Premenstrual syndromes: closing the 20th century chapters

The diagnosis of premenstrual syndromes and premenstrual dysphoric disorder--clinical procedures and research perspectives

Premenstrual syndromes (PMS) are quite prevalent among women of reproductive age. In up to 20% of women they are severe enough to warrant treatment, which is available and marketed as such. The impact of the cumulative burden of PMS is substantial and is in the same magnitude as affective disorders. Nevertheless, the definitions and diagnoses of PMS are still fragmented, not widely accepted and, if accepted, not always applied in day-to-day clinical practice. In the present paper, the current diagnostic entities are critically reviewed, problems with the current definitions are delineated and a unified definition is proposed. For clinical purposes, the recommended dinical practical diagnostic process and differential diagnosis are described. For clinical trials of medications for treatment of PMS/premenstrual dysphoric disorder, research diagnostic criteria, inclusion and exclusion criteria, as well as well-defined outcome measures, are of utmost importance; they are described here. The gaps of knowledge in the description and diagnosis of PMS are described, with suggestions for future directions for research.

How does premenstrual dysphoric disorder relate to depression and anxiety disorders?

Premenstrual dysphoric disorder (PMDD) is a severe variant of premenstrual syndrome that afflicts approximately 5% of all women of fertile age. The hallmark of this condition is the surfacing of symptoms during the luteal phase of the menstrual cycle, and the disappearance of symptoms shortly after the onset of menstruation. Whereas many researchers have emphasized the similarities between PMDD and anxiety disorders, and in particular panic disorder, others have suggested that PMDD should be regarded as a variant of depression. Supporting both these notions, the treatment of choice for PMDD, the serotonin reuptake inhibitors (SRIs), is also first line of treatment for depression and for most anxiety disorders. In this review, the relationship between PMDD on the one hand, and anxiety and depression on the other, is being discussed. Our conclusion is that PMDD is neither a variant of depression nor an anxiety disorder, but a distinct diagnostic entity, with irritability and affect lability rather than depressed mood or anxiety as most characteristic features. The clinical profile of SRIs when used for PMDD, including a short onset of action, suggests that this effect is mediated by other serotonergic synapses than the antidepressant and anti-anxiety effects of these drugs. Although we hence suggest that PMDD should be regarded as a distinct entity, it should be emphasized that this disorder does display intriguing similarities with other conditions, and in particular with panic disorder, which should be the subject of further studies. Also, the possibility that there are subtypes of PMDD more closely related to depression, or anxiety disorders, than the most common form of the syndrome, should not be excluded.

The etiology, biology, and evolving pathology of premenstrual syndromes

Menstrually related symptoms and disorders are multidimensional and affect diverse physiologic systems. Elucidation of the pathophysiologic mechanisms of these disorders should allow for a more precise diagnosis, and provide direction for targeted therapeutic interventions. Several biologic mechanisms that underlie menstrually related symptoms have been proposed. They focus mostly on gonadal hormones, their metabolites and interactions with neurotransmitters and neurohormonal systems, such as serotonin, GABA, cholecystokinin, and the renin-angiotensin-aldosterone system. Altered responses of these systems to gonadal hormone's fluctuations during the menstrual cycle, as well as an increased sensitivity to changes in gonadal hormones may contribute to menstrually related symptoms in vulnerable women. Disrupted homeostasis and deficient adaptation may be core underlying mechanisms. Future directions for clinically-relevant progress include identification of specific subgroups of menstrually-related syndromes, assessment of the genetic vulnerability and changes in vulnerability along the life cycle, the diversified mechanisms by which vulnerability is translated into pathophysiology and symptoms, the normalization process as well as syndromes-based and etiology-based clinical trials.

The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD)

Currently it is estimated that 3-8% of women of reproductive age meet strict criteria for premenstrual dysphoric disorder (PMDD). Assessment of published reports demonstrate that the prevalence of clinically relevant dysphoric premenstrual disorder is probably higher. 13-18% of women of reproductive age may have premenstrual dysphoric symptoms severe enough to induce impairment and distress, though the number of symptoms may not meet the arbitrary count of 5 symptoms on the PMDD list. The impairment and lowered quality of life for PMDD is similar to that of dysthymic disorder and is not much lower than major depressive disorder. Nevertheless, PMS/PMDD is still under-recognized in large published epidemiological studies, as well as assessments of burden of disease. It is demonstrated here that the burden of PMS/PMDD as well as the disability adjusted life years (DALY) lost due to this repeated-cyclic disorder is in the same magnitude as major recognized disorders. Appropriate recognition of the disorder and its impact should lead to treatment of more women with PMS/PMDD. Efficacious treatments are available. They should reduce individual suffering and impact on family, society, and economy.

Current update of hormonal and psychotropic drug treatment of premenstrual dysphoric disorder

This review discusses the current status of diagnosis and treatment of premenstrual dysphoric disorder (PMDD), with an emphasis on studies that have been published in the medical literature during the 2001 to 2002 interval. Serotonergic antidepressants are effective for PMDD, and are currently considered the first-line treatment. Recent clinical trials have shown that selective serotonin reuptake inhibitors, taken only during the symptomatic luteal phase, are also effective for PMDD. One study reported efficacy for a slow-release formulation of fluoxetine that was taken two times during the menstrual cycle. Oral contraceptives still lack definitive evidence of efficacy as a treatment for PMDD, although a new contraceptive formulation has appeared promising for the mood and behavioral symptoms of the disorder. The results of a meta-analysis of the published trials of progesterone and progestins further indicate that these hormones are not effective in the management of PMDD.

Evaluation of a unique oral contraceptive in the treatment of premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome (PMS). This is the first trial of a unique oral contraceptive containing a combination of drospirenone (DRSP, 3 mg) and ethinyl estradiol (EE, 30 microg) for the treatment of PMDD. DRSP is a spironolactone-like progestin with antiandrogenic and antimineralocorticoid activity. Spironolactone has been shown to be beneficial in PMS, whereas oral contraceptives have shown conflicting results. In this double-blind, placebo-controlled trial, 82 women with PMDD (Diagnostic and Statistical Manual of Mental Disorders, 4th ed. [DSM IV]) were randomized to receive DRSP/EE or placebo for three treatment cycles. The primary end point was change from baseline in luteal phase symptom scores as assessed on the Calendar of Premenstrual Experiences (COPE) scale. Patients treated with DRSP/EE showed a numerically greater change from baseline compared with those treated with placebo on each of the 22 COPE items and each of the 4 symptom factors. Between-group differences in symptom improvement reached statistical significance in factor 3 only (appetite, acne, and food cravings, p = 0.027). The secondary end points, Beck Depression Inventory (BDI) and Profile of Mood States (PMS), were consistent with the primary end point in that patients treated with the oral contraceptive showed a numerically greater improvement from baseline compared with those treated with placebo. The results of this study show a consistent trend in the reduction of symptoms that suggested a beneficial effect of DRSP/EE for the treatment of PMDD, despite limitations of the study design.

Are women with premenstrual dysphoric disorder prone to osteoporosis?

OBJECTIVE

The objective of this study was to examine whether bone mineral density (BMD) is reduced in women with premenstrual dysphoric disorder (PMDD).

METHODS

Thirty-eight healthy women participated: 20 with prospectively confirmed PMDD and 18 without PMDD. Bone mass was measured using dual-energy x-ray absorptiometry at three sites: lumbar spine anteroposterior, lumber spine lateral, and femoral neck. Results from the PMDD and control groups were compared with each other and with age- and sex-matched normative data.

RESULTS

The BMD of both groups was as expected for their age and sex, and groups did not differ in BMD or Z scores for any of the bone sites studied.

CONCLUSIONS

If women with PMDD are at an increased risk of developing osteoporosis, this risk is not manifested in their BMD.