Premenstrual Syndrome, Premenstrual Dysphoric Disorder, and Beyond: A Clinical Primer for Practitioners

Emerging Perspectives on the Impact of Diabetes Mellitus and Anti-Diabetic Drugs on Premenstrual Syndrome. A Narrative Review

Diabetes mellitus (DM) and premenstrual syndrome (PMS) are global health challenges. Both disorders are often linked to a range of physical and psychological symptoms that significantly impact the quality of life of many women. Yet, the exact relation between DM and PMS is not clear, and the management of both conditions poses a considerable challenge. In this review, we aimed to investigate the interplay between DM, anti-diabetic drugs, and the different theories and symptoms of PMS. Female sex hormones are implicated in the pathophysiology of PMS and can also impair blood glucose control. In addition, patients with diabetes face a higher susceptibility to anxiety and depression disorders, with a significant number of patients experiencing symptoms such as fatigue and difficulty concentrating, which are reported in patients with PMS as well. Complications related to diabetic medications, such as hypoglycemia (with sulfonylurea) and fluid retention (with thiazolidinediones) may also mediate PMS-like symptoms. DM can, in addition, disturb the normal gut microbiota (GM), with a consequent loss of beneficial GM metabolites that guard against PMS, particularly the short-chain fatty acids and serotonin. Among the several available anti-diabetic drugs, those (1) with an anti-inflammatory potential, (2) that can preserve the beneficial GM, and (3) possessing a lower risk for hypoglycemia, might have a favorable outcome in PMS women. Yet, well-designed clinical trials are needed to investigate the anti-diabetic drug(s) of choice for patients with diabetes and PMS.

Correlation of perceived stress with monthly cyclical changes in the female body

Background

Women are liable to stress-related disorders as female sex hormone, estrogen has been indicated to be protective against stress disorders. The hormone level varies with different phases of menstrual cycle. Moreover, postmenopausal women are at risk for stress-related disorders. So this study was done to correlate the different phases of menstrual cycle with the perceived stress in different phases of monthly cycle.

Methods

This study was conducted in the Department of Physiology, Shri Guru Ram Rai Institute of Medical and Health Sciences (SGRRIMHS), Dehradun. Four hundred girls in the age group of 18-26 years were selected for the study. The Perceived Stress Scale (PSS) questionnaire was circulated via Google forms after briefing them about the study. Informed consent was also taken. The menstrual history of the subjects was enquired by one-to-one interaction. The participants completed the PSS questionnaire twice in the same cycle. Data collected were statistically analyzed, using Independent t-test and Chi-square test and point biserial correlation test.

Result

The analysis showed strong statistical association of PSS with two phases of menstrual cycle. The PSS score was higher in the late luteal and menstrual phase, while it was less in the late follicular phase (P < 0.05). Conclusion: The decreased oestrogen levels in the late luteal & menstrual phase are strongly associated with perceived stress in our study. Hormonal changes in the monthly cycles are related with stress, behavioral shift and many other physical changes in females. This information to the family physicians would be beneficial in counseling the females regarding various changes occurring during the menstrual cycle.

Sleep Quality in Women with Premenstrual Syndrome Is Associated with Metabolic Syndrome-Related Variables

In this study, we examined whether metabolic syndrome (MetS)-related variables are simultaneously affected by sleep quality, premenstrual syndrome (PMS) and dietary consumption. In this cross-sectional study, data for 307 premenopausal women were available. The results showed that women experiencing PMS had significantly lower sleep quality and were more depressed and anxious (p < 0.001 for all). After the subjects were divided into groups according to PMS, the effect of sleep quality on MetS-related variables or MetS components significantly differed; only among women who experienced PMS were poor sleepers significantly higher in waist circumference (p = 0.018) and diastolic blood pressure (p = 0.012) than good sleepers. Among the MetS components, abdominal obesity in women with poor sleep quality was approximately three (16.9% vs. 3.0%, p= 0.020) times more common than in those with good sleep quality. However, these findings were not observed among those who did not experience PMS. Poor sleepers among women experiencing PMS consumed 2.8 times more alcoholic drinks than good sleepers (p = 0.006). The MetS-related variables in Korean women experiencing PMS are associated with sleep quality, and these associations may be modified by dietary habits.

Dimensional (premenstrual symptoms screening tool) vs categorical (mini diagnostic interview, module U) for assessment of premenstrual disorders

BACKGROUND

Premenstrual syndrome (PMS) is the constellation of physical and psychological symptoms before menstruation. Premenstrual dysphoric disorder (PMDD) is a severe form of PMS with more depressive and anxiety symptoms. The Mini international neuropsychiatric interview, module U (MINI-U), assesses the diagnostic criteria for probable PMDD. The Premenstrual Symptoms screening tool (PSST) measures the severity of these symptoms.

AIM

To compare the PSST ordinal scores with the corresponding dichotomous MINI-U answers.

METHODS

Arab women (n = 194) residing in Doha, Qatar, received the MINI-U and PSST. Receiver Operating Characteristics (ROC) analyses provided the cut-off scores on the PSST using MINI-U as a gold standard.

RESULTS

All PSST ratings were higher in participants with positive responses on MINI-U. In addition, ROC analyses showed that all areas under the curves were significant with the cutoff scores on PSST.

CONCLUSION

This study confirms that the severity measures from PSST can recognize patients with moderate/ severe PMS and PMDD who would benefit from immediate treatment.

Variation in the vitamin D receptor gene, plasma 25-hydroxyvitamin D, and risk of premenstrual symptoms

Background

Vitamin D status has been associated with the presence and severity of several premenstrual symptoms (PMSx) in some, but not all studies. Inconsistencies among findings may be explained by unaccounted genetic variation in the vitamin D receptor (VDR).

Objective

To determine whether associations between vitamin D status and individual PMSx are influenced by VDR genotype.

Methods

Seven hundred sixteen women aged 20-29 years old from the Toronto Nutrigenomics and Health study provided plasma samples and completed a questionnaire on the presence and severity of 15 common PMSx. Plasma 25-hydroxyvitamin D (25(OH)D) concentration was measured and participants were categorized into sufficient (≥ 50 nmol/L) and insufficient (< 50 nmol/L) vitamin D status groups. DNA was obtained from blood samples to genotype for a common VDR single nucleotide variant, rs796858. Using logistic regression, odds of experiencing PMSx were compared between vitamin D-sufficient and insufficient women, stratified by genotype.

Results

Among CC homozygotes, insufficient vitamin D status was associated with higher odds of experiencing premenstrual fatigue (OR, 2.53; 95% CI, 1.40, 4.56) and nausea (OR, 2.44; 95% CI, 1.00, 5.95). Among TT homozygotes, insufficient vitamin D status was associated with lower odds of experiencing fatigue (OR, 0.44; 95% CI, 0.20, 0.97) and increased appetite (OR, 0.48; 95% CI, 0.22, 1.04). Insufficient vitamin D status was associated with higher odds of increased appetite in women with the CT genotype (OR, 1.78; 95% CI, 1.03, 3.07). VDR genotype modified the association between vitamin D status and the following PMSx: increased appetite (interaction p = 0.027), fatigue (interaction p = 0.016), and nausea (interaction p = 0.039).

Conclusion

We found evidence that VDR genotype may modify the association between 25(OH)D and some PMSx. Insufficient 25(OH)D was associated with a higher risk of premenstrual fatigue in those with the CC genotype, but lower risk in those with the TT genotype.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12263-021-00696-2.

Perceived occupational competence and value among university students with premenstrual dysphoric disorder

Introduction

Premenstrual dysphoric disorder (PMDD) is defined as a mental health issue and is assessed using DSM-V diagnostic criteria. Premenstrual dysphoric disorder comprises emotional, behavioral, and physical symptoms that occur in the premenstrual phase and resolve shortly after the start of menstruation. These symptoms and functional impairment may negatively affect occupational competence and value. This study investigated perceived occupational competence and value in university students with premenstrual dysphoric disorder.

Methods

This cross-sectional study was performed at a public university with 35 students with PMDD and 35 age-matched students without PMDD. Occupational competence and value were evaluated using the Occupational Self-Assessment (OSA).

Results

There was a significant difference between the groups in OSA competence score ( p < 0.05), while there was no significant difference in OSA value score ( p > 0.05).

Conclusion

This study demonstrated that university students with PMDD experience more occupational competence challenges than peers without PMDD. Further studies should be performed to determine the role of occupational therapy in the rehabilitation of PMDD.

Effects of PMS50 supplementation on psychological symptoms of students with premenstrual syndrome

OBJECTIVE

To evaluate the effects of PMS50 supplementation on psychological symptoms in university students in Iran.

METHODS

This double-blind clinical trial was conducted at Ahvaz Jundishapur University of Medical Sciences, between December 2018 and March 2019. Fifty female students with moderate to severe premenstrual syndrome (PMS) randomly received either 550 mg/day of PMS50 (n = 25) or placebo (n = 25), starting from 1 week before till the end of menstruation for three consecutive menstrual cycles. Anthropometric indices, dietary intake, physical activity level, and severity of PMS were assessed at baseline and post-intervention. Data were analyzed by SPSS (version 22). Independent t test was used to compare the results between groups. Paired t test was used to compare the results within groups before and after study.

RESULTS

There was a significant improvement in psychological symptoms including depression, anger, feeling of hopelessness, desire to be alone, mood swings, irritability, anxiety, and poor concentration observed in the intervention group compared with the control group post-intervention. Restlessness was significantly reduced in both groups post-intervention. The mean scores of low self-esteem, change in appetite, and food cravings were decreased in both groups, but not significant between groups.

CONCLUSION

PMS50 supplementation may be effective in improvement of psychological symptoms in PMS. Clinical Trial Registration No.: IRCT20181218042038 N1.

Psychometric Properties of a DSM-5-Based Screening Tool for Women's Perceptions of Premenstrual Symptoms

A premenstrual screening tool is needed when time constraints and attrition limit the feasibility of daily ratings. The present study examines the utility of a novel, 33-item, retrospective, dimensional, DSM-5-based, screening measure developed to explore women's perceptions of premenstrual symptomatology. This is the first measure that examines perception of impairment for each DSM-5 symptom and assesses the frequency criterion. Participants (N = 331) reported symptoms ranging from none to a level consistent with a provisional DSM-5 diagnosis of Premenstrual Dysphoric Disorder (PMDD). Initial psychometric properties indicated a five-factor structure: (1) affective symptoms; (2) fatigue, sleep, and anhedonia; (3) symptom frequency; (4) impairment and severity of appetite change and physical symptoms; and (5) difficulty concentrating. The total symptom scale and the frequency, severity, and impairment subscales demonstrated high internal consistency. Strong correlations between this dimensional measure and other retrospective and prospective premenstrual symptom measures suggest strong convergent, concurrent, and predictive validity. Premenstrual symptom groups created using this screening measure (minimal, mild/moderate, severe) differed on other retrospective and prospective measures of premenstrual symptoms. There was evidence of divergent validity and lack of an acquiescence bias. We also report data describing women's perceptions of the frequency, level of impairment, and level of severity for each DSM-5 PMDD symptom over a 12-month period and discuss implications for future research on premenstrual phenomenology. Initial evidence for the reliability and construct validity of this symptom screening measure suggests potential value for assessing premenstrual symptomatology in research and practice.

Negative Mood Is Associated with Diet and Dietary Antioxidants in University Students During the Menstrual Cycle: A Cross-Sectional Study from Guangzhou, China

Postpubescent females may have negative mood or premenstrual syndrome during the menstrual cycle; with the emotional and physical symptoms interfering with their quality of life. Little is known about the relationship of dietary behaviors and dietary antioxidant intake with negative mood or premenstrual syndrome in university students in China; so we explored the relationship between negative mood and dietary behavior in female university students during the three menstrual cycle phases. Random sampling was used to enroll 88 individuals from a university in Guangzhou; China in the study. Data were collected using self-administered questionnaires. Descriptive statistics and multiple logistic regression analyses were performed. During the menstrual phase, tea, black coffee and carbonated beverage intake was higher in the group with a high negative affect scale score than in the low score group (p < 0.05). Likewise; during the premenstrual phase, fresh fruit (banana and red Chinese dates) intake was higher in the group with a high negative affect scale score than in the low-score group (p < 0.05). The logistic regression analysis results showed that negative mood was positively associated with tea, coffee, and carbonated beverage intake during the menstrual phase (β = 0.21, p = 0.0453, odds ratio = 1.23), and negative mood was positively associated with banana and red Chinese dates intake during the premenstrual phase (β = 0.59, p = 0.0172, odds ratio = 1.81). Our results suggest that negative mood may be associated with diet and specific food in university postpubescent females.

The effect of 8 weeks aerobic exercise on severity of physical symptoms of premenstrual syndrome: a clinical trial study

BACKGROUND

Premenstrual syndrome (PMS) is a common disorder among women of reproductive age. Nearly 40% of women report problems with their menstrual cycles. Exercise is one of the recommended treatments to reduce symptoms of premenstrual syndrome (PMS). The present study was conducted to determine the effect of 8 weeks aerobic exercise on severity of physical symptoms of premenstrual syndrome (PMS).

METHODS

This study was a randomized clinical trial (IRCT2015021721116N1) that was performed on 65 students living in student dormitories of Mashhad University of Medical Sciences in 2016, Iran. Samples were randomly assigned to control and intervention groups. The intervention group engaged in 8 weeks of aerobic exercises, three times a week, and 20 min for each session. The tools were research unit selection questionnaire, midwifery and personal particulars, temporary determination of premenstrual syndrome, Beck Depression, recorded daily symptoms of premenstrual syndrome and Borg scale. We analyzed the data using SPSS software and Mann-Whitney U test and Friedman test.

RESULTS

At the beginning of the study, both control and intervention groups were homogeneous. The results of independent t-test showed that among the physical symptoms of the premenstrual syndrome in the intervention group compared to the control group, at the end of the study, headache (p = 0.001), nausea, constipation diarrhea (p = 0.01), swollen (p = 0/001) had a significant reduction. Also, the comparison of the difference between the mean of the signs at the beginning and the end of the study, bloating (p = 0.01), Vomiting (p = 0.002), hot flashes (p = 0.04), increase in appetite (p = 0.008) were significantly decreased.

CONCLUSION

Aerobic exercise as one of the ways to treat premenstrual syndrome can reduce the physical symptoms of the syndrome.

TRIAL REGISTRATION

Name of registry: Zahra Mohebbi Dehnavi. IRCT registration number: IRCT 2015021721116 N1. Registration date: 2015 - 08-28. Registration timing: retrospective.

Relationship Between the Cortisol-Estradiol Phase Difference and Affect in Women

Affective disorders impact women's health, with a lifetime prevalence of over twelve per cent. They have been correlated with reproductive cycle factors, under the regulation of hormonal circadian rhythms. In affective disorders, circadian rhythms may become desynchronized. The circadian rhythms of cortisol and estradiol may play a role in affective disorders. The purpose of this study was to explore the temporal relationship between the rhythms of cortisol and estradiol and its relationship to affect. It was hypothesized that a cortisol-estradiol phase difference (PD) exists that correlates with optimal affect. A small scale, comparative, correlational design was used to test the hypothesis. Twenty-three women were recruited from an urban university. Salivary samples were collected over a twenty-four-hour period and fitted to a cosinor model. Subjective measures of affect were collected. Relationships between the cortisol-estradiol PD and affect were evaluated using a second-degree polynomial equation. Results demonstrated a significant correlation in affect measures (p < 0.05). An optimal PD was identified for affect to be 3.6 hours. The phase relationship between cortisol and estradiol may play a role in the development of alterations in affective disorders.

Exploring premenstrual dysphoric disorder (PMDD) in the work context: a qualitative study

This study aims to explore women's experience of premenstrual dysphoric disorder (PMDD) in the workplace, and identify if organizations can do anything to help. Analysis of 15 semi-structured interviews, using an inductive thematic analysis approach, revealed the most common symptoms women experience at work include difficulty in concentrating, self-doubt, paranoia, fatigue, tearfulness, a heightened sensitivity to the environment and people, outbursts, and finding social interaction particularly difficult during this premenstrual "episode" phase. It is these symptoms that contribute to observed presenteeism and absenteeism in the work context. After symptoms disappear (with onset of menstruation), women reported feelings of guilt and engage in over-compensatory behaviors such as working longer hours and taking work home during the remainder of the menstrual cycle (i.e. post-episode phase). Women alternate between these phases every month, which over time, accumulate and have additional consequences. Women are leaving the workforce through voluntary and/or involuntary turnover, sometimes giving up on careers entirely. The interviews also highlighted that organizations need greater awareness and support mechanisms in place for helping female employees with this condition. These findings could be of interest and have relevance to researchers, employers, policymakers, and health professionals.

The inconvenience due to women's monthly bleeding (ISY) survey: a study of premenstrual symptoms among 5728 women in Europe

OBJECTIVES

The aim of the ISY study was to investigate the prevalence of menstrual-related symptoms prior to and/or during menstrual or withdrawal bleeding among women from 12 European countries.

METHODS

A 15-min quantitative online survey was conducted in two waves from February to September 2015 among 5728 women aged between 18 and 45 years, with an equal distribution of women using a combined hormonal contraceptive, including regular combined oral contraceptives (COCs) (CHC group, n = 2739) and women using a non-hormonal contraceptive or no contraceptive (non-HC group, n = 2989).

RESULTS

The prevalence of at least one menstrual-related symptom was high in CHC users (93%) and in non-HC users (95%) (p < .0001) and the average number of symptoms reported was 5.3 vs. 5.9, respectively, (p < .0001). Pelvic pain, bloating/swelling, irritability and mood swing were reported in more than half of the women in both groups. Although generally modest, symptom severity was higher in non-HC users, except for headache. Overall, during the last four cycles, 60-75% of women did not require a treatment for most symptoms but headaches and pelvic pain. Mood swings/irritability, water retention/weight gain, lack of energy/mood swings and lack of energy/irritability were common symptoms that frequently co-occurred. No associations were reported between symptoms and age, educational qualifications or women's desire to reduce the frequency of menstruation.

CONCLUSIONS

Premenstrual and menstrual symptomatology was less frequent, less numerous and less severe (except for headache) in women using CHCs; however, it remains a common concern. Reducing the frequency of menstrual periods could reduce withdrawal-related symptoms.

Reduction of quality-adjusted life years (QALYs) in patients with premenstrual dysphoric disorder (PMDD)

PURPOSE

Premenstrual dysphoric disorder (PMDD) refers to the depression that occurs during the premenstrual phase and remits soon after the onset of menses. It affects the quality of life (QOL) of patients with PMDD. Therefore, this preliminary survey from chart recordings aimed to understand the symptom appearance and QOL reduction patterns in patients with PMDD, and to examine the extent of the loss of their quality-adjusted life years (QALYs).

METHODS

Participants were 66 untreated female patients with PMDD. Data on symptom appearance and QOL reduction during the menstrual cycle, and the EuroQoL-5D (EQ-5D) scores during the premenstrual phase and immediately after the completion of a menstrual period were collected.

RESULTS

The mean EQ-5D score of the 66 patients with PMDD was 0.795 ± 0.120 (range 0.362-0.949), indicating that their expected mean loss of QALYs was about 0.14 years.

CONCLUSIONS

If untreated, PMDD is expected to cause a mean loss of QALYs of about 0.14 years. However, on accounting for the period from disease development to menopause, and subtracting the menstruation-free periods such as pregnancy and breastfeeding, patients with untreated PMDD are expected to experience a QALY loss of about 3 years during their lifetime.

Validation of the Brazilian Portuguese version of the Premenstrual Symptoms Screening Tool (PSST) and association of PSST scores with health-related quality of life

Objective:

To develop and validate a Brazilian Portuguese version of the Premenstrual Symptoms Screening Tool (PSST), a questionnaire used for the screening of premenstrual syndrome (PMS) and of the most severe form of PMS, premenstrual dysphoric disorder (PMDD). The PSST also rates the impact of premenstrual symptoms on daily activities.

Methods:

A consecutive sample of 801 women aged ≥ 18 years completed the study protocol. The internal consistency, test-retest reliability, and content validity of the Brazilian PSST were determined. The independent association of a positive screen for PMS or PMDD and quality of life determined by the World Health Organization Quality of Life instrument-Abbreviated version (WHOQOL-Bref) was also assessed.

Results:

Of 801 participants, 132 (16.5%) had a positive screening for PMDD. The Brazilian PSST had adequate internal consistency (Cronbach's alpha = 0.91) and test-retest reliability. The PSST also had adequate convergent/discriminant validity, without redundancy. Content validity ratio and content validity index were 0.61 and 0.94 respectively. Finally, a positive screen for PMS/PMDD was associated with worse WHOQOL-Bref scores.

Conclusions:

These findings suggest that PSST is a reliable and valid instrument to screen for PMS/PMDD in Brazilian women.

A prospective study of caffeine and coffee intake and premenstrual syndrome

BACKGROUND

Clinically significant premenstrual syndrome (PMS) affects 15-20% of premenopausal women, substantially reducing quality of life. Women with PMS often are counseled to minimize caffeine intake, although only limited evidence supports this recommendation.

OBJECTIVE

We evaluated the association between total caffeine, coffee, and tea intake and the development of PMS in a case-control study nested within the prospective Nurses' Health Study II.

DESIGN

All participants were free from PMS at baseline (1991). PMS cases reported a new clinician-made diagnosis of PMS on biennial questionnaires between 1993 and 2005, and then confirmed symptom timing and moderate-to-severe impact and severity of symptoms with the use of a retrospective questionnaire (n = 1234). Controls did not report PMS and confirmed experiencing no symptoms or few mild symptoms with limited personal impact (n = 2426). Caffeine, coffee, and tea intake was measured by food-frequency questionnaires every 4 y, and data on smoking, body weight, and other factors were updated every 2-4 y. Logistic regression was used to evaluate the associations of total caffeine intake and frequency of coffee and tea consumption with PMS.

RESULTS

After adjustment for age, smoking, and other factors, total caffeine intake was not associated with PMS. The OR comparing women with the highest (quintile median = 543 mg/d) to the lowest (quintile median = 18 mg/d) caffeine intake was 0.79 (95% CI: 0.61, 1.04; P-trend = 0.31). High caffeinated coffee intake also was not associated with risk of PMS or specific symptoms, including breast tenderness (OR for ≥4 cups/d compared with <1/mo: 0.73; 95% CI: 0.48, 1.12; P-trend = 0.44).

CONCLUSIONS

Our findings suggest that caffeine intake is not associated with PMS, and that current recommendations for women to reduce caffeine intake may not help prevent the development of PMS.

Vitamin D Supplementation for Premenstrual Syndrome-Related Mood Disorders in Adolescents with Severe Hypovitaminosis D

STUDY OBJECTIVE

Premenstrual syndrome (PMS) might become severe enough to interfere with normal interpersonal relationships. This study was planned to assess whether administration of vitamin D (200,000 IU at first, followed by 25,000 IU every 2 weeks) for a 4-month period might lessen the appearance and the intensity of mood disorders associated with PMS in young girls with severe hypovitaminosis D. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: One hundred fifty-eight young girls (15-21 years old) with PMS-related severe symptoms of the emotional and cognitive domains and low serum 25-hydroxycholecalciferol (25-OH-D) levels (≤10 ng/mL) were randomly assigned to two treatment groups and treated for 4 months with vitamin D (group 1; n = 80) or placebo (group 2; n = 78). Clinical and hormonal effects were compared between the two groups.

RESULTS

In patients from group 1, levels of vitamin D reached the normal range (35-60 ng/mL) after the first month and remained stable throughout the whole study. At the end of treatment, anxiety score decreased from 51 to 20 (P < .001 vs baseline); irritability score declined from 130 to 70 (P < .001 vs baseline). Crying easily and sadness decreased by a score of 41 and 51 to a score of 30 and 31, respectively (P < .001). For disturbed relationships, the score decreased from 150 to 70 (P < .001). Conversely, no appreciable changes were noted in symptom intensity from patients of group 2. The frequency of adverse events (nausea and constipation) was not different between participants of group 1 and group 2.

CONCLUSION

On the basis of the present findings, vitamin D therapy can be proposed as a safe, effective, and convenient method for improving the quality of life in young women with severe hypovitaminosis D and concomitant mood disorders associated with PMS.

Migraine and reproductive life

Migraine is prevalent in women during the fertile age. Indeed, both neuroendocrine events related to reproductive stages (menarche, pregnancy, and menopause) and menstrual cyclicity and the use of exogenous sex hormones, such as hormonal contraception and replacement therapy, may cause significant changes in the clinical pattern of migraine. Menstrual migraine may be more severe, long-lasting, and refractory to both acute and prophylactic treatment and, therefore, requires tailored strategies. The use of headache diaries, which makes it possible to record prospectively the characteristics of every attack, is of paramount importance for evaluating the time pattern of headache and for identifying a clear link with menstrual cycle-related features. Estrogen variations are highly implicated in modulating the threshold to challenges by altering neuronal excitability, cerebral vasoactivity, pain sensitivity, and neuroendocrine axes throughout the menstrual cycle and not only at the time of menstruation. On the other hand, estrogen withdrawal may really constitute a triggering factor for migraine in women with peculiar characteristics of vulnerability with menstruation or following the discontinuation of exogenous estrogen, as happens with hormonal contraception during the fertile age or with hormone therapy at menopause. In addition, exogenous estrogen may contribute to the occurrence of neurological symptoms, such as aura. When aura occurs, hormonal treatment should be discontinued.

Comparison of Metabolic and Hormonal Profiles of Women With and Without Premenstrual Syndrome: A Community Based Cross-Sectional Study

BACKGROUND

Premenstrual syndrome (PMS) is reported by up to 85% of women of reproductive age. Although several studies have focused on the hormone and lipid profiles of females with PMS, the results are controversial.

OBJECTIVES

This study was designed to investigate the association of hormonal and metabolic factors with PMS among Iranian women of reproductive age.

MATERIALS AND METHODS

This study was a community based cross-sectional study. Anthropometric measurements, biochemical parameters, and metabolic disorders were compared between 354 women with PMS and 302 healthy controls selected from among 1126 women of reproductive age who participated in the Iranian PCOS prevalence study. P values < 0.05 were considered significant.

RESULTS

Prolactin (PRL) and triglycerides (TG) were significantly elevated in women with PMS, whereas their testosterone (TES), high density lipoprotein (HDL) and 17-hydroxyprogesterone (17-OHP) levels were significantly less than they were in women without the syndrome (P < 0.05). After adjusting for age and body mass index (BMI), linear regression analysis demonstrated that for every one unit increase in PMS score there was 12% rise in the probability of having metabolic syndrome (P = 0.033).

CONCLUSIONS

There was a significant association between PMS scores and the prevalence of metabolic syndrome. Further studies are needed to confirm and validate the relationships between lipid profile abnormalities and metabolic disorders with PMS.

The Association between the Risk of Premenstrual Syndrome and Vitamin D, Calcium, and Magnesium Status among University Students: A Case Control Study

Background: Premenstrual syndrome (PMS) is one of major health problems in childbearing age women. Herein, we compared the nutritional status of vitamin D, calcium (Ca) and magnesium (Mg) in young students affected by PMS with those of normal participants.

Methods: This study was conducted on 62 students aged 20‒25 yr in the city of Abadan (31 PMS cases and 31 controls). All participants completed four or more criteria according to the Utah PMS Calendar 3. Age, height, body mass index (BMI), serum Ca, Mg and vitamin D levels and a 24-hour food recall questionnaire were recorded.

Results: Vitamin D serum levels were lower than the normal range in the two groups. The odds ratios (CI 95%) of having PMS based on serum Ca and Mg concentrations were 0.81(0.67 – 0.89) and 0.86 (0.72 – 0.93), respectively. Based on serum levels, 855 of all participants showed vitamin D deficiency and more than one-third of the PMS cases were Mg deficient (P<0.05). In addition, there were signifi­cant differences in dietary intake of Ca and Mg, and potassium but not vitamin D in the two groups. Dietary intakes of Ca and Mg were quite below the recommendation in all participants.

Conclusion: Vitamin D, Ca and Mg nutritional status are compromised in PMS subjects. Because PMS is a prevalent health problem among young women, it merits more attention regarding improvement of their health and nutritional status.

A Comprehensive Review of Treatment Options for Premenstrual Syndrome and Premenstrual Dysphoric Disorder

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome that involves a combination of emotional and physical symptoms that result in significant functional impairment. Because of the debilitating nature of PMDD, multiple treatment options have been considered. This review provides a comprehensive overview of these therapeutic regimens to help health care professionals provide adequate treatment for PMDD and premenstrual syndrome. The treatments that are reviewed are organized into the following categories: psychiatric, anovulatory, supplements, herbal, nonpharmacological, and other. Selective serotonin reuptake inhibitors have been established as the first-line treatment for PMDD. Although luteal phase or continuous dosing can be used, additional research is needed to more thoroughly compare the efficacies and differential symptom response of continuous, semi-intermittent, luteal phase, and symptoms-onset dosing. The psychiatric medications venlafaxine, duloxetine, alprazolam, and buspirone have also been found to be useful treatments for PMDD. Various anovulatory-related treatments have demonstrated efficacy; however, the use of some of these treatments remains limited due to potential side effects and/or the availability of cheaper alternatives. Although a variety of supplement and herbal-related treatments have been proposed, with some warranting further research, at this time only calcium supplementation has demonstrated a consistent therapeutic benefit. In conclusion, serotoninergic antidepressants have been established as the first-line treatment option for PMDD; however, there are a variety of additional treatment options that should be considered if a patient fails to achieve an adequate therapeutic response with a selective serotonin reuptake inhibitor.

[Evaluating the relation of premenstrual syndrome and primary dysmenorrhea in women diagnosed with fibromyalgia]

OBJECTIVE

In this study, we aimed to investigate the presence of premenstrual syndrome (PMS), primary dysmenorrhea (PD) and depression among women with fibromyalgia (FM) and healthy females and to determine possible factors related with PMS and PD in FM.

METHOD

The present study was conducted on 98 female patients diagnosed with FM and 102 age and sex-matched healthy controls. All patients were evaluated for premenstrual syndrome (PMS) and primary dysmenorrhea (PD). Premenstrual syndrome was assessed among the patients for the presence of one or more affective or somatic symptoms within the five days preceding menses. The diagnosis of primary dysmenorrhea was defined as having abdominal pain or lower back pain lasting at least two days during a menstrual period. Dysmenorrhea was assessed via visual analog scale. Dysmenorrhea was rated via Multidimensional Scoring System. The Hamilton depression scale was applied to all patients.

RESULTS

Primary dysmenorrhea was established in 41% of FM patients and 28% of the control group. A statistically significant difference was found in PD between the two groups (p=0.03). PMS was established in 42% of the FM patients and 25% of the control group. A statistically significant difference was found in PMS between the two groups (p=0.03).

CONCLUSION

There is an increased frequency of premenstrual syndrome and dysmenorrhea in FM patients. The patients with high symptom severity scores and high depression scores among the FM patients are at risk of PMS and PD.

Is objective and accurate cognitive assessment across the menstrual cycle possible? A feasibility study

Objectives:

Variation in plasma hormone levels influences the neurobiology of brain regions involved in cognition and emotion processing. Fluctuations in hormone levels across the menstrual cycle could therefore alter cognitive performance and wellbeing; reports have provided conflicting results, however. The aim of this study was to assess whether objective assessment of cognitive performance and self-reported wellbeing during the follicular and luteal phases of the menstrual cycle is feasible and investigate the possible reasons for variation in effects previously reported.

Methods:

The Cambridge Neuropsychological Test Automated Battery and Edinburgh Postnatal Depression Scale were used to assess the cognitive performance and wellbeing of 12 women. Data were analysed by self-reported and hormone-estimated phases of the menstrual cycle.

Results:

Recruitment to the study and assessment of cognition and wellbeing was without issue. Plasma hormone and peptide estimation showed substantial individual variation and suggests inaccuracy in self-reported menstrual phase estimation.

Conclusion:

Objective assessment of cognitive performance and self-assessed wellbeing across the menstrual cycle is feasible. Grouping data by hormonal profile rather by self-reported phase estimation may influence phase-mediated results. Future studies should use plasma hormone and peptide profiles to estimate cycle phase and group data for analyses.

Early life emotional, physical, and sexual abuse and the development of premenstrual syndrome: a longitudinal study

BACKGROUND

Previous studies have suggested that violence victimization is prevalent among women with premenstrual syndrome (PMS). However, it is unclear whether early life abuse contributes directly to PMS or whether associations are explained by the high prevalence of PMS risk factors including smoking and obesity among women reporting childhood abuse.

METHODS

We have assessed the relation of early life abuse and the incidence of moderate-to-severe PMS in a study nested within the prospective Nurses' Health Study 2. Participants were aged 27-44 years and free from PMS at baseline, including 1,018 cases developing PMS over 14 years and 2,277 comparison women experiencing minimal menstrual symptoms. History of early life emotional, physical, and sexual abuse was self-reported in 2001.

RESULTS

After adjustment for obesity, smoking, and other factors, emotional abuse was strongly related to PMS (pTrend<0.0001); women reporting the highest level of emotional abuse had 2.6 times the risk of PMS as those reporting no emotional abuse (95% confidence interval, 1.7-3.9). Women reporting severe childhood physical abuse had an odds ratio of 2.1 (95% confidence interval, 1.5-2.9; pTrend<0.001) compared with those reporting no physical abuse. Sexual abuse was less strongly associated with risk. Adjustment for childhood social support minimally affected findings.

CONCLUSIONS

Findings from this large prospective study suggest that early life emotional and physical abuse increase the risk of PMS in the middle-to-late reproductive years. The persistence of associations after control for potential confounders and mediators supports the hypothesis that early life abuse is importantly related to PMS.

Identifying Chinese herbal medicine for premenstrual syndrome: implications from a nationwide database

BACKGROUND

Premenstrual syndrome (PMS) occurs in women during their reproductive age with a quite negative impact on their daily lives. Women with PMS experience a wide range of physical or psychological symptoms and seek treatment for them. Chinese herb medicine (CHM) is commonly used for PMS and the goal of this study is to investigate the prescription patterns of CHM for PMS by using a nationwide database.

METHODS

Prescriptions of CHM were obtained from two million beneficiaries randomly sampled from the National Health Insurance Research Database, a nationwide database in Taiwan. The ICD-9 code 625.4 was used to identify patients with PMS. Association rule mining and social network analysis were used to explore both the combinations and the core treatments for PMS.

RESULTS

During 1998-2011, a total of 14,312 CHM prescriptions for PMS were provided. Jia-Wei-Xiao-Yao-San (JWXYS) was the CHM which had the highest prevalence (37.5% of all prescriptions) and also the core of prescription network for PMS. For combination of two CHM, JWXYS with Cyperus rotundus L. was prescribed most frequently, 7.7% of all prescriptions, followed by JWXYS with Leonurus heterophyllus Sweet, 5.9%, and Cyperus rotundus L. with Leonurus heterophyllus Sweet, 5.6%.

CONCLUSIONS

JWXYS-centered CHM combinations were most commonly prescribed for PMS. To the best of our knowledge, this is the first pharmaco-epidemiological study to review CHM treatments for PMS. However, the efficacy and safety of these commonly used CHM were still lacking. The results of this study provide valuable references for further clinical trials and bench studies.

Menstrual suppression: current perspectives

Menstrual suppression to provide relief of menstrual-related symptoms or to manage medical conditions associated with menstrual morbidity or menstrual exacerbation has been used clinically since the development of steroid hormonal therapies. Options range from the extended or continuous use of combined hormonal oral contraceptives, to the use of combined hormonal patches and rings, progestins given in a variety of formulations from intramuscular injection to oral therapies to intrauterine devices, and other agents such as gonadotropin-releasing hormone (GnRH) antagonists. The agents used for menstrual suppression have variable rates of success in inducing amenorrhea, but typically have increasing rates of amenorrhea over time. Therapy may be limited by side effects, most commonly irregular, unscheduled bleeding. These therapies can benefit women’s quality of life, and by stabilizing the hormonal milieu, potentially improve the course of underlying medical conditions such as diabetes or a seizure disorder. This review addresses situations in which menstrual suppression may be of benefit, and lists options which have been successful in inducing medical amenorrhea.

Plasma 25-hydroxyvitamin D and risk of premenstrual syndrome in a prospective cohort study

Background

Moderate to severe premenstrual syndrome (PMS) affects 8–20 percent of premenopausal women. Previous studies suggest that high dietary vitamin D intake may reduce risk. However, vitamin D status is influenced by both dietary vitamin D intake and sunlight exposure and the association of vitamin D status with PMS remains unclear.

Methods

We assessed the relation of plasma 25-hydroxyvitamin D (25OHD), total calcium and parathyroid hormone levels with risk of PMS and specific menstrual symptoms in a case–control study nested within the prospective Nurses’ Health Study II. Cases were 401 women free from PMS at baseline who developed PMS during follow-up (1991–2005). Controls were women not experiencing PMS (1991–2005), matched 1:1 with cases on age and other factors. Timed luteal phase blood samples were collected between 1996 and 1999 from cases and controls. We used conditional logistic regression to model the relation of 25OHD levels with risk of PMS and individual menstrual symptoms.

Results

In analyses of all cases and controls, 25OHD levels were not associated with risk of PMS. However, results differed when the timing of blood collection vs. PMS diagnosis was considered. Among cases who had already been diagnosed with PMS at the time of blood collection (n = 279), 25OHD levels were positively associated with PMS, with each 10 nmol/L change in 25OHD associated with a 13% higher risk. Among cases who developed PMS after blood collection (n = 123), 25OHD levels were unrelated to risk of PMS overall, but inversely related to risk of specific menstrual symptoms. For example, each 10 nmol/L increase was associated with a significant 21% lower risk of breast tenderness (P = 0.02). Total calcium or parathyroid hormone levels were unrelated to PMS.

Conclusions

25OHD levels were not associated with overall risk of PMS. The positive association observed among women already experiencing PMS at the time of 25OHD measurement is likely due to confounding by indication related to use of dietary supplements to treat menstrual symptoms. Results from prospective analyses, which were less likely influenced by this bias, suggest that higher 25OHD levels may be inversely related to the development of specific menstrual symptoms.

The Iranian version of the Premenstrual Symptoms Screening Tool (PSST): a validation study

The objective of the current study was to translate and test psychometric properties of the Premenstrual Symptoms Screening Tool (PSST) in Iran. Using a standard "forward-backward" procedure, the English version of PSST was translated into Persian. A random sample of university students aged 18 years and over completed the questionnaire in Tehran, Iran. Psychometric properties of the Iranian version of PSST were assessed by performing reliability (internal consistency) and validity analyses [Content Validity Ratio (CVR) and Content Validity Index (CVI)]. In all, 925 female students took part in the study. Of these, 284 (30.7 %) had premenstrual syndrome (PMS) and 119 (12.9 %) had premenstrual dysphoric disorder (PMDD). Reliability of the PSST as measured by internal consistency was found to be satisfactory (Cronbach's alpha coefficient, 0.93). The content validity as assessed by CVR and CVI were desirable (0.7 and 0.8, respectively). The Iranian version of PSST seems to be a reliable and valid measure of detecting PMS and PMDD in Iranian young female populations.

A review of treatment and management modalities for premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) affects 5 to 8 percent of women and can significantly decrease their quality of life. Symptoms generally present during the late luteal phase of the menstrual cycle and can affect women emotionally, behaviorally, cognitively and physiologically. This article reviews the clinical literature on PMDD and the evidence behind various methods of symptom management. Evidence suggests that a holistic approach, including lifestyle modifications, pharmacotherapy and cognitive behavioral therapy, is most beneficial for symptom reduction and improvement in daily functioning and quality of life.

Evaluation of the effect of omega-3 fatty acids in the treatment of premenstrual syndrome: "a pilot trial"

INTRODUCTION

Premenstrual syndrome (PMS) refers to a cyclic appearance of somatic and psychiatric symptoms that affect some women. Finding an effective and safe method for the treatment of PMS has always been a serious concern, because approximately 40% of women report PMS, and in 2-10% of cases it is severe enough to affect their life style and job.

OBJECTIVE

The purpose of the present study is to evaluate the effect of omega-3 fatty acids on the treatment of PMS.

METHOD

A randomized double blind controlled trial was performed on 184 eligible women. The eligible women were randomly assigned into two groups. The number of women who have finalized the study with us was 124. In the case group (omega-3 group = group A, n = 70), omega-3 in an amount of 2 g was prescribed for a one per day basis on a single dosage (two 1 g pearls), and in the control group (placebo group = group B, n = 69) 2 placebo soft gel, which were completely similar to omega-3 soft gels, were prescribed. The severity and duration of each of the symptoms were compared in both groups 1.5 and 3 months after the beginning of treatment.

RESULTS

There were no significant differences between the two groups according to age, BMI, level of education, and the severity and duration of primary symptoms. After 45 days from starting omega-3, the mean severity of depression (P = 0.03), anxiety (P = 0.02), lack of concentration (P = 0.03) and bloating (P = 0.02) in the case group, were all significantly lower than in the control group. The duration of depression (P = 0.04) and bloating (P = 0.031) in the case group were less than in the control group. After 90 days from starting the treatment, the mean severity of depression (P = 0.007), anxiety (P = 0.004), lack of concentration (P = 0.009), bloating (P = 0.004), nervousness (P = 0.01) and the duration of depression (P = 0.01), nervousness (P = 0.02), anxiety (P = 0.03), lack of concentration (P = 0.02), bloating (P = 0.004), headache (P = 0.04) and breast tenderness (P = 0.02) were all lower in the case group.

CONCLUSION

It appears that omega-3 fatty acids may reduce the psychiatric symptoms of PMS including depression, nervousness, anxiety, and lack of concentration and may also reduce the somatic symptoms of PMS including bloating, headache and breast tenderness. These effects increased by longer duration of treatment.

Premenstrual syndrome and migraine

Premenstrual syndrome (PMS) includes a wide variety of physical, psychological, and cognitive symptoms that occur recurrently and cyclically during the luteal phase of the menstrual cycle and disappear soon after the onset of menstruation. Headache, often of migrainous type, is one of physical symptoms often reported in the diagnostic criteria for PMS. Menstrual migraine (MM) is a particular subtype of migraine occurring within the 2 days before and the 3 days after the onset of menses. According to this definition, therefore, some attacks of MM certainly occur in conjunction with the period of maximum exacerbation of PMS symptoms. The relationship between MM and PMS has been investigated through diary-based studies which have confirmed the possible correlation between these two conditions. In this paper we provide indications for the treatment of MM, making particular reference to those therapies that may be useful in the treatment of PMS symptoms. Even if triptans are the gold standard for the acute treatment, if symptomatic treatment is not sufficient one can resort to a short-term perimenstrual prophylaxis. Non-steroidal anti-inflammatory drugs have been demonstrated effective in MM prophylaxis. Among natural products there is some evidence of efficacy for magnesium, phytoestrogens, and ginkgolide B. Finally, also a combined oral contraceptive containing drospirenone, taken continuously for 168 days, has shown promising results.

Advances in the diagnosis of premenstrual syndrome and premenstrual dysphoric disorder

Premenstrual disorders negatively impact the quality of life and functional ability of millions of women. The two generally recognized premenstrual disorders are premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). These disorders are characterized by a wide variety of nonspecific mood, somatic and behavioral symptoms that occur only during the late luteal phase of a woman's cycle and disappear soon after the onset of menstruation. This paper reviews the diagnostic criteria for PMS and PMDD, describes some of the more common symptom diaries and other tools used to diagnose premenstrual disorders, and discusses the challenges inherent in diagnosing PMS and PMDD. A survey of peer-reviewed articles and relevant texts provided diagnostic criteria, descriptions of diagnostic tools and information about diagnostic challenges. The many nonspecific symptoms associated with premenstrual disorders complicate the diagnostic process. The use of proven symptom diaries and other diagnostic tools should aid in the differential diagnosis of premenstrual disorders. Patients need to report bothersome premenstrual symptoms, and clinicians should become more proficient in the diagnostic process in order to prevent underdiagnosis of these disorders.

Use of Vitex agnus-castus in migrainous women with premenstrual syndrome: an open-label clinical observation

Premenstrual syndrome (PMS) affects most women during their reproductive life. Headache is regarded as a typical symptom of PMS and, close to menses, migrainous women could experience their worst migraine attacks. Vitex agnus-castus (VAC) is a phytopharmaceutical compound, considered worldwide to be a valid tool to treat PMS. Aim of this study is to explore if headache is ameliorate in migrainous women treated with VAC for PMS by an open-label clinical observation. Migrainous women with PMS were enrolled in the study and advised to assume a treatment with VAC (40 mg/day) for PMS for a 3-month period. Effects both on PMS and headache were assessed. Out of 107 women, 100 completed the 3-month treatment for PMS. Out of them, 66 women reported a dramatic reduction of PMS symptoms, 26 a mild reduction, and 8 no effect. Concerning migraine, 42 % of patients experienced a reduction higher than 50 % in frequency of monthly attacks, and 57 % of patients experienced a reduction higher than 50 % in monthly days with headache. No patients reported remarkable side effects. Pending a placebo-controlled trial to confirm our results, we observed that the use of VAC in migrainous women affected by PMS resulted to be safe and well tolerated, and may positively influence the frequency and duration of migraine attacks.

Epidemiology of premenstrual symptoms and disorders

The aim of this paper is to review published literature on the types and prevalences of premenstrual disorders and symptoms, and effects of these on activities of daily life and other parameters of burden of illness. The method involved review of the pertinent published literature. Premenstrual disorders vary in prevalence according to the definition or categorization. The most severe disorder being premenstrual dysphoric disorder (PMDD) affects 3-8% of women of reproductive age. This disorder focuses on psychological symptoms whereas global studies show that the most prevalent premenstrual symptoms are physical. Both psychological and physical symptoms affect women's activities of daily life. A considerable burden of illness has been shown to be associated with moderate to severe premenstrual disorders. In conclusion, premenstrual symptoms are a frequent source of concern to women during their reproductive lives and moderate to severe symptoms impact on their quality of lives.

Perceived stress and severity of perimenstrual symptoms: the BioCycle Study

OBJECTIVE

To examine the longitudinal relation between perceived stress in the previous month and perimenstrual symptom severity across two cycles among regularly menstruating, healthy women (n = 259).

METHODS

At baseline (11 days before the first cycle), participants completed the 4-item Perceived Stress Scale (PSS) for the previous month (first cycle exposure) and questionnaires on lifestyle factors. On cycle day 22 of a standardized 28-day cycle, participants again completed the PSS for the previous week (second cycle exposure) and each week rated the severity (none, mild, moderate, severe) of 17 psychological and physical symptoms (e.g., crying, cramping, pain). Mixed models estimated the association between perceived stress scores and number of moderate/severe symptoms and symptom severity scores, allowing both stress and perimenstrual symptoms to vary by cycle.

RESULTS

Adjusting for age, education, passive and active smoking, and waist/height ratio (WHtR), high stress (fourth quartile PSS) was associated with an increased risk of reporting >or=8 or more (OR 7.2, 3.3-15.8) and >or=5 (OR 2.5, 1.6-4.1) symptoms as moderate/severe during the perimenstrual period compared with lower stress (quartiles one, two, and three). Stress scores were positively (p < 0.0001) associated with increased symptom severity scores for total, psychological, and physical symptoms.

CONCLUSIONS

These analyses show that higher perceived stress precedes an increased severity of perimenstrual symptoms. Stress reduction programs may be an effective, nonpharmaceutical treatment for physical and psychological symptom relief.

Progesterone for premenstrual syndrome

BACKGROUND

About 5% of women experience severe symptoms called premenstrual syndrome (PMS), only in the two weeks before their menstrual periods. Treatment with progesterone may restore a deficiency, balance menstrual hormone levels or reduce effects of falling progesterone levels on the brain or on electrolytes in the blood.

OBJECTIVES

The objectives were to determine if progesterone has been found to be an effective treatment for all or some premenstrual symptoms and if adverse events associated with this treatment have been reported.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and PsycINFO to February 2011. We contacted pharmaceutical companies for information about unpublished trials, for the first version of this review.The search strings are in Appendix 2.

SELECTION CRITERIA

We included randomised double-blind, placebo-controlled trials of progesterone on women with PMS diagnosed by at least two prospective cycles, without current psychiatric disorder.

DATA COLLECTION AND ANALYSIS

Two reviewers (BM and OF) extracted data independently and decided which trials to include. OF wrote to trial investigators for missing data.

MAIN RESULTS

From 17 studies, only two met our inclusion criteria. Together they had 280 participants aged between 18 and 45 years. One hundred and fifteen yielded analysable results. Both studies measured symptom severity using subjective scales. Differing in design, participants, dose of progesterone and how delivered, the studies could not be combined in meta-analysis.Adverse events which may or may not have been side effects of the treatment were described as mild.Both trials had defects. They intended to exclude women whose symptoms continued after their periods. When data from ineligible women were excluded from analysis in one trial, the other women were found to have benefited more from progesterone than placebo. The smaller study found no statistically significant difference between oral progesterone, vaginally absorbed progesterone and placebo, but reported outcomes incompletely.

AUTHORS' CONCLUSIONS

The trials did not show that progesterone is an effective treatment for PMS nor that it is not. Neither trial distinguished a subgroup of women who benefited, nor examined claimed success with high doses.

Oral contraceptives containing drospirenone for premenstrual syndrome

BACKGROUND

Premenstrual syndrome (PMS) is a common problem. Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome. Combined oral contraceptives, which provide both progestin and estrogen, have been examined for their ability to relieve premenstrual symptoms. An oral contraceptive containing drospirenone and a low estrogen dose has been approved for treating PMDD in women who choose oral contraceptives for contraception.

OBJECTIVES

To review all randomized controlled trials comparing a combined oral contraceptive containing drospirenone to a placebo or another combined oral contraceptive for effect on premenstrual symptoms.

SEARCH METHODS

We searched for studies of drospirenone and premenstrual syndrome in the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, and POPLINE (20 Dec 2011); EMBASE, LILACS, PsycINFO, ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP) of the World Health Organization (02 Mar 2011). We also examined references lists of relevant articles and wrote to known investigators to find other trials.

SELECTION CRITERIA

We included randomized controlled trials in any language that compared a combined oral contraceptive (COC) containing drospirenone with a placebo or with another COC for effect on premenstrual symptoms. The primary outcome included affective and physical premenstrual symptoms that were prospectively recorded. Adverse events related to combined oral contraceptive use were examined.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study quality. For continuous variables, the mean difference (MD) was computed with 95% confidence interval (CI). For dichotomous outcomes, the Peto odds ratio (OR) with 95% CI was calculated.

MAIN RESULTS

We included five trials with a total of 1920 women. Two placebo-controlled trials of women with PMDD showed less severe premenstrual symptoms after three months with drospirenone 3 mg plus ethinyl estradiol 20 μg than with placebo (MD -7.92; 95% CI -11.16 to -4.67). The drospirenone group had greater mean decreases in impairment of productivity (MD -0.31; 95% CI -0.55 to -0.08), social activities (MD -0.29; 95% CI -0.54 to -0.04), and relationships (MD -0.30; 95% CI -0.54 to -0.06). Side effects more common with the use of the drospirenone COC contraceptive were nausea, intermenstrual bleeding, and breast pain. The respective odds ratios were 3.15 (95% CI 1.90 to 5.22), 4.92 (95% CI 3.03 to 7.96), and 2.67 (95% CI 1.50 to 4.78). Total adverse events related to the study drug were more likely for the drospirenone COC group (OR 2.36; 95% CI 1.62 to 3.44). Three trials studied the effect of drospirenone 3 mg plus ethinyl estradiol 30 μg on less severe symptoms. A placebo-controlled six-month trial had insufficient data for primary outcome analysis. Another six-month study used levonorgestrel 150 µg plus ethinyl estradiol 30 µg for the comparison group but did not provide enough data on premenstrual symptoms. In a two-year trial, the drospirenone COC group had similar premenstrual symptoms to the comparison group given desogestrel 150 µg plus ethinyl estradiol 30 µg (OR 0.87; 95% CI 0.63 to 1.22). The groups were also similar for adverse events related to treatment (OR 1.02; 95% CI 0.78 to 1.33).

AUTHORS' CONCLUSIONS

Drospirenone 3 mg plus ethinyl estradiol 20 μg may help treat premenstrual symptoms in women with severe symptoms, that is, premenstrual dysphoric disorder. The placebo also had a large effect. We do not know whether the combined oral contraceptive works after three cycles, helps women with less severe symptoms, or is better than other oral contraceptives. Larger and longer trials of higher quality are needed to address these issues. Trials should follow CONSORT guidelines.

Reliability and component structure of the modified Daily Symptom Report (DSR-20)

OBJECTIVES

The purpose of the present study was to modify Freeman et al.'s (1996) Daily Symptom Report (DSR) for premenstrual syndrome (PMS) by adding items depicting aggressive and impulsive symptoms, to explore the component structure of this revised measure (DSR-20) in a sample of PMS sufferers, and to compare their scores with those from controls during the follicular and luteal cycle phases.

METHODS

The DSR-20 was administered to 140 PMS sufferers who were seeking treatment for PMS and 54 controls who considered themselves to be free from premenstrual complaints daily for three menstrual cycles.

RESULTS

Cronbach's α was 0.95 for the luteal DSR-20 scores of the PMS sufferers, indicating very high internal consistency of the 20 items. Exploratory Principal Components Analysis (PCA) of the luteal ratings of the PMS sufferers identified two components with high internal consistency (>0.90), describing psychological and physical premenstrual symptoms. PMS sufferers scored significantly higher than the controls on each of these components during the luteal, but not follicular, phase.

CONCLUSIONS

The DSR-20 total scale score is an internally consistent global measure of the intensity of PMS. The division of PMS symptoms into psychological and physical components, both of which significantly differentiated PMS sufferers from controls during the luteal phase, sheds further light on the description of PMS and provides a clinically relevant and practical means by which to summarise and interpret daily symptom ratings, necessary for the identification and investigation of the syndrome.

Global study of women's experiences of premenstrual symptoms and their effects on daily life

OBJECTIVES

To determine cross-cultural and other effects on women's experiences of premenstrual symptoms and their impact on activities of daily life (ADL).

STUDY DESIGN

Cross-sectional survey. Sample A total of 7226 women aged 15-49 recruited by random sampling with approximately 400 each from France, Germany, Hungary, Italy, Spain, UK, Brazil, Mexico, Hong Kong, Pakistan and Thailand. Approximately 1000 women in Japan and Korea and 500 Australian women were found using Internet panels.

MAIN OUTCOME MEASURES

Questionnaire of 23 premenstrual symptoms, sociodemographic and lifestyle variables, ADL and women's knowledge of premenstrual terms.

RESULTS

The most prevalent symptoms were abdominal bloating, cramps or abdominal pain, irritability, mastalgia and joint/muscle/back pains. Severity of symptoms was directly proportional to duration (number of affected cycles) (R = 0.78). A linear model found that symptom prevalence (duration × severity) was associated with age (linear and quadratic effects), parity, current smoking and country. Premenstrual physical and mental symptom domains had similar negative effects on ADL. Impact on ADL was affected by education and exercise participation. Women's knowledge of the terms premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) varied by symptom intensity, age, education and country.

CONCLUSIONS

Four of the five most prevalent premenstrual symptoms were physical. There was a great deal of similarities of women's experiences of these symptoms across countries and regions. Women's knowledge of PMS terms is highly dependent on the country in which they live.

Dietary B vitamin intake and incident premenstrual syndrome

BACKGROUND

Thiamine, riboflavin, niacin, vitamin B-6, folate, and vitamin B-12 are required to synthesize neurotransmitters that are potentially involved in the pathophysiology of premenstrual syndrome (PMS).

OBJECTIVE

The objective was to evaluate whether B vitamin intake from food sources and supplements is associated with the initial development of PMS.

DESIGN

We conducted a case-control study nested within the Nurses' Health Study II cohort. Participants were free of PMS at baseline (1991). After 10 y of follow up, 1057 women were confirmed as cases and 1968 were confirmed as controls. Dietary information was collected in 1991, 1995, and 1999 by using food-frequency questionnaires.

RESULTS

Intakes of thiamine and riboflavin from food sources were each inversely associated with incident PMS. For example, women in the highest quintile of riboflavin intake 2-4 y before the diagnosis year had a 35% lower risk of developing PMS than did those in the lowest quintile (relative risk: 0.65; 95% CI: 0.45, 0.92; P for trend = 0.02). No significant associations between incident PMS and dietary intakes of niacin, vitamin B-6, folate, and vitamin B-12 were observed. Intake of B vitamins from supplements was not associated with a lower risk of PMS.

CONCLUSIONS

We observed a significantly lower risk of PMS in women with high intakes of thiamine and riboflavin from food sources only. Further research is needed to evaluate the effects of B vitamins in the development of premenstrual syndrome.

Prevalence of premenstrual syndrome and premenstrual dysphoric disorder in a representative cohort of Spanish women of fertile age

OBJECTIVE

To assess the prevalence of premenstrual symptoms, premenstrual syndrome and premenstrual dysphoric disorder in a cohort of women of fertile age representative of the general Spanish population.

STUDY DESIGN

During the period between November 27th and December 22nd, 2008, a cross-sectional nationwide survey was conducted among a cohort of Spanish women aged between 15 and 49 years. Participants were personally interviewed at home and completed the premenstrual symptoms screening tool.

RESULTS

Of the 2108 participants, 1554 women (73.7%) complained of some of the premenstrual symptoms during the last 12 menstrual cycles. A total of 1415 (91%) women presented isolated symptoms and 139 (8.9%) a moderate/severe premenstrual syndrome. Twenty-four (1.1%) women fulfilled criteria for a diagnosis of premenstrual dysphoric disorder.

CONCLUSION

The prevalence of premenstrual symptoms (73.7%) and premenstrual dysphoric disorder (1.1%) in Spanish women aged between 15 and 49 years is similar to that reported in other Western countries. Only women with moderate or severe premenstrual syndrome or premenstrual dysphoric disorder, however, had daily life activities significantly impaired by premenstrual symptoms.

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

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