Premenstrual dysphoric disorders: a diversified cluster of vulnerability traits to depression

Sleep quality and excessive daytime sleepiness in women with Premenstrual Syndrome

OBJECTIVE

Examine the relationship between Premenstrual Syndrome (PMS) and sleep in different menstrual cycle phases.

METHODS

Case-control survey conducted at the Primary Care Service and Clinical Research Center at Hospital de Clínicas de Porto Alegre with women aged between 18 and 45 years old. Women filled the Brazilian version of the Premenstrual Symptoms Screen Tool (PSST) for the screening of PMS; participants with positive screening completed the Daily Record of Severity of Problems (DRSP) to confirm PMS diagnosis. We applied the Pittsburg Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) Brazilian versions in the luteal phase (LP) and follicular phase (FP).

RESULTS AND CONCLUSION

69 women were characterized with PMS and 52 without PMS. The risk of poor sleep quality (SQ) was two times higher in women with PMS (p = .006; OR = 3.057; IC95% 1.44-6.45). An interaction between no PMS and LP was found in ESS (p = .014; generalized estimating equation - GEE - adjusted for multiple comparisons by the Bonferroni test and adjusted by age); besides that, women with PMS had greater scores in ESS (p = .022; GEE adjusted by age).

Protective Effects of Tualang Honey against Oxidative Stress and Anxiety-Like Behaviour in Stressed Ovariectomized Rats

The present study aims to evaluate the antioxidant and anxiolytic-like effect of Tualang honey in stressed ovariectomized (OVX) rats. The animals were divided into; (i) nonstressed sham-operated control rats, (ii) sham-operated control rats exposed to stress, (iii) nonstressed OVX rats, (iv) OVX rats exposed to stress, (v) OVX rats exposed to stress and treated with 17 β-oestradiol (E2) (20 μg daily, sc), and (vi) OVX rats exposed to stress and treated with Tualang honey (0.2 g/kg body weight, orally). The open field test was used to evaluate the anxiety-like behaviour and ELISA kits were used to measure oxidant/antioxidant status of the brain homogenates. The result showed that anxiety-like behavior was significantly increased in stressed OVX compared to other groups, and administering either E2 or Tualang honey significantly decreased anxiety-like behaviour in stressed OVX rats. The levels of malondialdehyde (MDA) and protein carbonyl (PCO) were significantly decreased while the levels/activities of superoxide dismutase (SOD), glutathione S-transferases (GST), glutathione peroxidase (GPx), and glutathione reductase (GR) were significantly increased in the brain homogenates of treated stressed OVX groups compared to untreated stressed OVX. In conclusion, Tualang honey has protective effects against brain oxidative stress and may be useful alternative anxiolytic agent especially for postmenopausal women.

Effects of the menstrual cycle on bipolar disorder

OBJECTIVES

Several lines of research suggest that reproductive events may affect the course of bipolar disorder (BD) in some women. With respect to the menstrual cycle, the focus has been on dysphoric symptoms [e.g., premenstrual dysphoric disorder (PMDD)], and the exacerbation of depression, in the premenstrual phase. This article reviews the literature on the potential effects of the menstrual cycle on BD.

METHODS

A systematic search for published case reports and research studies available through March, 2013 was conducted. Several combinations of search terms were entered into PubMed and PsycInfo.

RESULTS

Overall, 25 case reports, ten retrospective studies, and 11 prospective studies were identified. The majority (64%) of case reports involved hypomanic or manic episodes in the premenstrual phase. Retrospective results suggest that 25-77% and 15-27% of women with BD meet the criteria for premenstrual syndrome (PMS) and PMDD, respectively. Menstrual cycle-related mood changes were reported by 64-68% of women with BD in retrospective studies, and were displayed by 44-65% of women in prospective studies.

CONCLUSIONS

Although research has focused on the premenstrual phase to the neglect of the periovulatory phase, it appears that a subgroup of women with BD, possibly those with hormonal sensitivity, experience menstrual cycle effects on depressive, hypomanic, and manic episodes. These phase-episode effects appear to be heterogeneous and may have implications for treatment. Whether they might best be described using course specifiers, similar to postpartum onset and rapid cycling, or as diagnostic entities, like PMDD, requires further study.

Perceived poor sleep quality in the absence of polysomnographic sleep disturbance in women with severe premenstrual syndrome

Women with severe premenstrual syndrome report sleep-related complaints in the late-luteal phase, but few studies have characterized sleep disturbances prospectively. This study evaluated sleep quality subjectively and objectively using polysomnographic and quantitative electroencephalographic measures in women with severe premenstrual syndrome. Eighteen women with severe premenstrual syndrome (30.5 ± 7.6 years) and 18 women with minimal symptoms (controls, 29.2 ± 7.3 years) had polysomnographic recordings on one night in each of the follicular and late-luteal phases of the menstrual cycle. Women with premenstrual syndrome reported poorer subjective sleep quality when symptomatic in the late-luteal phase compared with the follicular phase (P < 0.05). However, there were no corresponding changes in objective sleep quality. Women with premenstrual syndrome had more slow-wave sleep and slow-wave activity than controls at both menstrual phases (P < 0.05). They also had higher trait-anxiety, depression, fatigue and perceived stress levels than controls at both phases (P < 0.05) and mood worsened in the late-luteal phase. Both groups showed similar menstrual-phase effects on sleep, with increased spindle frequency activity and shorter rapid eye movement sleep episodes in the late-luteal phase. In women with premenstrual syndrome, a poorer subjective sleep quality correlated with higher anxiety (r = -0.64, P = 0.005) and more perceived nighttime awakenings (r = -0.50, P = 0.03). Our findings show that women with premenstrual syndrome perceive their sleep quality to be poorer in the absence of polysomnographically defined poor sleep. Anxiety has a strong impact on sleep quality ratings, suggesting that better control of mood symptoms in women with severe premenstrual syndrome may lead to better subjective sleep quality.

Mood instability in women with premenstrual syndrome

OBJECTIVE

Most women of reproductive age experience premenstrual symptoms. Mood swings within a day and from day to day are a common complaint of people with mood problems (mood instability). We investigated whether mood instability was higher in women with premenstrual syndrome (PMS) than in a control group with no PMS.

METHODS

We prospectively studied mood and physical symptoms over two menstrual periods in 29 women with self-identified PMS and 31 women without PMS. We excluded women on hormonal birth control or with a history of past or current diagnoses of depression. We used the mean square successive difference derived from twice daily visual analogue scale ratings of mood as the measure of mood instability.

RESULTS

The women with PMS showed more irritable and depressed mood instability than the women without PMS. These differences were present whether or not the late luteal phase (seven days before the start of menstruation) was included in the data. On visual inspection of mood ratings, typically irritable and depressed moods increased in the late luteal phase. However, women with self-identified PMS showed a variety of mood patterns throughout the cycle.

CONCLUSION

Women with PMS have increased mood instability within the seven day premenstrual phase and at other times as well. This supports the premise that PMS may represent a manifestation of an underlying problem of mood dysregulation in common with other mood disorders.

Influence of personality on pre-menstrual syndrome in athletes

The purpose of this study was to investigate the influence of personality on Premenstrual Syndrome (PMS) in athletes. The sample included 25 Brazilian athletes, between 18 and 49 years of age. A diary of PMS symptoms was used (based on the criteria from the American College of Obstetricians and Gynecologist, ACOG, 2000) and the Factorial Personality Inventory (Pasquali, Azevedo, & Ghesti, 1997). The Fisher exact test was used for data analysis, with p < .05. The athletes with PMS showed a strong need for performance, low need for assistance and introversión and very low need for change, while athletes without PMS demonstrated a very strong need for denial and strong needs for assistance, dominance, and persistence. There was a significant association between low denial (not submitting passively to external forces) and PMS (p < .05). It was concluded that certain personality traits may predispose athletes to react more intensely to needs and pressures produced by changes caused by the menstrual cycle, contributing to the onset of PMS.

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.

Prevalência de síndrome pré-menstrual em atletas

A síndrome pré-menstrual (SPM) é um conjunto de sintomas emocionais e físicos que afeta negativamente as atividades diárias das mulheres durante o período pré-menstrual. Embora seja um tema bastante estudado na população em geral, existe uma lacuna na literatura a respeito da presença de SPM em atletas. Dessa forma, o objetivo do estudo foi analisar a prevalência de SPM em atletas. Foi desenvolvido um estudo do tipo inquérito, com 57 atletas, com idade entre 18 e 47 anos, de 11 modalidades esportivas. Para identificar a presença de SPM, utilizou-se uma ficha autoaplicável baseada nos critérios do American College of Obstetricians and Gynecologists (ACOG, 2000); a confirmação diagnóstica foi feita através do preenchimento de um diário de sintomas durante dois ciclos menstruais consecutivos (baseado no ACOG, 2000). Para análise dos dados utilizou-se teste de Shapiro-Wilk e teste exato de Fisher, adotando P < 0,05. A prevalência de SPM estimada de forma retrospectiva foi de 68%, enquanto a avaliada pelo acompanhamento com os diários foi de 48%. Mastalgia, explosão de raiva, ansiedade e irritabilidade foram os sintomas mais citados. Foram observadas associações significativas entre SPM e volume de treinamento semanal (P = 0,041), número de sintomas totais (P < 0,0001), número de sintomas físicos (P = 0,004), mastalgia (P = 0,028) e desconforto abdominal (P = 0,015). A prevalência de SPM em atletas foi considerada alta e a análise retrospectiva a superestimou em relação ao acompanhamento diário. A alta prevalência, bem como a associação entre SPM e maior volume de treinamento semanal, instiga que o treinamento esportivo pode ter algum impacto na prevalência de SPM em atletas.

The impact of extroversion or menopause status on depressive symptoms among climacteric women in Taiwan

OBJECTIVE

The study was designed to test whether neuroticism moderated the effect of extroversion and mediated the impact of menopause status on depressive symptoms among women in Taiwan during their menopausal transition.

DESIGN

A sample of 197 women, aged 40 to 60 years, were recruited from the community. We used Ko's Depression Inventory, the Five-Factor Inventory-Chinese version, the Menopausal Symptoms Scale, and the Chinese version of the Modified Schedule of Affective Disorders and Schizophrenia-Lifetime to gather data. Moreover, each woman underwent a semistructured diagnostic interview in person to obtain her lifetime psychiatric history.

RESULTS

The hierarchy regression analyses showed that the interaction between neuroticism and extroversion was statistically significant. Further analyses indicated that in the high neuroticism group, extroversion was negatively associated with depressive symptoms; however, in the low neuroticism group, extroversion was not correlated with depressive symptoms. Menopause status was correlated with depressive symptoms, but after adding neuroticism and extroversion, the main effect of menopause status became insignificant. Results of the Sobel test showed that depressive symptoms of women during the menopause transition largely represented neuroticism.

CONCLUSIONS

The present study revealed that the lower levels of extroversion are associated with depression among all stages of menopausal women with high levels of neuroticism; moreover, all stages of menopausal women who have high levels of neuroticism are more vulnerable to depression. The results support that personality may play an important role in women's depression during the transition of menopausal status.

Hormonal therapy and depression: are we overlooking an important therapeutic alternative?

OBJECTIVE

This review aimed to examine evidence for the role of hormonal changes in the onset and course of depressive symptomatology and to assess the possible future role of hormonal therapies in the treatment of depression.

METHODS

A Medline and PsycINFO search of the literature published between 1965 and 2006 was made of studies of depressive symptoms and hormonal treatment in women at all stages of reproductive life.

RESULTS

The cyclic fluctuation of gonadal steroids at menarche coincides with the beginning of gender-based differences in depression rates, which continue throughout reproductive life until menopause. Modifications in hormonal status, whether related to endogenous or exogenous exposure or to hormone deprivation, appear to be associated with affective disorder in a subgroup of women. For these women, a growing body of evidence indicates a biological pattern of vulnerability to mood disorders in response to hormonal fluctuations. This could have three major implications: that women vary in vulnerability to mood disorder when abrupt change in steroid levels occur, that these effects could be cumulative across the female life span, and that women do not arrive at menopause with equal risk of mood disorders or equal susceptibility to the effects of hormonal replacement therapy as has been assumed by current clinical research and practice.

CONCLUSION

While hormonal therapies could have positive effects in the treatment and prevention of depressive disorders, further research is required to differentiate hormone-responsive subgroups of women for whom specific hormonal treatments may be most beneficial. To this end, we suggest that a multifactorial model of cumulative vulnerability, which takes into account hormonal exposure throughout life, genetic vulnerability, and environmental factors, may provide better prediction of treatment response.

Is premenstrual dysphoria a variant of panic disorder? A review

Patients with premenstrual dysphoric disorder (PMDD) and patients with panic disorder (PD) both experience high rates of panic attacks in laboratory panic provocation studies. Recently, this shared elevated rate of challenge-induced panic has received increasing attention. Researchers have suggested that PMDD and panic disorder may share a pathophysiological or psychobiological link. The purpose of this paper is to review the findings from PMDD challenge studies and the theories advanced to connect PMDD to panic disorder. Taken together, the results of the PMDD challenge studies confirm that agents that incite panic in PD patients do so as well in PMDD women. This shared elevated challenge-induced panic cannot be accounted for by explanations such as a history of PD in PMDD women. None of the physiological theories as currently expressed--suffocation false alarm, gamma-aminobutyric acid (GABA), noradrenergic, serotonergic, and cholecystokinin--yet provides a compelling candidate to account for shared elevated challenge-induced panic in PD and PMDD patients. Psychological perspectives on panic emphasize that bodily sensations themselves can cause fear. Researchers have yet to apply several influential psychological approaches--conditioning, catastrophic misinterpretation, and anxiety sensitivity--to PMDD patients. Because psychological factors influence anxious responding in challenge studies, the search for the biological abnormality best accounting for PMDD panic might benefit from a reframing of the question to one that considers the psychological perspective as well.

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.

Panic disorder in menopause: a case control study

OBJECTIVE

The course of panic disorder (PD) is often influenced by the different phases of the female reproductive cycle. The aim of this study is to assess PD in the climacteric stage and single out possible correlations between symptoms of PD and clinical and demographic variables in order to identify possible risk factors.

METHOD

Forty-five women between 40 and 60 years of age was assessed through the SCL-90, the SCID, a "Climacteric Symptoms Questionnaire" (CSQ) devised to evaluate psychological symptoms typically associated with menopause, the Kupperman Index for the analysis of climacteric symptoms, and plasma level of allopregnanolone (ALLO).

RESULTS

PD results in eight patients (18%). This group does not differ from the controls as far as socio-demographic data is concerned, but exhibits significantly higher values in the Kupperman Index, the SCL-90 total, and the CSQ. The plasma levels of ALLO correlate significantly inversely with the total of CSQ and, in any case, negatively with the other variables analysed.

CONCLUSIONS

PD may arise and worsen with menopause, in correlation with greater severity of the climacteric syndrome in its physical and psychological symptoms.

Early life menstrual characteristics and pregnancy experiences among women with and without major depression: the Harvard study of moods and cycles

BACKGROUND

Other than premenstrual dysphoria, few studies have examined the extent to which basic characteristics of the menstrual cycle and the occurrence of other reproductive landmarks impact on the risk of major depression.

METHODS

From a population-based sample of 4161 premenopausal women 36-45 years of age, we identified 332 women who met DSM criteria for past or current major depression and a sample of 644 women with no such history. In person interviews included a detailed assessment of menstrual cycle characteristics from age at menarche through study enrollment as well as other reproductive landmarks.

RESULTS

Risk of depression increased significantly with decreasing age at menarche (P<0.001). The risk of depression was also higher in women with heavier menstrual flow and cycle irregularity during the first 5 years of menstruation. Women with a history of multiple abortions were 2-3-times more likely to develop major depression (95% CI 1.6-4.1). Increasing months of breastfeeding was associated with a decreased risk of depression after adjustment for education, marital status, and number of livebirths (P-value, test of trend=0.012). This association was largely confined to depression during the postpartum period.

LIMITATIONS

Menstrual and pregnancy history exposures were self-reported and retrospectively assessed. However, women with and without a HISTORY of depression were subject to similar recall requirements that likely resulted in an underestimate of most risk estimates.

CONCLUSIONS

Clinicians involved in routine obstetrical and gynecological care of women need to recognize that menstrual and pregnancy history events may serve as potential markers for subsequent psychiatric sequelae.

Treatment of premenstrual dysphoric disorder with luteal phase dosing of sertraline

Sertraline (Zoloft, Pfizer Inc.) is a selective serotonin re-uptake inhibitor (SSRI) which has been approved by the US FDA for the treatment of premenstrual dysphoric disorder (PMDD). PMDD is a severe form of premenstrual syndrome (PMS) which affects at least 5 - 8% of women of reproductive age. It is characterised by cyclic appearance at the late luteal phase of the menstrual cycle, and disappearance following the beginning of menses, with no symptoms during at least 1 week of the cycle - usually during the mid-follicular phase. Due to the cyclic luteal occurrence of PMDD, luteal phase dosing of SSRIs has been suggested and proven effective for sertraline as well as several other SSRIs. The clinical response of sertraline is reported to be within several days following initiation of treatment. Despite repeated cyclic discontinuation, no significant discontinuation adverse effects have been reported. In addition to its proven clinical efficacy, luteal-phase dosing may offer the advantages of minimising adverse effects of SSRIs while reducing the personal and economic burden of taking a prescription medication continuously for long periods and thus increasing compliance.

Condições afetivo-emocionais em mulheres com síndrome pré-menstrual através do Z-Teste e do IDATE

A presente pesquisa visou constatar as condições afetivo-emocionais em mulheres com síndrome pré-menstrual (SPM), comparadas com outras mulheres sem sintomas pré-menstruais. A amostra foi constituída de 43 universitárias, na faixa etária de 18 e 35 anos, distribuídas em dois grupos: Grupo 1, constituído de 25 mulheres com SPM, e Grupo 2 (Controle), de 18 mulheres sem estas disfunções. Foram utilizados como instrumentos a técnica de Zulliger (Z-Teste forma coletiva) e o Inventário de Ansiedade-Traço-Estado - IDATE (Spielberger), e para tratamento estatístico na análise comparativa dos dados o t-Teste para amostras independentes. O nível de significância escolhido foi p < 0.05. Os resultados indicaram que as mulheres do grupo com síndrome pré-menstrual reagem emocionalmente de forma mais intensa e têm tendência à perda de controle emocional em índice maior que as mulheres do grupo sem sintomas pré-menstruais.

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 pathophysiologic background for current treatments of premenstrual syndromes

Multiple hypotheses on the etiology of premenstrual syndromes (PMS) that have been proposed during the past 70 years have led to a multitude of treatment modalities. During the past two decades, the following two classes of pharmacologic interventions have emerged: hormonal interventions--mostly suppression of ovulation; and neurotransmitter's activity stimulation--mostly by specific serotonin reuptake inhibitors. These treatment modalities are based on the hypothesis that the etiology and pathophysiology of PMS are related to ovulation-related luteal activity of gonadal hormones, and their interaction with serotonin and other neurotransmitters. Two other components of the pathophysiology of PMS--the genetic propensity and the dynamically evolving-vulnerability--have not yet been addressed for treatment. Environmental inputs to pathophysiology, which are not discussed here, have been addressed by attempts at changes of lifestyle, coping style, and environment.

Women with premenstrual dysphoric disorder do not recall aberrant parenting

Premenstrual dysphoric disorder (PMDD) is related to the affective disorders and thus is expected to share similar psychological risk factors. Depressed subjects have been found to recall lack of warmth and parental overcontrol in childhood as assessed by the Parental Bonding Instrument (PBI). The present study aimed to find out if such risk factors contributed to the development of PMDD in adulthood. Thirty-four women from South London who fulfilled rigorous criteria for PMDD and 22 controls were assessed for symptom severity, and each subject completed the PBI. All the women included in the study were free from other concurrent psychiatric disorders. Subjects with PMDD and controls had similar scores for warmth and parental overcontrol on the PBI and therefore had not been subject to more affectionless control. The PBI retained expected internal characteristics such as the inverse relationship of warmth and control scores. The findings indicate that recollection of parenting problems in childhood is not a major risk factor for subsequent development of PMDD in these women. A potential explanation for this is that PMDD is more biologically than psychosocially determined.

Role of estrogen in the aetiology and treatment of mood disorders

Worldwide, the prevalence of depression in women is significantly greater than in men. Available data suggest that estrogen, or its absence, is strongly implicated in the regulation of mood and behaviour, as well as in the pathobiology of mood disorders. The multiple effects of estrogens and their complex interactions with the CNS and endocrine system have been well documented, although the specific, multifaceted role of estrogen in each dysphoric state has yet to be elucidated. Several facts suggest that estrogen plays a vital role in the precipitation and course of mood disorders in women. Gender differences in the prevalence of depression first appear after menarche, continue through reproductive age, and dissipate after perimenopause. Periods of hormonal fluctuations or estrogen instability (i.e. premenstrually, postpartum, perimenopausally) have been associated with increased vulnerability to depression among susceptible women. It is plausible that the phenotype of these depressions is distinguishable from those that are not associated with reproductive events or that occur in men. Based on current knowledge, estrogen treatment for affective disorders may be efficacious in two situations: (i) to stabilise and restore disrupted homeostasis - as occurs in premenstrual, postpartum or perimenopausal conditions; and (ii) to act as a psychomodulator during periods of decreased estrogen levels and increased vulnerability to dysphoric mood, as occurs in postmenopausal women. There is growing evidence suggesting that estrogen may be efficacious as a sole antidepressant for depressed perimenopausal women. It is still unclear whether estrogen is efficacious as an adjunct to selective serotonin reuptake inhibitors or as one of the paradigms to manage treatment-resistance depression in menopausal women, but such efficacy is plausible.

Oral contraceptives and mood

The past 40 years of research on the mood and behavioural effects of combined oral contraceptives (OCs) have yielded inconclusive results due to dramatic changes in the compounds and to methodological flaws inherent in studies undertaken to assess the effects of OCs. Since the late 1960s, the dosages of oestrogen and progestin in marketed OCs significantly declined and novel progestins were developed to deliver higher levels of progestogenic activity with a lower risk of adverse oestrogenic and androgenic effects. This review evaluates controlled, comparative studies that have focused on the efficaciousness of OCs as treatment for premenstrual syndrome (PMS) and those examining whether OCs may cause negative mood. It is suggested that the mood and behavioural effects of OCs might be attributed to different progestin compounds and possibly, their oestrogen ratios. There is a great need for more longitudinal, randomised, placebo-controlled studies to further clarify the mood and behavioural effects of OCs.

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.

Premenstrual syndromes: closing the 20th century chapters

The need to re-evaluate premenstrual syndromes became apparent in 1997-1998 and early 1999. The success stories of some symptomatic treatment modalities and more sophisticated studies of pathobiology chart the pathways for future progress: the shift from a descriptive diagnosis to diagnoses based on etiology, the recognition of diversified vulnerabilities and their expression in particular situations, and specific treatment modalities.

Premenstrual syndrome

The advances in the careful screening and diagnosis of women with PMS has led to the ability to conduct epidemiologic, etiologic, and treatment studies in well-defined samples of women. Prospective symptom charting, scoring methods, and careful clinical psychiatric and medical evaluation are necessary to rule out concurrent psychiatric and medical disorders. Studies of women with PMDD have suggested several promising pharmacologic treatment options. Whether these treatment options are also successful for women with milder premenstrual symptoms, with premenstrual exacerbation of underlying conditions, or with premenstrual symptoms superimposed on underlying psychiatric and medical conditions remains to be studied. Treatment of premenstrual symptoms by pharmacologic or nonpharmacologic methods may be unsuccessful if the underlying psychiatric or medical condition is not addressed first.