The Significance of "Nonsignificance" in Randomized Controlled Studies: A Discussion Inspired by a Double-Blinded Study on St. John's Wort (Hypericum perforatum L.) for Premenstrual Symptoms

Diagnostic validity of premenstrual dysphoric disorder: revisited

The World Health Organization (WHO) and American Psychiatric Association (APA) have recognised premenstrual dysphoric disorder (PMDD) as an independent diagnostic entity, legitimising the distress and socio-occupational impairment experienced by affected women. However, the biological validity of this diagnosis remains inexplicit. This illness has also been criticised for a feminist-led, sympathetic reaction to the modern cultural challenges of urban, literate, employed, high-functioning women. This article systematically reviews existing literature on PMDD using the criteria established by Robins and Guze for the validity of a psychiatric diagnosis (clinical description, laboratory study, exclusion of other disorders, follow-up study, and family study). Despite the early recognition of premenstrual syndrome (PMS) in the 1950s, the research has encountered challenges due to two groups of proponents viewing it with psychologising bias and medicalising bias. PMDD is currently understood as the most severe form of PMS, characterised by the presence of psychological features. Recent evidence suggests that PMDD perhaps has neurodevelopmental underpinnings (attention deficit hyperactive disorder, adverse childhood experiences) affecting the fronto-limbic circuit that regulates the emotions. In addition, the affected individuals exhibit an increased sensitivity to gonadal hormonal fluctuations as observed during premenstrual, pregnancy, and perimenopausal phases of life. The prevalence is comparable between high-income countries and low- and middle-income countries (LAMIC), refuting the notion that it mostly affects modern women. Instead, a greater prevalence is observed in LAMIC. Despite the fact that educated women possess knowledge regarding the importance of getting help, there is a prevalent issue of inadequate help-seeking behaviour. This can be attributed to the perception of seeking help as an isolating experience, which is influenced by profound internalised stigma and discrimination in the workplace. Future studies must aim to develop culturally validated assessment tools and more research to understand the life course of the illness, in addition to systematically examining for more biological validators (animal models, genetics, imaging, neurotransmitters).

Nutritional practices to manage menstrual cycle related symptoms: a systematic review

Certain nutritional practices may reduce menstrual-related symptoms, but there is no current consensus on what foods/supplements are sufficiently evidenced to warrant promotion to reduce menstrual symptoms of naturally menstruating individuals. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two online databases were searched for published experimental studies that investigated the effects of foods/supplements on menstrual-related symptoms in eumenorrhoeic women. Extracted data and study characteristics were tabulated and grouped on the basis of food/supplement intervention and dosage compared with UK dietary reference values (DRV) and safe upper limits. In total, twenty-eight studies and twenty-one different foods/supplement interventions were included in the review. None of the studies reported a negative effect on symptoms, twenty-three reported a positive effect and five had no effect. Eighteen different ways of measuring menstrual-related symptoms were described across the studies. The results indicate a lack of consistency in studies to confidently provide information to eumenorrheic, naturally menstruating women regarding the use of foods/supplements to reduce menstrual symptoms. Determination of menstrual-related symptoms varied along with dose and duration of food or supplements provided. These data provide some evidence for the use of vitamin D, calcium, zinc and curcumin to reduce menstrual-related symptoms of non-hormonal contraceptive users, on an individual basis; however, further investigation is required prior to implementation with a focus on robust protocols to determine and measure changes in menstrual symptoms, with interventions adhering to DRV and safe upper limits.

Could Anise decrease the intensity of premenstrual syndrome symptoms in comparison to placebo? A double-blind randomized clinical trial

Background Premenstrual syndrome (PMS) has a high prevalence among women of reproductive ages but despite its high prevalence, it has no determined and absolute treatment, so far. So, the aim of the present study was to compare the effect Pimpinella Anisum (Anise) with placebo on the intensity of the symptoms of PMS. Methods The present study was a randomized double-blind controlled clinical trial. College students who were suffering from PMS and had the inclusion criteria were selected and randomly assigned into two groups of intervention (Anise) and control (placebo). Participants in the intervention group, received 110 mg capsules of Anise three times day (a total dose of 330 mg per day); the control group received similar capsules with the same dosing that contained starch. Consumption of the capsules was started 7 days before the start of the menstruation and continued until 3 days after, which was a total of 10 days during two consecutive menstruation cycles. The intensity of the symptoms of premenstrual syndrome was measured using Premenstrual Symptoms Screening Tool (PSST). To compare the intensity of the symptoms between the two study groups, generalized estimating equation statistical method was used. Results Eventually, sixty-seven 18-35 year old college students who were suffering from premenstrual syndrome were enrolled in the study. Comparing the mean score of the intensity of the syndrome between the two groups after the first and the second menstruation cycles showed a decrease in the intervention group to 13.9 (p-value<0.001; 95% CI: 16.5,-11.4) and 9.8 (p-value<0.001; 95% CI: 12.4,-7.3), respectively. Conclusion Results of the study showed that, in general, Anise was effective in decreasing the symptoms of premenstrual syndrome in comparison to placebo.

Effects and treatment methods of acupuncture and herbal medicine for premenstrual syndrome/premenstrual dysphoric disorder: systematic review

BACKGROUND

During their reproductive years about 10% of women experience some kind of symptoms before menstruation (PMS) in a degree that affects their quality of life (QOL). Acupuncture and herbal medicine has been a recent favorable therapeutic approach. Thus we aimed to review the effects of acupuncture and herbal medicine in the past decade as a preceding research in order to further investigate the most effective Korean Medicine treatment for PMS/PMDD.

METHODS

A systematic literature search was conducted using electronic databases on studies published between 2002 and 2012. Our review included randomized controlled clinical trials (RCTs) of acupuncture and herbal medicine for PMS/PMDD. Interventions include acupuncture or herbal medicine. Clinical information including statistical tests was extracted from the articles and summarized in tabular form or in the text. Study outcomes were presented as the rate of improvement (%) and/or end-of-treatment scores.

RESULTS

The search yielded 19 studies. In screening the RCTs, 8 studies in acupuncture and 11 studies in herbal medicine that matched the criteria were identified. Different acupuncture techniques including traditional acupuncture, hand acupuncture and moxibustion, and traditional acupuncture technique with auricular points, have been selected for analysis. In herbal medicine, studies on Vitex Agnus castus, Hypericum perforatum, Xiao yao san, Elsholtzia splendens, Cirsium japonicum, and Gingko biloba L. were identified. Experimental groups with Acupuncture and herbal medicine treatment (all herbal medicine except Cirsium japonicum) had significantly improved results regarding PMS/PMDD.

CONCLUSIONS

Limited evidence supports the efficacy of alternative medicinal interventions such as acupuncture and herbal medicine in controlling premenstrual syndrome and premenstrual dysphoric disorder. Acupuncture and herbal medicine treatments for premenstrual syndrome and premenstrual dysphoric disorder showed a 50% or better reduction of symptoms compared to the initial state. In both acupuncture and herbal medical interventions, there have been no serious adverse events reported, proving the safety of the interventions while most of the interventions provided over 50% relief of symptoms associated with PMS/PMDD. Stricter diagnostic criteria may have excluded many participants from some studies. Also, depending on the severity of symptoms, the rate of improvement in the outcomes of the studies may have greatly differed.

Premenstrual dysphoric disorder and severe premenstrual syndrome in adolescents

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

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

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

Herbal treatments for alleviating premenstrual symptoms: a systematic review

Premenstrual syndrome (PMS) is a condition of cyclical and recurrent physical and psychological discomfort occurring 1 to 2 weeks before menstrual period. More severe psychological symptoms have been described for the premenstrual dysphoric disorder (PMDD). No single treatment is universally recognised as effective and many patients often turn to therapeutic approaches outside of conventional medicine. This systematic review is aimed at analysing the effects of herb remedies in the above conditions. Systematic literature searches were performed in electronic databases, covering the period January 1980 to September 2010. Randomised controlled clinical trials (RCTs) were included. Papers quality was evaluated with the Jadad' scale. A further evaluation of PMS/PMDD diagnostic criteria was also done. Of 102 articles identified, 17 RCTs were eligible and 10 of them were included. The heterogeneity of population included, study design and outcome presentation refrained from a meta-analysis. Vitex agnus castus was the more investigated remedy (four trials, about 500 women), and it was reported to consistently ameliorate PMS better than placebo. Single trials also support the use of either Gingko biloba or Crocus sativus. On the contrary, neither evening primrose oil nor St. John's Wort show an effect different than placebo. None of the herbs was associated with major health risks, although the reduced number of tested patients does not allow definitive conclusions on safety. Some herb remedies seem useful for the treatment of PMS. However, more RCTs are required to account for the heterogeneity of the syndrome.

Women's health: selected topics

Complementary and alternative medicine (CAM) therapies have become increasingly popular for the treatment of a variety of conditions. The World Health Organization has recognized the value of traditional healing techniques, which are classified as CAM, for 30 years. In the United States nearly 50% of women use CAM for common medical conditions, significantly more than men. This pattern is frequently seen in the treatment of women's health conditions such as infertility, premenstrual syndrome, and menopause. This article provides an integrative approach for conditions commonly encountered in the primary care setting among women, discusses alternative therapies used to treat these health conditions, and provides an evidence-based summary of recommendations based on a review of the literature.

The efficacy of Hypericum perforatum (St John's wort) for the treatment of premenstrual syndrome: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Premenstrual syndrome (PMS) is a common condition. Some of the most widely prescribed medications are selective serotonin reuptake inhibitors (SSRIs), based on the hypothesized role of serotonin in the production of PMS symptoms. PMS sufferers, especially those experiencing mild to moderate symptoms, are often reluctant to take this form of medication and instead buy over-the-counter preparations to treat their symptoms, for which the evidence base with regard to efficacy is limited. Hypericum perforatum (St John's wort) influences the serotonergic system. As such, this widely available herbal remedy deserves attention as a PMS treatment.

OBJECTIVE

To investigate the effectiveness of Hypericum perforatum on symptoms of PMS.

STUDY DESIGN

This randomized, double-blind, placebo-controlled, crossover study was conducted between November 2005 and June 2007.

SETTING

Institute of Psychological Sciences, University of Leeds, Leeds, UK.

PARTICIPATION

36 women aged 18-45 years with regular menstrual cycles (25-35 days), who were prospectively diagnosed with mild PMS.

INTERVENTION

Women who remained eligible after three screening cycles (n = 36) underwent a two-cycle placebo run-in phase. They were then randomly assigned to receive Hypericum perforatum tablets 900 mg/day (standardized to 0.18% hypericin; 3.38% hyperforin) or identical placebo tablets for two menstrual cycles. After a placebo-treated washout cycle, the women crossed over to receive placebo or Hypericum perforatum for two additional cycles.

MAIN OUTCOME MEASURES

Symptoms were rated daily throughout the trial using the Daily Symptom Report. Secondary outcome measures were the State Anxiety Inventory, Beck Depression Inventory, Aggression Questionnaire and Barratt Impulsiveness Scale. Plasma hormone (follicle-stimulating hormone [FSH], luteinizing hormone [LH], estradiol, progesterone, prolactin and testosterone) and cytokine (interleukin [IL]-1beta, IL-6, IL-8, interferon [IFN]-gamma and tumour necrosis factor [TNF]-alpha) levels were measured in the follicular and luteal phases during Hypericum perforatum and placebo treatment.

RESULTS

Hypericum perforatum was statistically superior to placebo in improving physical and behavioural symptoms of PMS (p < 0.05). There were no significant effects of Hypericum perforatum compared with placebo treatment for mood- and pain-related PMS symptoms (p > 0.05). Plasma hormone (FSH, LH, estradiol, progesterone, prolactin and testosterone) and cytokine (IL-1beta, IL-6, IL-8, IFNgamma and TNFalpha) levels, and weekly reports of anxiety, depression, aggression and impulsivity, also did not differ significantly during the Hypericum perforatum and placebo cycles (p > 0.05).

CONCLUSION

Daily treatment with Hypericum perforatum was more effective than placebo treatment for the most common physical and behavioural symptoms associated with PMS. As proinflammatory cytokine levels did not differ significantly between Hypericum perforatum and placebo treatment, these beneficial effects are unlikely to be produced through this mechanism of action alone. Further work is needed to determine whether pain- and mood-related PMS symptoms benefit from longer treatment duration. Trial registration number (International Standard Randomised Controlled Trial Number Register) ISRCTN31487459.

The importance of early phase research

Early phase research in complementary and alternative medicine (CAM) is especially important because of the large influence it has on the subsequent expenditure of money and effort in particular areas of CAM therapies. The culture of biomedical research has, however, blurred the distinction between early and late-phase research, and this has distorted the very distinct aims of these two activities. The purpose of this paper is to reaffirm the critical role of early phase CAM research and to encourage CAM researchers to value and conduct early phase studies for their proper purposes.