Luteal phase administration of agents for the treatment of premenstrual dysphoric disorder

Patient Experiences of Health Care Providers in Premenstrual Dysphoric Disorder: Examining the Role of Provider Specialty

Background: Premenstrual dysphoric disorder (PMDD) is a severe mood disorder that affects ∼5% of menstruating individuals. Although symptoms are limited to the luteal phase of the menstrual cycle, PMDD causes significant distress and impairment across a range of activities. PMDD is under-recognized by health care providers, can be difficult to diagnose, and lies at the intersection of gynecology and psychiatry. Thus, many patients are misdiagnosed, or encounter challenges in seeking care. The aim of this study was to examine patients' experiences with different health care specialties when seeking care for PMDD symptoms. Methods: We examined data from the 2018 Global Survey of Premenstrual Disorders conducted by the International Association for Premenstrual Disorders (IAPMD). Patients rated their health care providers (general practitioners, psychiatrists, gynecologists, psychotherapists) in three key areas related to treatment of premenstrual mood complaints: interpersonal factors, awareness and knowledge of PMDD, and whether the patient was asked to track symptoms daily. Intraclass correlations examined between- and within-person variance. Multilevel regression models predicted ratings on each provider competency item, with ratings nested within individuals to examine the within-patient effect of provider type on outcomes. Results: The sample included 2,512 patients who reported seeking care for PMDD symptoms. Regarding interpersonal factors, psychotherapists were generally rated the highest. On awareness and knowledge of PMDD, gynecologists and psychiatrists were generally rated the highest. Gynecologists were more likely than other providers to ask patients to track symptoms daily. Conclusions: These findings suggest that different providers have different strengths in assessing and treating PMDD. Further, graduate and medical training programs may benefit from increased curricular development regarding evidence-based evaluation and treatment of PMDD.

A forced swim-based rat model of premenstrual depression: effects of hormonal changes and drug intervention

Premenstrual dysphoric disorder (PMDD), a form of premenstrual syndrome (PMS), is a severe health disturbance that affects a patient’s emotions; it is caused by periodic psychological symptoms, and its pathogenesis remains unclear. As depression-like symptoms are found in a majority of clinical cases, a reliable animal model of premenstrual depression is indispensable to understand the pathogenesis. Herein, we describe a novel rat model of premenstrual depression, based on the forced swimming test, with a regular estrous cycle. The results showed that in the estrous cycle, the depression-like behavior of rats occurred in the non-receptive phase and disappeared in the receptive phase. Following ovariectomy, the depression-like symptoms disappeared and returned after a hormone priming regimen. Moreover, fluoxetine, an anti-depressant, could reverse the behavioral symptoms in these model rats with normal estrous cycle. Further, the model rats showed significant changes in the serum levels of estrogen and progesterone, hippocampal levels of allopregnanolone, 5-hydroxytryptamine, norepinephrine, and γ-aminobutyric acid (GABA), and in the expression of GABA_A receptor 4α subunit, all of which were reversed to physiological levels by fluoxetine. Overall, we established a reliable and standardized rat model of premenstrual depression, which may facilitate the elucidation of PMS/PMDD pathogenesis and development of related therapies.

Paeonol at Certain Doses Alleviates Aggressive and Anxiety-Like Behaviours in Two Premenstrual Dysphoric Disorder Rat Models

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome (PMS), a common mental health disturbance associated with several periodic psychological symptoms in women. Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for PMS/PMDD patients; however, side effects are inevitable, especially in long-term treatment. In previous studies, the natural compound paeonol in Moutan Cortex was found to play effective roles in central nervous system disorders with its anti-inflammatory, anti-oxidant, and neuroprotective effects. Consequently, we assume that paeonol might produce positive effects in the treatment of PMS/PMDD. In this study, the open-field test (OFT) and elevated plus maze (EPM) and light dark box (LDB) tests were performed in mice to determine the optimal dose of paeonol for treating anxiety. Then, paeonol was used to treat the progesterone withdrawal (PWD) and resident intruder paradigm (RIP) rat models of PMDD. Using these two reliable models, the OFT and EPM, LDB, and composite aggressive tests were performed to evaluate the effect of the drug on behavioural symptoms of PMDD. From the dosage screening results, the optimal anti-anxiety dose of paeonol was identified as 17.5 mg/kg/d for 7 days. With regard to the effect of paeonol on PMDD rat models, a significantly improvement was found in the behavioural symptoms, but the effective dose varied in different models. For the PWD model rats, treatment with 6.05 mg/kg paeonol could significantly improve anxiety and irritability, while that with 24.23 mg/kg paeonol resulted in anxiety-like effects in behavioural tests. In RIP model rats, treatment with 12.11 mg/kg paeonol demonstrated excellent effects in improving anxiety, particularly irritable emotional behaviour. In conclusion, our study indicates that paeonol is a potential therapeutic compound for PMS/PMDD; it is a drug option that helps establish dosage guidance for treatment of this condition.

Contraceptive options for women with premenstrual dysphoric disorder: current insights and a narrative review

Premenstrual syndrome and its most severe form, premenstrual dysphoric disorder (PMDD), are two well-defined clinical entities that affect a considerable number of women. Progesterone metabolites and certain neurotransmitters, such as gamma-aminobutyric acid and serotonin, are involved in the etiology of this condition. Until recently, the only treatment for women with PMDD was psychoactive drugs, such as selective serotonin reuptake inhibitors. Several years ago, there has been evidence of the beneficial role of combined hormonal contraceptives in controlling PMDD symptoms. Oral combined hormonal contraceptives that contain drospirenone in a 24+4-day regimen are the only drugs that have been approved by US Food and Drug Administration for the treatment of PMDD, but there is scientific evidence that other agents, with other formulations and regimens, could also be effective for the treatment of this condition. However, it remains unclear whether the beneficial effect of combined hormonal contraceptives is associated with the type of estrogen or progestogen used or the treatment regimen.

Daily symptom ratings for studying premenstrual dysphoric disorder: A review

BACKGROUND

To review how daily symptom ratings have been used in research into premenstrual dysphoric disorder (PMDD), and to discuss opportunities for the future.

METHODS

PsycINFO and Medline were systematically searched, resulting in the inclusion of 75 studies in which (1) participants met the diagnostic criteria for late luteal phase dysphoric disorder (LLPDD) or PMDD and (2) diaries were used to study LLPDD/PMDD.

RESULTS

To date, diaries have been used to gain insight into the aetiology and phenomenology of PMDD, to examine associated biological factors, and to assess treatment efficacy. We found low consistency among the diaries used, and often only part of the menstrual cycle was analysed instead of the whole menstrual cycle. We also observed that there was substantial variability in diagnostic procedures and criteria.

LIMITATIONS

This review excluded diary studies conducted in women with premenstrual syndrome, women seeking help for premenstrual complaints without a clear diagnosis, and women without premenstrual complaints.

CONCLUSIONS

Prospective daily ratings of symptoms and related variables provide a valuable and important tool in the study of PMDD. This paper addresses some options for improving the use of diaries and proposes the use of experience sampling and ecological momentary assessment to investigate within-person variability in symptoms in more detail.

Premenstrual Dysphoric Disorder: Epidemiology and Treatment

Recently designated as a disorder in the DSM-5, premenstrual dysphoric disorder (PMDD) presents an array of avenues for further research. PMDD's profile, characterized by cognitive-affective symptoms during the premenstruum, is unique from that of other affective disorders in its symptoms and cyclicity. Neurosteroids may be a key contributor to PMDD's clinical presentation and etiology, and represent a potential avenue for drug development. This review will present recent literature on potential contributors to PMDD's pathophysiology, including neurosteroids and stress, and explore potential treatment targets.

Personal history of major depression may put women at risk for premenstrual dysphoric symptomatology

BACKGROUND

Premenstrual dysphoric disorder (PMDD) is a chronic condition that significantly affects a woman's well-being on a monthly basis. Although co-occurrence of PMDD and major depressive disorder (MDD) is common, most studies examine whether women with PMDD are at risk for depression and investigations of PMDD in depressed women are scant. Therefore, the present study examined rates of PMDD in young depressed women.

METHODS

PMDD was assessed using a structured clinical interview (SCID-PMDD) in a sample of 164 young women with (n=85) and without (n=79) any history of depression.

RESULTS

Rates of PMDD were elevated among women with MDD in this sample. This result held true regardless of participants' MDD status (current, lifetime or past history-only symptoms of MDD) and regardless of whether all or most DSM-IV-TR PMDD criteria were met.

LIMITATIONS

Sample size in the present study was relatively small, and daily diary data were not available to confirm a PMDD diagnosis.

CONCLUSIONS

The current study highlights the need for clinicians to assess for PMDD in young female patients with major depression. Depressed women experiencing the added physical and psychological burden of PMDD may have a more severe disease course, and future studies will need to identify appropriate treatments for this subset of depressed women.

A rodent model of premenstrual dysphoria: progesterone withdrawal induces depression-like behavior that is differentially sensitive to classes of antidepressants

Premenstrual dysphoric disorder (PMDD) is characterized by a range of physical and affective symptoms including anxiety, irritability, anhedonia, social withdrawal and depression. We demonstrate robust and reproducible depression-like behavior during progesterone withdrawal (PWD) protocols with different methodological variables. Comparable immobility in the forced swim test was evident with different routes of administration (i.e. injections vs. implants), with and without exogenous estrogens in addition to progesterone, and in both single and multiple withdrawal paradigms. Furthermore, withdrawal from physiological doses of progesterone resulted in modest social withdrawal in the social preference test and anhedonia in the saccharin preference test without altering general activity levels or total liquid consumption. However, progesterone withdrawal did not alter serotonin levels in the cortex or hippocampus. Furthermore tryptophan depletion did not augment immobility during PWD. Neither fluoxetine nor duloxetine reduced depression-like behavior during PWD in the forced swim test. In contrast, the tricyclic antidepressant, amitriptyline, was effective in reducing the immobility in forced swim test. These data demonstrate that progesterone withdrawal is a reproducible model of PMDD in several critical behavioral domains. Furthermore, these data do not support alterations in serotonin levels in the etiology of hormonally induced depression.

Diagnosing premenstrual dysphoric disorder: the reliability of a structured clinical interview

Premenstrual dysphoric disorder (PMDD), a diagnosis included for further study in the DSM-IV-TR (American Psychiatric Association 2000), lacks a structured interview. The reliability of a Structured Clinical Interview for DSM-IV-TR-Defined PMDD (SCID-PMDD) was assessed with 96 participants who spanned the full range of premenstrual problems. All individual SCID-PMDD items had high inter-rater agreement, and the overall reliability of diagnosis was high (kappa = 0.96). The SCID-PMDD provides a structured, sensitive, and reliable measure of the symptoms and impairment criteria for PMDD.

Prefrontal brain asymmetry and pre-menstrual dysphoric disorder symptomatology

BACKGROUND

Pre-menstrual dysphoric disorder (PMDD), a dysphoric form of pre-menstrual syndrome, is included as a diagnosis for further study in the DSM-IV-TR (APA, 2000). The present study investigated whether a marker of risk for major depressive disorder (MDD), prefrontal brain asymmetry, also characterizes women with PMDD.

METHODS

In a sample of 25 college women with PMDD symptomatology and 25 matched controls, resting frontal electroencephalographic (EEG) activity was assessed on four occasions within a two-week span.

RESULTS

Across several frontal sites women with PMDD had relatively less left than right prefrontal brain activity, consistent with a diathesis-stress model for menstrual-related dysphoria.

CONCLUSIONS

The findings suggest an overlap in the risk profile for MDD and PMDD.

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

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

The morama bean (Tylosema esculentum): a potential crop for southern Africa

The morama bean is an underutilized leguminous oilseed native to the Kalahari Desert and neighboring sandy regions of Botswana, Namibia, and South Africa (Limpopo, North-West, Gauteng, and Northern Cape provinces), and forms part of the diet of the indigenous population in these countries. It is also known as gemsbok bean, moramaboontjie, elandboontjie, braaiboonjie, marama, marumana, tsi, tsin, gami, and ombanui. It is reported as an excellent source of good quality protein (29-39%); its oil (24-48%) is rich in mono- and di-unsaturated fatty acids and contains no cholesterol. Morama is a good source of micronutrients such as calcium, iron, zinc, phosphate, magnesium, and B vitamins including folate. It is also reported to be a potential source of phytonutrients including phenolic compounds (e.g., tannins), trypsin inhibitors, phytates, and oligosaccharides, components which have been shown in other foods to contribute to health in particular, prevention of noncommunicable diseases such as cardiovascular diseases, diabetes, and some cancers. From a nutritional and health perspective, the morama bean has potential commercial value as a cash crop and value-added products, particularly in the communities where it is found.

Duloxetine treatment for women with premenstrual dysphoric disorder: a single-blind trial

Premenstrual dysphoric disorder (PMDD) affects 3-8% of women of reproductive age and is characterized by severe mood symptoms that cause important functional impairment. Serotonergic antidepressants appear to be an effective treatment for this disorder. The purpose of this study was to collect evidence on the efficacy and tolerability of duloxetine, a dual reuptake inhibitor of serotonin and norepinephrine, in the treatment of PMDD. We conducted a pilot, single-blind, non-controlled, fixed-dose trial. After two cycles for diagnosis confirmation, including a single-blind placebo cycle, 20 women with PMDD were treated continuously for three menstrual cycles with 60 mg/d duloxetine. The primary measure of the efficacy of treatment with duloxetine was the significant reduction in premenstrual symptoms demonstrated by the comparison between the mean Daily Record of Severity of Problems (DRSP) scores at baseline to endpoint (p=0.0002). Statistically significant symptom reduction was observed in the first treatment cycle and throughout all the treatment phase. Clinical response, defined as a reduction 50% of baseline premenstrual symptoms, occurred in 65% of subjects (intention-to-treat population). Significant improvements were demonstrated by secondary measures, including reduction in self-rated functional impairment (p=0.01) and improvement in quality of life (p=0.04). The main side-effects associated with duloxetine were dry mouth, nausea, drowsiness, insomnia, decreased appetite, decreased libido, and sweating. Duloxetine was effective and generally well tolerated in the treatment of PMDD. Further large-scale, double-blind, placebo-controlled studies are needed to evaluate duloxetine as an additional treatment strategy for the management of PMDD.

Time to relapse after short- or long-term treatment of severe premenstrual syndrome with sertraline

CONTEXT

The duration of treatment after achieving a satisfactory response is unknown in the treatment of premenstrual syndrome. This information is needed in view of the improvement provided by medication vs the adverse effects and costs of drugs.

OBJECTIVE

To compare rates of relapse and time to relapse between short- and long-term treatment with sertraline hydrochloride administered in the luteal phase of the menstrual cycle.

DESIGN

Eighteen-month survival study with a randomized double-blind switch to placebo after 4 or 12 months of sertraline treatment.

SETTING

Academic medical center.

PARTICIPANTS

One hundred seventy-four patients with premenstrual syndrome or premenstrual dysphoric disorder.

MAIN OUTCOME MEASURE

Relapse, defined as symptoms returning to the entry criterion level as assessed with daily ratings.

RESULTS

The relapse rate was 41% during long-term treatment compared with 60% after short-term sertraline therapy, with a median time to relapse of 8 months vs 4 months (hazard ratio, 0.58; 95% confidence interval, 0.34-0.98; P = .04). Patients with severe symptoms at baseline were more likely to experience relapse compared with patients in the lower symptom severity group (hazard ratio, 2.02; 95% confidence interval, 1.18-3.41; P = .01) and were more likely to experience relapse with short-term treatment (P = .03). Duration of treatment did not affect relapse in patients in the lower symptom severity group (P = .50). Patients who demonstrated remission were least likely to experience relapse (hazard ratio, 0.22; 95% confidence interval, 0.10-0.45; P < .001). Further analysis comparing relapse in the first 6 months of placebo treatment in each group yielded similar results.

CONCLUSIONS

The relapse rate was significantly greater after short-term treatment compared with long-term treatment. The relapse rate was also high during extended drug treatment. Subjects with severe symptoms at baseline were most likely to experience relapse, and relapse occurred more swiftly regardless of treatment duration. These findings suggest that the severity of symptoms at baseline and symptom remission with treatment should be considered in determining the duration of treatment.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00318773.

Role of calcium metabolism in premenstrual syndrome

Premenstrual syndrome has been the subject of many myths and misconceptions over the centuries. It is a very common problem affecting millions of young women during their reproductive lives and is characterized by numerous recurrent, cyclical emotional and physical symptoms during the luteal phase of the menstrual cycle. The etiology of this disorder has remained poorly understood until only recently. Alterations in calcium homeostasis have long been associated with many affective disorders. Cyclical fluctuations of the ovarian steroid hormones across the menstrual cycle influence calcium metabolism, affect intestinal calcium absorption and modulate 1,25-dihydroxyvitamin D synthesis. Evidence now strongly suggests that abnormalities in calcium and vitamin D metabolism, specifically calcium and vitamin D deficiency, are responsible for these luteal-phase symptoms. Calcium and vitamin D supplementation may offer a simple solution to millions of women affected with premenstrual syndrome.

Selective serotonin reuptake inhibitors for premenstrual syndrome and premenstrual dysphoric disorder: a meta-analysis

OBJECTIVE

To systematically review evidence of the treatment benefits of selective serotonin reuptake inhibitors (SSRIs) for symptoms related to severe premenstrual syndrome (PMS) and premenstrual dysphoric disorder.

DATA SOURCES

We conducted electronic database searches of MEDLINE, Web of Science, Cochrane Library, Embase, PsycINFO, and Cinahl through March 2007, and hand-searched reference lists and pertinent journals.

METHODS OF STUDY SELECTION

Studies included in the review were double-blind, randomized, controlled trials comparing an SSRI with placebo that reported a change in a validated score of premenstrual symptomatology. Studies had to report follow-up for any duration longer than one menstrual cycle among premenopausal women who met clinical diagnostic criteria for PMS or premenstrual dysphoric disorder. From 2,132 citations identified, we pooled results from 29 studies (in 19 citations) using random-effects meta-analyses and present results as odds ratios (ORs).

TABULATION, INTEGRATION, AND RESULTS

Our meta- analysis, which included 2,964 women, demonstrates that SSRIs are effective for treating PMS and premenstrual dysphoric disorder (OR 0.40, 95% confidence interval [CI] 0.31-0.51). Intermittent dosing regimens were found to be less effective (OR 0.55, 95% CI 0.45-0.68) than continuous dosing regimens (OR 0.28, 95% CI 0.18-0.42). No SSRI was demonstrably better than another. The choice of outcome measurement instrument was associated with effect size estimates. The overall effect size is smaller than reported previously.

CONCLUSION

Selective serotonin reuptake inhibitors were found to be effective in treating premenstrual symptoms, with continuous dosing regimens favored for effectiveness.

Management Strategies for Premenstrual Syndrome/Premenstrual Dysphoric Disorder

Objective:

To evaluate the current nonpharmacologic and pharmacologic treatment options for symptoms of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD).

Data Sources:

Literature was obtained through searches of MEDLINE Ovid (1950–March week 3, 2008) and EMBASE Drugs and Pharmacology (all years), as well as a bibliographic review of articles identified by the searches. Key terms included premenstrual syndrome, premenstrual dysphoric disorder, PMS, PMDD, and treatment.

Study Selection/Data Extraction:

All pertinent clinical trials, retrospective studies, and case reports in human subjects published in the English language were identified and evaluated for the safety and efficacy of pharmacologic and nonpharmacologic treatments of PMS/PMDD. Data from these studies and information from review articles were included in this review.

Data Synthesis:

Selective serotonin-reuptake inhibitors (SSRIs) have been proven safe and effective for the treatment of PMDD and are recommended as first-line agents when pharmacotherapy is warranted. Currently fluoxetine, controlled-release paroxetine, and sertraline are the only Food and Drug Administration-approved agents (or this indication. Suppression of ovulation using hormonal therapies is an alternative approach to treating PMDD when SSRIs or second-line psychotropic agents are ineffective; however, adverse effects limit their use. Anxiolytics, spironolactone, and nonsteroidal antiinflammatory drugs can be used as supportive care to relieve symptoms. Despite lack of specific evidence, lifestyle modifications and exercise are first-line recommendations for all women with PMS/PMDD and may be all that is needed to treat mild-to-moderate symptoms. Herbal and vitamin supplementation and complementary and alternative medicine have been evaluated for use in PMS/PMDD and have produced unclear or conflicting results. More controlled clinical trials are needed to determine their safety and efficacy and potential for drug interactions.

Conclusions:

Healthcare providers need to be aware of the symptoms of PMS and PMDD and the treatment options available. Treatment selection should be based on Individual patient symptoms, concomitant medical history, and need for contraception.

Symptom-onset dosing with citalopram in the treatment of premenstrual dysphoric disorder (PMDD): a case series

The efficacy and tolerability of symptom-onset dosing with citalopram in the treatment of premenstrual dysphoric disorder (PMDD) was evaluated in an open trial. Eight outpatients, aged 18-45 years and diagnosed with PMDD, were treated with 10-20 mg of citalopram from the start of premenstrual symptoms until the onset of menses. Primary efficacy variables were the premenstrual tension scale (PMTS-O) and the clinical global impression of improvement (CGI). Treatment was associated with significant improvement in PMDD symptoms (p < 0.001).

Extrasynaptic GABAA receptors in the crosshairs of hormones and ethanol

Gamma-aminobutyric acid (GABA) is the main chemical inhibitory neurotransmitter in the brain. In the central nervous system (CNS) it acts on two distinct types of receptor: an ion channel, i.e., an "ionotropic" receptor permeable to Cl- and HCO3- (GABAA receptors) and a G-protein coupled "metabotropic" receptor that is linked to various effector mechanisms (GABAB receptors). This review will summarize novel developments in the physiology and pharmacology of GABAA receptors (GABAARs), specifically those found outside synapses. The focus will be on a particular combination of GABAAR subunits sensitive to ovarian and adrenal cortical steroid hormone metabolites that are synthesized in the brain (neurosteroids) and to sobriety impairing concentrations of ethanol. These receptors may be the final common pathway for interactions between ethanol and ovarian and stress-related neurosteroids.

Attenuation of estrous cycle-dependent marble burying in female rats by acute treatment with progesterone and antidepressants

Premenstrual dysphoric disorder (PMDD) is characterized by the recurrence of a cluster of physical and negative mood symptoms, especially irritability, appearing when estrogen and progesterone levels decrease during the late luteal phase of the menstrual cycle. The aim of the present study was to explore a new potential model of premenstrual irritability. It has been suggested that burying of harmless objects by rodents may reflect a form of impulsive or anxiety-like behavior. This study demonstrates changes in burying behavior during various phases of the estrous cycle in some but not all female rats. Burying behavior was found to be enhanced at metestrus and decreased at proestrus, characterized by low and high ovarian hormone levels, respectively. No habituation of the cycle-dependent burying was observed. Enhanced burying was not observed in reproductive senescent and ovariectomized females characterized by stable, low levels of ovarian hormones. Increased marble burying at metestrus was reversed by acute treatment with antidepressants fluoxetine, desipramine, nomifensine, the benzodiazepine agonist diazepam, and progesterone, while the neuroleptic chlorpromazine was without effect. Reversal of cycle-dependent burying was unrelated to the drugs' effects on locomotor activity. These results indicate that estrous cycle-dependent marble-burying behavior displayed by a subgroup of female rats might be a manifestation of ovarian hormone-dependent irritability. This manifestation may be used to elucidate the neuroendocrine mechanisms triggering premenstrual irritability, and the detailed mode of action of antidepressants when used for PMDD.

Premenstrual dysphoric disorder in an adolescent female

BACKGROUND

A severe cyclic constellation of affective symptoms during the luteal phase of the menstrual cycle is termed premenstrual dysphoric disorder (PMDD).

CASE

A 17-yr-old female was referred for evaluation of behavior changes with her menses. Parents noted behavior changes, two to three days before the onset and lasting till the end of her menses. Menarche was at 13 years. Periods were regular, with normal flow and duration and no dysmenorrhea. Psychosocial history was unremarkable. There was no history of sexual activity or abuse. Her physical exam was unremarkable. With the working diagnosis of premenstrual dysphoric syndrome she was asked to keep track of her menses on a menstrual calendar and her symptoms with a daily diary. She was treated with Fluoxetine 20 mg/day during the luteal phase of her menstrual cycle with complete resolution of her symptoms.

COMMENTS

In PMDD the mood disturbance occurs during the late luteal phase of the menstrual cycle (approximately 1 week before the onset of menstrual bleeding), remits after the onset of menses, and can be established by a prospective daily symptom log for two consecutive cycles. The symptoms are more severe than that of premenstrual syndrome, are associated with significant functional impairment and are cyclical. Symptoms were documented prospectively as starting a few days before her menstrual bleeding and remitting at the end of it. She responded to episodic use of a selective serotonin reuptake inhibitor. This disorder needs to be better recognized, because it can be easily treated.

Neurosteroids in the context of stress: implications for depressive disorders

Animal models indicate that the neuroactive steroids 3alpha,5alpha-THP (allopregnanolone) and 3alpha,5alpha-THDOC (allotetrahydroDOC) are stress responsive, serving as homeostatic mechanisms in restoring normal GABAergic and hypothalamic-pituitary-adrenal (HPA) function following stress. While neurosteroid increases to stress are adaptive in the short term, animal models of chronic stress and depression find lower brain and plasma neurosteroid concentrations and alterations in neurosteroid responses to acute stressors. It has been suggested that disruption in this homeostatic mechanism may play a pathogenic role in some psychiatric disorders related to stress. In humans, neurosteroid depletion is consistently documented in patients with current depression and may reflect their greater chronic stress. Women with the depressive disorder, premenstrual dysphoric disorder (PMDD), have greater daily stress and a greater rate of traumatic stress. While results on baseline concentrations of neuroactive steroids in PMDD are mixed, PMDD women have diminished functional sensitivity of GABA(A) receptors and our laboratory has found blunted allopregnanolone responses to mental stress relative to non-PMDD controls. Similarly, euthymic women with histories of clinical depression, which may represent a large proportion of PMDD women, show more severe dysphoric mood symptoms and blunted allopregnanolone responses to stress versus never-depressed women. It is suggested that failure to mount an appropriate allopregnanolone response to stress may reflect the price of repeated biological adaptations to the increased life stress that is well documented in depressive disorders and altered allopregnanolone stress responsivity may also contribute to the dysregulation seen in HPA axis function in depression.

Fluctuating serotonergic function in premenstrual dysphoric disorder and premenstrual syndrome: findings from neuroendocrine challenge tests

RATIONALE

Premenstrual dysphoric disorder (PMDD) has been assumed to be a subtype of premenstrual syndrome (PMS) with depressive symptoms, such as depressive mood, tension, anxiety, and mood liability during luteal phase. At present, no conclusion has been established about serotonergic function in PMDD.

OBJECTIVE

The purpose of this study was to investigate the serotonergic function of PMDD subjects in comparison to PMS without PMDD subjects and normal controls via neuroendocrine challenge tests.

SUBJECTS AND METHODS

Twenty-four women (seven with PMDD, eight with PMS without PMDD, and nine normal controls) were tested on three occasions (follicular phase, early luteal phase, and late luteal phase) receiving paroxetine 20 mg orally as a serotonergic probe at 8:00 A: .M: . Plasma ACTH and cortisol were measured prior to the administration and every hour for 6 h thereafter.

RESULTS

As a whole, there were significant differences in serotonergic function measured by ACTH and cortisol responses to paroxetine challenge across these three groups. PMDD subjects showed higher serotonergic function in follicular phase but lower serotonergic function in luteal phase, compared with women with PMS without PMDD and normal controls.

CONCLUSION

The present findings suggest that PMDD women have fluctuating serotonergic function across their menstrual cycles and that the pattern may be different from PMS without PMDD.

The premenstrual syndrome revisited

More women - and their families - are affected by the physical and psychological irregularities due to premenstrual symptoms than by any other condition. Up to 90% of women of childbearing age report perceiving one or more symptoms during the days before menstruation, symptoms which can alter their behaviour and wellbeing and which, therefore, can affect their family, social and work circle. However, and notwithstanding this general prevalence, the clinical entity that in a large number of cases results from these symptoms, commonly known as the premenstrual syndrome, still lacks defined and validated contents so that recommendations of treatments backed by adequate experimental and clinical evidence are only slowly appearing. In the present paper, we review recent experimental data as to a possible aetiology of the premenstrual problem. We propose a Premenstrual Profile, i.e. a new register of symptoms, to be used for the differential diagnosis of the three forms of the premenstrual alteration. Finally, we review the evidence-based recommendations from reliable sources as regards the treatment of "normal" and "abnormal" premenstrual symptoms.

Increased depressive-like traits in an animal model of premenstrual irritability

Women are at higher risk of anxiety and mood disorders, especially at transitions across the reproductive life cycle (premenstruum, postpartum, menopause). Premenstrual dysphoric disorder (PMDD) is one of female mood disorders associated with changing ovarian hormone levels. Because anxiety and depression frequently occur in women with PMDD, premenstrual dysphoria might be a manifestation of certain vulnerability traits increasing the risk of those disorders. The present study was conducted to elucidate a potential association between estrous cycle-dependent aggression, the rodent model of "premenstrual irritability" (resident-intruder test), and anxiety (elevated plus maze), depressive-like traits (forced swim test) as well as carbohydrate craving in female Wistar rats. Some aggressive and nonaggressive females were restraint-stressed before testing to determine their sensitivity to stress at different hormonal stages. The results revealed that females expressing the estrous cycle-dependent aggression but not those not expressing cycle-dependent aggression spent longer time immobile and shorter time swimming in the forced swim test at metestrus compared to proestrus phase of the estrous cycle. There was no difference between aggressive and nonaggressive females in anxiety, locomotor activity and sensitivity to restraint stress and sucrose consumption. The present study suggests a common neurobiological background for the estrous cycle-dependent aggression and depressive-like traits in rodents. This phenomenon could potentially aid the elucidation of premenstrual emotional dysfunctions and might be used as an ethological model to study a biochemical and genetic proneness to depression.

Steroid withdrawal in the mouse results in anxiogenic effects of 3alpha,5beta-THP: a possible model of premenstrual dysphoric disorder

RATIONALE

3alpha-OH-5alpha[beta]-pregnan-20-one (THP) is a positive modulator of the GABAA receptor (GABAR), which underlies its reported anxiolytic effect. However, there are conditions such as premenstrual dysphoric disorder (PMDD) where increases in THP levels can be associated with adverse mood.

OBJECTIVES

In order to test for conditions where THP might be anxiogenic, we developed a mouse model of THP withdrawal. Because delta-containing GABAR are highly sensitive to THP modulation, results were compared in wild-type and delta knockout mice.

METHODS

Finasteride, a 5alpha-reductase blocker, was administered for 3 days to female wild-type or delta knockout mice. Then, animals were tested in the elevated plus maze, following acute administration of THP, lorazepam, flumazenil, or 4,5,6,7-tetrahydroisoxazolo[5,4-c]pyridin-3-ol (THIP), and results compared to vehicle-injected controls. CA1 hippocampal GABAR alpha4 subunit levels were assessed by Western blot.

RESULTS

After THP withdrawal, THP produced anxiogenic effects, decreasing open arm entries on the elevated plus maze, following a brief shock, in contrast to its expected anxiolytic effects. As we have shown in rats, THP withdrawal also resulted in increased expression of the alpha4 subunit in mouse CA1 hippocampus. As expected for increases in alpha4-containing GABAR, THP withdrawn mice were relatively insensitive to the benzodiazepine (BDZ) lorazepam and had atypical responses to the BDZ antagonist flumazenil when tested on the plus maze. In contrast, they showed a greater anxiolytic response to THIP, which has greater efficacy at alpha4betadelta than other GABAR. Although THP withdrawal in delta knockout mice also increased the alpha4 GABAR subunit, the anxiogenic effects of THP and the anxiolytic effects of THIP were not observed, implicating alpha4betadelta GABAR in these effects.

CONCLUSIONS

Based on these behavioral and pharmacological findings, we suggest that THP withdrawal in the mouse may serve as a rodent model of PMDD.

Expert Guidelines for the Treatment of Severe PMS, PMDD, and Comorbidities: The Role of SSRIs

The hallmark feature of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) is the predictable, cyclic nature of symptoms or distinct on/offness that begins in the late luteal phase of the menstrual cycle and remits shortly after the onset of menstruation. PMDD is distinguished from PMS by the severity of symptoms, predominance of mood symptoms, and role dysfunction, particularly in personal relationships and marital/family domains. Several treatment modalities are beneficial in PMDD and severe PMS, but the selective serotonin reuptake inhibitors (SSRIs) have emerged as first-line therapy. The SSRIs can be administered continuously throughout the entire month, intermittently from ovulation to the onset of menstruation, or semi-intermittently with dosage increases during the late luteal phase. These guidelines present practical treatment algorithms for the use of SSRIs in women with pure PMDD or severe PMS, PMDD and underlying subsyndromal clinical features of mood or anxiety, or premenstrual exacerbation of a mood/anxiety disorder.

Paroxetine use in the treatment of premenstrual dysphoric disorder

Premenstrual dysphoric disorder, which affects 3-8% of women of reproductive age, is characterized by a combination of symptoms that may include depressed mood, irritability, anxiety and/or physical symptoms. These symptoms occur during the luteal phase of the menstrual cycle, with remission generally occurring within 3 days after the onset of menses. Presently, treatment guidelines for premenstrual dysphoric disorder focus on lifestyle management and psychopharmacologic interventions, with selective serotonin reuptake inhibitors being considered the first line of medication intervention. The US Food and Drug Administration and Health Canada recently approved paroxetine for the treatment of premenstrual dysphoric disorder. This article reviews the properties of this medication and its use in the treatment of premenstrual dysphoric disorder.

Menstrual disorders in the college age female

College-age young women frequently experience a variety of menstrual-related complaints, including dysmenorrheal, menorrhagia, irregular menses, and menstrual-related mood changes. These problems deserve careful evaluation; they may reflect normal ovulatory menstrual symptoms or be suggestive of significant pathology that can have a major impact on future reproductive and general health. The menstrual cycle is a vital sign whose normalcy suggests an overall good health and whose abnormality requires evaluation. Eating disorders and the female athlete triad increase the risk of osteoporosis; polycystic ovary syndrome is associated with future cardiovascular risks. Diagnosis and management of these problems will not only improve a young woman's current health, sense of well-being, and overall quality of life but may also lower her risks for future disease and ill-health. This article addresses normal menstrual function, excessive bleeding, infrequent or absent menses, pain with menses, menstrual-related mood disorders, and recommendations about routine gynecologic examinations and evaluation.