Symptom-associated alterations in functional connectivity in primary and secondary provoked vestibulodynia

ABSTRACT

Primary provoked vestibulodynia (PVD) is marked by the onset of symptoms at first provoking vulvar contact, whereas secondary PVD refers to symptom onset after some period of painless vulvar contact. Different pathophysiological processes are believed to be involved in the development and maintenance of primary PVD and secondary PVD. The primary aim of this study was to test the hypotheses that the resting state functional connectivity of the brain and brain stem regions differs between these subtypes. Deep clinical phenotyping and resting state brain imaging were obtained in a large sample of a women with primary PVD (n = 46), those with secondary PVD (n = 68), and healthy control women (n = 94). The general linear model was used to test for differences in region-to-region resting state functional connectivity and psychosocial and symptom assessments. Direct statistical comparisons by onset type indicated that women with secondary PVD have increased dorsal attention-somatomotor network connectivity, whereas women with primary PVD predominantly show increased intrinsic resting state connectivity within the brain stem and the default mode network. Furthermore, compared with women with primary PVD, those with secondary PVD reported greater incidence of early life sexual abuse, greater pain catastrophizing, greater 24-hour symptom unpleasantness, and less sexual satisfaction. The findings suggest that women with secondary PVD show greater evidence for central amplification of sensory signals, whereas women with primary PVD have alterations in brain stem circuitry responsible for the processing and modulation of ascending and descending peripheral signals.

Striatal dopamine D2-type receptor availability and peripheral 17β-estradiol

Research using rodent models has established a relationship between the steroid hormone estrogen and dopamine function, by revealing changes throughout the estrous cycle and by directly manipulating neuroendocrine signaling through ovariectomy and administration of estrogen. However, a direct link between estrogen levels and dopamine signaling had not been established in humans. The goal of this study, therefore, was to assess the relationship between circulating 17β-estradiol and dopamine signaling in the human brain by testing for a relationship between two proxies for these variables: peripheral 17β-estradiol and striatal dopamine D₂-type receptor availability, measured with [¹⁸F]fallypride and positron emission tomography (PET). Sixteen (23-45 years of age) women were tested on 2 days of the menstrual cycle estimated prospectively to occur during (a) the early follicular phase, when estrogen levels are near their nadir, and (b) the periovulatory phase, when estrogen levels peak. PET scans with [¹⁸F]fallypride were performed on these 2 days, and serum 17β-estradiol was measured using radioimmunoassay. Dopamine D₂-type receptor availability did not differ significantly in the whole striatum or the caudate, putamen, or accumbens subregions during the high-estrogen vs. the low-estrogen phases of the menstrual cycle. We conclude that circulating estrogen levels do not affect dopamine D₂-type receptor availability in the human striatum although other indices of dopaminergic function may be affected.

Ecological Momentary Assessment of Non-Menstrual Pelvic Pain: Potential Pathways of Central Sensitization in Adolescents and Young Adults with and without Primary Dysmenorrhea

Purpose

Primary dysmenorrhea (PD; menstrual pain without an identified organic cause) has been proposed as a possible risk factor for the development of chronic pelvic pain, but the mechanism through which this process occurs is unknown. One possible mechanism is central sensitization – alterations in the central nervous system that increase responsiveness to pain leading to hypersensitivity. Repeated episodes of pain, such as those experienced over time with PD, may alter how the brain processes pain. Ecological momentary assessment (EMA; collection of data in real time in participants’ natural environments) is a novel data collection method that may help elucidate pain occurring during non-menstrual cycle phases.

Patients and Methods

The current observational study assessed the feasibility and acceptability of using EMA via text messages to collect pelvic pain data during menstrual and non-menstrual cycle phases in a community sample of adolescents and young adults (AYA) aged 16–24 years with and without PD and explored occurrence rates and intensity of non-menstrual pelvic pain (NMPP) in each of these groups.

Results

Thirty-nine AYA with PD and 53 healthy controls reported pelvic pain level via nightly text message. Global response rate was 98.5%, and all participants reported that the EMA protocol was acceptable. AYA with PD reported higher intensity (2.0 vs 1.6 on 0–10 numeric rating scale; p=0.003) and frequency (8.7% vs 3.1% of days; p=0.004) of NMPP compared to healthy controls.

Conclusion

The EMA protocol was feasible and acceptable. Though both the intensity and frequency of NMPP were low and at levels that would not typically warrant clinical assessment or intervention, these repeated nociceptive events may represent a potential mechanism contributing to the transition from cyclical to chronic pelvic pain in some individuals.

Effectiveness of transdermal nicotine patch in premenopausal female smokers is moderated by within-subject severity of negative affect and physical symptoms

RATIONALE

Nicotine patches may be less effective in female compared with male smokers. However, it is unknown if negative affect and physical symptoms influence transdermal nicotine patch-related effects on smoking behaviors.

METHODS

Eighty-one acutely tobacco-abstinent premenopausal female smokers attended three counter-balanced experimental sessions across the menstrual cycle (early follicular, late follicular, and mid-luteal) and were randomized to patch condition (nicotine [21 mg] vs. placebo [0 mg] transdermal patch). Negative affect and physical symptoms were assessed prior to patch administration. The patch was removed 5 h post-administration, and participants completed a smoking reinstatement task. Multilevel linear models tested associations of patch condition, negative affect and physical symptoms, and their interaction on smoking behavior.

RESULTS

There was a significant patch condition × Negative Affect and Pain symptoms interaction on the number of cigarettes smoked (p < 0.05). When Negative Affect and Pain were lower-than-usual, females administered a nicotine patch smoked significantly fewer cigarettes than females administered a placebo patch (p < .05), but there were no significant patch differences when Negative Affect and Pain were higher-than-usual. There was also a significant patch condition × Negative Affect interaction on time delay. The effects of patch condition on time delay to smoking were greater during sessions in which Negative Affect was higher-than-usual.

CONCLUSIONS

Results suggest that among female smokers transdermal nicotine patch effectiveness may interact with negative affect and pain. Understanding and considering female-specific factors that may impact the efficacy of one of the most commonly used cessation medications is important for improving smoking cessation in female smokers.

Resting-state functional connectivity in women with PMDD

BACKGROUND

Premenstrual dysphoric disorder (PMDD) is an understudied, debilitating disorder of women. Given evidence for prefrontal cortical and limbic dysfunction in PMDD, we compared intrinsic connectivity of the executive control network (ECN), default mode network (DMN), and amygdala in women with PMDD vs. controls.

METHODS

Thirty-six women (18 PMDD, 18 control) participated in fMRI during the follicular and luteal phases of the menstrual cycle. At each time, resting-state functional connectivity was evaluated both before and after participants performed an emotion regulation task. The ECN was identified using independent components analysis, and connectivity of left and right amygdala seeds was also evaluated.

RESULTS

Nonparametric permutation testing identified a cluster in the left middle temporal gyrus (MTG) with significantly stronger connectivity to the left ECN in women with PMDD vs. controls in all four fMRI sessions. Women with PMDD exhibited no difference in functional connectivity between menstrual cycle phases. Amygdala connectivity did not differ between the groups but differed significantly with menstrual phase, with left amygdala connectivity to cingulate cortex being significantly stronger during the follicular vs. luteal phase. Right amygdala connectivity to the middle frontal gyrus was also stronger during the follicular vs. luteal phase, with no group differences. These findings suggest that women with PMDD have different intrinsic network dynamics in the left executive control network compared to healthy controls.

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.

Brain activation during emotion regulation in women with premenstrual dysphoric disorder

BACKGROUND

Difficulties in regulating emotions are linked to the core symptoms of premenstrual dysphoric disorder (PMDD). We therefore investigated the neural substrates of emotion-regulation problems in women with PMDD.

METHODS

On the basis of self-evaluations over 2 months on the Daily Record of Severity of Problems, eligible participants were assigned to two groups: PMDD and control (18 per group). Functional magnetic resonance imaging (fMRI) and a well-validated task were used to assess brain function during emotion regulation. Participants were tested twice, once during the follicular (asymptomatic) and once in the late luteal (symptomatic) phase of the menstrual cycle.

RESULTS

Women with PMDD gave higher ratings of negative affect in the luteal phase than in the follicular phase, and compared with healthy control participants during the luteal phase. A region-of-interest fMRI analysis indicated that during the late luteal phase, women with PMDD had hypoactivation in right dorsolateral prefrontal cortex (dlPFC) during all conditions of the emotion-regulation task, not only in the contrast that isolated emotion regulation. An exploratory whole-brain, voxel-wise analysis showed that women with PMDD had less activation in the precentral gyrus during the luteal phase than the follicular phase, and less activation in the postcentral gyrus compared with control participants.

CONCLUSIONS

During the luteal phase of the menstrual cycle, women with PMDD experience difficulty regulating emotions. Hypoactivation in the right dlPFC may contribute to this problem, but may be related more generally to other affective symptoms of PMDD. Hypofunction in the right pre- and postcentral gyri warrants additional study.

Rates of Anovulation in Adolescents and Young Adults with Moderate to Severe Primary Dysmenorrhea and Those without Primary Dysmenorrhea

STUDY OBJECTIVE

To evaluate rates of presumptive anovulation in eumenorrheic adolescents and young adults with moderate to severe primary dysmenorrhea and those without primary dysmenorrhea.

DESIGN

Participants completed luteinizing hormone surge ovulation predictor test kits. Anovulatory cycles were defined by never receiving a positive result before the next menstrual period; participants were grouped as anovulatory if they experienced at least 1 anovulatory cycle during study participation. Participants rated daily level of menstrual pain on a 0-10 numeric rating scale.

SETTING

A university-based clinical research laboratory.

PARTICIPANTS

Thirty-nine adolescents and young adults (ages 16-24) with primary dysmenorrhea and 52 age-matched control girls.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Rates of presumptive anovulation.

RESULTS

One hundred sixty-eight cycles were monitored, 29.8% (N = 50) of which were anovulatory (37.1% [39/105] vs 17.5% [11/63] of cycles in control and dysmenorrhea groups, respectively). During study participation, control girls were significantly more likely to have had at least 1 anovulatory cycle than were girls with primary dysmenorrhea (44.2% [23/52] vs 17.9% [7/39] of participants, respectively; P < .01). Cycle length and number of bleeding days between ovulatory and anovulatory cycles were similar. The primary dysmenorrhea group's maximum menstrual pain ratings did not differ between ovulatory and anovulatory cycles (4.77 and 4.36, respectively; P > .05).

CONCLUSION

Our data support previous findings of increased rates of ovulation in primary dysmenorrhea. However, menstruation after anovulatory cycles can be as painful as menstruation after ovulatory cycles. These data support the idea that regular menses do not necessarily indicate that a normal ovulatory cycle has occurred. Previous implications that ovulation is necessary for the development of substantial menstrual pain are incomplete.

Disease-Related Microstructural Differences in the Brain in Women With Provoked Vestibulodynia

Provoked vestibulodynia (PVD) is a chronic pelvic pain disorder affecting 16% of the female population. Neuroimaging studies have highlighted central abnormalities in PVD, similar to other chronic pelvic pain disorders, including brain regions involved in sensory processing and modulation of pain. The aim of the study was to determine alterations in the subvoxel, microstructural organization within tissues in PVD compared with healthy control participants (HCs) and a disease control group (irritable bowel syndrome [IBS]). Diffusion tensor imaging magnetic resonance imaging was conducted in 87 age-matched premenopausal women (29 PVD, 29 HCs, 29 IBS). Statistical parameter mapping of fractional anisotropy (FA) and mean diffusivity (MD) maps were used to identify microstructural difference in the brain specific to PVD or shared with IBS. PVD alterations in microstructural organization of the brain were predominantly observed in fibers associated with sensorimotor integration and pain processing that relay information between the thalamus, basal ganglia, sensorimotor, and insular cortex. PVD, compared with HCs, showed extensive increases in the FA of somatosensory and basal ganglia regions. In contrast, PVD and IBS subjects did not show any FA-related group differences. PVD subjects showed greater MD in the basal ganglia compared with HCs (higher MD in the internal capsule and pallidum) and IBS (higher MD in the putamen and pallidum). Increases in MD were associated with increased vaginal muscle tenderness and vulvar pain. The current findings highlight possible shared mechanisms between 2 different pelvic pain disorders, but also highlight the widespread alterations observed specifically in PVD compared with HCs.

PERSPECTIVE

Alterations in microstructure in PVD were observed in fibers associated with sensorimotor integration and pain processing, which were also associated with increased vaginal muscle tenderness and vulvar pain. These alterations may be contributing to increased pain sensitivity and tenderness, highlighting the need for new therapies targeting the central nervous system.

Experimental and procedural pain responses in primary dysmenorrhea: a systematic review

Primary dysmenorrhea (PD) has been the focus of a number of experimental pain studies. Although a number of reviews exist, few have critically evaluated the existing body of research on PD and experimental and procedural pain. Data from 19 published research articles that include women with PD and responses to an experimental or procedural pain stimulus (or stimuli) suggest that women with PD may have elevated pain reactivity, as compared to women without PD. This pattern appears to be true across different phases of the menstrual cycle. However, there is an abundance of conflicting findings, which may be due to significant methodological issues such as inconsistent definitions of PD, wide variation in experimental pain methodologies, and inaccurate assessment of the menstrual cycle. Future research should focus on identifying specific symptoms (i.e., pain threshold ratings) to more clearly define what constitutes PD, establish reliable and valid laboratory testing protocols, and assess the menstrual cycle with greater precision.

Pain Catastrophizing Predicts Menstrual Pain Ratings in Adolescent Girls with Chronic Pain

OBJECTIVES

The current study aimed to explore relationships among self-reported menstrual pain ratings, acute laboratory pain, pain catastrophizing, and anxiety sensitivity in a sample of girls without pain (No Pain group) and girls with a chronic pain condition (Chronic Pain group).

SETTING

A laboratory at an off-campus Medical School office building.

SUBJECTS

Eighty-four postmenarchal girls (43 No Pain, 41 Chronic Pain) ages 10-17 participated in the study.

METHODS

All participants completed self-report questionnaires assessing menstrual pain, pain catastrophizing, and anxiety sensitivity and completed a cold pressor task. Pain intensity during the task was rated on a 0 (no pain) to 10 (worst pain possible) numeric rating scale.

RESULTS

After controlling for age, average menstrual pain ratings (without medication) were significantly correlated with cold pressor pain intensity for the No Pain group only. In the Chronic Pain group, menstrual pain ratings were significantly correlated with pain catastrophizing and anxiety sensitivity. In a multiple linear regression analysis, after controlling for age, only pain catastrophizing emerged as a significant predictor of menstrual pain ratings in the Chronic Pain group.

CONCLUSION

Results demonstrate differences in relationships among menstrual pain, acute laboratory pain, and psychological variables in girls with no pain compared with girls with chronic pain. In addition, pain catastrophizing may be a particularly salient factor associated with menstrual pain in girls with chronic pain that warrants further investigation.

Emotion regulation in women with premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) is a psychiatric disorder that causes serious impairments in the functioning and quality of life of affected women. Until recently, research efforts were somewhat hampered by the lack of formal diagnostic criteria, which have now been codified as a category in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Better characterization of deficits in socioemotional functioning caused by PMDD may aid in improving treatment efforts. In this investigation, prospective symptom ratings, based on DSM-5 criteria, were used to measure PMDD symptoms in 36 women (18 with PMDD and 18 healthy controls). Two self-report inventories, the Emotion Regulation Questionnaire and the Difficulties in Emotion Regulation Scale, were used to measure ability to regulate emotions, and socioemotional functioning was measured by inventories of social connectedness, perceived stress, and affect. Potential relationships between ability to regulate emotion and PMDD symptom severity, as well as other measures of socioemotional functioning and affective state, were tested. Women with PMDD reported significantly more behavioral impulsivity and greater difficulties in regulating emotion and in socioemotional functioning. Cognitive or behavioral strategies to improve these problems may benefit women with PMDD and help to alleviate distress caused by this disorder.

Ethinyl Estradiol/Drospirenone for the Treatment of the Emotional and Physical Symptoms of Premenstrual Dysphoric Disorder

A combined oral contraceptive pill containing 20 μg of ethinyl estradiol and 3 mg of the progestin drospirenone in a novel dose regimen (24 active pills followed by 4 placebo pills), has demonstrated efficacy for the symptoms of premenstrual dysphoric disorder, a severe form of premenstrual syndrome, with an emphasis on the affective symptoms. Drospirenone has progestagenic, anti-androgenic and anti-aldosterone properties, which differ from earlier generations of progestins, and reducing the hormone pill-free interval allows for better suppression of ovarian steroid production.

Treatment of premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) is comprised of a cluster of affective, behavioral and somatic symptoms recurring monthly during the luteal phase of the menstrual cycle. The disorder affects 3-8% of menstruating women and represents the more severe and disabling end of the spectrum of premenstrual disorders, which includes premenstrual syndrome and premenstrual aggravation of underlying affective disorder. Rigorous and specific diagnostic criteria for PMDD were specified in the Diagnostic and Statistical Manual of Mental Disorders IV (1994) and reaffirmed in the Diagnostic and Statistical Manual of Mental Disorders V (2013) and, consequently, there has been a marked increase in well-designed, placebo-controlled studies evaluating treatment modalities. Although the exact pathogenesis of PMDD is still elusive, treatment of PMDD and severe premenstrual syndrome has centered on neuromodulation via serotonin reuptake inhibitor antidepressants, and ovulation suppression utilizing various contraceptive and hormonal preparations. Unlike the approach to the treatment of depression, serotonergic antidepressants need not be given daily, but can be effective when used cyclically, only in the luteal phase or even limited to the duration of the monthly symptoms. Less, well-substantiated alternative treatments, such as calcium supplementation, agnus castus (chasteberry), Hypericum perforatum (St John's wort) and cognitive/behavioral/relaxation therapies, may be useful adjuncts in the treatment of PMDD. This review provides an overview of current information on the treatment of PMDD.

The Cerebellum and Premenstrual Dysphoric Disorder

The cerebellum constitutes ten percent of brain volume and contains the majority of brain neurons. Although it was historically viewed primarily as processing motoric computations, current evidence supports a more comprehensive role, where cerebro-cerebellar feedback loops also modulate various forms of cognitive and affective processing. Here we present evidence for a role of the cerebellum in premenstrual dysphoric disorder (PMDD), which is characterized by severe negative mood symptoms during the luteal phase of the menstrual cycle. Although a link between menstruation and cyclical dysphoria has long been recognized, neuroscientific investigations of this common disorder have only recently been explored. This article reviews functional and structural brain imaging studies of PMDD and the similar but less well defined condition of premenstrual syndrome (PMS). The most consistent findings are that women with premenstrual dysphoria exhibit greater relative activity than other women in the dorsolateral prefrontal cortex and posterior lobules VI and VII of the neocerebellum. Since both brain areas have been implicated in emotional processing and mood disorders, working memory and executive functions, this greater activity probably represents coactivation within a cerebro-cerebellar feedback loop regulating emotional and cognitive processing. Some of the evidence suggests that increased activity within this circuit may preserve cerebellar structure during aging, and possible mechanisms and implications of this finding are discussed.

Elevated gray matter volume of the emotional cerebellum in women with premenstrual dysphoric disorder

OBJECTIVE

Premenstrual dysphoric disorder (PMDD) is characterized by severe, negative mood symptoms during the luteal phase of each menstrual cycle. We recently reported that women with PMDD show a greater increase in relative glucose metabolism in the posterior cerebellum from the follicular to the luteal phase, as compared with healthy women, and that the phase-related increase is proportional to PMDD symptom severity. We extended this work with a study of brain structure in PMDD.

METHODS

High-resolution magnetic resonance imaging (MRI) scans were obtained from 12 women with PMDD and 13 healthy control subjects (whole-brain volume-corrected p<.05). Voxel-based morphometry was used to assess group differences in cerebral grey-matter volume (GMV), using a statistical criterion of p<.05, correcting for multiple comparisons in the whole-brain volume.

RESULTS

PMDD subjects had greater GMV than controls in the posterior cerebellum but not in any other brain area. Age was negatively correlated with GMV within this region in healthy women, but not in women with PMDD. The group difference in GMV was significant for women over age 30(p=.0002) but not younger participants (p>.1).

CONCLUSIONS

PMDD appears to be associated with reduced age-related loss in posterior cerebellar GMV. Although the mechanism underlying this finding is unclear, cumulative effects of symptom-related cerebellar activity may be involved.

Pathophysiology of premenstrual syndrome and premenstrual dysphoric disorder

Premenstrual syndrome (PMS) and premenstrual dysphoric disorder are triggered by hormonal events ensuing after ovulation. The symptoms can begin in the early, mid or late luteal phase and are not associated with defined concentrations of any specific gonadal or non-gonadal hormone. Although evidence for a hormonal abnormality has not been established, the symptoms of the premenstrual disorders are related to the production of progesterone by the ovary. The two best-studied and relevant neurotransmitter systems implicated in the genesis of the symptoms are the GABArgic and the serotonergic systems. Metabolites of progesterone formed by the corpus luteum of the ovary and in the brain bind to a neurosteroid-binding site on the membrane of the gamma-aminobutyric acid (GABA) receptor, changing its configuration, rendering it resistant to further activation and finally decreasing central GABA-mediated inhibition. By a similar mechanism, the progestogens in some hormonal contraceptives are also thought to adversely affect the GABAergic system. The lowering of serotonin can give rise to PMS-like symptoms and serotonergic functioning seems to be deficient by some methods of estimating serotonergic activity in the brain; agents that augment serotonin are efficacious and are as effective even if administered only in the luteal phase. However, similar to the affective disorders, PMS is ultimately not likely to be related to the dysregulation of individual neurotransmitters. Brain imaging studies have begun to shed light on the complex brain circuitry underlying affect and behaviour and may help to explicate the intricate neurophysiological foundation of the syndrome.

An overview of four studies of a continuous oral contraceptive (levonorgestrel 90 mcg/ethinyl estradiol 20 mcg) on premenstrual dysphoric disorder and premenstrual syndrome

BACKGROUND

This article presents an overview of four studies that evaluated a continuous oral contraceptive (OC) containing levonorgestrel (90 mcg) and ethinyl estradiol (20 mcg; LNG/EE) for managing premenstrual dysphoric disorder (PMDD) and premenstrual syndrome (PMS).

STUDY DESIGN

Three randomized, double-blind, placebo-controlled trials and one open-label, single-treatment substudy examined mean changes from baseline in the Daily Record of Severity of Problems (DRSP) or Penn Daily Symptom Rating (DSR).

RESULTS

Improvements from baseline in mean DRSP and DSR scores were observed, but results were not consistent among the studies. Mean percent improvement of premenstrual symptoms ranged from 30% to 59% in controlled trials and 56% to 81% in an open-label substudy. A large placebo effect was also observed in the placebo-controlled studies. Continuous LNG/EE yielded a favorable safety profile.

CONCLUSIONS

These data, although not consistent, indicate that continuous LNG/EE may reduce the symptoms of PMDD and PMS, providing an option for women who are appropriate candidates for a continuous OC as a contraceptive, the approved indication for this medication.

Neuroimaging evidence of cerebellar involvement in premenstrual dysphoric disorder

BACKGROUND

Premenstrual dysphoric disorder (PMDD) is a debilitating cyclic disorder that is characterized by affective symptoms, including irritability, depression, and anxiety, which arise in the luteal phase of the menstrual cycle and resolve soon after the onset of menses. Despite a prevalence of up to 8% in women of reproductive age, few studies have investigated the brain mechanisms that underlie this disorder.

METHODS

We used positron emission tomography with [(18)F] fluorodeoxyglucose and self-report questionnaires to assess cerebral glucose metabolism and mood in 12 women with PMDD and 12 healthy comparison subjects in the follicular and late luteal phases of the menstrual cycle. The primary biological end point was incorporated regional cerebral radioactivity (scaled to the global mean) as an index of glucose metabolism. Relationships between regional brain activity and mood ratings were assessed. Blood samples were taken before each session for assay of plasma estradiol and progesterone concentrations.

RESULTS

There were no group differences in hormone levels in either the follicular or late luteal phase, but the groups differed in the effect of menstrual phase on cerebellar activity. Women with PMDD but not comparison subjects showed an increase in cerebellar activity (particularly in the right cerebellar vermis) from the follicular phase to the late luteal phase (p = .003). In the PMDD group, this increase in cerebellar activity was correlated with worsening of mood (p = .018).

CONCLUSIONS

These findings suggest that the midline cerebellar nuclei, which have been implicated in other mood disorders, also contribute to negative mood in PMDD.

Premenstrual syndrome and premenstrual dysphoric disorder: quality of life and burden of illness

Premenstrual symptoms are distressing for up to 20% of reproductive-aged women and are associated with impairment in interpersonal or workplace functioning for at least 3-8%. Typical symptoms of premenstrual syndrome and the severe form, premenstrual dysphoric disorder, include irritability, anger, mood swings, depression, tension/anxiety, abdominal bloating, breast pain and fatigue. The symptoms recur monthly and last for an average of 6 days per month for the majority of the reproductive years. For women with premenstrual dysphoric disorder, the symptoms can be as disabling as major depressive disorder. It has been estimated that affected women experience almost 3000 days of severe symptoms during the reproductive years. Until two decades ago, there were no effective treatments for severe premenstrual syndrome. Even in 2000, almost three-quarters of women in the USA with premenstrual disorders either did not seek help or sought treatment unsuccessfully from at least three clinicians for over 5 years. This review will focus on the epidemiology, diagnosis, treatment outcomes, quality of life and burden of illness for premenstrual disorders.

YAZ in the treatment of premenstrual dysphoric disorder

Premenstrual disorders negatively affect millions of U.S. women. The premenstrual disorder at the most severe end of the spectrum is premenstrual dysphoric disorder (PMDD). The specific diagnostic criteria developed for PMDD and the availability of validated symptom diaries have allowed a more organized study of severe premenstrual disorders. The U.S Food and Drug Administration has now approved 4 agents for the treatment of PMDD: 3 antidepressants (i.e., selective serotonin reuptake inhibitors) and 1 low-dose combination oral contraceptive (COC) that contains the progestin drospirenone and is administered using a regimen of 24 days of active pills in a 28-day cycle (drospirenone/20EE-24/4). Drospirenone is unique among progestins used in COCs in that it has both antimineralocorticoid and antiandrogenic activities. Two pivotal studies have shown drospirenone/20EE-24/4 to be effective in treating the mood, physical and behavioral symptoms of PMDD and symptoms specifically associated with food, water retention and negative interpersonal relationships.

The pharmacologic management of premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) is characterized by physical, affective and behavioral symptoms that are linked to the luteal phase of the menstrual cycle and relieved soon after the onset of menses. The disorder is chronic and exerts a major impact on personal relationships and occupational productivity for the estimated 6% of reproductive-aged women who fulfill strict PMDD criteria and the almost 20% of women who nearly meet these criteria. There are now various pharmacologic options that have demonstrated efficacy for PMDD and two of these approaches have an approved indication for treatment from the US FDA: three selective serotonin re-uptake inhibitors; and for women who also desire hormonal contraception, a low dose oral contraceptive pill containing the progestin drospirenone, in a new dosing regimen. Due to the unique pathophysiology of the disorder, the selective serotonin re-uptake inhibitors can be effectively administered intermittently, with dosing limited to the luteal phase of the cycle (2 weeks prior to menses). In the future, new pharmacotherapy will likely evolve from research evaluating other hormonal formulations that inhibit ovulation, without simulating PMDD-like symptoms, or novel pharmacologic agents that modulate the central neurotransmission.

Multilevel local anesthetic nerve blockade for the treatment of vulvar vestibulitis syndrome

OBJECTIVE

Vulvar vestibulitis syndrome is a major cause of dyspareunia. This pilot study was designed to evaluate a novel treatment approach.

STUDY DESIGN

This is a prospective study of 27 women with vulvar vestibulitis. The protocol included 5 treatment sessions with caudal epidural, pudendal nerve block, and vestibular infiltration of local anesthetic agents.

RESULTS

There were significant improvements in vestibular pain as determined by the vulvalgesiometer, McGill pain questionnaire, self-report, and the Female Sexual Functioning Inventory.

CONCLUSION

Serial multilevel nerve blocks administered for the treatment of vulvar vestibulitis is a conceptually neurophysiologically based modality that may be effective and merits a placebo-controlled study.

Drospirenone: a novel progestin

Drospirenone is a novel progestin available in combined oral contraceptives and menopausal hormonal therapy. Similar to its parent compound spirolactone, an analog of spironolactone, drospirenone has antimineralocorticoid and antiandrogenic activity. Combined with ethinyl estradiol in oral contraceptive formulations, drospirenone-containing contraceptives have similar efficacy and safety profiles to other low-dose oral contraceptives, but seem to offer improved tolerability with regard to weight gain, mood changes, acne and treatment of a severe form of premenstrual syndrome called premenstrual dysphoric disorder. Combined with estradiol as a continuous hormone therapy regimen, the compound was shown to reduce vasomotor symptoms, maintain bone mass, have a beneficial effect on body weight and, more importantly, was shown to lower blood pressure in postmenopausal women.

Vasomotor symptoms in menopause: physiologic condition and central nervous system approaches to treatment

OBJECTIVE

The decline in concentrations of gonadal hormones during menopause gives rise to a range of physiologic and psychologic changes that may impact a woman's health and quality of life significantly. Most notable among these are vasomotor symptoms (hot flashes and night sweats) and mood and sleep disturbances.

STUDY DESIGN

This article reviews the physiologic condition underlying menopausal vasomotor symptoms and centrally active, nonhormonal therapies that have demonstrated efficacy for their treatment.

RESULTS

Despite the emergence of a range of nonhormonal treatments for vasomotor symptoms, a need still exists for safe and effective therapeutic options that directly target the underlying thermoregulatory mechanisms for women who want treatment but prefer to avoid hormone therapy or for whom hormone therapy is contraindicated.

CONCLUSION

The availability of centrally active therapies for menopausal vasomotor symptoms with risks and benefits clearly defined by results from well-designed clinical trials has the potential to allay safety concerns that are associated with the treatment of these common symptoms.

Oral contraceptives and neuroactive steroids

A deregulation in the peripheral and brain concentrations of neuroactive steroids has been found in certain pathological conditions characterized by emotional or affective disturbances, including major depression and anxiety disorders. In this article we summarize data pertaining to the modulatory effects of oral contraceptive treatment on neuroactive steroids in women and rats. Given that the neuroactive steroids concentrations are reduced by oral contraceptives, together with the evidence that a subset of women taking oral contraceptives experience negative mood symptoms, we propose the use of this pharmacological treatment as a putative model to study the role of neuroactive steroids in the etiopathology of mood disorders. Moreover, since neuroactive steroids are potent modulators of GABA(A) receptor function and plasticity, the treatment with oral contraceptives might also represent a useful experimental model to further investigate the physiological role of these steroids in the modulation of GABAergic transmission.

Neurophysiologic changes during estrogen augmentation in perimenopausal depression

BACKGROUND

Estrogen augmentation of antidepressant medication has been an effective treatment in a subgroup of women experiencing affective symptoms during perimenopause. It has been suggested that estrogen facilitates serotonergic transmission in brain regions involved in mood disorders. We investigated differences in physiologic brain changes with estrogen augmentation in women with perimenopausal depression who reached remission compared to those who did not reach remission. We also assessed whether such changes were correlated with serum hormone levels.

METHODS

Quantitative electroencephalography (QEEG) was used to examine neurophysiologic brain changes in remission and non-remission of depressive symptoms. Women with major depressive disorder (MDD) in partial remission who were taking antidepressant medication for a minimum of 8 weeks and were experiencing two or more perimenopausal symptoms (hot flashes, night sweats, irregular periods, memory impairment, vaginal dryness) were recruited from the community. Absolute power, relative power, and QEEG cordance, a measure that has moderately strong associations with cerebral perfusion, were obtained before and after 6 weeks of treatment with 0.625 mg of conjugated estrogen per day.

RESULTS

Women who experienced remission of depressive symptoms (Ham-D< or =7) had a significant decrease in right frontal QEEG cordance (p=0.008, t((8))=-3.54) which was not present in non-remitters. No significant correlations were found between hormone levels and QEEG cordance.

CONCLUSION

In women with perimenopausal depression, physiologic brain changes in the right frontal region during estrogen augmentation were associated with remission of depression.

Relationships among self-rated tanner staging, hormones, and psychosocial factors in healthy female adolescents

STUDY OBJECTIVE

Females are more likely than males to suffer from various mood and pain disorders. However, this female predominance does not appear to develop until puberty. The purpose of the present study was to examine the associations among hormone concentrations, self-rated Tanner staging and dysmenorrhea, and to determine whether various psychosocial factors modulate these relationships.

DESIGN

As part of a larger prospective study of the influence of puberty on laboratory pain response, Tanner ratings, estradiol and follicle stimulating hormone concentrations, dysmenorrhea and psychosocial parameters including depression, anxiety, somatization, and socioeconomic status were observed.

PARTICIPANTS

124 healthy girls ages 8 to 18 were evaluated.

MAIN OUTCOME MEASURE

There were significant correlations between pubertal status utilizing self-rated diagrams of Tanner stage and hormonal markers of pubertal development, specifically estradiol and FSH. Tanner stage but not estradiol was correlated with presence of dysmenorrhea. There was no effect of body mass index (BMI), socioeconomic status (SES), anxiety, depression, or somatization on presence or absence of painful menses. There was no correlation between BMI or SES and age of menarche. However, Tanner stage was correlated with BMI but not with SES.

RESULTS AND CONCLUSIONS

Tanner self-staging is at least as accurate as estradiol and FSH measurements alone in evaluating healthy female adolescents' physical changes and menstrual pain. Tanner self-ratings are thus particularly useful in large, epidemiologic, or cross cultural studies where physical examination and blood sampling may not be feasible due to cost, access, or psychosocial barriers.

Decreased neuroactive steroids induced by combined oral contraceptive pills are not associated with mood changes

OBJECTIVE

To evaluate the effects of a low-dose combined oral contraceptive pill (OCP) on peripheral neuroactive steroid concentrations, precursors for neuroactive steroid synthesis, and mood in healthy women desiring contraception. These neuroactive steroids are gamma-aminobutyric acid receptor agonists and are important in the modulation of affect and adaptation to stress.

DESIGN

Prospective observational study.

SETTING

Human ambulatory patient study.

PATIENT(S)

Healthy OCP-naive women without current or history of affective disorder.

INTERVENTION(S)

A 0.020-mg ethinyl E2-0.1-mg levonorgestrel containing OCP for 3 months.

MAIN OUTCOME MEASURE(S)

Serum neuroactive steroids allopregnanolone, allotetrahydrodeoxycorticosterone, and DHEA; neuroactive steroid precursors P and pregnenolone; E2; and mood and anxiety as assessed by the Premenstrual Syndrome Daily Ratings Form, Beck Depression Inventory, Spielberger State-Trait Anxiety Inventory, and Profile of Mood States.

RESULT(S)

The combined OCP resulted in a decrease in neuroactive steroids and neuroactive steroid precursors as well as in E2. However, this decline was not associated with adverse mood changes on any of the well-validated assessment tools.

CONCLUSION(S)

Healthy women without underlying mood or anxiety disorder who were given a low-dose OCP did not experience adverse psychological symptoms despite a significant reduction in neuroactive steroids.

Treatment of premenstrual disorders

Premenstrual disorders are characterized by a wide variety of affective and somatic symptoms. This diversity of presenting symptoms has led to the use of many different types of treatment approaches, none of which has proven to be successful in all women with these disorders. Non-pharmacologic options include aerobic exercise, dietary changes and supplementation, and cognitive-behavioral therapy. Of the pharmacologic agents used to treat premenstrual symptoms, 3 selective serotonin reuptake inhibitors have received a Food and Drug Administration (FDA) indication for treating premenstrual dysphoric disorder (PMDD). Agents that are often used off label to treat premenstrual symptoms include spironolactone and oral contraceptives (OCs); gonadotropin-releasing hormone (GnRH) agonists and alprazolam are used less frequently in these patients. OCs have historically had little consistent data from controlled clinical trials to support their efficacy until a number of recent studies showed that an OC containing the novel progestin drospirenone is effective in reducing premenstrual symptoms in many women. A new drospirenone-containing OC formulation that is administered for 24 days in a 28-day cycle has been shown to be effective in treating PMDD.

Diagnosis of premenstrual disorders

Premenstrual disorders are characterized by numerous mood, somatic and behavioral symptoms that occur during the late luteal phase of a woman's menstrual cycle and abate soon after the onset of menses. Diagnostic criteria for premenstrual syndrome (PMS) were published by the American College of Obstetricians and Gynecologists in 2000; the American Psychiatric Association had previously established very specific diagnostic criteria for premenstrual dysphoric disorder (PMDD). Both diagnoses require 2 months of prospective symptom ratings, which can be accomplished using forms designed by individual clinicians or employing 1 of a number of validated instruments. The patient will need to provide a complete family and personal history of mental disorders and medical diseases. A thorough physical examination and certain basic laboratory tests should either identify or rule out many potential causes of the symptoms. The diseases, disorders or situations considered in the differential diagnosis of PMS and PMDD will depend on the woman's presenting symptoms. Many women with a bothersome or debilitating premenstrual disorder go undiagnosed, either because they do not report their symptoms to a clinician or because the clinician has difficulty diagnosing the disorder.

Premenstrual disorders: prevalence, etiology and impact

Millions of reproductive-age U.S. women experience premenstrual symptoms with varying degrees of severity. The large number and variety of premenstrual symptoms reported have made premenstrual disorders difficult to characterize. A number of mechanisms have been proposed to explain the etiology of premenstrual symptoms. Some women appear to have a genetic predisposition toward severe premenstrual symptoms or to have vulnerability traits that increase their risk. It has been suggested that 1 or more neurotransmitters and/or neurohormonal systems in certain women may have an abnormal response to normal fluctuations in gonadal hormones across the menstrual cycle. Premenstrual disorders can have a significant negative impact on a woman's quality of life and work productivity.

Premenstrual syndrome in adolescents: diagnosis and treatment

It is estimated that 60-80% of menstruating women experience some degree of premenstrual symptomatology; however the diagnosis of premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD) is assigned, using defined criteria, to those women whose lives are significantly affected by moderate to severe symptoms. Though these diagnoses are not frequently made in the adolescent group, the literature suggests that a similar proportion of teens would also meet criteria for PMS/PMDD. In adolescents, treatment should begin with education and lifestyle changes; however, many of the treatments used commonly in adults can also be employed safely in severe adolescent cases.

New treatment approaches for premenstrual disorders

Several approaches to alleviating the symptoms of premenstrual disorders are available to women and can be tailored according to individual needs and preferences. This article discusses methods that entail changes to lifestyle and diet and managing life stresses without relying on drug therapy, as well as a variety of medications that may be necessary in addition to or in place of recommended lifestyle modifications. New pharmacologic research is promising and is discussed along with the need to provide empathetic counseling for patients to determine the approach that will work best for each individual.

Gynecological health of females with congenital heart disease

Because of major advances in diagnostic and surgical methods, females with congenital heart disease (CHD) now survive into and beyond their reproductive years. Management of pregnancy in this patient population is well described, but gynecologic management such as menstruation, contraception and menopause have received scanty attention. Accordingly, the gynecologic health issues confronting these patients are described. Menstrual patterns in acyanotic females with CHD are similar to the general population, but cyanotic females have menstrual irregularities including amenorrhea, which implies anovulation and an increased risk of uterine carcinoma. Anticoagulants predispose to heavy vaginal bleeding and corpus luteum rupture. Contraceptives must be selected according to individual patient profiles. Hormone replacement therapy is warranted for relief of menopausal symptoms as in the general population and should be relatively safe because estrogen dose is low.

The pains of endometriosis

Endometriosis is a disease defined by the presence of endometrial tissue outside of the uterus. Severe pelvic pain is often associated with endometriosis, and this pain can be diminished with therapies that suppress estrogen production. Many women with endometriosis also suffer from other chronic pain conditions. Recent studies suggest that mechanisms underlying these pains and sensitivity to estrogen involve the growth into the ectopic endometrial tissue of a nerve supply, which could have a varied and widespread influence on the activity of neurons throughout the central nervous system.

Estrogen augmentation of antidepressants in perimenopausal depression: a pilot study

OBJECTIVE

To investigate the effects of estrogen augmentation on mood and memory in women with perimenopausal depression who had experienced a partial response to antidepressant medications.

METHOD

In a double-blind, placebo-controlled trial, 17 subjects taking antidepressant medication were randomly assigned to either 0.625 mg/day of conjugated estrogen (N = 11) or matching placebo (N = 6) for 6 weeks. Women between the ages of 40 and 60 years with DSM-IV major depressive disorder (MDD) in partial remission who had been taking antidepressant medication for a minimum of 8 weeks and were experiencing 1 or more perimenopausal symptoms (hot flashes, night sweats, irregular periods, sleep disturbance, memory impairment) were recruited from the community. The primary outcome measures were the final scores for the Hamilton Rating Scale for Depression (HAM-D) and the Buschke Selective Reminding Test. Data were gathered from April 2002 to August 2003.

RESULTS

Women receiving estrogen had a significantly larger decrease in HAM-D scores than women receiving placebo (t = 2.86, df = 15, p = .012). Group differences in tests of verbal memory were not significant, although improved scores in verbal memory were significantly correlated with a decrease in follicle-stimulating hormone (p = .021).

CONCLUSION

Short-term, low-dose estrogen augmentation of antidepressant medication was significantly associated with improved mood, but not memory, in perimenopausal women with MDD in partial remission.

The clinical nature and formal diagnosis of premenstrual, postpartum, and perimenopausal affective disorders

Various mood and anxiety disorders are more prevalent in reproductive-aged women, and appear to be linked to hormonal and reproductive events. Premenstrual affective disorders consist of premenstrual syndrome, premenstrual dysphoric disorder, and premenstrual exacerbation of mood or anxiety disorders. Postpartum affective disorders can range from postpartum "blues" to postpartum depression with or without psychosis, and also include anxiety disorders, such as panic disorder, generalized anxiety disorder, social phobia, and obsessive-compulsive disorder. In perimenopausal women, the vulnerability to mood and anxiety disorders is increased. All of these disorders share risk factors, and have etiologic features in common, such as exposure to the rise and fall of ovarian sex steroids. The following is a review of these syndromes and their etiology, diagnosis, and treatment.

Estrogen replacement therapy in the treatment of major depressive disorder in perimenopausal women

BACKGROUND

Increased vulnerability to mood disorders has been reported during perimenopause. Fluctuating estrogen levels accompany the perimenopausal transition. Thus, estrogen replacement therapy (ERT) has been proposed as a potentially effective treatment for mood disorders occurring during perimenopause.

METHOD

We examined the efficacy of ERT in the treatment of depression in 16 perimenopausal women with DSM-IV-defined major depressive disorder who were participating in the Mood Disorders Research Program at the Department of Psychiatry of the University of California, Los Angeles. Ten antidepressant- and ERT-naive women received ERT alone. Six women who were nonresponders or partial responders to an antidepressant received ERT in addition to existing treatment with fluoxetine. The Hamilton Rating Scale for Depression (HAM-D) was administered to all patients at baseline and weekly thereafter during the 8-week open-protocol trial. Partial response was operationalized as a final HAM-D score < or = 50% of the baseline score. Remission was defined as a final HAM-D score < or = 7.

RESULTS

All patients exhibited clinical improvement as measured by HAM-D scores after the first week of treatment. Of the 10 perimenopausal depressed women receiving ERT alone, 6 remitted, 3 partially responded to treatment, and 1 did not respond by the end of the trial. Of the 6 women receiving antidepressant treatment with ERT, 1 patient remitted and 5 had a partial response by the end of the trial.

CONCLUSION

This small study suggests that for some antidepressant-naive perimenopausal women with clinical depression, ERT may have antidepressant efficacy. In depressed women who have minimal response to a selective serotonin reuptake inhibitor, ERT may augment response. Further controlled trials are needed.

Menstrual cycle-related brain metabolite changes using 1H magnetic resonance spectroscopy in premenopausal women: a pilot study

Proton magnetic resonance spectroscopy (1H-MRS) was used to assess neurochemical brain changes across the menstrual cycle in five women with premenstrual dysphoric disorder (PMDD) and six control subjects. Women with PMDD and control subjects were scanned on days 8 and 26 within one menstrual cycle (i.e. at times of complete absence and height of PMDD symptoms, respectively). The point resolved spectroscopic sequence (PRESS) was used to localize a voxel of 8 ml in the medial frontal gray matter and in the occipito-parietal white matter. The ratio of N-acetyl-aspartate to creatine in the region of the medial prefrontal cortex and the cingulate gyrus declined significantly from the follicular to the luteal phase in both groups of subjects. The menstrual phase-dependent significant increase in the ratio of choline to creatine was observed in the parietal white matter. The myo-inositol/creatine ratio exhibited a trend toward higher levels in the PMDD patients in the luteal phase of the menstrual cycle. Differences between PMDD and control subjects were not statistically significant. Menstrual cycle phase-dependent changes in ovarian hormonal concentrations may influence the neurochemistry of brain activity in premenopausal women.

Insulin-like growth factor-1 and insulin-like growth factor-binding protein-3 in women with premenstrual syndrome

OBJECTIVE

To determine whether women with premenstrual syndrome (PMS) have aberrations of the GH axis as has been demonstrated in individuals with depression.

DESIGN

Prospective trial.

SETTING

Department of Obstetrics and Gynecology, University of California, Los Angeles.

PATIENT(S)

After prospective screening, 32 healthy women with PMS and 32 asymptomatic controls completed the study.

INTERVENTION(S)

Subjects completed a daily PMS symptom diary and a Beck Depression Inventory. They underwent phlebotomy 5 days and 12 days after the LH midcycle surge, which was identified with the use of a urinary LH detection kit.

MAIN OUTCOME MEASURE(S)

Serum levels of insulin-like growth factor-1 (IGF-1), insulin-like growth factor-binding protein-3 (IGFBP-3), E2, and progesterone.

RESULT(S)

Levels of IGF-1, IGFBP-3, E2, and progesterone did not differ between women with prospectively documented PMS and control subjects.

CONCLUSION(S)

Premenstrual syndrome and affective disorder share common symptoms and possibly a common cause. Biochemical markers such as alterations in the somatotropic system often are associated with major depression. Levels of IGF-1 and IGFBP-3 did not differ between women with PMS and control subjects, supporting the concept that PMS and endogenous depression are biologically distinct entities.

Progesterone metabolite allopregnanolone in women with premenstrual syndrome

OBJECTIVE

To evaluate the anxiolytic 3alpha-5alpha-reduced progesterone metabolite allopregnanolone in the luteal phase of the menstrual cycle in women with premenstrual syndrome (PMS) and controls.

METHODS

Thirty-five women with prospectively documented PMS and 36 controls were evaluated. Serum progesterone and allopregnanolone levels were measured on days 19 and 26 of the cycle as determined by urinary LH detection kits. Analysis of variance and Student t tests were used to analyze the data.

RESULTS

Allopregnanolone levels were significantly lower on day 26 in the PMS group than in controls (3.6 +/- 0.8 versus 7.5 +/- 1.3 ng/mL; P < .04). Significant differences in the ratio of the metabolite to progesterone also were noted, with a smaller ratio in the PMS subjects (0.9 +/- 0.3 versus 3.2 +/- 1.3 ng/mL; P < .05). There were no significant differences between the PMS and control groups with respect to serum progesterone levels.

CONCLUSION

Subjects with PMS manifested lower levels of the anxiolytic metabolite allopregnanolone in the luteal phase when compared with controls. Diminished concentrations of allopregnanolone in women with PMS may lead to an inability to enhance gamma aminobutyric acid-mediated inhibition during states of altered central nervous system excitability, such as ovulation or physiologic or psychological stress. The lowered metabolite levels could contribute to the genesis of various mood symptoms of the disorder, such as anxiety, tension, and depression.

Cognitive functioning in premenstrual syndrome

OBJECTIVE

To evaluate cognitive functioning in women with premenstrual syndrome (PMS) and controls during the follicular and luteal phases of the menstrual cycle.

METHODS

Thirty women with PMS and 31 controls were selected on the basis of psychiatric interview and prospective daily diary recordings. Subjects were tested on two occasions, follicular (days 8-10) and luteal (days 24-26), using complex tasks consisting of measures validated previously for the assessment of "executive" frontal-lobe functions. Tests were counterbalanced for order across subjects.

RESULTS

The Beck Depression Inventory scores were significantly different between the groups and across time (P < .001). Women with PMS had a mean luteal phase Beck score of 13.3 consistent with mild-to-moderate premenstrual depression. There were no statistically significant score differences in tests for attention, memory, cognitive flexibility, and overall mental agility. The evaluation of our preliminary data with 30 PMS subjects and 31 controls indicated a very small effect size (.02). To detect an effect size this small (if in fact one exists) with a power of .8 would require a sample of more than 1000 subjects per group.

CONCLUSION

Our sample of women with PMS failed to demonstrate objective evidence of diminished cognitive performance, despite subjective feelings of inadequacy.

Decreased central opioid activity in premenstrual syndrome: luteinizing hormone response to naloxone

OBJECTIVE

To evaluate central opioid activity in women with prospectively documented premenstrual syndrome (PMS) and control women in the mid- and late luteal phases of the menstrual cycle.

METHODS

Blood was collected every 15 minutes 1 hour before (0800) and 2 hours after treatment (0900-1100). The treatment was administered in a randomized fashion and consisted of naloxone 1 or 4 mg or placebo, and blood was assayed for luteinizing hormone (LH). Baseline estradiol, progesterone, and prolactin were measured at 0800 and 0900 hours.

RESULTS

There was a significant increase in LH area under the curve and mean LH in response to naloxone in the midluteal phase in the control (P < .001). The PMS subjects did not display a significant increase in LH concentration in response to naloxone in the midluteal phase. There were no significant LH responses to naloxone in either group in the late luteal phase. There were no significant differences in estradiol, progesterone, or prolactin concentrations or estrogen to progesterone ratios between groups.

CONCLUSION

Control women have an enhanced central opioid tone during the midluteal phase that diminishes and becomes minimal in the late luteal phase of the menstrual cycle. In contrast, women with PMS have a loss of central opioid tone during the midluteal phase as indicated by the loss of LH response to naloxone. This attenuated central opioid tone in women with PMS as compared with asymptomatic control women may play a role in the pathophysiology of PMS.

Menstrual patterns in women with congenital heart disease

To examine the extent to which congenital heart disease (CHD) influences ovarian function, 98 women (mean age 32.7 years) were asked to complete a mailed questionnaire regarding their menstrual patterns. Patients were divided into acyanotic (60%) and cyanotic (38.8%) groups. Cycle lengths, duration of menstrual cycle, regularity of menses, amount of flow, and breakthrough bleeding were compared in these two groups and against age-matched controls. The mean age of menarche for the sample (13.4 years) was significantly different (p < 0.004) when compared to their controls (12.5 years). With the exception of breakthrough bleeding, statistical differences were not found between the study population and the controls. When the menstrual histories of cyanotic women were compared with those of acyanotic women, differences were found for all categories of menstrual patterns with the exception of the amount of menstrual flow. Menstrual patterns of cyanotic women compared to controls were found to be significantly different for all categories with the exception of amount of flow. In general, women with CHD have menstrual patterns similar to those in the general population.

Menstrual cycle and social behavior in vervet monkeys

We assessed the relationship between social behavior and the menstrual cycle in 11 adult female vervet monkeys (Cercopithecus aethiops sabaeus) living in an established, stable social group. The findings indicated that fluctuations in ovarian steroids are accompanied by behavioral changes in vervet monkeys. A significant increase in aggressive action, avoidance of social overtures, and retreats from threat occurred during the late luteal phase. However, the social environment can greatly affect behavior independent of the phase of the menstrual cycle. The 10 nondominant (or subordinate) individuals not only exhibited behavioral changes across their own menstrual cycles, but also were responsive to the dominant female's cycle. During the dominant female's late luteal phase, subordinate females significantly increased aggression and decreased social activity. Some of behavioral patterns in female vervet monkeys are therefore relatively independent of direct hormonal modulation and support the contention of the dominant female as the driving force for behavioral changes related to aggression and social interaction. The differential effect of hormones and social status and other environmental factors on behavior has not been critically evaluated in human studies of the premenstrual syndrome. The present study suggests that it is important to assess which behavioral patterns in women are hormonally mediated and which are dependent on the environment.