Premenstrual changes: a comparison of five populations

Several studies have suggested that a special relationship exists between premenstrual and major affective disorders. The present report describes the incidence of reported premenstrual symptoms in women with and without prospectively confirmed premenstrual syndrome, women with bipolar or seasonal affective disorder, and controls. The inability of reported symptoms to differentiate women with and without confirmed premenstrual syndrome, as well as the reduced prevalence of reported premenstrual changes in our affective populations relative to previous reports, is discussed.     

Symptom cyclicity in women with the premenstrual syndrome: an 8-year follow-up study.

Does premenstrual tension (PMT) change with time? In 1982 and again in 1990, nine women with the premenstrual syndrome kept a daily record of eight psychological and five physical symptoms for three menstrual cycles. Urine samples were collected once or twice weekly for the analysis of pregnanediol. Premenstrual tension was estimated by Fourier analysis. By 1990, all the women continued to menstruate at regular intervals and there was little change in either PMT prevalence or in mean PMT severity (ANOVA, p = 0.43 for psychological symptoms and 0.52 for physical symptoms). It is concluded that age-related changes in PMT may be trivial.     

Premenstrual symptoms and perimenopausal depression

OBJECTIVE: The role of ovarian steroids in both premenstrual dysphoria and perimenopausal depression has led to the suggestion that these conditions represent expressions of the same underlying disorder. Premenstrual mood symptoms were evaluated in women with perimenopause-related depression. METHOD: Self-reports and daily symptom ratings during one menstrual cycle were examined in 70 depressed perimenopausal women attending a menopause clinic and 35 nondepressed perimenopausal women. RESULTS: Twenty-six percent of the depressed and 9% of the nondepressed women reported premenstrual symptoms. Thirty-one percent of the depressed and 20% of the nondepressed women met criteria for significant menses-related symptom cyclicity (at least a 30% increase in the average ratings of at least two of four measured negative mood symptoms in the premenstrual versus the postmenstrual week); 5 of these depressed women and none of the comparison subjects described premenstrual symptoms on self-reports. Finally, 21% of the depressed and 3% of the nondepressed women met criteria for premenstrual dysphoria (symptom cyclicity and at least moderate severity, with symptoms exceeding a minimum luteal symptom severity threshold of 2.5). CONCLUSIONS: A higher-than-expected rate of menses-related symptom cyclicity and premenstrual dysphoria was observed in perimenopausal depressed women. However, neither menses-related symptom cyclicity nor premenstrual dysphoria was an invariant accompaniment of perimenopausal depression. Additionally, the rate of premenstrual dysphoria was not predicted by initial self-reports.     

Premenstrual syndrome and premenstrual dysphoric disorder: definitions and diagnosis

Because of the prevalence, chronicity and distress caused by premenstrual symptoms (PMS), diagnosis and effective treatments are important information for clinicians. The DSM-IV requires at least five specified symptoms for premenstrual dysphoric disorder (PMDD), a severe dysphoric form of PMS, while the ICD-10 requires only one distressing symptom for a diagnosis of PMS. Many women who seek treatment fall between these two diagnostic approaches, and standard diagnostic criteria for clinically significant PMS are needed. A diagnosis of PMS consists of determining the timing of the symptoms in relation to menses, meaningful change between post- and premenstrual symptom severity and a clinically significant severity of the symptoms. A differential diagnosis to distinguish PMS from other medical and psychiatric conditions is important for appropriate treatment. No hormone or laboratory test indicates a PMS diagnosis. The current diagnostic standard requires confirmation of subjective symptom reports by prospective daily diaries. Diagnostic criteria for PMS must recognize the broad range of symptoms, the temporal pattern of the symptoms and the critical issue of symptom severity, which differentiates clinically significant PMS from normal menstrual cycle changes.     

Prevalence of clinically significant depressive symptoms in black and white patients in family practice settings

The authors administered the Zung Self-Rating Depression Scale to 764 black and 773 white adult outpatients in primary care settings. There was no significant difference between the races in prevalence of depressive symptoms or distribution of symptom severity levels.     

Differences in Thrombotic Risk Factors in Black and White Women with Adverse Pregnancy Outcome

Introduction

Black women have an increased risk of adverse pregnancy outcomes and the characteristics of thrombotic risk factors in this population are unknown. The objective of this study was to examine the racial differences in thrombotic risk factors among women with adverse pregnancy outcomes.

Methods

Uniform data were collected in women with adverse pregnancy outcomes (pregnancy losses, intrauterine growth restriction (IUGR), prematurity, placental abruption and preeclampsia) referred to Thrombosis Network Centers funded by the Centers for Disease Control and Prevention (CDC).

Results

Among 343 white and 66 black women seen for adverse pregnancy outcomes, protein S and antithrombin deficiencies were more common in black women. The prevalence of diagnosed thrombophilia was higher among whites compared to blacks largely due to Factor V Leiden mutation. The prevalence of a personal history of venous thromboembolism (VTE) did not differ significantly by race. A family history of VTE, thrombophilia, and stroke or myocardial infarction (MI) was higher among whites. Black women had a higher body mass index, and a higher prevalence of hypertension, while the prevalence of sickle cell disease was approximately 27 fold higher compared to the general US black population.

Conclusions

Thrombotic risk factors differ significantly in white and black women with adverse pregnancy outcomes. Such differences highlight the importance of considering race separately when assessing thrombotic risk factors for adverse pregnancy outcomes.     

Late luteal phase dysphoric disorder in young women

The authors determined the prevalence of late luteal phase dysphoric disorder in 217 university women aged 17-29 years. Unaware of the focus on premenstrual syndrome (PMS), the participants rated DSM-III-R symptoms of late luteal phase dysphoric disorder over 90 days. Using a 30% or greater premenstrual change as an index of luteal variation, the authors found that 10 women (4.6%) met the symptom criteria during two menstrual cycles. Compared to 25 young women seeking treatment for PMS who met the same diagnostic criteria, the 10 women from the university sample reported significantly less fatigue and impaired concentration and somewhat less severe depression and overall symptoms.     

Menstrual problems in women with primary affective illness

Reports in the literature on the relationship between manifestations or exacerbations of symptoms of affective psychiatric illness and menstruation are often conflicting and confusing. For example, McClure et al.,¹ in a study investigating premenstrual symptoms of women calling a suicide prevention center, suggest that hypomanic premenstrual symptoms may be an indicator of a tendency to an affective illness. However, Coppen² reports that women suffering from affective disturbance have a normal prevalence of menstrual disorders and that two-thirds of these patients report that affective symptoms are unchanged or improved at menstruation. In contrast, Mandell and Mandell³ found that an increased number of women called the Los Angeles Suicide Prevention Center in the late luteal and menstrual phase of their cycle, and MacKinnon and MacKinnon⁴ report that women who died from accident or suicide did so very much more frequently in the premenstrual phase than at other times. Correlations have also been reported between premenstrual or menstrual phases of cycle and admission to a hospital for acute psychiatric illness.⁵In view of the seemingly conflicting reports in the literature, the present study was undertaken to determine the extent of premenstrual and menstrual somatic and affective disturbances in a carefully selected, well-defined group of women with primary affective illness. The possible relationship between hormonal changes and affective menstrual symptoms is discussed.     

Racial variation in initial stroke severity

BACKGROUND AND PURPOSE: Blacks experience greater morbidity and mortality from stroke than do whites. The degree to which this is due to the severity of the initial stroke is not known. The objective of this study is to determine whether there is a racial difference in initial stroke severity. METHODS: A secondary analysis of a prospective cohort of 984 veterans (29.7% black) admitted to any of 9 geographically diverse Veterans Administration Hospitals for acute stroke between April 1995 and March 1997 was performed. Initial stroke severity was ascertained by using the modified Canadian Neurological Scale (CNS) applied retrospectively to medical record data. Stroke severity, unadjusted and adjusted for covariates, was compared between black and white patients. RESULTS: Blacks had greater initial stroke severity than did whites (mean CNS score 7.96 versus 8.32, respectively; P=0.039), with a 0.5-point difference on the scale corresponding to a single-level decrement in either speech or strength of half of an extremity. This difference persisted with adjustment for other important predictors of stroke severity (P=0. 035). However, there was no significant racial difference in severity when CNS scores were collapsed into a priori clinically relevant categories. CONCLUSIONS: Compared with whites, blacks show greater severity of stroke at hospital admission. It remains uncertain whether the relatively small but significant difference at presentation fully explains the striking racial differences in morbidity and mortality from stroke.     

The premenstrual syndrome: Selection of women for treatment trials

Statements made at interview by 31 women presenting with the premenstrual syndrome (PMS) were compared with the moods and physical symptoms reported daily during the next 6 menstrual cycles. Diagnosis was confirmed in 21 women (premenstrual tension (PMT) present in 5/6 cycles), not substantiated in two (PMT in 1/6 cycles) and in doubt in eight. Placebo treatment was associated with a significant over-all reduction in both the incidence and the severity of mood-related PMT, but had no clear effect on premenstrual physical symptoms; women with PMT in 5 cycles were usually placebo-resistant. Criteria are proposed for the selection of women for treatment trials based on their response to placebo.     

The premenstrual syndrome – an equivalent of depression?

The prevalence and symptoms of premenstrual syndrome (PMS) were studied in a survey using a random selection of fertile women (n = 1,852). The prevalence of PMS was 72.8%. 7.5% of the women with PMS felt they needed to see a physician. The survey responses from this latter group were compared with the answers from the remaining women with PMS. The symptoms differ significantly in many respects between the groups. Women who want to see a physician report, to a greater extent, symptoms during the premenstrual period which are seen in depressive states. Oral contraceptives do not seem to affect premenstrual symptoms in this group. The results suggest that severe premenstrual symptoms of predominantly depressive nature are probably a manifestation of an underlying depressive disorder.     

The relationship between retrospective premenstrual symptom reporting and present oral contraceptive use

The premenstrual assessment form (PAF) was used to assess the degree and type of premenstrual changes reported by 101 oral contraceptive users and 149 non-users (aged 18-45 yr) attending general health and gynaecology clinics. Women using oral contraceptives did not complain of fewer or less severe symptoms overall, but their severity scores on the subscales of premenstrual anxiety, fatigue, low mood, water retention, and impaired social functioning were significantly lower than those of non-users. The duration of oral contraceptive use and the type of preparation (combined or phased) taken were not related to the degree of premenstrual change reported. Complaints of symptoms beginning more than two days before menstruation were less frequently reported by pill-users (p less than 0.01) and were associated with a greater severity of all types of premenstrual change (p less than 0.0001). Women who had experienced difficulties tolerating oral contraceptives reported a greater number of moderate/severe premenstrual changes (p less than 0.0001).     

Self-preoccupation and general stress level as sensitizing factors in premenstrual and menstrual distress

This study considered whether general stress level and self-preoccupation sensitize women to symptoms of menstrual and premenstrual distress and whether this effect is more pronounced for premenstrual symptoms. Equal-size categories of normal college women reporting greater distress during the premenstrual period (PD), during the menstrual period (MD), or about equally in both periods were constituted. The PD women demonstrated significantly greater self-preoccupation than either the MD or equivalent groups; they also reported higher general stress than either comparison group, although statistical reliability was not attained. However, when both sensitizing factors were introduced into the same analysis, high self-preoccupation and a high level of general stress were found only in the PD group. The present evidence suggests that stress and personality not only sensitize premenstrual symptoms in PMS women but are prominent features in normal women who report more serious symptoms during the premenstrual period.     

Ovarian morphology in premenstrual dysphoria

Ovarian cyclicity is a prerequisite for premenstrual dysphoria (PMD), as illustrated by the fact that this condition is effectively eliminated by ovariectomy or by treatment with a GnRH agonist. Despite the possibility of differences in ovarian function between women with and without PMD, no study comparing ovarian morphology in these two groups has ever been published. Fifty-two women were recruited for this study; 26 had premenstrual dysphoria, fulfilling criteria slightly modified from those of the premenstrual dysphoric disorder, and 26 were asymptomatic age-matched controls. Ovarian morphology was assessed using transvaginal 7 MHz ultrasonography on day 5 after the start of menses, and venous blood was sampled for hormone analysis on days 3 and 8, the expected day of ovulation, and day -4 of the menstrual cycle. There were no significant differences between the groups with respect to the prevalence of polycystic ovaries (PCO), the total number of follicles, the total ovarian volume or serum levels of androgen hormones. In addition, serum free testosterone levels in late premenstrual phase showed an inverse association to premenstrual symptoms of irritability and a similar inverse association trend to symptoms of depressed mood. Unexpectedly, the prevalence of ovaries with fewer than five antral or growing follicles was significantly higher in women with PMD than in controls (p=0.016). While the results do not support a role for PCO or androgen hormones in eliciting late luteal phase irritability, the possible relationship between oligofollicular ovaries and PMD deserves further study.     

Eating disorders in white and black women

OBJECTIVE: Epidemiological studies of eating disorders in the United States have focused on white women and girls, and the prevalence of eating disorders in ethnic minority groups is unknown. This study examined the prevalence of anorexia nervosa, bulimia nervosa, and binge eating disorder in a geographically and economically diverse community sample of young white and black women who previously participated in the 10-year National Heart, Lung, and Blood Institute (NHLBI) Growth and Health Study. METHOD: All NHLBI Growth and Health Study participants were recruited for this study. A two-stage case finding method was used, consisting of a telephone screening (sensitivity=0.90, specificity=0.98) and an in-person confirmatory diagnostic interview. RESULTS: A total of 86.0% of the original NHLBI Growth and Health Study cohort participated, including 985 white women (mean age=21.3) and 1,061 black women (mean age=21.5). Fifteen white (1.5%) and no black women met lifetime criteria for anorexia nervosa; more white women (N=23, 2.3%) than black women (N=4, 0.4%) met criteria for bulimia nervosa; binge eating disorder also was more common among white women (N=27, 2.7%) than black women (N=15, 1.4%). Few women (white: N=16, 28.1%; black: N=1, 5.3%) ever had received treatment for an eating disorder. CONCLUSIONS: Results suggest that eating disorders, especially anorexia nervosa and bulimia nervosa, are more common among white women than among black women. The low treatment rates in both groups suggest that health professionals need to be more alert to the possibility of eating disorders in women.     

Continuous or intermittent dosing with sertraline for patients with severe premenstrual syndrome or premenstrual dysphoric disorder

OBJECTIVE: The authors compared the efficacy and acceptability of continuous versus intermittent treatment with a selective serotonin reuptake inhibitor in women with severe premenstrual syndrome and determined the effects of postmenstrual symptom severity and depression history as covariates of the treatment response. METHOD: Patients who met symptom criteria and reported impaired functioning after three screening cycles were randomly assigned to three cycles of double-blind, placebo-controlled treatment with continuous (full-cycle dosing) or intermittent (luteal-phase dosing) sertraline. The design was stratified for severity of postmenstrual symptoms and history of major depression. Flexible sertraline dose was 50-100 mg/day. Outcome measures were the Daily Symptom Rating Form score and patient global ratings of functioning. RESULTS: Both sertraline groups improved significantly more than the placebo group as assessed by total premenstrual Daily Symptom Rating Form scores for 3 treatment months. Daily Symptom Rating Form factors that were significantly more improved in the sertraline groups were mood and physical symptoms. Sertraline improvement occurred swiftly in the first month of treatment. Gradual placebo improvement was similar to sertraline in the third month. Subjects with higher postmenstrual symptoms before treatment remained more symptomatic regardless of the dosing regimen. A history of major depression was not associated with treatment response. More sertraline-treated subjects reported improved functioning in the domains of family relationships, social activities, and sexual activity. CONCLUSIONS: Premenstrual dosing does not differ from continuous dosing with sertraline in premenstrual syndrome treatment. Higher levels of postmenstrual symptoms limit treatment response and are important to define in treatment of premenstrual syndrome.     

A comparison of black and white women with binge eating disorder

OBJECTIVE: Binge eating disorder was introduced in DSM-IV as a psychiatric disorder needing further study. This community-based study describes the relationship between race and clinical functioning in black and white women with and without binge eating disorder. METHOD: A group of 150 women with binge eating disorder (52 black, 98 white) and a race-matched group of 150 healthy comparison subjects were recruited from the community. Eating and psychiatric symptoms were assessed through interviews and self-report. RESULTS: Black and white women with binge eating disorder differed significantly on numerous eating disorder features, including binge frequency, restraint, history of other eating disorders, treatment-seeking behavior, and concerns with eating, weight, and shape. Black and white healthy comparison subjects differed significantly in obesity rates. CONCLUSIONS: For both black and white women, binge eating disorder was associated with significant impairment in clinical functioning. Yet, racial differences in clinical presentation underscore the importance of considering race in psychopathology research.     

Timing and severity of symptoms associated with the menstrual cycle in a community-based sample in the Midwestern United States

This study describes the experience of menstruation among normal women, establishing a baseline for comparison with women reporting symptoms of a menstrual disorder. A community-based sample of 900 women kept a daily log of 50 physical, social, and psychological symptoms for a period of time that included two menstrual cycles. Twenty-five items were derived from the DSM-IV criteria for premenstrual dysphoric disorder (PMDD) and 13 from the premenstrual syndrome (PMS) literature. An additional 12 items were positively worded versions of some of the PMDD items. Women were told that the study was about women's health, with no specific reference to menstruation. Time sequence charts revealed that all symptoms peaked on the first day of menses, with severity levels more than 2 S.D. above the mean for each individual symptom. Women were more likely to endorse distress when symptoms were positively worded than when they were negatively worded. This study shows the importance of reducing bias in self-reports of menstrual symptoms, and illustrates the lag between hormonal changes in the luteal phase and the peak of symptom severity at onset of menses. Further research is needed to determine the nature and extent to which women with a presumed disorder vary from this baseline pattern.     

The premenstrual syndrome: amelioration of symptoms after hysterectomy.

What is the role of the uterus in the aetiology of the premenstrual syndrome (PMS)? Twelve women kept a daily symptom record before and after hysterectomy. Psychological and physical symptom patterns were analysed by Fourier analysis and the response to hysterectomy by maximum likelihood ANOVA. Hysterectomy was associated with a 66% reduction in mean premenstrual tension (PMT) severity for both psychological and physical symptoms (p less than 0.005). The milder symptoms appeared unrelated to post-operative changes in health or ovarian function. Seven women experienced mood-related PMT in every pre-hysterectomy cycle; the persistence of unfailing mood-related PMT in one of these women after hysterectomy suggests that her symptoms were hormonally controlled and the loss of regular PMT in the other six women suggests that a uterine factor, or psychological factors associated with the menstrual cycle were implicated. We conclude that a uterus is not essential for the expression of PMT, but that its removal often results in the amelioration of symptoms.