Diagnostic and therapeutic algorithm for the treatment of premenstrual dysphoric disorder

Many women experience psychological and physical symptoms associated with menstrual cycle. In 3% to 5% of women that meet the criteria for premenstrual dysphoric disorder, the symptoms are severe and impair their social and occupational functioning. Although the etiology of premenstrual dysphoric disorder is unknown, the symptoms of dysphoria, including depression and anxiety, have been associated with serotonergic dysregulation. Selective serotonin reuptake inhibitors, taken only during the symptomatic luteal phase, are considered as first-line therapy for premenstrual dysphoric disorder.     

Isolating with physical restraint low status female monkeys during luteal phase might make an appropriate premenstrual depression syndrome model

BACKGROUND: Rhesus monkeys (Macaca mulatta) have a close phylogenetic relationship to humans, and have a similar 28-day menstrual cycle with similar hormonal fluctuations. In this study, we attempt to establish the premenstrual depression syndrome of rhesus monkey (M. mulatta) models by isolation with physical restraint of low social status young female monkeys during their luteal phase. METHODS: Low social status young female rhesus monkeys (M. mulatta) were isolated with physical restraint during their luteal phase by using a specifically designed isolating-cage. During the entire menses cycle, serum levels of 5-hydroxytrypamine, noradrenalin and adrenalin were detected by capillary zone electrophoresis, and the changes in the serum levels of progesterone, estradiol and prolactin were investigated by radioimmunoassay. At the same time, the pharmaceutical interference effect of Jingqianshu granule, a traditional Chinese medicine specifically used to cure premenstrual depression patients, was tested using this premenstrual depression syndrome monkey model. RESULTS: After being immured in two consecutive menstrual cycles, monkeys presented depressive symptoms during the premenstrual phase of three consecutive menstrual cycles. The serum contents of the three kinds of monoamine neurotransmitters in depressive monkeys were significantly higher than the normal ones. The serum levels of progesterone and prolactin increased obviously, and a marked change in the pattern of progesterone secretion could be observed. Moreover, the premenstrual depressive symptoms of model group monkeys could not only be cured by Jingqianshu granule, but the higher serum levels of prolactin and monoamine neurotransmitters in these monkeys could be reduced by this herbal medicine. These data were well in line with clinical observations of women with premenstrual depression syndrome. CONCLUSION: Our results in this study for the first time indicate that isolation with physical restraint of low status young female monkeys during their luteal phase makes an appropriate premenstrual depression syndrome model. This model might potentially facilitate studies on the etiology of premenstrual depression syndrome and the development of better methods for the therapy of this disease.     

Menstrual cycle symptoms: comparison of a non-clinical sample with a patient group

This study compared findings of a community group of women (n = 32), who claimed they did not require help for menstrual cycle complaints, with a patient group (n = 75) with confirmed premenstrual syndrome (PMS). Subjects completed a battery of psychological tests to identify personality characteristics, levels of depression, anxiety, stress and marital adjustment. Menstrual cycle symptoms were assessed with the Menstrual Distress Questionnaire (MDQ, Moos, 1985) during follicular (day 6-8) and premenstrual phases (day 26-28) of two adjusted cycles and with daily symptom ratings. Daily 24-h urines were collected for oestradiol and pregnanediol levels for one cycle. After prospective assessment, the non-clinical sample were differentiated into those with pronounced cyclical symptom changes (Hi-volunteers, n = 13) and others with minimal cyclical changes (Lo-volunteers, n = 19). The total non-clinical sample could be distinguished from the patient group on depression, stress, and self-esteem scores. The non-clinical subgroup with pronounced cyclical symptoms is proposed as an 'at-risk' group for future treatment seeking.     

Food craving, mood and the menstrual cycle

Seventy-six women, with a mean age of 35.7 years, who reported premenstrual craving for sweet foods in a retrospective questionnaire, were assessed prospectively with a pre- and post-menstrual eating questionnaire and daily ratings of craving, mood, irritability and breast tenderness over two menstrual cycles. In 72% of these women a perimenstrual pattern of food craving was confirmed. In 13% this craving was confined to the menstrual phase. There was no consistent association between food craving and mood change, either in timing or severity. Women with more severe mood change did not report more severe craving. There was also no association between food craving and cyclical breast tenderness. Perimenstrual food craving, therefore, appears to be a cyclical phenomenon in its own right, of uncertain aetiology and worthy of further study.     

Changes in Australian women''s perception of the menopause and menopausal symptoms before and after the climacteric

The symptoms and perceptions of menopause of 60 Australian women were studied, by questionnaire, when they were premenopausal and 10 years later when they were postmenopausal. Menopausal symptoms expected and experienced by the women were compared, fewer women experiencing hot flushes, headache, depression and nervousness and more experiencing insomnia, increase in appetite, abdominal fullness, numbness and muscular problems. The symptoms women thought were due to hormonal changes at menopause were compared. In 1993 more women cited osteoporosis, insomnia, loss of libido, obesity and loss of muscle tone as due to hormone change while fewer cited depression. The premenstrual symptoms and their severity experienced by a woman when she was premenopausal significantly predicts the type and severity of the menopausal symptoms experienced by the woman. The expected menopausal symptoms and their severity cited by a woman also significantly predicts the type of severity of the menopausal symptoms experienced. More premenstrual symptoms predict the menopausal symptoms than those menopausal symptoms the women expected. The expectation menopause will be ‘a relief’ or ‘a nuisance’ significantly predicted the overall menopause experience described by the women. Their negative attitudes about doctors' understanding and information available about menopause remained unchanged but they forget menstrual cycle problems over the 10 years. The results suggest a possible physiological basis for premenstrual and menopausal symptoms. Assistance for women with their premenstrual and menstrual cycle symptoms may improve their quality of life at menopause.     

The role of low progesterone and tension as triggers of perimenstrual chocolate and sweets craving: some negative experimental evidence.

Approximately half of the 40-50% of North American women who crave chocolate or sweets do so principally in the perimenstrum, the part of the menstrual cycle surrounding the onset of menstruation. We test two hypotheses about the events that trigger these cravings: 1) the premenstrual drop in progesterone levels; or 2) dysphoria or tension in the perimenstruum. Chocolate craving, sweets craving, and other perimenstrual symptoms were rated daily for six menstrual cycles by a sample of women with severe premenstrual syndrome (PMS). Forty-four women satisfied criteria for cyclicity in chocolate craving, and 44 for sweet craving, determined during the first two cycles. Thirty-four subjects satisfied criteria for craving of both chocolate and sweets. After placebo treatments during the third cycle, subjects were randomly assigned, double blind, to administration of placebo, oral micronized progesterone, or alprazolam (a tranquillizer). Treatments were administered from the beginning of the third week to the second day postonset of menstruation during the fourth to sixth months of study. Neither progesterone nor alprazolam decreased chocolate or sweets craving.     

The role of menstrual cycle phase and anxiety sensitivity in catastrophic misinterpretation of physical symptoms during a CO2 challenge

The current study examined the interactive effects of anxiety sensitivity (AS; fear of anxiety and anxiety-related sensations) and menstrual cycle phase (premenstrual phase vs. follicular phase) on panic-relevant responding (i.e., cognitive and physical panic symptoms, subjective anxiety, and skin conductance level). Women completed a baseline session and underwent a 3-min 10?% CO₂-enriched air biological challenge paradigm during her premenstrual and follicular menstrual cycle phases. Participants were 55 women with no current or past history of panic disorder recruited from the general community (M _age?=?26.18, SD?=?8.9) who completed the biological challenge during both the premenstrual and follicular cycle phases. Results revealed that women higher on AS demonstrated increased cognitive panic symptoms in response to the challenge during the premenstrual phase as compared to the follicular phase, and as compared to women lower on AS assessed in either cycle phase. However, the interaction of AS and menstrual cycle phase did not significantly predict physical panic attack symptoms, subjective ratings of anxiety, or skin conductance level in response to the challenge. Results are discussed in the context of premenstrual exacerbations of cognitive, as opposed to physical, panic attack symptoms for high AS women, and the clinical implications of these findings.     

Hyperandrogenemia, psychological distress, and food cravings in young women

Reproductive disorders and psychological distress are common co-morbidities of obesity in young women. Psychological and reproductive disturbances may also be associated with increased food cravings but the relationships between these factors have not been explored. This study aimed to explore the pattern of food cravings and to determine the relationship between psychological distress, reproductive health and food cravings in overweight and obese young women using baseline data in a weight loss trial. A total of 198 young women were included in this analysis (BMI 33.3 ± 0.3 kg/m², age 28 ± 0.3 years). The most frequently craved food item was chocolate (3.9 ± 0.08 i.e., sometimes-often). The most frequently craved food categories were fast foods (2.6 ± 0.07) and sweets (2.5 ± 0.05). Psychological distress was significantly correlated with food cravings (R² = 0.18, P < 0.05). High fat (r = 0.2), sweets (r = 0.17) and overall cravings (r = 0.20) were significantly correlated with energy intake (P < 0.05). Psychological distress did not correlate with energy intake (P > 0.05). Participants with menstrual disturbances had greater fast food cravings independent of age, BMI and PCOS status (P < 0.05). Participants with hyperandrogenemia had greater high fat food cravings independent of age, BMI and PCOS status (P < 0.01). Energy intake did not differ with menstrual disturbances or hyperandrogenemia (P > 0.05). These results suggest that psychological distress, hyperandrogenemia and menstrual disturbances are associated with greater food cravings. Further investigations are required to elucidate the relationship between hyperandrogenemia and food cravings in young women.     

Electrodermal activity in menstrual cycle phases: a comparison of within- and between-subjects designs

Electrodermal activity (EDA) changes in menstrual cycle were studied in two experiments. In both experiments subjects were presented with 16 80-dB tones; 15 tones were 4 s, 1000 Hz, and the last one - change trial - was a 6-s, 3000-Hz tone. In Expt. 1, a within-subjects design was employed, and 15 women were studied throughout a complete menstrual cycle. No significant changes in EDA associated with menstrual cycle phases were found, but significant decreases in electrodermal responsiveness during experimental sessions in EDA parameters were observed. In Expt. 2, with a between-subjects design, 56 women were divided in menstrual (n = 10), follicular (n = 12), ovulatory (n = 14), luteal (n = 13) and premenstrual (n = 7) groups, according to the cycle phase in which the subject was at the time of recording. At the ovulatory phase there were significant increases in skin conductance response (SCR) magnitude, skin conductance level, SCR habituation rate, and SCR amplitude to stimulus change, in relation to menstrual, luteal, and premenstrual phases. The discrepancies in the EDA data coming from the two experiments may be explained by practice effects appearing in Expt. 1.     

乳腺增生病患者精神状态的研究

目的 探讨乳腺增生病人的精神状态。方法 采用SCL-90评定60例乳腺增生女患者和60例健康妇女在月经周期4个不同时期的精神状态。结果 研究组躯体化、抑郁及焦虑因子显著高于对照组；在月经前期、分泌期、月经期等3个时期总分较对照组高；在月经期及月经前期总均分及人际关系敏感因子对照组高。结论 乳腺增生患者精神症状，主要是躯体化、抑郁、焦虑、人际关系敏感等因子与健康人存在差异。     

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

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

Symptoms of depression in late luteal phase dysphoric disorder: a variant of mood disorder?

BACKGROUND: In premenstrual syndrome, depressed mood in the luteal phase of the menstrual cycle is acknowledged, whereas the presence of symptoms of depression during the follicular phase remains in debate. METHODS: On the basis of prospective daily recording of the presence and severity of symptoms for at least two menstrual cycles, 43 women were diagnosed with Late Luteal Phase Dysphoric Disorder (LLPD) according to the criteria of the third edition revision of the Diagnostic and Statistical Manual of Mental Disorders. They were compared to a group of 85 women who showed no evidence of LLPD for two menstrual cycles. Structured psychiatric interviews were administered during the follicular phase. Only those subjects without Axis I disorders were subsequently included in the study. RESULTS: Those women with minor/moderate symptoms of depression had an odds of suffering from LLPD of 1.9 (95% CI=1.5-2.4, p<0.001) in relation to increasing severity of symptoms of depression at the total MADRS scale (1-point increase). The ORs of LLPD in relation to each dimension (1-point increase) of the emotional/affective, cognitive, and neurovegetative symptoms were 1.6 (95% CI=1.2-2.3, p=0.003), 2.8 (95% CI=0.9-8.5, p=0.077) and 3.3 (95% CI=1.9-5.9, p<0.001), respectively. LIMITATIONS: No hormonal changes that may be associated with symptoms of LLPD were determined in this study. CONCLUSIONS: LLPD is likely to represent a variant of a depressive disorder, where premenstrual psychobiological changes seem to exacerbate mild depressive symptoms and signs to which LLPD women are otherwise predisposed. This hypothesis opens new perspectives for prevention and of even treatment for LLPD. Further longitudinal studies with larger populations and evaluation of hormonal changes are needed to confirm these data.     

Sleep quality and the sleep electroencephalogram in women with severe premenstrual syndrome

STUDY OBJECTIVES: Women with severe premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD) commonly report sleep disturbances, but the few studies using conventional polysomnographic measures have produced conflicting results. We investigated sleep quality and sleep composition using conventional and quantitative electroencephalographic analyses in women with severe PMS, as compared with that of controls. DESIGN AND PARTICIPANTS: Women (aged 18-40 years) were screened to ensure that their PMS symptoms were severe and that they had ovulatory menstrual cycles. Nine women with PMS or PMDD and 12 asymptomatic control subjects then had laboratory-based polysomnographic recordings at 2 phases of the menstrual cycle: follicular phase and late luteal (premenstrual) phase. RESULTS: Women with severe PMS reported a significantly poorer subjective sleep quality during the late luteal phase (P = 0.02), but there was no evidence of disturbed sleep based on the polysomnogram specific to premenstrual symptom expression: both groups of women had increased wakefulness after sleep onset (P = 0.02) and increased sigma power (P < 0.01), especially in the 14-to 15-Hz band during non-rapid eye movement sleep, in the late luteal phase compared with the follicular phase. There were, however, some group differences in electroencephalographic measures regardless of menstrual phase, including decreased delta incidence (P = 0.02) and increased theta incidence and amplitude (P < 0.05) in women with PMS, suggesting the possibility of sleep electroencephalogram trait markers in women with PMS. CONCLUSION: Perceived poor quality sleep is a characteristic of severe PMS, but sleep composition based on polysomnographic measures and quantitative electroencephalographic analysis does not differ in association with premenstrual symptom expression in the late luteal phase.     

Blunting of neuroendocrine responses to infusion of L-tryptophan in women with perimenstrual mood change

The neuroendocrine response to L-tryptophan infusion was measured at two stages of the menstrual cycle, premenstrually and postmenstrually, in 13 women with and 13 women without premenstrual depression (the MC and NMC groups respectively). Previous studies have shown that in non-depressed women, this challenge test results in an increase in circulating prolactin and growth hormone. In depressed women both responses are blunted. In this study the growth hormone and cortisol responses were smaller in the MC group than the NMC group on both occasions. The prolactin response was blunted premenstrually compared with postmenstrually in both groups. These findings suggest that women who experience premenstrual depression may have neuroendocrine abnormalities throughout the cycle. The neurotransmitter abnormalities reflected in these altered endocrine responses appear to interact with neuroendocrine changes that normally occur premenstrually resulting in a vulnerability to depression at that phase of the cycle.     

The MMPI and premenstrual syndrome: profile fluctuations between best and worst times during the menstrual cycle

The MMPI was administered during the patient-perceived best time of the menstrual cycle and during the patient-perceived worst time of the cycle in order to examine the stability of MMPI profile configurations. Subjects were 214 women who were referred to two metropolitan outpatient premenstrual syndrome (PMS) clinics for moderate to severe premenstrual complaints. This sample was selected from 1,849 intake files after screening by strict selection criteria for PMS. The results indicate that there are wide fluctuations in profile patterns between the best and worst times of the menstrual cycle for a large number of patients. Caution in using the MMPI is strongly advised.     

Changes in premenstrual symptoms in women with schizophrenia: a prospective study

OBJECTIVE: We investigated whether the psychiatric symptoms and clinical features of schizophrenia change during the premenstrual phase in female patients. METHODS: We observed 30 female schizophrenic inpatients over one menstrual cycle. All subjects met DSM-IV criteria for schizophrenia, and all had a regular menstrual cycle. All subjects completed the Daily Rating Form (DRF) every evening, and one psychiatrist rated the subjects (using the Brief Psychiatric Rating Scale [BPRS]) once during each of the three menstrual phases (premenstrual, menstrual, and postmenstrual). Serum levels of estradiol (E2) and progesterone were measured on the fifth to seventh day of both the premenstrual and postmenstrual phases. Data from the 24 subjects who completed the DRF correctly and completely were used for statistical analysis. RESULTS: The mean total BPRS score for the 24 subjects was highest in the premenstrual phase and lowest in the postmenstrual phase, and a statistically significant difference was found among the three menstrual phases. Mean subtotal BPRS scores showed statistically significant differences among the three menstrual phases in anxiety/depression and withdrawal/retardation, but not in the psychotic symptom subscales. Mean serum E2 level showed a trend of increasing from the premenstrual phase to the postmenstrual phase. However, there was no significant correlation between DeltaBPRS and DeltaE2. When the criterion of 30% change was applied, the DRF items of depressed mood, anxious/nervous/restless, hostile/aggressive, and less/impaired work showed high frequencies of change in the premenstrual phase. Somatic items of abdominal pain, breast pain, and headache showed significant change with the 30% change rule on the DRF. On both the BPRS and DRF scores, premenstrual change of affective and behavioral symptoms was prominent, whereas the change of psychotic symptoms was minimal on the BPRS. In addition, in the premenstrual phase, there was a statistically significant correlation between the total BPRS score and the mean total DRF score. There was no correlation between premenstrual change in symptoms and hormonal levels of E2, progesterone, and the estradiol/progesterone (E/P) ratio. CONCLUSIONS: The findings of this study suggest that premenstrual exacerbation of schizophrenic symptoms in female patients may not be a worsening of the schizophrenic symptoms but a concurrence of affective, behavioral, and somatic symptoms.     

Influences of premenstrual syndrome on daily psychological states and salivary cortisol level

The purpose of this study is to investigate the influences of premenstrual syndrome (PMS) on daily psychological states and salivary cortisol level. First, 42 women recorded their PMS symptoms and basal body temperatures every day for approximately two menstrual cycles. Based on these prospective records of PMS symptoms, participants were divided into two groups: Normal group (n=22) and PMS group (n=17). There were no significant differences between the two groups in age, height, weight, age at menarche, menstrual cycle length, menstrual period, depression score, and stressor score. Next, 14 women (7 Normal group, 7 PMS group) were selected and they were measured twice, once during the premenstrual phase and once during the postmenstrual phase of their cycles. Each day, they took saliva samples and recorded their psychological states six times (from waking to going to bed) per day at their homes. Results showed that the fear score in PMS group was high in the premenstrual phase, whereas salivary cortisol level in PMS group was low in the same phase compared to the Normal group. These results suggested the possibility of dysregulation of the stress system in women with PMS.     

Sleep patterns related to menstrual cycle phase and premenstrual affective symptoms

An ovulatory menstrual cycle is characterized by fluctuating levels of progesterone. Progesterone, a gonadal hormone known for its soporific and thermogenic effects, is present in negligible levels prior to ovulation and in high levels after ovulation. To describe and compare sleep patterns in relation to ovulatory cycles and premenstrual mood state, sleep was monitored in healthy women at two phases of the menstrual cycle. Results indicated that rapid-eye-movement (REM) latency was significantly shorter during the postovulatory (luteal) phase compared to the preovulatory (follicular) phase, but there was no significant difference in latency to sleep onset or the percentage of REM sleep. While there were no menstrual cycle phase differences in the percentages of various sleep stages, the women with negative affect symptoms during the premenstruum demonstrated significantly less delta sleep during both menstrual cycle phases in comparison with the asymptomatic subjects.     

Female Sexual Arousal and the Menstrual Cycle

Abstract

Self-reports of sexual arousal were significantly affected by conditions under which they were elicited. Such self-reports in women not taking oral contraceptives were congruent with a hormonal basis for such arousal only when the women were “unaware” that the study investigated sexual arousal as a function of the menstrual cycle. The “unaware” condition was operationalized by means of daily self-reports elicited from males and females for 11 weeks under the guise of a study of biological rhythms. A composite of one to three menstrual cycles for 26 women not taking oral contraceptives showed that sexual arousal during the luteal phase, when progesterone is relatively high, was significantly lower compared to peaks around ovulation, and premenstrual and late menstrual days (p<.02). For the “aware” condition, women were asked to remember moods for the premenstrual, menstruating and luteal phases of the very last cycle on which they had just finished giving “unaware” daily self-reports. A 2 × 3 analysis of variance (with “aware” versus “unaware” conditions and premenstrual, menstruating, and luteal phases of the last cycle as the two independent variables) yielded a significant interaction effect with F=6.5, df=2, 50, p<.003. In the “unaware” condition, sexual arousal was reported lowest during the luteal phase. The opposite pattern was reported in the “aware” condition. The results suggest that cyclical variability may not be simply due to women's misattribulions. However, “awareness” has an effect on self-report measures and may bias reports according to cultural stereotypes. Daily self-reports of sexual arousal for men were averaged over the duration of the study. This average was 3.16. The equivalent average for women not taking oral contraceptives was 2.35 and for women taking oral contraceptives was 2.62. Analysis of variance of these three means yielded a significant difference with F=4.49, df=2, 59, p<.02.     

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

BACKGROUND: Other than premenstrual dysphoria, few studies have examined the extent to which basic characteristics of the menstrual cycle and the occurrence of other reproductive landmarks impact on the risk of major depression. METHODS: From a population-based sample of 4161 premenopausal women 36-45 years of age, we identified 332 women who met DSM criteria for past or current major depression and a sample of 644 women with no such history. In person interviews included a detailed assessment of menstrual cycle characteristics from age at menarche through study enrollment as well as other reproductive landmarks. RESULTS: Risk of depression increased significantly with decreasing age at menarche (P<0.001). The risk of depression was also higher in women with heavier menstrual flow and cycle irregularity during the first 5 years of menstruation. Women with a history of multiple abortions were 2-3-times more likely to develop major depression (95% CI 1.6-4.1). Increasing months of breastfeeding was associated with a decreased risk of depression after adjustment for education, marital status, and number of livebirths (P-value, test of trend=0.012). This association was largely confined to depression during the postpartum period. LIMITATIONS: Menstrual and pregnancy history exposures were self-reported and retrospectively assessed. However, women with and without a HISTORY of depression were subject to similar recall requirements that likely resulted in an underestimate of most risk estimates. CONCLUSIONS: Clinicians involved in routine obstetrical and gynecological care of women need to recognize that menstrual and pregnancy history events may serve as potential markers for subsequent psychiatric sequelae.