Is it premenstrual syndrome? Keys to focused diagnosis, therapies for multiple symptoms

Advances in the diagnosis of premenstrual syndrome and premenstrual dysphoric disorder

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The efficacy of Hypericum perforatum (St John's wort) for the treatment of premenstrual syndrome: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Premenstrual syndrome (PMS) is a common condition. Some of the most widely prescribed medications are selective serotonin reuptake inhibitors (SSRIs), based on the hypothesized role of serotonin in the production of PMS symptoms. PMS sufferers, especially those experiencing mild to moderate symptoms, are often reluctant to take this form of medication and instead buy over-the-counter preparations to treat their symptoms, for which the evidence base with regard to efficacy is limited. Hypericum perforatum (St John's wort) influences the serotonergic system. As such, this widely available herbal remedy deserves attention as a PMS treatment.

OBJECTIVE

To investigate the effectiveness of Hypericum perforatum on symptoms of PMS.

STUDY DESIGN

This randomized, double-blind, placebo-controlled, crossover study was conducted between November 2005 and June 2007.

SETTING

Institute of Psychological Sciences, University of Leeds, Leeds, UK.

PARTICIPATION

36 women aged 18-45 years with regular menstrual cycles (25-35 days), who were prospectively diagnosed with mild PMS.

INTERVENTION

Women who remained eligible after three screening cycles (n = 36) underwent a two-cycle placebo run-in phase. They were then randomly assigned to receive Hypericum perforatum tablets 900 mg/day (standardized to 0.18% hypericin; 3.38% hyperforin) or identical placebo tablets for two menstrual cycles. After a placebo-treated washout cycle, the women crossed over to receive placebo or Hypericum perforatum for two additional cycles.

MAIN OUTCOME MEASURES

Symptoms were rated daily throughout the trial using the Daily Symptom Report. Secondary outcome measures were the State Anxiety Inventory, Beck Depression Inventory, Aggression Questionnaire and Barratt Impulsiveness Scale. Plasma hormone (follicle-stimulating hormone [FSH], luteinizing hormone [LH], estradiol, progesterone, prolactin and testosterone) and cytokine (interleukin [IL]-1beta, IL-6, IL-8, interferon [IFN]-gamma and tumour necrosis factor [TNF]-alpha) levels were measured in the follicular and luteal phases during Hypericum perforatum and placebo treatment.

RESULTS

Hypericum perforatum was statistically superior to placebo in improving physical and behavioural symptoms of PMS (p < 0.05). There were no significant effects of Hypericum perforatum compared with placebo treatment for mood- and pain-related PMS symptoms (p > 0.05). Plasma hormone (FSH, LH, estradiol, progesterone, prolactin and testosterone) and cytokine (IL-1beta, IL-6, IL-8, IFNgamma and TNFalpha) levels, and weekly reports of anxiety, depression, aggression and impulsivity, also did not differ significantly during the Hypericum perforatum and placebo cycles (p > 0.05).

CONCLUSION

Daily treatment with Hypericum perforatum was more effective than placebo treatment for the most common physical and behavioural symptoms associated with PMS. As proinflammatory cytokine levels did not differ significantly between Hypericum perforatum and placebo treatment, these beneficial effects are unlikely to be produced through this mechanism of action alone. Further work is needed to determine whether pain- and mood-related PMS symptoms benefit from longer treatment duration. Trial registration number (International Standard Randomised Controlled Trial Number Register) ISRCTN31487459.

Le syndrome prémenstruel: revue générale

Premenstrual syndrome (PMS) is a recurrent disorder that occurs in the luteal phase of the menstrual cycle. It is characterized by intense physical, psychological, and behavioral changes that interrupt interpersonal relationships and disrupt the lives of affected women. Premenstrual syndrome is believed to affect 75% of women of childbearing age. Because no tests can confirm PMS, the diagnosis should be made on the basis of a patient-completed daily symptom calendar and the exclusion of other medical disorders. PMS symptoms occur during the luteal phase of the menstrual cycle and remit with the onset of menstruation or shortly afterward. The aetiology of PMS is still unknown uncertain, but are likely associated with aberrant responses to normal hormonal fluctuations during the menstrual cycle. A wide range of therapeutic interventions has been tested in the treatment of premenstrual symptoms. Most non-pharmacological interventions that have been proven efficacious require a series of interventions. If non-medical approaches are ineffective, drug therapy may be appropriate. Several pharmaceutics agents have been shown to relieve symptoms. Calcium carbonate and selective serotonin reuptake inhibitors have demonstrated excellent efficacy.

Understanding premenstrual syndrome from a Chinese medicine perspective

Premenstrual syndrome (PMS) is a common disorder of some women during their reproductive years, characterized by a range of cyclical physical and/or mood symptoms experienced during the last few days of each menstrual cycle. Several treatment approaches have been applied, but have shown limited success, as the exact cause and pathophysiology of PMS is still not fully identified. In this paper, the etiology and pathogenesis of PMS is compared from both a Traditional Chinese Medicine (TCM) perspective and the Western biomedicine paradigm. TCM has used herbal medicines to treat the symptoms of the premenstrual and menstrual phases for centuries. To date, very few studies on the application of TCM to PMS have applied rigorous research methods. We examine the case of PMS from each paradigm: The biomedical view and that of TCM. Similarities and differences are identified and explored, and possible treatment approaches are considered and discussed in the light of these two models.

Premenstrual syndrome and associated symptoms in adolescent girls

OBJECTIVE

To investigate the frequency of premenstrual syndrome (PMS) associated symptoms and effects of nutrition on PMS in adolescent girls.

PATIENTS AND METHODS

One hundred and seventy-one adolescent girls who had menstrual cycles were included in this study. They were given a questionnaire on criteria for PMS, dysmenorrhea and regularity of menstrual cycle. Modified Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria were used for the diagnosis of PMS. We also investigated which nutritional supplements affect the PMS-associated symptoms and signs.

RESULTS

One hundred and five adolescent girls out of 171 (61.4%) met DSM-IV criteria for PMS. There was an association between dysmenorrhea and PMS in 60 (57.1%). Half of the girls, i.e. 52 (49.5%) had mild, 39 (37.1%) had moderate and 14 (13.4%) had severe PMS. The most common symptom of PMS was negative affect particularly in the form of stress (87.6%) and nervousness (87.6%). There was a statistically significant negative relationship between milk consumption and the following: abdominal bloating, cramps, craving for some foods and increased appetite.

CONCLUSION

PMS and dysmenorrhea are frequently overlapping. We also found that PMS is associated with dietary habits.

Novel Uses of Selective Serotonin Reuptake Inhibitors in Women

Selective serotonin reuptake inhibitors (SSRIs) are commonly used as first-line therapy to treat mood disorders due to their demonstrated efficacy, safety, and tolerability profiles. SSRIs may play an intricate role in treating hormone-mediated disorders that disturb the quality of life for women. Selected uses of SSRIs, specifically in the treatment of hot flashes, premenstrual dysphoric disorder, and postpartum depression, are explored in this article. Data from several studies support the use of SSRIs in these conditions, and therefore, these agents have the potential to significantly improve mood, cognitive function, physical symptoms, and social functioning in patients with these disorders. In addition, SSRIs may prove to be viable alternatives to current therapies that may be contraindicated, poorly tolerated, or lack efficacy in patients with these disorders.

Evaluation and Management of Premenstrual Syndrome and Premenstrual Dysphoric Disorder

OBJECTIVE

To review premenstrual disorders, their varied symptoms, possible etiology, and treatment options.

DATA SOURCES

Published articles identified through MEDLINE (1966-2001) using the search terms premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) and the additional terms treatment and etiology. Additional references were identified from the bibliographies of the retrieved articles.

DATA SYNTHESIS

PMS refers to a group of menstrually related disorders that are estimated to affect up to 40% of women of childbearing age. The varied symptoms of PMS include mood swings, tension, anger, irritability, headache, bloating, and increased appetite with food cravings. PMS symptoms occur during the luteal phase of the menstrual cycle and remit with the onset of menstruation or shortly afterward. Approximately 5% of women with PMS suffer from PMDD, a more disabling and severe form of PMS in which mood symptoms predominate. Because no tests can confirm PMS or PMDD, the diagnosis should be made on the basis of a patient-completed daily symptom calendar and the exclusion of other medical disorders. The causes of PMS and PMDD are uncertain, but are likely associated with aberrant responses to normal hormonal fluctuations during the menstrual cycle. For most women, symptoms can be relieved or reduced through lifestyle interventions, such as dietary changes and exercise, and drug therapy with hormonal or psychotropic agents. For PMDD, selective serotonin reuptake inhibitors have recently emerged as first-line therapy. Certain dietary supplements, including calcium, also may be an option for some women.

CONCLUSION

PMS and PMDD are complex but highly treatable disorders. Pharmacists can improve the recognition and management of these common conditions by providing patient education on premenstrual symptoms and counseling women on lifestyle interventions and pharmacotherapy to relieve their discomfort.