The role of hormones and hormonal treatments in premenstrual syndrome

Emotion regulation-based internet-delivered cognitive behavioural therapy for premenstrual dysphoric disorder: study protocol for a randomised controlled trial in Sweden

INTRODUCTION

Premenstrual dysphoric disorder (PMDD) is a cyclic mood disorder affecting around 2%-5% of women of reproductive age. Pharmacological interventions exist, but many patients with PMDD experience residual symptoms, discontinue medications or refrain from them due to side effects. Thus, non-pharmacological treatments are needed as an alternative or additive treatment strategy. Evidence indicates that cognitive behavioural therapy (CBT) is a promising candidate. However, further research is required to establish its efficacy and identify ways to improve the treatment. Specifically, incorporating components targeting emotional and interpersonal dysregulation could theoretically enhance its effects. Furthermore, increasing the generally low accessibility of CBT for PMDD necessitates scalable and cost-effective ways to deliver treatment. The current study aims to evaluate the effects and cost-effectiveness of an internet-delivered CBT (ICBT) intervention for PMDD incorporating skills training in emotion regulation and interpersonal effectiveness.

METHODS AND ANALYSIS

The study is a parallel two-group randomised controlled trial with 1:1 allocation to 8 weeks of therapist-guided ICBT or a waitlist control condition. Following recruitment and inclusion, 164 individuals aged 18-45 years who fulfil the Diagnostic Manual of Mental Disorders-5 criteria for PMDD will be randomly assigned to the two groups. Primary outcomes are pretreatment to post-treatment group differences in premenstrual symptoms and their impact on everyday life, as well as psychological and functional impairment during the premenstrual phase. Secondary outcomes include treatment effects on quality of life and difficulties in emotion regulation. Long-term treatment effects will be assessed 6 and 12 months postintervention. Data will be analysed using latent Gaussian process modelling and linear mixed models. The economic evaluation will analyse individual-level societal costs and outcomes between trial arms. Recruitment is expected to begin in February 2025, with study completion anticipated by February 2028.

ETHICS AND DISSEMINATION

The study has been approved by the Swedish Ethical Review Authority (2023-00655-01). Results will be disseminated via presentations and publications in international journals and national outlets for clinicians and patients with PMDD.

PROTOCOL VERSION

PS2024_v1.

TRIAL REGISTRATION NUMBER

NCT06496139.

Menstrually-related mood disorders and postpartum depression: Convergent aspects in aetiology

Females diagnosed with Menstrually-related mood disorders (MRMDs) have more risk to develop postpartum depression (PPD). There are overlapping symptoms between MRMDs and PPD such as anxiety, depressed mood, irritability, that can contribute to a lower quality of life. MRMDs and PPD share components in their etiology such as dramatic hormonal oscillations, and alterations in Hypothalamus-Pituitary-Adrenal (HPA) axis activity that may impair GABAergic neurotransmission. As well, stressful events that impact HPA regulation may play an important role in the etiology of MRMDs and PPD. Here we review common hormone fluctuations across the menstrual cycle and pregnancy/postpartum to identify shared pathways that could contribute to greater sensitivity in people with MRMDs and PPD. This review summarizes hormone sensitivity, HPA axis activity and neurosteroids effects on GABAergic transmission and the potential role of chronic stress in developing MRMDs and PPD. In addition, other potential etiopathological factors, such as serotonin and the immune system, are discussed. Investigating the etiopathology of MRMDs and PDD will help to better understand the complexity of factors involved in these disorders that affect females across the reproductive years.

The behavioral and physiological correlates of affective mood switching in premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD), a more severe manifestation of premenstrual syndrome (PMS), is characterized by emotional, behavioral, and physical symptoms that begin in the mid-to-late luteal phase of the menstrual cycle, when estradiol and progesterone levels precipitously decline, and remit after the onset of menses. Remotely monitoring physiologic variables associated with PMDD depression symptoms, such as heart rate variability (HRV), sleep, and physical activity, holds promise for developing an affective state prediction model. Switching into and out of depressive states is associated with an increased risk of suicide, and therefore, monitoring periods of affective switching may help mitigate risk. Management of other chronic health conditions, including cardiovascular disease and diabetes, has benefited from remote digital monitoring paradigms that enable patients and physicians to monitor symptoms in real-time and make behavioral and medication adjustments. PMDD is a chronic condition that may benefit from real-time, remote monitoring. However, clinical practice has not advanced to monitoring affective states in real-time. Identifying remote monitoring paradigms that can detect within-person affective state change may help facilitate later research on timely and efficacious interventions for individuals with PMDD. This narrative review synthesizes the current literature on behavioral and physiological correlates of PMDD suitable for remote monitoring during the menstrual cycle. The reliable measurement of heart rate variability (HRV), sleep, and physical activity, with existing wearable technology, suggests the potential of a remote monitoring paradigm in PMDD and other depressive disorders.

Clinical Correlates of Premenstrual Suicidal Ideation Among Women in Makkah Population

Introduction Suicidal ideation (SI), planning, and attempts have been found to be more common in women with premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). This study assessed the association between PMS, PMDD, and SI within the Makkah population, in Saudi Arabia. Methodology A descriptive cross-sectional study that simply characterizes the prevalence of a health outcome in a specified population was done on 733 women using an online questionnaire. Data about demographics, menstrual cycle, PMS, past psychiatric history, prior history of PMDD, and previous drug treatment for PMDD were collected. The chi-square and Fisher exact tests were applied. Results Of the participants, 540 (73.7%) had an age represented the age of 18-25 years old, 551 (75.2%) were single, 592 (80.8%) did not have children, 352 (48.0%) had a four-year college education, and 552 (75.3%) had a monthly income of less than 5000 SR. Exactly 704 (96.0%) were menstruating, 539 (73.5%) had regular menstrual cycles, 640 (87.3%) reported low shock trauma, 201 (27.4%) reported a history of anxiety, and 541 (73.8%) reported an impact of premenstrual disorders on mental health. Of them, 662 (90.3%) experienced premenstrual symptoms, 53 (7.2%) had a previous diagnosis of premenstrual symptoms, and 62 (8.5%) had a history of a suicide attempt. Those aged 18 to 25 years, who have no children, have a monthly income of less than 5000, are unemployed, have irregular menstruation, have medical interventions due to premenstrual symptoms, have a lifelong history of depression or anxiety, and have a history of high shock trauma had a significantly higher prevalence of a history of a suicide attempt. These factors were independent predictors on regression analysis. Conclusion The link between PMD and the likelihood of suicide attempts highlights how crucial it is to treat severe PMDs in the context of mental health.

Electroencephalography findings in menstrually-related mood disorders: A critical review

The female reproductive years are characterized by fluctuations in ovarian hormones across the menstrual cycle, which have the potential to modulate neurophysiological and behavioral dynamics. Menstrually-related mood disorders (MRMDs) comprise cognitive-affective or somatic symptoms that are thought to be triggered by the rapid fluctuations in ovarian hormones in the luteal phase of the menstrual cycle. MRMDs include premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), and premenstrual exacerbation (PME) of other psychiatric disorders. Electroencephalography (EEG) non-invasively records in vivo synchronous activity from populations of neurons with high temporal resolution. The present overview sought to systematically review the current state of task-related and resting-state EEG investigations on MRMDs. Preliminary evidence indicates lower alpha asymmetry at rest being associated with MRMDs, while one study points to the effect being luteal-phase specific. Moreover, higher luteal spontaneous frontal brain activity (slow/fast wave ratio as measured by the delta/beta power ratio) has been observed in persons with MRMDs, while sleep architecture results point to potential circadian rhythm disturbances. In this review, we discuss the quality of study designs as well as future perspectives and challenges of supplementing the diagnostic and scientific toolbox for MRMDs with EEG.

Levonorgestrel intrauterine device and depression: A Swedish register-based cohort study

BACKGROUND

The levonorgestrel intrauterine device (LNG-IUD) is traditionally viewed as a safe contraceptive with limited systemic effects. However, three recent studies have indicated an increased risk of depression subsequent to LNG-IUD use. This study aimed to examine the potential associated risk between LNG-IUDs and depression, and determine which women are at risk.

METHODS

This longitudinal cohort study was based on data from seven Swedish national population-based registers. All Nordic-born women aged 15-24 years residing in Sweden between 2010 and 2017 were included. Cox regression was implemented to estimate the adjusted hazard ratio (AHR) for developing depression, defined as first depression diagnosis or redeemed prescription for antidepressant treatment. We adjusted for age, education level, parental country of origin, parental psychiatric health, previous hormonal contraceptive use and medical indications for contraceptive use.

FINDINGS

703,157 women were included in the analysis. The LNG-IUD was associated with 57 % increased risk of depression [AHR 1.57 (95 % CI 1.51-1.64)]. The greatest risk increase was seen in adolescent women [AHR 2.57, (95 % CI 2.36-2.80)] and women who used the LNG-IUD as their first hormonal contraceptive method [AHR 1.63, (95 % CI 1.50-1.78)]. The risk of depression decreased at the end of study period [AHR 1.43, (95 % CI 1.36-1.51)], once the LNG-IUD became more widely accessible among nulliparous women.

CONCLUSIONS

Adolescent women who use the LNG-IUD as their first-ever hormonal contraceptive are at increased risk of developing depression. However, additional impact from confounding factors is likely as risk estimates decreased over the study period. Further research needs to determine if there is a causal relationship between LNG-IUDs and depression.

The benefits of estetrol addition to drospirenone for contraception

Ethinylestradiol and drospirenone combined oral contraceptive formulations have been marketed for >20 years. Drospirenone has antimineralocorticoid and anti-androgenic effects that may offer several health benefits. Recently, 2 new drospirenone-containing oral contraceptives entered the market, 1 as a progestin-only pill containing 4 mg drospirenone and the other as a combined oral contraceptive containing 15 mg estetrol and 3 mg drospirenone. Estetrol has a unique differential effect on nuclear and membrane estrogen α-receptors when compared with other estrogens, leading to low impact on the liver, breast, and hemostasis parameters and a beneficial effect on the endometrium, vagina, cardiovascular system, bone, and brain. Phase 3 clinical studies demonstrated that the Pearl Index (pregnancies per 100-woman-years) for drospirenone alone is 4.0 in the United States and 0.93 in the European Union and for the estetrol-drospirenone combination it is 2.65 and 0.44, respectively. Drospirenone alone demonstrates high rates of unscheduled bleeding and low rates of scheduled bleeding, whereas the estetrol-drospirenone combination demonstrates a predictable and regular bleeding profile for most users with a high stable rate of scheduled bleeding and a low rate of unscheduled bleeding, reported primarily as spotting only. The adverse event profiles and discontinuation rates owing to adverse events are comparable, and no clinically significant effects were observed on metabolic parameters with either product. Hemostatic assays for drospirenone do not fully evaluate all parameters although the testing that is available suggests negligible effects, whereas validated hemostatic assays demonstrate that the estetrol-drospirenone combination has limited impact on hemostasis. The introduction of 4 mg drospirenone and 15 mg estetrol with 3 mg drospirenone are valuable additions to the contraceptive market. Adding estetrol to 3 mg drospirenone provides advantages of contraceptive efficacy and a regular, predictable bleeding profile with minimal impact on hemostasis parameters.

Progesterone and Its Metabolites Play a Beneficial Role in Affect Regulation in the Female Brain

Premenstrual dysphoric disorder is a female affective disorder that is defined by mood symptoms. The condition is linked to unstable progesterone concentrations. Progestin supplementation is given in cases of threatened or recurrent miscarriage and for luteal phase support. Progesterone is essential for implantation, immune tolerance, and modulation of uterine contractility. For a long time, the administration of progestins was associated with an unfavorable impact on mood, leading to negative affect, and, therefore, was contraindicated in existing mood disorders. Establishing the role of the natural progesterone derivative allopregnanolone in advances in the treatment of postpartum depression has shed new light on the general pathophysiology of mood disorders. Allopregnanolone directly interacts with gamma-aminobutyric acid type A (GABA-A) receptors even at nanomolar concentrations and induces significant anti-depressant, anti-stress, sedative, and anxiolytic effects. Postpartum depression is caused by a rapid drop in hormones and can be instantly reversed by the administration of allopregnanolone. Premenstrual dysphoric disorder can also be considered to result from insufficient neuroactive steroid action due to low progesterone derivative concentration, unstable hormone levels, or decreased receptor sensitivity. The decrease in progesterone levels in perimenopause is also associated with affective symptoms and an exacerbation of some psychosomatic syndromes. Bioidentical progesterone supplementation encounters several obstacles, including limited absorption, first-pass effect, and rapid metabolism. Hence, non-bioidentical progestins with better bioavailability were widely applied. The paradoxical, unfavorable effect of progestins on mood can be explained by the fact that progestins suppress ovulation and disturb the endocrine function of the ovary in the luteal phase. Moreover, their distinct chemical structure prevents their metabolism to neuroactive, mood-improving derivatives. A new understanding of progesterone-related mood disorders can translate the study results from case series and observational studies to cohort studies, clinical trials, and novel, effective treatment protocols being developed.

Grey matter morphology in women with premenstrual dysphoric disorder treated with a selective progesterone receptor modulator

Premenstrual dysphoric disorder (PMDD) is characterized by severe cyclic mood symptoms emerging in the luteal phase of the menstrual cycle. The variation in progesterone levels and its metabolites during the luteal phase seems critical to the occurrence of PMDD symptoms. Notably, the efficacy of selective progesterone receptor modulator (SPRM) treatment on the mental symptoms of PMDD has been recently demonstrated. In the present study, structural magnetic resonance imaging was used to assess the effects of SPRM treatment, compared with placebo, on grey matter morphology in women with PMDD. In total, 35 women were scanned during the luteal phase, before and after three months of treatment with SPRM or placebo. Symptom severity was assessed using the Daily Record of Severity of Problems (DRSP), while gonadal hormone levels were measured by liquid chromatography-tandem mass spectrometry. Region-of-interest and whole-brain approaches were employed to perform voxel-based morphometry analyses, subcortical volumetric analyses, and surface-based morphometry analyses. No interaction or main effects of treatment and time were observed on grey matter volume and cortical surface measures (cortical thickness, gyrification index, sulcal depth, and fractal dimension). The relationship between change in brain morphology and symptom severity was also explored but no treatment-dependant grey matter structure change was related to symptom severity change. These findings suggest that SPRM treatment does not impart macrostructural changes onto grey matter structure, at least in the short term.

mPR-Specific Actions Influence Maintenance of the Blood–Brain Barrier (BBB)

Cerebral cavernous malformations (CCMs) are characterized by abnormally dilated intracranial microvascular sinusoids that result in increased susceptibility to hemorrhagic stroke. It has been demonstrated that three CCM proteins (CCM1, CCM2, and CCM3) form the CCM signaling complex (CSC) to mediate angiogenic signaling. Disruption of the CSC will result in hemorrhagic CCMs, a consequence of compromised blood–brain barrier (BBB) integrity. Due to their characteristically incomplete penetrance, the majority of CCM mutation carriers (presumed CCM patients) are largely asymptomatic, but when symptoms occur, the disease has typically reached a clinical stage of focal hemorrhage with irreversible brain damage. We recently reported that the CSC couples both classic (nuclear; nPRs) and nonclassic (membrane; mPRs) progesterone (PRG)-receptors-mediated signaling within the CSC-mPRs-PRG (CmP) signaling network in nPR(−) breast cancer cells. In this report, we demonstrate that depletion of any of the three CCM genes or treatment with mPR-specific PRG actions (PRG/mifepristone) results in the disruption of the CmP signaling network, leading to increased permeability in the nPR(−) endothelial cells (ECs) monolayer in vitro. Finally, utilizing our in vivo hemizygous Ccm mutant mice models, we demonstrate that depletion of any of the three CCM genes, in combination with mPR-specific PRG actions, is also capable of leading to defective homeostasis of PRG in vivo and subsequent BBB disruption, allowing us to identify a specific panel of etiological blood biomarkers associated with BBB disruption. To our knowledge, this is the first report detailing the etiology to predict the occurrence of a disrupted BBB, an indication of early hemorrhagic events.

Premenstrual Syndrome and Premenstrual Dysphoric Disorder as Centrally Based Disorders

Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) encompass a variety of symptoms that occur during the luteal phase of the menstrual cycle and impair daily life activities and relationships. Depending on the type and severity of physical, emotional or behavioral symptoms, women of reproductive age followed for at least two prospective menstrual cycles may receive one of the two diagnoses. PMDD is the most severe form of PMS, predominantly characterized by emotional and behavioral symptoms not due to another psychiatric disorder. PMS and PMDD are common neuro-hormonal gynecological disorders with a multifaceted etiology. Gonadal steroid hormones and their metabolites influence a plethora of biological systems involved in the occurrence of specific symptoms, but there is no doubt that PMS/PMDD are centrally based disorders. A more sensitive neuroendocrine threshold to cyclical variations of estrogens and progesterone under physiological and hormonal therapies is present. Moreover, altered brain sensitivity to allopregnanolone, a metabolite of progesterone produced after ovulation potentiating GABA activity, along with an impairment of opioid and serotoninergic systems, may justify the occurrence of emotional and behavioral symptoms. Even neuro-inflammation expressed via the GABAergic system is under investigation as an etiological factor of PMS/PMDD. Pharmacological management aims to stabilize hormonal fluctuations and to restore the neuroendocrine balance. The rationale of suppressing ovulation supports prescription of combined hormonal contraception (CHC). Its effect on mood is highly variable and depends on biochemical characteristics of exogenous steroids and on type and severity of symptoms. Hormonal regimens reducing the estrogen-free interval or suppressing menstruation seem better choices. Psychoactive agents, such as serotonin reuptake inhibitors (SSRIs), are effective in reducing the symptoms of PMS/PMDD and may be prescribed continuously or only during the luteal phase. Novel therapeutic approaches include inhibition of progesterone receptors in the brain, i.e., with ulipristal acetate, reduced conversion of progesterone with dutasteride, and modulation of the action of allopregnanolone on the brain GABAergic system with sepranolone.

Brain reactivity during aggressive response in women with premenstrual dysphoric disorder treated with a selective progesterone receptor modulator

Premenstrual dysphoric disorder (PMDD) is a psychiatric condition characterized by late luteal phase affective, cognitive, and physical impairment. The disorder causes significant suffering in about 5% of women in their reproductive age. Altered sensitivity of cognitive-affective brain circuits to progesterone and its downstream metabolite allopregnanolone is suggested to underlie PMDD symptomatology. Core mood symptoms include irritability and anger, with aggression being the behavioral outcome of these symptoms. The present study sought to investigate the neural correlates of reactive aggression during the premenstrual phase in women with PMDD, randomized to a selective progesterone receptor modulator (SPRM) or placebo. Self-reports on the Daily Record of Severity of Problems were used to assess PMDD symptoms and gonadal hormone levels were measured by liquid chromatography tandem mass spectrometry. Functional magnetic resonance imaging was performed in 30 women with PMDD, while performing the point subtraction aggression paradigm. Overall, a high SPRM treatment response rate was attained (93%), in comparison with placebo (53.3%). Women with PMDD randomized to SPRM treatment had enhanced brain reactivity in the dorsal anterior cingulate cortex and dorsomedial prefrontal cortex during the aggressive response condition. The fronto-cingulate reactivity during aggressive responses depended on treatment, with a negative relationship between brain reactivity and task-related aggressiveness found in the placebo but not the SPRM group. The findings contribute to define the role of progesterone in PMDD symptomatology, suggesting a beneficial effect of progesterone receptor antagonism, and consequent anovulation, on top-down emotion regulation, i.e., greater fronto-cingulate activity in response to provocation stimuli.

The impact of dysmenorrhea and premenstrual syndrome on academic performance of college students, and their willingness to seek help

Objective

To reveal the characteristics and prevalence of dysmenorrhea and Premenstrual syndrome (PMS) among college students and to investigate their impact on their academic performance.

Materials and Methods

This cross-sectional study was conducted between December 2017 and January 2018 at Koç University, Turkey. An online survey that included multiple-choice and short paragraph questions was prepared. Female students aged between 18 and 27 years were invited with an email to provide online informed consent to proceed to the survey.

Results

The final analysis included 352 students. The prevalence of dysmenorrhea was found as 90.1%. Fifty-six percent of the participants reported lower academic performance during menstruation. However, only 32.8% of the students with dysmenorrhea presented to the gynecology clinic. The prevalence of PMS alone and with dysmenorrhea was 71.3% and 65.9%, respectively. The most common symptom among those who reported affected academic performance was depression (prevalence of 27.5%). However, only 19.9% of students with PMS consulted a healthcare professional.

Conclusion

Symptoms of dysmenorrhea and PMS are generally neglected by students. Quality of life can be affected more than estimated. Considering the reluctance to disclose menstrual disorders, health care providers should be aware of them and ask women about their symptoms during routine visits.

Plasma Interleukin-10 Levels Are Altered in Women with Severe Premenstrual Syndrome: A Preliminary Study

Background: The precise pathophysiology of premenstrual syndrome (PMS) is unknown, and chronic inflammation has been implicated in PMS. However, inflammatory markers, including cytokines and C-reactive protein (CRP), have not been investigated before and after menstruation in relation to PMS among the same participants. This study investigated whether the plasma levels of tumor necrosis factor-α, interleukin (IL)-6, IL-10, and CRP are related to PMS. Methods: The study included 21 healthy Japanese women (aged 19-24 years) with a regular menstrual cycle. Inflammatory marker levels in plasma were determined using enzyme-linked immunosorbent assay. In addition, the level of depressiveness was assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. Results: Of the 21 women, 7 were considered to have moderate-to-severe PMS (PMS [+] group) and 14 were considered to have no or mild PMS (PMS [-]), and none of the participants had premenstrual dysphoric disorder. The IL-10 levels were significantly lower before than after menstruation in the PMS (-) group. The IL-10 levels before menstruation were significantly higher in the PMS (+) group than in the PMS (-) group. Other markers did not show relevant differences between the groups. The CES-D scores were higher in the PMS (+) group than in the PMS (-) group both before and after menstruation. There were positive correlations between the CES-D scores and IL-6 levels before menstruation and the CES-D scores and IL-10 levels after menstruation. Conclusions: The IL-10 levels before menstruation were higher in women with PMS than in those without PMS, and these levels might be related to PMS.

Fluctuations in progesterone moderate the relationship between daily mood and alcohol use in young adult women

BACKGROUND

Research has demonstrated associations between hormonal fluctuations during the menstrual cycle and women's alcohol use. This association has been explained by mood changes that, for some women, accompany decreasing levels of progesterone during the menstrual cycle, particularly during the late luteal/premenstrual phase. The current study examined whether participants' daily ratings of mood interact with changing levels of progesterone to predict alcohol use.

METHOD

Young adult women attended two sessions scheduled two weeks apart, during which they completed questionnaires and provided salivary samples for the assay of progesterone levels. In the intervening two weeks, participants completed daily logs of their mood, alcohol use, and menses. Ordered Generalized Linear Mixed Models assessed the effects of daily mood (examined as both a within- and between-subject variable) on the likelihood of drinking, as a function of menstrual cycle phase and changes in progesterone across the two weeks.

RESULTS

One standard deviation increase in progesterone corresponded to a 1.61 decrease in the odds of drinking. This main effect was moderated by daily mood. Women were more likely to drink during a decrease in progesterone on days they rated their mood as negative, whereas during an increase in progesterone they were more likely to drink on days they reported a positive mood. Between-subject analyses showed that women who reported lower overall mood during the two-week period were more likely to drink with an increase in progesterone and less likely with a decrease.

CONCLUSIONS

Women's likelihood to drink increased when they experienced negative mood in the context of decreasing levels of progesterone, whereas the negative-mood/drinking association was mitigated among those with increasing levels of progesterone. However, compared to women who on average had an overall more positive mood, women with an overall lower mood (and corresponding higher levels of depression and anxiety at baseline) did not experience the protective effects of rising progesterone levels on drinking.

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

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

Anxiolytic- and anxiogenic-like effects of Montanoa tomentosa (Asteraceae): Dependence on the endocrine condition

ETHNOPHARMACOLOGICAL RELEVANCE

Montanoa tomentosa Cerv. (MT) is a native plant from Mexico used in traditional medicine as a remedy for reproductive impairments and relaxing effects. In previous studies, it has been shown that the endocrine state could modify the antianxiety-like actions of anxiolytic compounds. Although women are the primary user of MT, no studies have evaluated the potential impact of the endocrine milieu on its anti-anxiety actions.

AIMS OF THE STUDY

Ascertain the antianxiety effects of M. tomentosa in rats with different hormonal conditions, and to analyze the participation of the GABA_A receptor in ovariectomized rats treated with MT.

MATERIALS AND METHODS

The animal model of anxiety used was the elevated plus-maze (EPM). Rats' endocrine conditions were: a) Low hormone levels (rats in diestrus I and II phases); b) High hormone levels (proestrus/estrus phases); c) No hormones (ovariectomized rats); and d) Rats under progesterone withdrawal (PW). To evaluate the participation of the GABA_A receptor in the anxiolytic-like action of MT the antagonist picrotoxin was used.

RESULTS

Results showed that MT induced dose-dependent anxiolytic-like actions in rats with low hormone level conditions. Also, MT reduced anxiety-like behavior in female rats under PW, in contrast to diazepam which was ineffective. MT's anxiolytic-like effect was blocked by picrotoxin, suggesting the participation of the GABA_A receptor complex. However, increased anxiety-like behavior was observed in rats with a high hormone level condition and low doses of MT.

CONCLUSIONS

Beneficial anxiolytic-like actions of MT are observed under low hormone conditions, particularly in the PW challenge (a condition that can be related to a premenstrual period). Furthermore, the participation of the GABA_A receptor is evidenced. However, hormonal variations could induce the opposite effects, hence women should be cautious.

Changes in premenstrual symptoms in women starting or discontinuing use of oral contraceptives

It is not clear whether oral contraceptive (OC) treatment affects premenstrual symptoms in women. The aim of the present study was to evaluate changes in premenstrual symptoms (PMS) in women starting to use or discontinuing the use of OCs. Twenty-four healthy women with no previous diagnosis of premenstrual dysphoric disorder were included in this study with a prospective crossover design. Nineteen women completed daily ratings of somatic and mood symptoms during two hormonally different cycles, during a normal menstrual cycle and while using OCs. The menstrual cycle phases were hormonally verified and the low-dose, monophasic OCs were used in a 21/7 regimen. The onset of OC use significantly decreased premenstrual somatic symptoms, but it did not affect mood symptoms. In the women who discontinued OC use, no significant changes in neither somatic nor mood symptoms appeared in the premenstrual phase.

Protein intake and the risk of premenstrual syndrome

OBJECTIVE

To examine the relationship between protein intake and the risk of incident premenstrual syndrome (PMS).

DESIGN

Nested case-control study. FFQ were completed every 4 years during follow-up. Our main analysis assessed protein intake 2-4 years before PMS diagnosis (for cases) or reference year (for controls). Baseline (1991) protein intake was also assessed.

SETTING

Nurses' Health Study II (NHS2), a large prospective cohort study of registered female nurses in the USA.ParticipantsParticipants were premenopausal women between the ages of 27 and 44 years (mean: 34 years), without diagnosis of PMS at baseline, without a history of cancer, endometriosis, infertility, irregular menstrual cycles or hysterectomy. Incident cases of PMS (n 1234) were identified by self-reported diagnosis during 14 years of follow-up and validated by questionnaire. Controls (n 2426) were women who did not report a diagnosis of PMS during follow-up and confirmed experiencing minimal premenstrual symptoms.

RESULTS

In logistic regression models adjusting for smoking, BMI, B-vitamins and other factors, total protein intake was not associated with PMS development. For example, the OR for women with the highest intake of total protein 2-4 years before their reference year (median: 103·6 g/d) v. those with the lowest (median: 66·6 g/d) was 0·94 (95 % CI 0·70, 1·27). Additionally, intakes of specific protein sources and amino acids were not associated with PMS. Furthermore, results substituting carbohydrates and fats for protein were also null.

CONCLUSIONS

Overall, protein consumption was not associated with risk of developing PMS.

The effect of omega 3 fatty acid supplementation on premenstrual syndrome and health-related quality of life: a randomized clinical trial

INTRODUCTION

Most reproductive aged women suffer from somatic and mental disorders prior to menstruation. This study investigated whether omega-3 supplement improved premenstrual symptoms and health-related quality of life among reproductive aged women.

METHODS

A multi-center, balanced (1:1), placebo-controlled, parallel-group randomized clinical trial was conducted in an urban academic institution. A sample consisting of 95 Iranian women aged 20-35 years who were suffering from premenstrual symptoms were randomly allocated into two groups. The treatment consisted of omega-3 supplement containing 1 g fish oil. Placebo was free of oil. The premenstrual symptoms' screening tool and 12-item short form health survey questionnaire were used for data collection.

RESULTS

No statistically significant differences in the baseline characteristics of the groups were reported. Most premenstrual symptoms and their interference with daily activities were significantly reduced over the follow-up period. The mean score of overeating in the omega-3 supplement group and insomnia in the placebo group showed no difference between the groups. The longer use of omega-3 supplement provides improvement of premenstrual symptoms and activities. The mean scores of physical and mental components of quality of life were significantly improved in the omega-3 supplement and placebo groups.

DISCUSSION

The treatment of premenstrual symptoms using omega-3 supplement reduced symptoms and ameliorated women's quality of life.

Effects of GABA active steroids in the female brain with a focus on the premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) afflicts 3%-5% of women of childbearing age, and is characterised by recurrent negative mood symptoms (eg, irritability, depression, anxiety and emotional lability) during the luteal phase of the menstrual cycle. The aetiology of PMDD is unknown, although a temporal association with circulating ovarian steroids, in particular progesterone and its metabolite allopregnanolone, has been established during the luteal phase. Allopregnanolone is a positive modulator of the GABA_A receptor: it is sedative in high concentrations but may precipitate paradoxical adverse effects on mood at levels corresponding to luteal phase concentrations in susceptible women. Saccadic eye velocity (SEV) is a measure of GABA_A receptor sensitivity; in experimental studies of healthy women, i.v. allopregnanolone decreases SEV. Women with PMDD display an altered sensitivity to an i.v. injection of allopregnanolone compared to healthy controls in this model. In functional magnetic resonance imaging (fMRI) studies, women with PMDD react differently to emotional stimuli in contrast to controls. A consistent finding in PMDD patients is increased amygdala reactivity during the luteal phase. Post-mortem studies in humans have revealed that allopregnanolone concentrations vary across different brain regions, although mean levels in the brain also reflect variations in peripheral serum concentrations. The amygdala processes emotions such as anxiety and aggression. This is interesting because allopregnanolone is detected at high concentrations within the region into which marked increases in blood flow are measured with fMRI following progesterone/allopregnanolone administration. Allopregnanolone effects are antagonised by its isomer isoallopregnanolone (UC1010), which significantly reduces negative mood symptoms in women with PMDD when administered s.c. in the premenstrual phase. This was shown in a randomised, placebo-controlled clinical trial in which the primary outcome was change in symptom scoring on the Daily Rating of Severity of Problems (DRSP): the treatment reduced negative mood scores (P < .005), as well as total DRSP scores (P < .01), compared to placebo in women with PMDD. In conclusion, the underlying studies of this review provide evidence that allopregnanolone is the provoking factor behind the negative mood symptoms in PMDD and that isoallopregnanolone could ameliorate the symptoms as a result of its ability to antagonise the allopregnanolone effect on the GABA_A receptor.

Intake of dietary fat and fat subtypes and risk of premenstrual syndrome in the Nurses' Health Study II

Approximately 8-20 % of reproductive-aged women experience premenstrual syndrome (PMS), substantially impacting quality of life. Women with PMS are encouraged to reduce fat intake to alleviate symptoms; however, its role in PMS development is unclear. We evaluated the association between dietary fat intake and PMS development among a subset of the prospective Nurses' Health Study II cohort. We compared 1257 women reporting clinician-diagnosed PMS, confirmed by premenstrual symptom questionnaire and 2463 matched controls with no or minimal premenstrual symptoms. Intakes of total fat, subtypes and fatty acids were assessed via FFQ. After adjustment for age, BMI, smoking, Ca and other factors, intakes of total fat, MUFA, PUFA and trans-fat measured 2-4 years before were not associated with PMS. High SFA intake was associated with lower PMS risk (relative risk (RR) quintile 5 (median=28·1 g/d) v. quintile 1 (median=15·1 g/d)=0·75; 95 % CI 0·58, 0·98; P trend=0·07). This association was largely attributable to stearic acid intake, with women in the highest quintile (median=7·4 g/d) having a RR of 0·75 v. those with the lowest intake (median=3·7 g/d) (95 % CI 0·57, 0·97; P trend=0·03). Individual PUFA and MUFA, including n-3 fatty acids, were not associated with risk. Overall, fat intake was not associated with higher PMS risk. High intake of stearic acid may be associated with a lower risk of developing PMS. Additional prospective research is needed to confirm this finding.

Using positron emission tomography to investigate hormone-mediated neurochemical changes across the female lifespan: implications for depression

Ovarian hormones, particularly oestrogen and progesterone, undergo major fluctuations across the female lifespan. These hormone transition periods, such as the transition from pregnancy to postpartum, as well as the transition into menopause (perimenopause), are also known to be times of elevated susceptibility to depression. This study reviews how these transition periods likely influence neurochemical changes in the brain that result in disease vulnerability. While there are known associations between oestrogen/progesterone and different monoaminergic systems, the interactions and their potential implications for mood disorders are relatively unknown. Positron Emission Tomography (PET) allows for the in-vivo quantification of such neurochemical changes, and, thus, can provide valuable insight into how both subtle and dramatic shifts in hormones contribute to the elevated rates of depression during pre-menstrual, post-partum, and perimenopausal periods in a woman's life. As one better understands how to address the challenges of PET studies involving highly vulnerable populations, such as women who have recently given birth, one will gain the insight necessary to design and individualize treatment and therapy. Understanding the precise time-line in younger women when dramatic fluctuations in the hormonal milieu may contribute to brain changes may present a powerful opportunity to intervene before a vulnerable state develops into a diseased state in later life.

Neurosteroid biosynthesis down-regulation and changes in GABAA receptor subunit composition: a biomarker axis in stress-induced cognitive and emotional impairment

By rapidly modulating neuronal excitability, neurosteroids regulate physiological processes, such as responses to stress and development. Excessive stress affects their biosynthesis and causes an imbalance in cognition and emotions. The progesterone derivative, allopregnanolone (Allo) enhances extrasynaptic and postsynaptic inhibition by directly binding at GABA_A receptors, and thus, positively and allosterically modulates the function of GABA. Allo levels are decreased in stress-induced psychiatric disorders, including depression and post-traumatic stress disorder (PTSD), and elevating Allo levels may be a valid therapeutic approach to counteract behavioural dysfunction. While benzodiazepines are inefficient, selective serotonin reuptake inhibitors (SSRIs) represent the first choice treatment for depression and PTSD. Their mechanisms to improve behaviour in preclinical studies include neurosteroidogenic effects at low non-serotonergic doses. Unfortunately, half of PTSD and depressed patients are resistant to current prescribed 'high' dosage of these drugs that engage serotonergic mechanisms. Unveiling novel biomarkers to develop more efficient treatment strategies is in high demand. Stress-induced down-regulation of neurosteroid biosynthesis and changes in GABA_A receptor subunit expression offer a putative biomarker axis to develop new PTSD treatments. The advantage of stimulating Allo biosynthesis relies on the variety of neurosteroidogenic receptors to be targeted, including TSPO and endocannabinoid receptors. Furthermore, stress favours a GABA_A receptor subunit composition with higher sensitivity for Allo. The use of synthetic analogues of Allo is a valuable alternative. Pregnenolone or drugs that stimulate its levels increase Allo but also sulphated steroids, including pregnanolone sulphate which, by inhibiting NMDA tonic neurotransmission, provides neuroprotection and cognitive benefits. In this review, we describe current knowledge on the effects of stress on neurosteroid biosynthesis and GABA_A receptor neurotransmission and summarize available pharmacological strategies that by enhancing neurosteroidogenesis are relevant for the treatment of SSRI-resistant patients. Linked Articles This article is part of a themed section on Pharmacology of Cognition: a Panacea for Neuropsychiatric Disease? To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.19/issuetoc.

Treatment of premenstrual dysphoric disorder with the GABAA receptor modulating steroid antagonist Sepranolone (UC1010)-A randomized controlled trial

CONTEXT

Allopregnanolone is a metabolite from progesterone and a positive modulator of the GABA_A receptor. This endogenous steroid may induce negative mood in sensitive women when present in serum levels comparable to the premenstrual phase. Its endogenous isomer, isoallopregnanolone, has been shown to antagonize allopregnanolone effects in experimental animal and human models.

OBJECTIVE

The objective was to test whether inhibition of allopregnanolone by treatment with the GABA_A modulating steroid antagonist (GAMSA) Sepranolone (UC1010) during the premenstrual phase could reduce symptoms of the premenstrual dysphoric disorder (PMDD). The pharmacokinetic parameters of UC1010 when given as a subcutaneous injection were measured in healthy women prior to the study in women with PMDD.

DESIGN

This was an explorative randomized, double-blind, placebo-controlled study.

SETTING

Swedish multicentre study with 10 centers.

PARTICIPANTS

Participants were 26 healthy women in a pharmacokinetic phase I study part, and 126 women with PMDD in a phase II study part. Diagnosis followed the criteria for PMDD in DSM-5 using Daily Record of Severity of Problems (DRSP) and Endicott's algorithm.

INTERVENTION

Subjects were randomized to treatment with UC1010 (10 or 16mg) subcutaneously every second day during the luteal phase or placebo during one menstrual cycle.

OUTCOME MEASURES

The primary outcome measure was the sum of all 21 items in DRSP (Total DRSP score). Secondary outcomes were Negative mood score i.e. the ratings of the 4 key symptoms in PMDD (anger/irritability, depression, anxiety and lability) and impairment (impact on daily life).

RESULTS

26 healthy women completed the pharmacokinetic phase I study and the dosing in the following trial was adjusted according to the results. 106 of the 126 women completed the phase II study. Within this group, a significant treatment effect with UC1010 compared to placebo was obtained for the Total DRSP score (p=0.041) and borderline significance (p=0.051) for the sum of Negative mood score. Nineteen participants however showed symptoms during the follicular phase that might be signs of an underlying other conditions, and 27 participants had not received the medication as intended during the symptomatic phase. Hence, to secure that the significant result described above was not due to chance, a post hoc sub-group analysis was performed, including only women with pure PMDD who completed the trial as intended (n=60). In this group UC1010 reduced Total DRSP scores by 75% compared with 47% following placebo; the effect size 0.7 (p=0.006), and for sum of Negative mood score (p=0.003) and impairment (p=0.010) with the effect size 0.6. No severe adverse events were reported during the treatment and safety parameters (vital signs and blood chemistry) remained normal during the study.

CONCLUSIONS

This explorative study indicates promising results for UC1010 as a potential treatment for PMDD. The effect size was comparable to that of SSRIs and drospirenone containing oral contraceptives. UC1010 was well tolerated and deemed safe.

The role of emotion regulation in the experience of menstrual symptoms and perceived control over anxiety-related events across the menstrual cycle

Hormonal variation throughout the menstrual cycle is posited to impact various physical and mental health symptoms; however, this is not observed in all women and mechanisms are not well understood. Difficulty in emotion regulation may elucidate differences that women experience in physical and mental health functioning between menstrual phases. We examined the moderating role of difficulty in emotion regulation in the relation between menstrual phase and menstrual symptom severity and perceived control over anxiety-related events, in healthy, regularly menstruating women. The participants were 37 women (M_age = 26.5, SD = 9.6). A series of regression analyses were used to examine whether individual differences in emotion regulation difficulties moderate the relation between menstrual phase and our outcomes, severity of menstrual symptoms and perceived control over anxiety-related events, using a within-subjects design. The analyses revealed that difficulty in emotion regulation significantly moderated the relation between menstrual phase and perceived control over anxiety-related events (β = -0.42, p < .05), but not menstrual symptom severity. Women who reported higher emotion regulation difficulty experienced greater differences in perceived control over anxiety-related events between menstrual phases. Specifically, women with lower difficulty in emotion regulation report greater increase in control over anxiety during the late luteal phase compared to women with higher emotion regulation difficulty. Difficulty in emotion regulation may play an important role in understanding differences in menstrual phase-associated impairments, thereby informing the development of targeted interventions for vulnerable women.

The time course of binocular rivalry during the phases of the menstrual cycle

Binocular rivalry occurs when markedly different inputs to the two eyes initiate alternations in perceptual dominance between the two eyes' views. A link between individual differences in perceptual dynamics of rivalry and concentrations of GABA, a prominent inhibitory neurotransmitter in the brain, has highlighted binocular rivalry as a potential tool to investigate inhibitory processes in the brain. The present experiment investigated whether previously reported fluctuations of GABA concentrations in a healthy menstrual cycle (Epperson et al., 2002) also are associated with measurable changes in rivalry dynamics within individuals. We obtained longitudinal measures of alternation rate, dominance, and mixture durations in 300 rivalry tracking blocks measured over 5 weeks from healthy female participants who monitored the start of the follicular and luteal phases of their cycle. Although we demonstrate robust and stable individual differences in rivalry dynamics, across analytic approaches and dependent measures, we found no significant change or even trends across menstrual phases in the temporal dynamics of dominance percepts. We found only sparse between-phase differences in skew and kurtosis on mixture percepts when data were pooled across sessions and blocks. These results suggest a complex dynamic between hormonal steroids, binocular rivalry, and GABAeric signaling in the brain and thus implicate the need to consider a systemic perspective when linking GABA with perceptual alternations in binocular rivalry.

Women with premenstrual dysphoric disorder have altered sensitivity to allopregnanolone over the menstrual cycle compared to controls-a pilot study

RATIONALE

In premenstrual dysphoric disorder (PMDD), a condition that afflicts 3-8 % of women in fertile ages, the cyclic recurrence of debilitating mood symptoms is restricted to the luteal phase of the menstrual cycle. The progesterone metabolite allopregnanolone is produced by the corpus luteum, and circulating levels are reflected in the brain. Allopregnanolone is a modulator of the GABAA receptor, enhancing the effect of γ-aminobutyric acid (GABA). Previous studies have demonstrated different sensitivity to other GABAA receptor agonists, i.e., benzodiazepines, alcohol, and pregnanolone, in PMDD patients compared to controls.

OBJECTIVES

This study aimed to investigate the sensitivity to intravenous allopregnanolone over the menstrual cycle in PMDD patients.

METHODS

Allopregnanolone, 0.05 mg/kg, was administered intravenously once in the mid-follicular and once in the luteal phase of the menstrual cycle to 10 PMDD patients and 10 control subjects. The saccadic eye velocity (SEV) was recorded by electrooculography as a measurement of functional GABAA receptor activity, at baseline and repeatedly after the injection. A mixed model was used to analyze data.

RESULTS

There was a highly significant group × phase interaction in the SEV response to allopregnanolone (F(1,327.489) = 12.747, p < 0.001). In the PMDD group, the SEV response was decreased in the follicular phase compared to the luteal phase (F(1,168) = 7.776, p = 0.006), whereas in the control group, the difference was opposite during the menstrual cycle (F(1,158.45) = 5.70, p = 0.018).

CONCLUSIONS

The effect of exogenous allopregnanolone is associated with menstrual cycle phase in PMDD patients and in controls. The results suggest an altered sensitivity to allopregnanolone in PMDD patients.

Premenstrual disorder and the adolescent: clinical case report, literature review, and diagnostic and therapeutic challenges

OBJECTIVE

The aim of this paper is to present a case with premenstrual dysphoric disorder and to review the diagnosis from an adolescent medicine approach, discussing why diagnosis and treatment must be distinct for this age group and different from the adult approach.

INTRODUCTION

Premenstrual disorder is a periodic, recurrent, debilitating condition with either physical and/or psychological symptoms that occur during the late luteal phase of the menstrual cycle.

CASE

We report the case of a 16-year-old female diagnosed with premenstrual disorder.

DISCUSSION

Physical signs, behavioral changes, and mood disturbances that occur before menstruation have long been recognized in women, but how well is the disorder defined for adolescents? Due to the unique characteristics of teens, do the current diagnostic criteria appropriately represent this population?

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.

Neurosteroids and GABAergic signaling in health and disease

Endogenous neurosteroids such as allopregnanolone, allotetrahydrodeoxycorticosterone, and androstanediol are synthesized either de novo in the brain from cholesterol or are generated from the local metabolism of peripherally derived progesterone or corticosterone. Fluctuations in neurosteroid concentrations are important in the regulation of a number of physiological responses including anxiety and stress, reproductive, and sexual behaviors. These effects are mediated in part by the direct binding of neurosteroids to γ-aminobutyric acid type-A receptors (GABAARs), resulting in the potentiation of GABAAR-mediated currents. Extrasynaptic GABAARs containing the δ subunit, which contribute to the tonic conductance, are particularly sensitive to low nanomolar concentrations of neurosteroids and are likely their preferential target. Considering the large charge transfer generated by these persistently open channels, even subtle changes in neurosteroid concentrations can have a major impact on neuronal excitability. Consequently, aberrant levels of neurosteroids have been implicated in numerous disorders, including, but not limited to, anxiety, neurodegenerative diseases, alcohol abuse, epilepsy, and depression. Here we review the modulation of GABAAR by neurosteroids and the consequences for health and disease.

Sex hormones affect neurotransmitters and shape the adult female brain during hormonal transition periods

Sex hormones have been implicated in neurite outgrowth, synaptogenesis, dendritic branching, myelination and other important mechanisms of neural plasticity. Here we review the evidence from animal experiments and human studies reporting interactions between sex hormones and the dominant neurotransmitters, such as serotonin, dopamine, GABA and glutamate. We provide an overview of accumulating data during physiological and pathological conditions and discuss currently conceptualized theories on how sex hormones potentially trigger neuroplasticity changes through these four neurochemical systems. Many brain regions have been demonstrated to express high densities for estrogen- and progesterone receptors, such as the amygdala, the hypothalamus, and the hippocampus. As the hippocampus is of particular relevance in the context of mediating structural plasticity in the adult brain, we put particular emphasis on what evidence could be gathered thus far that links differences in behavior, neurochemical patterns and hippocampal structure to a changing hormonal environment. Finally, we discuss how physiologically occurring hormonal transition periods in humans can be used to model how changes in sex hormones influence functional connectivity, neurotransmission and brain structure in vivo.

Elevation of brain allopregnanolone rather than 5-HT release by short term, low dose fluoxetine treatment prevents the estrous cycle-linked increase in stress sensitivity in female rats

Withdrawal from long-term dosing with exogenous progesterone precipitates increased anxiety-linked changes in behavior in animal models due to the abrupt decrease in brain concentration of allopregnanolone (ALLO), a neuroactive metabolite of progesterone. We show that a withdrawal-like effect also occurs during the late diestrus phase (LD) of the natural ovarian cycle in rats, when plasma progesterone and ALLO are declining but estrogen secretion maintains a stable low level. This effect at LD was prevented by short-term treatment with low dose fluoxetine. During LD, but not at other stages of the estrous cycle, exposure to anxiogenic stress induced by whole body vibration at 4 Hz for 5 min evoked a significant decrease in tail flick latency (stress-induced hyperalgesia) and a decrease in the number of Fos-positive neurons present in the periaqueductal gray (PAG). The threshold to evoke fear-like behaviors in response to electrical stimulation of the dorsal PAG was lower in the LD phase, indicating an increase in the intrinsic excitability of the PAG circuitry. All these effects were blocked by short-term administration of fluoxetine (2 × 1.75 mg kg(-1) i.p.) during LD. This dosage increased the whole brain concentration of ALLO, as determined using gas chromatography-mass spectrometry, but was without effect on the extracellular concentration of 5-HT in the dorsal PAG, as measured by microdialysis. We suggest that fluoxetine-induced rise in brain ALLO concentration during LD offsets the sharp physiological decline, thus removing the trigger for the development of anxiogenic withdrawal effects.

Fluoxetine elevates allopregnanolone in female rat brain but inhibits a steroid microsomal dehydrogenase rather than activating an aldo-keto reductase

Background and Purpose

Fluoxetine, a selective serotonin reuptake inhibitor, elevates brain concentrations of the neuroactive progesterone metabolite allopregnanolone, an effect suggested to underlie its use in the treatment of premenstrual dysphoria. One report showed fluoxetine to activate the aldo-keto reductase (AKR) component of 3α-hydroxysteroid dehydrogenase (3α-HSD), which catalyses production of allopregnanolone from 5α-dihydroprogesterone. However, this action was not observed by others. The present study sought to clarify the site of action for fluoxetine in elevating brain allopregnanolone.

Experimental Approach

Adult male rats and female rats in dioestrus were treated with fluoxetine and their brains assayed for allopregnanolone and its precursors, progesterone and 5α-dihydroprogesterone. Subcellular fractions of rat brain were also used to investigate the actions of fluoxetine on 3α-HSD activity in both the reductive direction, producing allopregnanolone from 5α-dihydroprogesterone, and the reverse oxidative direction. Fluoxetine was also tested on these recombinant enzyme activities expressed in HEK cells.

Key Results

Short-term treatment with fluoxetine increased brain allopregnanolone concentrations in female, but not male, rats. Enzyme assays on native rat brain fractions and on activities expressed in HEK cells showed fluoxetine did not affect the AKR producing allopregnanolone from 5α-dihydroprogesterone but did inhibit the microsomal dehydrogenase oxidizing allopregnanolone to 5α-dihydroprogesterone.

Conclusions and Implications

Fluoxetine elevated allopregnanolone in female rat brain by inhibiting its oxidation to 5α-dihydroprogesterone by a microsomal dehydrogenase. This is a novel site of action for fluoxetine, with implications for the development of new agents and/or dosing regimens to raise brain allopregnanolone.

Switching between forest and trees: opposite relationship of progesterone and testosterone to global-local processing

Sex differences in attentional selection of global and local components of stimuli have been hypothesized to underlie sex differences in cognitive strategy choice. A Navon figure paradigm was employed in 32 men, 41 naturally cycling women (22 follicular, 19 luteal) and 19 users of oral contraceptives (OCs) containing first to third generation progestins in their active pill phase. Participants were first asked to detect targets at any level (divided attention) and then at either the global or the local level only (focused attention). In the focused attention condition, luteal women showed reduced global advantage (i.e. faster responses to global vs. local targets) compared to men, follicular women and OC users. Accordingly, global advantage during the focused attention condition related significantly positively to testosterone levels and significantly negatively to progesterone, but not estradiol levels in a multiple regression model including all naturally cycling women and men. Interference (i.e. delayed rejection of stimuli displaying targets at the non-attended level) was significantly enhanced in OC users as compared to naturally cycling women and related positively to testosterone levels in all naturally cycling women and men. Remarkably, when analyzed separately for each group, the relationship of testosterone to global advantage and interference was reversed in women during their luteal phase as opposed to men and women during their follicular phase. As global processing is lateralized to the right and local processing to the left hemisphere, we speculate that these effects stem from a testosterone-mediated enhancement of right-hemisphere functioning as well as progesterone-mediated inter-hemispheric decoupling.

Social stimulation and corticolimbic reactivity in premenstrual dysphoric disorder: a preliminary study

BACKGROUND

Premenstrual dysphoric disorder (PMDD), characterized by luteal phase-induced negative affect and loss of impulse control, often results in compromised social interactions. Although amygdala activation is generally linked to negative affect, increased amygdala reactivity to aversive stimuli in the luteal phase has not been consistently reported in PMDD. We tested the hypothesis that amygdala hyper-reactivity in PMDD is symptom specific, rather than generalized, and linked to socially relevant stimuli. Blood oxygenation level dependent signal changes during exposure to negative images with social and non-social content were evaluated in the mid-follicular and late luteal phase of the menstrual cycle. Fourteen women with PMDD and 13 healthy controls participated.

RESULTS

When compared with healthy controls, women with PMDD in the luteal phase had enhanced reactivity to social stimuli compared to non-social stimuli in the amygdala and insula, but attenuated reactivity in the anterior cingulate cortex. Functional couplings between emotion processing and controlling areas were significantly different, being positive in women with PMDD and negative in healthy controls. Changes in progesterone levels in women with PMDD correlated positively with altered amygdala reactivity.

CONCLUSIONS

Socially relevant aversive stimulation elicited enhanced activity in affective processing brain regions that were functionally coupled to compromised activity in cognitive control areas. Because increased reactivity correlated positively with alterations in ovarian steroid levels, data preliminary support the hypothesis that enhanced progesterone sensitivity in PMDD affects corticolimbic processing of social emotions.

Premenstrual syndrome symptomatology among married women of fertile age based on methods of contraception (hormonal versus non-hormonal methods of contraception)

INTRODUCTION

Premenstrual syndrome (PMS) refers to the cyclic occurrence of a set of disturbing physical, emotional or behavioral alterations that are of sufficient severity to interfere with interpersonal relations and routine life. Normal variations in gonadal estrogen and progesterone lead to biochemical reactions in the brain, resulting in PMS symptoms. This study aims to investigate the prevalence of PMS and PMDD signs among married women of fertile age (MWFA) based on the methods of birth control.

METHOD AND MATERIALS

In a descriptive study, a number of 400 married women referring to 20 family healthcare clinics that use contraceptive methods were recruited and PMS questionnaire were administered to them.

RESULTS

From 400 subjects, 205 took oral contraceptive pills (hormonal methods of contraception) and 195 used other birth control methods (non-hormonal method). A number of 345 subjects (86.25%) at least experienced one PMS symptom and 55 subjects (13.75%) did not report any symptoms. Of those who use hormonal contraceptives (HCs), 182 (88.8%) reported PMS symptoms and 23(11.2) lacked any symptoms.

CONCLUSION

About 86% of the subjects showed moderate to severe of PMS symptoms. Although using hormonal contraceptive method can theoretically reduce PMS symptoms, such effect was not observed in this study. The results of this research should be generalized with caution. Future studies are suggested.

Premenstrual dysphoric disorder and prefrontal reactivity during anticipation of emotional stimuli

Premenstrual disorder (PMDD) affects around 5% of women in childbearing ages. An increased sensitivity in emotion processing areas of the brain to variations in ovarian steroid levels has been suggested as part of the pathophysiology in PMDD, but prior neuroimaging studies of emotion processing are yet inconclusive. Previous behavioral studies of women with PMDD have, however, reported enhanced luteal phase startle responsivity during emotional anticipation. Here we used functional magnetic resonance imaging (fMRI) to investigate central neural circuitry activity during anticipation of, and exposure to, emotional stimuli across the menstrual cycle in women with and without PMDD. As compared to healthy controls, women with PMDD displayed significantly enhanced reactivity in the prefrontal cortex during anticipation of, but not exposure to, negative emotional stimuli during the luteal phase. In PMDD patients, BOLD reactivity during anticipation or viewing of negative emotional stimuli was not dependent on absolute levels of estradiol or progesterone. However, progesterone levels were positively correlated with emotion-induced reactivity in the dorsolateral prefrontal cortex to positive emotional stimuli. These findings suggest that cortical emotional circuitry reactivity during anticipation is altered in PMDD during the luteal phase, which might be part of the pathophysiology behind the emotional symptoms or lack of emotional control reported by women with PMDD.

Rapid impact of progesterone on the neuronal growth cone

In the last two decades, sensory neurons and Schwann cells in the dorsal root ganglia (DRG) were shown to express the rate-limiting enzyme of the steroid synthesis, cytochrome P450 side-chain cleavage enzyme (P450scc), as well as the key enzyme of progesterone synthesis, 3β-hydroxysteroid dehydrogenase (3β-HSD). Thus, it was well justified to consider that DRG neurons similarly are able to synthesize progesterone de novo from cholesterol. Because direct progesterone effects on axonal outgrowth in peripheral neurons have not been investigated up to now, the present study provides the first insights into the impact of exogenous progesterone on axonal outgrowth in DRG neurons. Our studies including microinjection and laser scanning microscopy demonstrate morphological changes especially in the neuronal growth cones after progesterone treatment. Furthermore, we were able to detect a distinctly enhanced motility only a few minutes after the start of progesterone treatment using time-lapse imaging. Investigation of the cytoskeletal distribution in the neuronal growth cone before, during, and after progesterone incubation revealed a rapid reorganization of actin filaments. To get a closer idea of the underlying receptor mechanisms, we further studied the expression of progesterone receptors in DRG neurons using RT-PCR and immunohistochemistry. Thus, we could demonstrate for the first time that classical progesterone receptor (PR) A and B and the recently described progesterone receptor membrane component 1 (PGRMC1) are expressed in DRG neurons. Antagonism of the classical progesterone receptors by mifepristone revealed that the observed progesterone effects are transmitted through PR-A and PR-B.

Progesterone facilitates exploration, affective and social behaviors among wildtype, but not 5α-reductase Type 1 mutant, mice

Progesterone (P4) facilitates exploration, anxiety and social behaviors in estrogen (E2)-primed mice. Some of these effects may be due to actions of its 5α-reduced metabolite, 5α-pregnan-3α-ol-20-one (3α,5α-THP). In order to address the role of P4 and its metabolite, 3α,5α-THP, a mouse model was utilized. We hypothesized that if P4's metabolism to 3α,5α-THP is essential to facilitate exploratory, anti-anxiety and social behaviors of mice, then wildtype, but not 5α-reductase knockout (5α-RKO), mice will have greater expression of these behaviors. Experiment 1: Mice were ovariectomized (ovx), E2-primed and administered P4 (0, 125, 250, or 500μg) subcutaneously and then tested 4h later in a battery of tasks: open field, elevated plus maze, and social interaction. Experiment 2: Ovx, E2-primed mice were administered P4 (4mg/kg), 3α,5α-THP (4mg/kg), medroxyprogesterone acetate (MPA, which does not convert to 3α,5α-THP; 4mg/kg), or vehicle subcutaneously and tested 4h later. There was a dose-dependent effect of P4 to wildtype, but not 5α-RKO, mice. Neither wildtype, nor 5α-RKO, mice had increased exploration, anti-anxiety or pro-social behavior with MPA administration. Progesterone only exerted effects on anti-anxiety behavior, and increased 3α,5α-THP in the prefrontal cortex and hippocampus, when administered to wildtype mice. 3α,5α-THP to both WT and 5α-RKO mice increased exploration, anti-anxiety and social interaction and 3α,5α-THP levels in the hippocampus and prefrontal cortex. Thus, metabolism of P4 by the 5α-reductase enzyme may be essential for enhancement of these behaviors.

The Relationship between Life Style, Menstrual Attitude and Premenstrual Syndrome in Nursing Students

PURPOSE

The purpose of this study was to identify the relationships between life style, menstrual attitude and premenstrual syndrome in nursing students.

METHODS

The study participants were 246 nursing students of a university in Gyeunggi province. Data were collected by a self-administered questionnaire from May to June, 2012. Collected data were analyzed using the SPSS/WIN 20.0 program with descriptive statistics, Pearson correlation coefficient, t-test, one-way ANOVA and Scheffe test.

RESULTS

Students who had undesirable alcohol habits (r=.15, p=.020) and negative menstrual attitude (r=.17, p=.009) experienced more a severe premenstrual syndrome (PMS). Students with dysmenorrhea had more severe PMS (F=12.41, p<.001) and a negative menstrual attitude (F=6.18, p<.001).

CONCLUSION

These finding suggest that PMS would be alleviated by nursing interventions to improve alcohol habits and decrease negative menstrual attitudes, and nursing interventions for dysmenorrhea would be helpful in PMS management in nursing students. Further studies on the development of nursing interventions related to these factors are needed for PMS management.

Menstrual cycle phase modulates emotional conflict processing in women with and without premenstrual syndrome (PMS)--a pilot study

Background

Premenstrual syndrome (PMS) is characterized by a cluster of psychological and somatic symptoms during the late luteal phase of the menstrual cycle that disappear after the onset of menses. Behavioral differences in emotional and cognitive processing have been reported in women with PMS, and it is of particular interest whether PMS affects the parallel execution of emotional and cognitive processing. Related to this is the question of how the performance of women with PMS relates to stress levels compared to women without PMS. Cortisol has been shown to affect emotional processing in general and it has also been shown that women with severe PMS have a particular cortisol profile.

Methods

We measured performance in an emotional conflict task and stress levels in women with PMS (n = 15) and women without PMS (n = 15) throughout their menstrual cycle.

Results

We found a significant increase (p = 0.001) in the mean reaction time for resolving emotional conflict from the follicular to the luteal cycle phase in all subjects. Only women with PMS demonstrated an increase in physiological and subjective stress measures during the luteal menstrual cycle phase.

Conclusions

Our findings suggest that the menstrual cycle modulates the integration of emotional and cognitive processing in all women. Preliminary data are supportive of the secondary hypothesis that stress levels are mediated by the menstrual cycle phase only in women with PMS. The presented evidence for menstrual cycle-specific differences in integrating emotional and cognitive information highlights the importance of controlling for menstrual cycle phase in studies that aim to elucidate the interplay of emotion and cognition.

Higher luteal progesterone is associated with low levels of premenstrual aggressive behavior and fatigue

Contradictory findings show both positive and negative effect of progesterone on the premenstrual mood changes in women. Here we present the study investigating this relationship on the large sample of premenstrual women. 122 healthy, reproductive age women collected daily morning saliva samples and recorded intensity scores for the mood symptoms: irritability, anger, sadness, tearfulness, insomnia, and fatigue. Saliva samples were assayed for progesterone concentrations and mood intensity scores were used to calculate behavioral indices. Women with low Aggression/Irritability and Fatigue had consistently higher progesterone levels during the luteal phase than women with high Aggression/Irritability and Fatigue. Additionally, Aggression/Irritability and Fatigue correlated negatively with maximal progesterone value during the luteal phase. Our results demonstrated a negative effect of low progesterone level on the premenstrual mood symptoms such as aggressive behavior and fatigue in healthy reproductive age women. This supports a previously proposed model of biphasic action of progesterone metabolites on mood.