based treatment options for premenstrual disorders, with an acknowledgement that many patients may benefit from a multimodal approach that combines several interventions: pharmacologic agents (hormonal and nonhormonal), psychological counseling, complementary and alternative treatments, exercise and nutritional therapies, patient education and self-help strategies, and surgical management. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence. Based on review of extrapolated data from adult populations and expert consensus, it was determined that the recommendations also apply to adolescents, with a few exceptions that are noted in the Clinical Practice Guideline.

Sex steroids and the female brain across the lifespan: insights into risk of depression and Alzheimer's disease

Despite widespread sex differences in prevalence and presentation of numerous illnesses affecting the human brain, there has been little focus on the effect of endocrine ageing. Most preclinical studies have focused on males only, and clinical studies often analyse data by covarying for sex, ignoring relevant differences between the sexes. This sex- (and gender)-neutral approach is biased and contributes to the absence of targeted treatments and services for all sexes (and genders). Female health has been historically understudied, with grave consequences for their wellbeing and health equity. In this Review, we spotlight female brain health across the lifespan by informing on the role of sex steroids, particularly oestradiol, on the female brain and on risk for diseases more prevalent in females, such as depression and Alzheimer's disease.

Sex Differences in Depression and Anxiety

Depression and anxiety disorders carry a tremendous worldwide burden and emerge as a significant cause of disability among western societies. Both disorders are known to disproportionally affect women, as they are twice more likely to be diagnosed and moreover, they are also prone to suffer from female-specific mood disorders. Importantly, the prevalence of these affective disorders has notably risen after the COVID pandemic, especially in women. In this chapter, we describe factors that are possibly contributing to the expression of such sex differences in depression and anxiety. For this, we overview the effect of transcriptomic and genetic factors, the immune system, neuroendocrine aspects, and cognition. Furthermore, we also provide evidence of sex differences in antidepressant response and their causes. Finally, we emphasize the importance to consider sex as a biological variable in preclinical and clinical research, which may facilitate the discovery and development of new and more efficacious antidepressant and anxiolytic pharmacotherapies for both women and men.

The relationship between high physical activity and premenstrual syndrome in Japanese female college students

BACKGROUND

In recent years, moderate physical activity has attracted the attention of experts and women as a way to cope with premenstrual syndrome (PMS). Studies investigated the effects of exercise on PMS, but only a few reports focused on the relationship between physical activity, which included not only exercise but also routine bodily movements, and PMS. Therefore, the present study investigated the relationship between the amount of physical activity and PMS symptoms among sexually mature female students.

METHODS

A total of 381 female university students in Japan were surveyed using a paper or web-based questionnaire with the same content. The questionnaire consisted of basic information, PMS symptoms, and physical activity based on the International Physical Activity Questionnaire (IPAQ). Participants were divided into two groups (≥ 3000 The Metabolic Equivalent of Task (MET)-minutes/week and < 3000 MET-minutes/week) based on their total physical activity as calculated using the IPAQ guidelines. The two groups were then compared in terms of the severity of their PMS physical and psychological symptoms as calculated based on the American College of Obstetricians and Gynecologists' PMS diagnostic criteria. The Wilcoxon's rank-sum test was used for statistical analyses. We then divided the participants based on the presence or absence of each symptom and used the chi-square test to compare the intergroup differences in ratios. The statistical significance level was set at p < 0.05.

RESULTS

Those with total physical activity of ≥ 3000 MET-minutes/week had lower total PMS symptom scores (p < 0.01), physical symptom scores (p = 0.01), and psychological symptom scores (p = 0.01) compared with those with total physical activity of < 3000 MET-minutes/week.

CONCLUSION

These results suggest that young women with high physical activity (≥ 3000 MET-minutes/week) have milder symptoms of PMS.

How Do Elite Female Athletes Cope with Symptoms of Their Premenstrual Period? A Study on Rugby Union and Football Players' Perceived Physical Ability and Well-Being

Women's participation in sports has recently grown worldwide, including in sports typically associated with men (e.g., rugby and football). Similarly, literature on female athletes has increased, but how they cope with premenstrual (PM) physical and affective symptoms remains a poorly studied topic. Our study aimed to explain which coping strategies elite female rugby and football players use during their PM period to maintain perceived physical ability (PPA) and well-being. A mediation model analysis considering coping strategies (i.e., avoiding harm, awareness and acceptance, adjusting energy, self-care, and communicating) as independent variables, PPA and well-being as dependent variables, and PM physical and affective symptoms and PM cognitive resources as mediators was run on the data collected via an anonymous online survey. A dysfunctional impact of avoiding harm (indirect) and adjusting energy (both direct and indirect) and a functional indirect influence of awareness and acceptance, self-care, and communicating as coping strategies were found on PPA and well-being during the PM period. As predicted, PM physical and affective symptoms as mediators reduced PPA and well-being, while PM cognitive resources enhanced them. These results may inform practitioners on how to support elite female athletes' PPA and well-being by knowing and reinforcing the most functional PM coping strategies for them.

Daily cortisol awakening response and menstrual symptoms in young females

Menstrual symptoms include some rhythmical changes and stress perception but women differ in duration and severity of these symptoms. It is not known whether these differences are associated with cortisol awakening response (CAR). The aim of the current study was to follow young women daily for the CAR and menstrual parameters throughout the whole menstrual cycle. Healthy and regularly cycling young women (n = 16, 17 to 31-year-old) participated in the current study. The daily records of severity of problems (DRSP) was filled in daily by the participants. CAR was also assessed daily form the salivary samples collected at a 0-, 15-, 30- and 60-min post-awakening. In terms of daily awakening cortisol profiles, women had either 2-20 (n = 3), or 20-200 (n = 8) or 200-2000 (n = 5) ng/ml cortisol according to the median levels throughout their cycle. CAR was weakly and negatively correlated with DRSP scores but strongly and positively with oestradiol (R²  = 0.300; p = 0.000) and progesterone (R²  = 0.490; p = 0.000) concentrations. Individuals with higher oestradiol and progesterone concentrations did not have high DRSP scores. In conclusion, CAR had a very high between-subject difference but had a low within-subject difference throughout the days of menstrual cycle, suggesting that CAR is a relatively stable personal trait. Moreover, the interplay between cortisol, progesterone and oestradiol appears to be important for the severity of menstrual symptoms.

Top 100 Cited Papers on Premenstrual Syndrome/Premenstrual Dysphoric Disorder: A Bibliometric Study

BACKGROUND

Premenstrual syndrome/premenstrual dysphoric disorder is a serious condition affecting women worldwide, causing clinically significant distress or interference. Therefore, solving these diseases has become the utmost concern worldwide, culminating in numerous studies. In this study, we performed bibliometric analysis on the 100 most cited papers with the aim of identifying research hot spots and trends in this field.

METHODS

We screened the Science Citation Index Expanded (SCIE) of Web of Science (WOS) to identify the top 100 cited studies on PMS/PMDD. Next, we analyzed relevant literature from various journals, countries/regions, institutions, authors, and keywords. Finally, we used VOSviewer and Citespace software to generate knowledge maps and identify hot spots and trends.

RESULTS

The top 100 highly cited studies were published in 55 journals, between 1999 and 2017, across 24 countries/regions around the world. Most articles were published in Obstetrics and Gynecology, whereas Psych neuroendocrinology had the largest average number of citations per paper. The United States had the highest number of publications, followed by England, Canada, and Sweden. The top three institutions that published the highly cited literature were the University of Pennsylvania, Yale University, and National Institute of Mental Health (NIMH). Obstetrics, Gynecology, Psychiatry, and Reproductive Biology were the main research directions, whereas the top 10 Co-occurrence of Keywords included double-blind, fluoxetine, efficacy, prevalence, epidemiology, phase sertraline treatment, depression, progesterone, placebo, and placebo-controlled trial. Results from cluster analysis indicated that more comprehensive epidemiology and steroid pathogenesis have gradually become the hot spots and trends.

CONCLUSION

These findings demonstrated that bibliometric analysis can intuitively and rapidly reveal the frontiers and hot spots of research in PMS/PMDD. Notably, epidemiology, steroid pathogenesis, GABAA receptor delta subunits, and double-blind placebo-controlled trials are potential areas of focus for future research.

Altered resting-state functional networks in patients with premenstrual syndrome: a graph-theoretical based study

Premenstrual syndrome (PMS) is a menstrual cycle-related disorder. Previous studies have indicated alterations of brain functional connectivity in PMS patients. However, little is known about the overall organization of brain network in PMS patients. Functional magnetic resonance imaging data deriving from 20 PMS patients and 21 healthy controls (HCs). Pearson correlation between mean time-series was used to estimate connectivity matrix between each paired regions of interest, and the connectivity matrix for each participant was then binarized. Graph theory analysis was applied to assess each participant's global and local topological properties of brain functional network. Correlation analysis was performed to evaluate relationships between the daily rating of severity of problems (DRSP) and abnormal network properties. PMS patients had lower small-worldness values than HCs. PMS-related alterations of nodal properties were mainly found in the posterior cingulate cortex, precuneus and angular gyrus. The PMS-related abnormal connectivity components were mainly associated with the thalamus, putamen and middle cingulate cortex. In the PMS group, the DRSP score were negatively correlated with the area under the curves of nodal local efficiency in the posterior cingulate cortex. Our study suggests that the graph-theory method may be one potential tool to detect disruptions of brain connections and may provide important evidence for understanding the PMS from the disrupted network organization perspective.

Functional brain network topology across the menstrual cycle is estradiol dependent and correlates with individual well-being

The menstrual cycle (MC) is a sex hormone‐related phenomenon that repeats itself cyclically during the woman's reproductive life. In this explorative study, we hypothesized that coordinated variations of multiple sex hormones may affect the large‐scale organization of the brain functional network and that, in turn, such changes might have psychological correlates, even in the absence of overt clinical signs of anxiety and/or depression. To test our hypothesis, we investigated longitudinally, across the MC, the relationship between the sex hormones and both brain network and psychological changes. We enrolled 24 naturally cycling women and, at the early‐follicular, peri‐ovulatory, and mid‐luteal phases of the MC, we performed: (a) sex hormone dosage, (b) magnetoencephalography recording to study the brain network topology, and (c) psychological questionnaires to quantify anxiety, depression, self‐esteem, and well‐being. We showed that during the peri‐ovulatory phase, in the alpha band, the leaf fraction and the tree hierarchy of the brain network were reduced, while the betweenness centrality (BC) of the right posterior cingulate gyrus (rPCG) was increased. Furthermore, the increase in BC was predicted by estradiol levels. Moreover, during the luteal phase, the variation of estradiol correlated positively with the variations of both the topological change and environmental mastery dimension of the well‐being test, which, in turn, was related to the increase in the BC of rPCG. Our results highlight the effects of sex hormones on the large‐scale brain network organization as well as on their possible relationship with the psychological state across the MC. Moreover, the fact that physiological changes in the brain topology occur throughout the MC has widespread implications for neuroimaging studies.

Altered fractional amplitude of low-frequency fluctuation in women with premenstrual syndrome via acupuncture at Sanyinjiao (SP6)

BACKGROUND

Premenstrual syndrome (PMS) is a prevalent gynecological disease and is significantly associated with abnormal neural activity. Acupuncture is an effective treatment on PMS in clinical practice. However, few studies have been performed to investigate whether acupuncture might modulate the abnormal neural activity in patients with PMS. Thereby, the aim of the study was to assess alterations of the brain activity induced by acupuncture stimulation in PMS patients.

METHODS

Twenty PMS patients were enrolled in this study. All patients received a 6-min resting-state functional magnetic resonance imaging (rs-fMRI) scan before and after electro-acupuncturing stimulation (EAS) at Sanyinjiao (SP6) acupoint in the late luteal phase of menstrual. Fractional amplitude of low-frequency fluctuation (fALFF) method was applied to examine the EAS-related brain changes in PMS patients.

RESULTS

Compared with pre-EAS at SP6, increased fALFF value in several brain regions induced by SP6, including brainstem, right thalamus, bilateral insula, right paracentral lobule, bilateral cerebellum, meanwhile, decreased fALFF in the left cuneus, right precuneus, left inferior temporal cortex.

CONCLUSIONS

Our findings provide imaging evidence to support that SP6-related acupuncture stimulation may modulate the neural activity in patients with PMS. This study may partly interpret the neural mechanisms of acupuncture at SP6 which is used to treat PMS patients in clinical.

TRIAL REGISTRATION

The study was registered on http://www.chictr.org.cn . The Clinical Trial Registration Number is ChiCTR-OPC-15005918, registry in 29/01/2015.

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.

Regulated aberrant amygdala functional connectivity in premenstrual syndrome via electro-acupuncture stimulation at sanyinjiao acupoint（SP6）

Background: Acupuncture is an effective therapy for premenstrual syndrome (PMS). However, the mechanisms behind this method are still unclear. Our previous study found that aberrant amygdala resting-state functional networks were involved in PMS. Thereby, a deep investigation on the alterations of amygdala resting-state functional networks induced by acupuncture stimulation might contribute to a better understanding of the intricate mechanisms of acupuncture treatment on PMS. Methods: Twenty three PMS patients were recruited in this study. All patients received a 6-minute electro-acupuncture stimulation (EAS) at Sanyinjiao acupoint (SP6) and underwent two 6-minute resting-state fMRI scannings before and after EAS. With amygdala as the seed region, functional connectivity (FC) method was adopted to examine EAS-related modulation of intrinsic connectivity in PMS patients by comparing pre-EAS. Results: The results showed that EAS at SP6 induced increased FC between the left amygdala and brainstem, right hippocampus, and decreased FC between the left amygdala and left thalamus, bilateral supplementary motor area (SMA). Moreover, the results also showed that EAS at SP6 induced increased FC between the right amygdala and brainstem, right hippocampus, right orbitofrontal cortex, bilateral anterior cingulate cortex (ACC), and decreased FC between the right amygdala and right SMA. Conclusions: Based on the results of our previous study, our findings might improve our understanding of neural mechanisms behind acupuncture effects on PMS.

The prevalence of premenstrual dysphoric disorder among adolescents in Ethiopia: a systematic review and meta-analysis

The rates of prevalence of premenstrual dysphoric disorder (PMDD) in Ethiopia were high and inconsistent across studies. However, there was no previous systematic reviews and meta-analysis conducted on this topic. Therefore, this review aimed to systematically review previous studies on the topic and summarize the prevalence of PMDD among students in Ethiopia and formulate recommendations for future clinical services. The preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines were used to conduct this systematic review and meta-analysis. Popular databases such as PubMed, EMBASE, Psych-INFO, SCOPUS, Google Scholar, African Index Medicus, and African Journals Online (AJOL) were searched for relevant studies. We used a Comprehensive Meta-Analysis software version 3.0 (CMA-3.0) to conduct a meta-analysis. The random-effects model was used to estimate the pooled prevalence. The magnitude of statistical heterogeneity between the eligible articles was checked by Cochrane Q and the I² statistics. The funnel plot and Egger's regression tests were used to assess potential publication bias. A total of 12 studies that were published between 2003 and 2019 was included in our systematic review and meta-analysis. The pooled estimated prevalence of premenstrual dysphoric disorder among female students in Ethiopia was 54.5% (95% CI 40.8-67.6). The pooled estimated prevalence of premenstrual dysphoric disorder was approximately similar for both studies that recruited study participants from either high school or higher education. Further, the pooled estimated prevalence of premenstrual dysphoric disorder was ranging from 51.2 to 57.2% in leave-one-out sensitivity analysis, suggesting that the removal of one study did not affect the overall prevalence estimate. The pooled estimated prevalence of premenstrual dysphoric disorder among female students in Ethiopia was high. Early screening and appropriate interventions at primary healthcare settings are warranted.

Association Between Smoking and Premenstrual Syndrome: A Meta-Analysis

Results of basic science studies demonstrate shared actions of endogenous neuroactive steroid hormones and drugs of abuse on neurotransmission. As such, premenstrual syndrome (PMS) may be associated with smoking, however, results from studies examining this relationship have been mixed. Following PRISMA guidelines, we extracted unique studies examining the relationship between smoking and PMS. We used the escalc () function in R to compute the log odds ratios and corresponding sampling variance for each study. We based quality assessment on the nature of PMS diagnosis and smoking estimation, confounding adjustment, participation rate, and a priori specification of target population. Our final sample included 13 studies, involving 25,828 study participants. Smoking was associated with an increased risk for PMS [OR = 1.56 (95% CI: 1.25-1.93), p < 0.0001]. Stratified by diagnosis, the effect size estimate was higher for Premenstrual Dysphoric Disorder (PMDD) [OR = 3.15 (95% CI: 2.20-4.52), p < 0.0001] than for PMS [OR = 1.27 (95% CI: 1.16-1.39), p < 0.0001]. We review some of the basic mechanisms for the observed association between smoking and PMS. Given nicotine's rewarding effects, increased smoking behavior may be a mechanism to alleviate affective symptoms of PMS. However, smoking may lead to worsening of PMS symptoms because nicotine has effects on neurocircuitry that increases susceptibility to environmental stressors. Indeed, prior evidence shows that the hypothalamic-pituitary-adrenal (HPA) axis is already sub-optimal in PMS, hence, smoking likely further deteriorates it. Combined, this complicates the clinical course for the treatment of both PMS and Tobacco Use Disorder in this population.

Thalamocortical dysconnectivity in premenstrual syndrome

Premenstrual syndrome (PMS) is a menstrual cycle-related disorder. Although the precise pathophysiology is not fully understood, it is increasingly believed that the central nervous system plays a vital role in the development of PMS. The aim of this study is to elucidate specific functional connectivity between the thalamus and cerebral cortex. Resting-state functional magnetic resonance imaging (fMRI) data were obtained from 20 PMS patients and 21 healthy controls (HCs). Seed-based functional connectivity between the thalamus and six cortical regions of interest, including the prefrontal cortex (PFC), posterior parietal cortex, somatosensory cortex, motor cortex/supplementary motor area, temporal and occipital lobe, was adopted to identify specific thalamocortical connectivity in the two groups. Correlation analysis was then used to examine relationships between the neuroimaging findings and clinical symptoms. Activity in distinct cortical regions correlated with specific sub-regions of the thalamus in the two groups. Comparison between groups exhibited decreased prefrontal-thalamic connectivity and increased posterior parietal-thalamic connectivity in the PMS patients. Within the PMS group, the daily record of severity of problems (DRSP) score negatively correlated with the prefrontal-thalamic connectivity. Our findings may provide preliminary evidence for abnormal thalamocortical connectivity in PMS patients and may contribute to a better understanding of the pathophysiology of PMS.

Contraception counseling for women with premenstrual dysphoric disorder (PMDD): current perspectives

Premenstrual Dysphoric Disorder (PMDD) is a severe form of premenstrual syndrome (PMS) affecting up to 7% of reproductive age women. Women with PMDD are of reproductive age; therefore, contraception and treatment of PMDD are important considerations. The disorder as described in the DSM-V is characterized by moderate to severe psychological, behavioral and physical symptoms beginning up to two weeks prior to menses, resolving soon after the onset of menstruation and significantly interfering with daily functioning. PMDD develops in predisposed individuals after they are exposed to progesterone at the time of ovulation. It has been hypothesized that PMDD is in part attributable to luteal phase abnormalities in serotonergic activity and to altered configuration of ℽ-aminobutyric acid subunit A (GABA_A) receptors in the brain triggered by the exposure to the neuroactive steroid progesterone metabolite, allopregnanolone (Allo). A large body of evidence suggests that selective serotonin reuptake inhibitors (SSRIs) can be effective in the treatment of PMDD. Combined hormonal contraceptive (CHC) pills, specifically the 20 mcg ethinyl estradiol/3mg drospirenone in a 24/4 extended cycle regimen has been shown to significantly improve the emotional and physical symptoms of PMDD. Other combined monophasic, extended cycle hormonal contraceptive pills with less androgenic progestins may also be helpful, although not well studied. Copper intrauterine devices (IUDs) are recommended for those not seeking hormonal contraceptives. Progestin-only methods including the progestin-only pill (POP), levonorgestrel (LNG) IUD, etonorgestrel implant or depot medroxyprogesterone acetate (DMPA) have the potential to negatively affect mood symptoms for women with or without baseline mood disorders, including PMDD. Careful counseling and close follow-up is recommended for patients with PMDD seeking these contraceptive methods.

Premenstrual Dysphoric Disorder: Ranking the Symptoms and Severity in Indian College Students

Background: Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are common conditions causing significant impairment in various domains of life. Both the conditions are associated with physical, emotional, and behavioral symptoms. There is dearth of studies regarding symptomatology and severity of the condition in Indian college students.

Aim: Aim of this study is to categorize and rank the symptoms and severity of PMDD in college students in India.

Materials and methods: A cross-sectional survey was conducted in various colleges of Mysuru. A total of 600 girls were approached over a period of 1 year. Confidentiality was assured and written informed consent was taken. Girls with irregular periods and those who had an absence of menstruation since last 3 consecutive menstrual cycles were excluded. A total of 571 filled up forms were taken for analysis. Data was analyzed using SPSS 22 version software. Chi-square test was used as the test of significance for qualitative data.

Results: The mean age of participants was 21.12 ± 2.6 years. Majority of the subjects were unmarried and were from urban background. The prevalence of PMS/PMDD was 46.1%, out of which 10.2% met the criteria for PMDD. Physical symptoms (91.4%) were the most commonly reported symptom domain in the PMDD category, followed by anger or irritability (84.5%). Almost half of the subjects with no or mild PMS had reported physical symptoms. The least reported symptom was insomnia. PMDD group had reported maximum impairment in the domain of relationship with family members (77.6%), followed by home responsibilities and relationship with coworkers.

Conclusion: This study suggests that the prevalence of clinically relevant PMS/PMDD is higher than widely cited estimates and is a cause of concern for health care authorities in India. Physical complaints are the most commonly reported among all the symptoms in all groups. There is a need to actively assess for premenstrual symptoms in young women for comprehensive treatment and good outcome.

Short-term, low-dose fluoxetine prevents oestrous cycle-linked increase in anxiety-like behaviour in female rats

BACKGROUND AND AIMS

We sought a robust behavioural test that evoked increased anxiety-like behaviour during the late dioestrus phase of the oestrous cycle (similar to the premenstrual period in women) and tested whether this could be prevented by acute low-dose fluoxetine (FLX).

METHODS

Female Wistar rats in different stages of their cycle were exposed to four different tests of anxiety-like behaviour.

RESULTS

No oestrous cycle differences were detected in fear potentiated startle or conditioned freezing to an aversive context. In a light switch-off test where rats move from one compartment of a shuttle-box to the other to turn off an aversive light, females displayed enhanced responding in late dioestrus. During isolation restraint stress females in late dioestrus emitted three times more 22 kHz ultrasound vocalisations (USV) than at other cycle stages. Using the USV test, short-term administration of low-dose FLX (1.75 mg kg^-1, i.p.) designed to blunt the sharp fall in brain allopregnanolone concentration during late dioestrus but without affecting 5-HT systems, prevented the increase in isolation stress-evoked USVs.

CONCLUSIONS

The light switch-off and isolation restraint-induced USV tests evoke unconditioned adverse emotional responses that are ethologically relevant and sensitive to oestrous cycle stage. The USV test fulfils many criteria required of a model for premenstrual syndrome in women. Using the USV test, short-term administration of FLX to increase brain allopregnanolone concentration without affecting 5-HT systems prevented the increased USV responding in late dioestrus. Short-term low-dose FLX treatment may have potential to alleviate development of adverse premenstrual symptoms in women.

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.

Pre-menstrual Dysphoric Disorder: A Review

Introduction: Premenstrual dysphoric disorder (PMDD) is a distressing disorder amongst women of reproductive age group with significant implication in the productivity and quality of life of women who suffer from it. It is generally neglected as it is mostly undifferentiated from premenstrual symptoms—milder presentation of the same spectrum of problem but of lesser intensity and impairment.

Objective: Here, in this article, we aim to highlight various studies and the research done on PMDD in the context of Indian women.

Method: Reviewing the last 40 years’ database including Medline (PUBMED), Cochrane Library, EMBASE, Trip, Psych INFO, CINAHL, the Allied and Complementary Medicine Database (AMED), and the British Nursing Index.

Results: PMDD is a troublesome disorder, often underdiagnosed. A thorough history including menstrual and sexual history, conducting a thorough physical examination, assessing the comorbidities, and finally using a proper and structured treatment protocol for managing the condition are recommended. Sertraline is the most widely studied drug which is found to be effective in PMDD.

Women's Psychiatry

Brain disorders and mental diseases, in particular, are common and considered as a top global health challenge for the twenty-first century. Interestingly, women suffer more frequently from mental disorders than men. Moreover, women may respond to psychotropic drugs differently than men, and, through their lifespan, they endure sex-orientated social stressors. In this chapter, we present how women may differ in the development and manifestation of mental health issues and how they differ from men in pharmacokinetics and pharmacodynamics. We discuss issues in clinical trials regarding women participation, issues in the use of psychotropic medications in pregnancy, and challenges that psychiatry faces as a result of the wider use of contraceptives, of childbearing at older age, and of menopause. Such issues, among others, demand further women-oriented psychiatric research that can improve the care for women during the course of their lives. Indeed, despite all these known sex differences, psychiatry for both men and women patients uses the same approach. Thereby, a modified paradigm for women's psychiatry, which takes into account all these differences, emerges as a necessity, and psychiatric research should take more vigorously into account sex differences.

Cortical and subcortical changes in patients with premenstrual syndrome

BACKGROUND

Premenstrual syndrome (PMS) is characterized by a series of emotional, physical and behavioral symptoms. Although PMS is related to dysfunctions of the central nervous system, the neuropathological mechanism of PMS still has not been clearly established. The aim of this study is to evaluate potential differences in both cortical thickness and subcortical volumes in PMS patients compared to healthy controls (HCs).

METHODS

Twenty PMS patients and twenty HCs underwent a structural magnetic resonance imaging scan and clinical assessment. Cortical thickness and subcortical volumes were computed using the FreeSurfer image analysis suite. Relationships between cortical thickness/subcortical volumes and the daily rating of severity of problems (DRSP) score were then measured in patients.

RESULTS

Compared to HCs, PMS patients exhibited reduced cortical thickness in the medial prefrontal cortex (MPFC), orbitofrontal cortex (OFC) and insula, and increased subcortical volumes of the amygdala, thalamus and pallidum. Furthermore, negative correlations were detected between the DRSP and cortical thickness in the anterior cingulate cortex and precuneus.

LIMITATIONS

The study is limited by a small sample size and narrow age range of participants.

CONCLUSIONS

Our findings indicate that the abnormal morphological changes are mainly implicated in emotional regulation and visceral perception in PMS patients. We hope that our study may contribute to a better understanding of PMS.

Altered Brain Regional Homogeneity Following Electro-Acupuncture Stimulation at Sanyinjiao (SP6) in Women With Premenstrual Syndrome

Background: Premenstrual syndrome (PMS) is a menstrual cycle-related disorder which causes physical and mood changes prior to menstruation and is associated with the functional dysregulation of the brain. Acupuncture is an effective alternative therapy for treating PMS, and sanyinjiao (SP6) is one of the most common acupoints used for improving the symptoms of PMS. However, the mechanism behind acupuncture's efficacy for relieving PMS symptoms remains unclear. The aim of this study was to identify the brain response patterns induced by acupuncture at acupoint SP6 in patients with PMS. Materials and Methods: Twenty-three females with PMS were enrolled in this study. All patients underwent resting-state fMRI data collection before and after 6 min of electroacupuncture stimulation (EAS) at SP6. A regional homogeneity (ReHo) approach was used to compare patients' brain responses before and after EAS at SP6 using REST software. The present study was registered at http://www.chictr.org.cn, and the Clinical Trial Registration Number is ChiCTR-OPC-15005918. Results: EAS at SP6 elicited decreased ReHo value at the bilateral precuneus, right inferior frontal cortex (IFC) and left middle frontal cortex (MFC). In contrast, increased ReHo value was found at the bilateral thalamus, bilateral insula, left putamen and right primary somatosensory cortex (S1). Conclusions: Our study provides an underlying neuroimaging evidence that the aberrant neural activity of PMS patients could be regulated by acupuncture at SP6.

Altered brain structure in women with premenstrual syndrome

BACKGROUND

Functional brain abnormalities have been noted in premenstrual syndrome (PMS). However, the brain structural alterations related to PMS remain unclear. This study aimed to identify possible abnormalities in gray matter (GM) volumes and structural covariance patterns among PMS patients.

METHODS

Structural magnetic resonance imaging data were obtained from 20 PMS patients and 20 healthy controls. Voxel-based morphometry (VBM) analysis was applied to examine GM volumes changes between the two groups. Receiver operating characteristic (ROC) curve was used to investigate the most reliable biomarker for distinguishing PMS patients from health controls based on the intergroup differences. Correlation analysis was then performed to assess relationships between the daily rating of severity of problems (DRSP) and abnormal brain regions. Finally, the regions identified from VBM analysis were served as seeds to characterize the whole-brain structural covariance patterns.

RESULTS

Compared with healthy controls, PMS patients showed increased GM volumes in the precuneus/posterior cingulate cortex (precuneus/PCC) and thalamus, and decreased GM volumes in the insula. The precuneus/PCC exhibited the highest classification power by ROC analysis and positively correlated with the DRSP. Moreover, different patterns of structural covariance in the two groups were mainly located in the dorsolateral prefrontal cortex, anterior cingulate cortex, angular gyrus and hippocampus.

LIMITATIONS

This study is limited by a small sample and narrow age range of participants.

CONCLUSIONS

Our findings may provide preliminary evidence for brain morphology alterations in PMS patients and contribute to a better understanding of the pathophysiology of PMS.

Female psychopharmacology matters! Towards a sex-specific psychopharmacology

There is increasing recognition that women have a higher prevalence of certain psychiatric illnesses, and a differential treatment response and course of illness compared to men. Additionally, clinicians deal with a number of disorders like premenstrual syndrome, premenstrual dysphoric disorder, and postpartum depression, which affect women specifically and for which treatment and biological pathways are still unclear. In this article we highlight recent research which suggests that different biological mechanisms may underlie sex differences in responsiveness to stress. Sex differences are evident at the receptor level; where the corticotropin-releasing factor receptor shows differential coupling to adaptor proteins in males and females. The neuropeptide oxytocin also shows sex-specific effects in a range of social behaviors. It may act as a biomarker in post-traumatic stress disorder where sex differences are evident. Studies in women using hormonal contraception show that some of these oxytocin-mediated effects are likely influenced by sex hormones. In female rats rapid changes in circulating progesterone levels are associated with exaggerated behavioral responses to mild stress and blunted responses to benzodiazepines that could be prevented by acute treatment with low-dose fluoxetine. Perceived barriers in research on women have hindered progress. The development of a sex-specific psychopharmacology as a basis for translating this type of research into clinical practice is vital to improve treatment outcomes for women.

Larger volume and different functional connectivity of the amygdala in women with premenstrual syndrome

OBJECTIVES

To assess structural and functional changes of the amygdala due to premenstrual syndrome (PMS) using magnetic resonance imaging (MRI).

METHODS

Twenty PMS patients and 21 healthy control (HC) subjects underwent a 6-min resting-state fMRI scan during the luteal phase as well as scanning high-resolution T1-weighted images. Subcortical amygdala-related volume and functional connectivity (FC) were estimated between the two groups. Each subject completed a daily record of severity of problems (DRSP) to measure the severity of clinical symptoms.

RESULTS

Greater bilateral amygdalae volumes were found in PMS patients compared with HC subjects, and PMS patients had increased FC between the amygdala and certain regions of the frontal cortex (e.g. medial prefrontal cortex (mPFC), anterior cingulate cortex (ACC), right precentral gyrus), the right temporal pole and the insula, as well as decreased FC between the bilateral amygdalae and the right orbitofrontal cortex and right hippocampus. The strength of FC between the right amygdala and right precentral gyrus, left ACC and left mPFC were significantly and positively correlated with DRSP scores in PMS patients.

CONCLUSIONS

Our findings may improve our understanding of the neural mechanisms involved in PMS.

KEY POINTS

• Functional and structural MRI used to explore amygdala in PMS patients. • Aberrant amygdala structural and functional connectivity were found in PMS patients. • Amygdala strength FC was positively correlated with individual clinical symptom scores.

Premenstrual Dysphoric Disorder Symptoms Following Ovarian Suppression: Triggered by Change in Ovarian Steroid Levels But Not Continuous Stable Levels

OBJECTIVE

Premenstrual dysphoric disorder (PMDD) symptoms are eliminated by ovarian suppression and stimulated by administration of ovarian steroids, yet they appear with ovarian steroid levels indistinguishable from those in women without PMDD. Thus, symptoms could be precipitated either by an acute change in ovarian steroid levels or by stable levels above a critical threshold playing a permissive role in expression of an underlying infradian affective "pacemaker." The authors attempted to determine which condition triggers PMDD symptoms.

METHOD

The study included 22 women with PMDD, ages 30 to 50 years. Twelve women who experienced symptom remission after 2-3 months of GnRH agonist-induced ovarian suppression (leuprolide) then received 1 month of single-blind (participant only) placebo and then 3 months of continuous combined estradiol/progesterone. Primary outcome measures were the Rating for Premenstrual Tension observer and self-ratings completed every 2 weeks during clinic visits. Multivariate repeated-measure ANOVA for mixed models was employed.

RESULTS

Both self- and observer-rated scores on the Rating for Premenstrual Tension were significantly increased (more symptomatic) during the first month of combined estradiol/progesterone compared with the last month of leuprolide alone, the placebo month, and the second and third months of estradiol/progesterone. There were no significant differences in symptom severity between the last month of leuprolide alone, placebo month, or second and third months of estradiol/progesterone. Finally, the Rating for Premenstrual Tension scores in the second and third estradiol/progesterone months did not significantly differ.

CONCLUSIONS

The findings demonstrate that the change in estradiol/progesterone levels from low to high, and not the steady-state level, was associated with onset of PMDD symptoms. Therapeutic efforts to modulate the change in steroid levels proximate to ovulation merit further study.

Altered fractional amplitude of low frequency fluctuation in premenstrual syndrome: A resting state fMRI study

BACKGROUND

Premenstrual syndrome (PMS) is becoming highly prevalent among female and is characterized by emotional, physical and behavior symptoms. Previous evidence suggested functional dysregulation of female brain was expected to be involved in the etiology of PMS. The aim of present study was to evaluate the alterations of spontaneous brain activity in PMS patients based on functional magnetic resonance imaging (fMRI).

METHODS

20 PMS patients and 21 healthy controls underwent resting-state fMRI scanning during luteal phase. All participants were asked to complete a prospective daily record of severity of problems (DRSP) questionnaire.

RESULTS

Compared with healthy controls, the results showed that PMS patients had increased fALFF in bilateral precuneus, left hippocampus and left inferior temporal cortex, and decreased fALFF in bilateral anterior cingulate cortex (ACC) and cerebellum at luteal phase. Moreover, the DRSP scores of PMS patients were negatively correlated with the mean fALFF in ACC and positively correlated with the fALFF in precuneus.

LIMITATIONS

(1) the study did not investigate whether or not abnormal brain activity differences between groups in mid-follicular phase, and within-group changes. between phases.(2) it was relatively limited sample size and the participants were young; (3) fALFF could not provide us with more holistic information of brain network;(4) the comparisons of PMS and premenstrual dysphoric disorder (PMDD) were not involved in the study.

CONCLUSIONS

The present study shows abnormal spontaneous brain activity in PMS patients revealed by fALFF, which could provide neuroimaging evidence to further improve our understanding of the underlying neural mechanism of PMS.

The steroid metabolome in women with premenstrual dysphoric disorder during GnRH agonist-induced ovarian suppression: effects of estradiol and progesterone addback

Clinical evidence suggests that symptoms in premenstrual dysphoric disorder (PMDD) reflect abnormal responsivity to ovarian steroids. This differential steroid sensitivity could be underpinned by abnormal processing of the steroid signal. We used a pharmacometabolomics approach in women with prospectively confirmed PMDD (n=15) and controls without menstrual cycle-related affective symptoms (n=15). All were medication-free with normal menstrual cycle lengths. Notably, women with PMDD were required to show hormone sensitivity in an ovarian suppression protocol. Ovarian suppression was induced for 6 months with gonadotropin-releasing hormone (GnRH)-agonist (Lupron); after 3 months all were randomized to 4 weeks of estradiol (E2) or progesterone (P4). After a 2-week washout, a crossover was performed. Liquid chromatography/tandem mass spectrometry measured 49 steroid metabolites in serum. Values were excluded if >40% were below the limit of detectability (n=21). Analyses were performed with Wilcoxon rank-sum tests using false-discovery rate (q<0.2) for multiple comparisons. PMDD and controls had similar basal levels of metabolites during Lupron and P4-derived neurosteroids during Lupron or E2/P4 conditions. Both groups had significant increases in several steroid metabolites compared with the Lupron alone condition after treatment with E2 (that is, estrone-SO4 (q=0.039 and q=0.002, respectively) and estradiol-3-SO4 (q=0.166 and q=0.001, respectively)) and after treatment with P4 (that is, allopregnanolone (q=0.001 for both PMDD and controls), pregnanediol (q=0.077 and q=0.030, respectively) and cortexone (q=0.118 and q=0.157, respectively). Only sulfated steroid metabolites showed significant diagnosis-related differences. During Lupron plus E2 treatment, women with PMDD had a significantly attenuated increase in E2-3-sulfate (q=0.035) compared with control women, and during Lupron plus P4 treatment a decrease in DHEA-sulfate (q=0.07) compared with an increase in controls. Significant effects of E2 addback compared with Lupron were observed in women with PMDD who had significant decreases in DHEA-sulfate (q=0.065) and pregnenolone sulfate (q=0.076), whereas controls had nonsignificant increases (however, these differences did not meet statistical significance for a between diagnosis effect). Alterations of sulfotransferase activity could contribute to the differential steroid sensitivity in PMDD. Importantly, no differences in the formation of P4-derived neurosteroids were observed in this otherwise highly selected sample of women studied under controlled hormone exposures.

The ESC/E(Z) complex, an effector of response to ovarian steroids, manifests an intrinsic difference in cells from women with premenstrual dysphoric disorder

Clinical evidence suggests that mood and behavioral symptoms in premenstrual dysphoric disorder (PMDD), a common, recently recognized, psychiatric condition among women, reflect abnormal responsivity to ovarian steroids. This differential sensitivity could be due to an unrecognized aspect of hormonal signaling or a difference in cellular response. In this study, lymphoblastoid cell line cultures (LCLs) from women with PMDD and asymptomatic controls were compared via whole-transcriptome sequencing (RNA-seq) during untreated (ovarian steroid-free) conditions and following hormone treatment. The women with PMDD manifested ovarian steroid-triggered behavioral sensitivity during a hormone suppression and addback clinical trial, and controls did not, leading us to hypothesize that women with PMDD might differ in their cellular response to ovarian steroids. In untreated LCLs, our results overall suggest a divergence between mRNA (for example, gene transcription) and protein (for example, RNA translation in proteins) for the same genes. Pathway analysis of the LCL transcriptome revealed, among others, over-expression of ESC/E(Z) complex genes (an ovarian steroid-regulated gene silencing complex) in untreated LCLs from women with PMDD, with more than half of these genes over-expressed as compared with the controls, and with significant effects for MTF2, PHF19 and SIRT1 (P<0.05). RNA and protein expression of the 13 ESC/E(Z) complex genes were individually quantitated. This pattern of increased ESC/E(Z) mRNA expression was confirmed in a larger cohort by qRT-PCR. In contrast, protein expression of ESC/E(Z) genes was decreased in untreated PMDD LCLs with MTF2, PHF19 and SIRT1 all significantly decreased (P<0.05). Finally, mRNA expression of several ESC/E(Z) complex genes were increased by progesterone in controls only, and decreased by estradiol in PMDD LCLs. These findings demonstrate that LCLs from women with PMDD manifest a cellular difference in ESC/E(Z) complex function both in the untreated condition and in response to ovarian hormones. Dysregulation of ESC/E(Z) complex function could contribute to PMDD.

Emotional interference and attentional processing in premenstrual syndrome

BACKGROUND AND OBJECTIVES

Premenstrual syndrome (PMS) is characterized by menstrual cycle-related affective, behavioral, and/or somatic symptoms. By applying the emotional Stroop task (EST) the current study examined if changes in processing emotional information, which have been demonstrated in affective disorders, are also present in PMS.

METHODS

Via online screening, telephone interviews, and daily records over two months 55 women for the PMS group (on the basis of the specific inclusion criteria and a prospectively confirmed PMS) and 55 'non-PMS' controls were recruited. All participants completed three emotional Stroop tasks (EST) with neutral and negative word, picture, and facial stimuli, during the follicular and luteal phase of the menstrual cycle.

RESULTS

Mixed 2 × 2 univariate analyses of variance and post-hoc comparisons showed primarily a greater emotional Stroop effect with respect to picture and facial stimuli in the luteal menstrual cycle phase in women with PMS, compared to the control group. No significant group differences were observed for word stimuli. With respect to the facial stimuli, a kind of paradox effect was revealed (Stroop facilitation) in the PMS group.

LIMITATIONS

This study provides important information regarding cognitive processes in women suffering from PMS that have to be interpreted in the light of the following limitations: a limited representativeness of the sample, the determination of menstrual cycle phases based on symptom diaries but not hormone levels, and a limited interpretability of our results as causal relationships.

CONCLUSIONS

Our findings are in line with the assumption that alterations in cognitive-emotional processes are associated with PMS. Further research on the etiology of PMS should focus more on cognitive-emotional processing and its interaction with biological changes relating to the menstrual cycle.

Abnormal Spontaneous Brain Activity in Women with Premenstrual Syndrome Revealed by Regional Homogeneity

Background: Previous studies have revealed that the etiologies of premenstrual syndrome (PMS) refer to menstrual cycle related brain changes. However, its intrinsic neural mechanism is still unclear. The aim of the present study was to assess abnormal spontaneous brain activity and to explicate the intricate neural mechanism of PMS using resting state functional magnetic resonance imaging (RS-fMRI). Materials and Methods: The data of 20 PMS patients (PMS group) and 21 healthy controls (HC group) were analyzed by regional homogeneity (ReHo) method during the late luteal phase of menstrual cycle. In addition, all the participants were asked to complete a daily record of severity of problems (DRSP) questionnaire. Results: Compared with HC group, the results showed that PMS group had increased ReHo mainly in the bilateral precuneus, left inferior temporal cortex (ITC), right inferior frontal cortex (IFC) and left middle frontal cortex (MFC) and decreased ReHo in the right anterior cingulate cortex (ACC) at the luteal phase. Moreover, the PMS group had higher DRSP scores, and the DRSP scores positively correlated with ReHo in left MFC and negatively correlated with ReHo in the right ACC. Conclusion: Our results suggest that abnormal spontaneous brain activity is found in PMS patients and the severity of symptom is specifically related to the left MFC and right ACC. The present findings may be beneficial to explicate the intricate neural mechanism of PMS.

A specific profile of luteal phase progesterone is associated with the development of premenstrual symptoms

There is a consensus that the development of premenstrual dysphoric states is related to cyclical change in gonadal hormone secretion during the menstrual cycle. However, results from studies seeking to link symptom severity to luteal phase progesterone concentration have been equivocal. In the present study we evaluated not only the absolute concentrations of progesterone but also the kinetics of the change in progesterone concentration in relation to development of premenstrual symptoms during the last 10days of the luteal phase in a population of 46 healthy young adult Brazilian women aged 18-39 years, mean 26.5±6.7years. In participants who developed symptoms of premenstrual distress, daily saliva progesterone concentration remained stable during most of the mid-late luteal phase, before declining sharply during the last 3days prior to onset of menstruation. In contrast, progesterone concentration in asymptomatic women underwent a gradual decline over the last 8days prior to menstruation. Neither maximum nor minimum concentrations of progesterone in the two groups were related to the appearance or severity of premenstrual symptoms. We propose that individual differences in the kinetics of progesterone secretion and/or metabolism may confer differential susceptibility to the development of premenstrual syndrome.

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.

Ethinyl Estradiol/Drospirenone for the Treatment of the Emotional and Physical Symptoms of Premenstrual Dysphoric Disorder

A combined oral contraceptive pill containing 20 μg of ethinyl estradiol and 3 mg of the progestin drospirenone in a novel dose regimen (24 active pills followed by 4 placebo pills), has demonstrated efficacy for the symptoms of premenstrual dysphoric disorder, a severe form of premenstrual syndrome, with an emphasis on the affective symptoms. Drospirenone has progestagenic, anti-androgenic and anti-aldosterone properties, which differ from earlier generations of progestins, and reducing the hormone pill-free interval allows for better suppression of ovarian steroid production.

Environmental enrichment prevents anxiety-like behavior induced by progesterone withdrawal in two strains of rats

Stress vulnerability could influence the treatment response to anxiety associated with abrupt hormonal suppression. The present study explored the effects of different treatments on experimental anxiety induced by progesterone withdrawal (PW) in a stress-sensitive rat strain, Wistar Kyoto (WKY), in the burying behavior test (BBT). The following experimental series was conducted using independent groups of Wistar (control strain) and WKY ovariectomized rats: Experiment 1: Rats were treated for 5days with oil, a constant dose of progesterone (0.5mg/rat, s.c) or a combination of progesterone (0.5mg/rat, s.c) plus fluoxetine (10 mg/kg, i.p); on day 6, all rats were subjected to BBT. Experiment 2: Rats received corn oil or decreasing doses of progesterone (0.84, 0.67, 0.5, 0.33 and 0.17mg/rat; one dose daily); on day 6, the rats were subjected to BBT. Experiment 3: Rats were divided into two groups that were subjected to 30days of standard conditions or environmental enrichment (EE); from days 25 to 30, all rats received a fixed dose of progesterone (0.5mg/rat, s.c.) or vehicle. On day 31, the rats were tested with BBT. Results showed that PW increased anxiety in both strains, and fluoxetine prevented anxiety in WKY rats. In contrast, a gradual reduction of progesterone prevents the anxiety in Wistar but not in WKY. EE was preventive against the anxiety induced by PW in both strains of rats. Thus, the results suggest that anxiety induced by PW is prevented by EE while the anxiolytic effect of pharmacological treatments depends on stress vulnerability.

Contraceptive options for women with premenstrual dysphoric disorder: current insights and a narrative review

Premenstrual syndrome and its most severe form, premenstrual dysphoric disorder (PMDD), are two well-defined clinical entities that affect a considerable number of women. Progesterone metabolites and certain neurotransmitters, such as gamma-aminobutyric acid and serotonin, are involved in the etiology of this condition. Until recently, the only treatment for women with PMDD was psychoactive drugs, such as selective serotonin reuptake inhibitors. Several years ago, there has been evidence of the beneficial role of combined hormonal contraceptives in controlling PMDD symptoms. Oral combined hormonal contraceptives that contain drospirenone in a 24+4-day regimen are the only drugs that have been approved by US Food and Drug Administration for the treatment of PMDD, but there is scientific evidence that other agents, with other formulations and regimens, could also be effective for the treatment of this condition. However, it remains unclear whether the beneficial effect of combined hormonal contraceptives is associated with the type of estrogen or progestogen used or the treatment regimen.

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).

A lack of consistent evidence for cortisol dysregulation in premenstrual syndrome/premenstrual dysphoric disorder

Although decades of research has examined the association between cortisol regulation and premenstrual syndrome/premenstrual dysphoric disorder (PMS/PMDD), no review exists to provide a general set of conclusions from the extant research. In the present review we summarize and interpret research that has tested for associations between PMS/PMDD and cortisol levels and reactivity (n=38 original research articles). Three types of studies are examined: correlational studies, environmental-challenge studies, and pharmacological-challenge studies. Overall, there was very little evidence that women with and without PMS/PMDD demonstrate systematic and predictable mean-level differences in cortisol, or differences in cortisol response/reactivity to challenges. Methodological differences in sample size, the types of symptoms used for diagnosis (physical and psychological vs. only affective), or the type of cortisol measure used (serum vs. salivary), did not account for differences between studies that did and did not find significant effects. Caution is recommended before accepting the conclusion of null effects, and recommendations are made that more rigorous research be conducted, considering symptom-specificity, within-person analyses, and multiple parameters of cortisol regulation, before final conclusions are drawn.