Characteristics of premenstrual syndrome

To characterize the symptoms associated with premenstrual syndrome (PMS), the menstrual symptom calendars of 100 women diagnosed with PMS were factor-analyzed. Scores on 18 symptoms were recorded daily for one menstrual cycle prior to the women's first clinic visits. Two factors were found to predominate throughout the cycle: The first included emotional and behavioral symptoms and the second included physical and cognitive symptoms. The two factors were constant throughout all the phases of the menstrual cycle. Emotional symptoms clustered together throughout the menstrual cycle and were the dominant symptoms on factor I. However, they loaded (correlation of the variable with the factor) on factors I and II during the postmenstrual phase. Behavioral symptoms loaded on factor I throughout the menstrual cycle; however, they were prevalent predominantly in the later half of the intermenstrual and the premenstrual phases. Physical symptoms loaded predominantly on factor II and were less prevalent than the emotional symptoms. The cognitive symptoms loaded on factor II during the premenstrual phase. These findings are relevant for defining PMS criteria for women who seek treatment.     

Evaluating premenstrual symptoms in medical practice

Essential diagnostic criteria for evaluating premenstrual syndrome (PMS) symptoms are marked change in intensity of symptoms measured on postmenstrual and premenstrual days and documentation of changes for at least two cycles. Four symptom evaluation methods in a PMS treatment program are compared and discussed: physician interview, menstrual symptom questionnaire, daily symptom ratings, and the Hopkins symptom checklist. Data from 241 patients who met the criteria for marked change in symptoms show that premenstrual symptom levels are severe, a subgroup has moderate symptoms continuing in the follicular phase, and that emotional symptoms are predominant. Diagnostic evaluation needs to distinguish menstrually related disorder from undiagnosed physical or psychiatric illness. Further research is needed to identify a classification system of multiple subtypes of menstrual disorders.     

An overview of premenstrual syndrome

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

Relationships among premenstrual symptoms and menstrual cycle characteristics

The severity of premenstrual syndrome symptoms has been described by different investigators as varying directly or inversely with the severity of dysmenorrhea. In a large population of women undergoing comprehensive psychological and medical evaluation for premenstrual syndrome complaints, the authors examined the relationship between menstrual cycle parameters and premenstrual syndrome. The severity of premenstrual symptoms varied directly with the severity of dysmenorrhea and premenstrual spotting but was not associated with any other menstrual cycle parameter. Multivariate analysis revealed that social and psychological variables are more strongly associated with variations in premenstrual symptoms than are any menstrual cycle parameters.     

Psychological aspects of premenstrual syndrome

Premenstrual syndrome (PMS) is a group of psychological and physical symptoms which regularly occur during the luteal phase of the menstrual cycle and resolve by the end of menstruation. The severe and predominantly psychological form of PMS is called premenstrual dysphoric disorder (PMDD). The exact aetiology of PMS is not known. PMS results from ovulation and appears to be caused by the progesterone produced following ovulation in women who have enhanced sensitivity to this progesterone. The increased sensitivity may be due to neurotransmitter (mainly serotonin) dysfunction. The key diagnostic feature is that the symptoms must be absent in the time between the end of menstruation and ovulation. Prospective symptom rating charts are used for this purpose. Treatment is achieved by suppression of ovulation or reducing progesterone sensitivity with selective serotonin re-uptake inhibitors. In this chapter, the authors describe the aetiology, symptoms, diagnosis and evidence-based management of premenstrual syndrome.     

Premenstrual dysphoric disorder in an adolescent female

BACKGROUND: A severe cyclic constellation of affective symptoms during the luteal phase of the menstrual cycle is termed premenstrual dysphoric disorder (PMDD). CASE: A 17-yr-old female was referred for evaluation of behavior changes with her menses. Parents noted behavior changes, two to three days before the onset and lasting till the end of her menses. Menarche was at 13 years. Periods were regular, with normal flow and duration and no dysmenorrhea. Psychosocial history was unremarkable. There was no history of sexual activity or abuse. Her physical exam was unremarkable. With the working diagnosis of premenstrual dysphoric syndrome she was asked to keep track of her menses on a menstrual calendar and her symptoms with a daily diary. She was treated with Fluoxetine 20 mg/day during the luteal phase of her menstrual cycle with complete resolution of her symptoms. COMMENTS: In PMDD the mood disturbance occurs during the late luteal phase of the menstrual cycle (approximately 1 week before the onset of menstrual bleeding), remits after the onset of menses, and can be established by a prospective daily symptom log for two consecutive cycles. The symptoms are more severe than that of premenstrual syndrome, are associated with significant functional impairment and are cyclical. Symptoms were documented prospectively as starting a few days before her menstrual bleeding and remitting at the end of it. She responded to episodic use of a selective serotonin reuptake inhibitor. This disorder needs to be better recognized, because it can be easily treated.     

Assessment of menstrual cycle symptoms by trend analysis

The physical, psychological, and behavioral changes associated with the menstrual cycle can be assessed statistically by time series analysis. One such method, Trigg's technique for trends, has been adapted for the study of prospective symptom ratings used in evaluation of the premenstrual syndrome. Such analysis provides both qualitative and quantitative information concerning menstrual cycle symptomatology. The pattern of symptoms, as denoted by Trigg's tracking signal, can be identified. The premenstrual syndrome can be defined mathematically in terms of significant symptom trends at specified times in the menstrual cycle. The overall severity of symptoms at any point in the cycle can be gauged by the exponentially smoothed average symptom ratings. A derived statistic, the menstrual cycle ratio, is proposed as a global index of menstrual cycle morbidity which can be easily standardized to allow for comparability of research reports.     

Trend analysis of the symptoms of 150 women with a history of the premenstrual syndrome

The daily symptom records of 150 untreated women with a convincing history of the premenstrual syndrome were investigated qualitatively and quantitatively by means of time series analysis in the form of Trigg's technique for trends. Symptoms were monitored with use of a modified menstrual distress questionnaire. Analysis showed that, depending on the symptom cluster, 60.7% to 85.3% of the women showed symptom trends consistent with the syndrome, 14.0% to 35.3% had trends not typical of the syndrome, and in 0% to 5.3% of records significant trends were absent. Since over 80% of the women were found to have premenstrual syndrome trends for three or more of the six symptom clusters studied, including 32% who showed this trend pattern for all symptoms, a retrospective history of premenstrual syndrome is likely to be confirmed on prospective assessment for at least some symptoms. Quantitatively women who fulfilled the diagnostic criteria for premenstrual syndrome differed from those who did not by exhibiting significantly greater exacerbation of symptoms premenstrually and lesser morbidity postmenstrually. While water retention, negative affect, and pain were the three symptom clusters associated with the most severe ratings, the majority of women suffered from a mixture of physical, psychological, and behavioral complaints, and it was not possible to subdivide the study group by the type of symptoms.     

Prospectively reported symptom change across the menstrual cycle in users and non-users of oral contraceptives

The aim of this research was to examine the pattern and incidence of premenstrual change in a reliable manner by addressing key methodological issues. One hundred and eighty-one women from the general population (mean age 30 years) completed a modified version of the Moos Menstrual Distress Questionnaire daily for 70 days. All symptom sub-scales fluctuated significantly across the menstrual cycle. Symptoms were at their lowest during the follicular phase and increased premenstrually. Somatic symptoms peaked menstrually and fluid retention peaked premenstrually. In general, however, symptom severity changed little from the premenstrual to the menstrual phase. A very high incidence of premenstrual change was noted, with over 40% of women demonstrating a 30% premenstrual increase in each symptom sub-scale. Close to 50% of women experienced increases in negative affect and over 70% experienced increases in fluid retention. Oral contraceptive (OC) use did not alter the incidence or severity of premenstrual change. Overall differences in symptom severity, however, were noted, with monophasic OC users reporting higher levels of fluid retention and somatic symptoms than the triphasic OC group. The results of this research suggest that women respond to the occurrence of normal neuroendocrine events that are not dependent on the sequelae to ovulation.     

Efficacy of Yasmin in premenstrual symptoms

Objective To evaluate the effect of oral contraception formulation with drospirenone (Yasmin) on premenstrual symptoms. Materials and methods An open-label non-comparative clinical trial was conducted. One hundred women who desired oral contraception for at least 6 months were recruited. The subjects received a blister pack which contained 21 tablets of 3 mg drospirenone/30 μg ethinyl estradiol for the first four cycles (1 cycle = 28 days). Cycle-5 and -6 blister packs were dispensed during the next visit in cycle 4. The subjects were evaluated on menstruation-related symptoms by using the women’s health assessment questionnaire (WHAQ) at baseline and at each follow-up visit for three phases of their menstrual cycle. The measured outcome was the mean score changes from baseline to cycle 6 of WHAQ categories. Results Of the total 100 subjects, 92 (92%) completed the study. At the premenstrual phase, a significant decrease was seen from baseline to cycle 6 in the mean WHAQ scores for impaired concentration, water retention, negative effect, increased appetite, feeling of well-being and undesirable hair change. At the menstrual phase, a significant decrease was seen from baseline to cycle 6 regarding the mean WHAQ scores for impaired concentration, negative effect, feeling of well-being, and undesirable hair change. At the postmenstrual phase, significant changes were consistently observed regarding the feeling of well-being and undesirable hair change. Conclusions Oral contraception formulation with drospirenone (Yasmin) has an ameliorating effect on premenstrual symptoms. This oral contraception may have a role in women who are looking forward to use contraception and also suffer from premenstrual symptoms.     

Prevalence of menstrual cycle symptom cyclicity and premenstrual dysphoric disorder in a random sample of women using and not using oral contraceptives

BACKGROUND: The prevalence of symptom cyclicity and premenstrual dysphoric disorder in randomly recruited samples of women has not been ascertained. We assessed this prospectively in 83 Icelandic women, aged 20-40 years, using and not using oral contraceptives (OCs). METHODS: A check list of 57 symptoms, divided into 7 symptom groups, was used to assess experiences. All symptoms and summarized symptom scores within symptom groups were tested for significant change between the follicular and the luteal phase of each menstrual cycle. When a symptom or a summarized symptom score was higher during the luteal phase compared to the follicular phase the cyclicity is labelled 'expected' cyclicity and the opposite 'unexpected' cyclicity. RESULTS: The women charted from 1-7 menstrual cycles each, with 66 of them charting 3-4 cycles. Cyclicity was never displayed by 9.6% of participants; 80.7% displayed expected cyclicity and 72.3% unexpected cyclicity at least once. Cyclicity in somatic symptoms was most often demonstrated by participants. Expected and unexpected cyclicity in summary symptom scores in well-being and in psychoemotional symptoms was very similar among participants. There was not much difference in cyclicity between non OC users and OC users. Fifty-one percent of the participants were self-defined with premenstrual syndrome with 2%-6% of them meeting the criteria of premenstrual dysphoric disorder. CONCLUSIONS: The normalcy of cyclicity found in this study might explain the high prevalence of premenstrual syndrome in many recall surveys. The importance of prospective daily ratings for establishing symptom cyclicity in women cannot be over emphasized.     

Negative mood changes during hormone replacement therapy: a comparison between two progestogens

OBJECTIVE: The aim of this study was to compare side effects of medroxyprogesterone acetate and norethindrone acetate during postmenopausal hormone replacement therapy in women with and without a history of premenstrual syndrome.Study Design: Fifty-one postmenopausal women were randomly selected in a double-blind crossover study. The women received 2 mg of estradiol continuously during five 28-day cycles and 10 mg of medroxyprogesterone or 1 mg of norethindrone sequentially for 12 days of each cycle. Daily symptom rating scales were kept. RESULTS: The women showed cyclic changes, with negative mood and physical symptoms culminating during the late progestogen phase and positive mood during the estrogen-only phase. Symptoms declined with time but remained after 5 months. Women with a history of premenstrual syndrome responded strongly to both progestogens. Medroxyprogesterone acetate induced less negative and more positive mood symptoms than norethindrone in women with no history of premenstrual syndrome. In both groups medroxyprogesterone caused more physical symptoms than norethindrone. CONCLUSION: The addition of medroxyprogesterone to estrogen is preferable to norethindrone with respect to mood symptoms in women without a history of premenstrual syndrome.     

The effect of hysterectomy and bilateral oophorectomy in women with severe premenstrual syndrome

The etiology of premenstrual syndrome is unknown, although this syndrome is linked to the menstrual cycle. Fourteen women with severe, debilitating premenstrual syndrome volunteered for a study of therapy by hysterectomy, oophorectomy, and continuous estrogen replacement. All had completed their families and had failed to benefit from previous medical treatment. The diagnosis and severity of premenstrual syndrome were assessed by means of prospective charting and psychological evaluation. All patients had clearly cyclic symptoms and psychological scores consistent with a major disruption of their lives before surgery. Six months after surgery, premenstrual syndrome symptom charting revealed complete disappearance of a cyclic pattern with scores equivalent to those of a normal population. Psychological measures 6 months after operation showed dramatic improvement in mood, general affect, well-being, life satisfaction, and overall quality of life. Surgical therapy, involving oophorectomy, hysterectomy, and continuous estrogen replacement, is effective in relieving the symptoms of premenstrual syndrome and is indicated for a small, selected group of women.     

Severity of premenstrual symptoms in a health maintenance organization population

OBJECTIVE: To describe severity of emotional and physical symptoms in a large diverse sample; to examine demographic, health status, and behavioral correlates of symptom severity; and to describe use of medications and alternative remedies for premenstrual symptoms. METHODS: A total of 1194 women, ages 21-45, selected from members of a large northern California health maintenance organization, completed daily ratings of symptom severity for two menstrual cycles. An empirically derived algorithm defined symptom severity groups as minimal (n = 186), moderate (n = 801), severe (n = 151), or premenstrual dysphoric disorder (n = 56). Symptom severity as a continuous variable was defined by the two-cycle mean symptom ratings in the luteal phase. Demographic, health status, and behavioral factors and use of treatments for premenstrual symptoms were assessed by self-report. RESULTS: Luteal phase symptom-specific ratings were generally significantly greater in the premenstrual dysphoric disorder group than in the other groups (P <.001). Symptom severity score increased with each comorbidity and decreased with each year of age. Symptom severity was also inversely associated with oral contraceptive use (emotional symptoms) and better perceived health (physical symptoms). Hispanics reported greater severity of symptoms, and Asians less, relative to whites. Use of herbal and nutritional supplements for premenstrual symptoms steadily increased from 10.8% in the minimal group to 30.4% in the premenstrual dysphoric disorder group (P <.01). CONCLUSION: The degree of premenstrual symptom severity varies in the population, is relatively constant within each woman over two consecutive cycles, particularly for emotional symptoms, and is influenced by age, race/ethnicity, and health status.     

Changes in premenstrual symptoms in women starting or discontinuing use of oral contraceptives

Abstract

It is not clear whether oral contraceptive (OC) treatment affects premenstrual symptoms in women. The aim of the present study was to evaluate changes in premenstrual symptoms (PMS) in women starting to use or discontinuing the use of OCs. Twenty-four healthy women with no previous diagnosis of premenstrual dysphoric disorder were included in this study with a prospective crossover design. Nineteen women completed daily ratings of somatic and mood symptoms during two hormonally different cycles, during a normal menstrual cycle and while using OCs. The menstrual cycle phases were hormonally verified and the low-dose, monophasic OCs were used in a 21/7 regimen. The onset of OC use significantly decreased premenstrual somatic symptoms, but it did not affect mood symptoms. In the women who discontinued OC use, no significant changes in neither somatic nor mood symptoms appeared in the premenstrual phase.     

Psychological aspects of premenstrual symptoms

This article reviews the literature linking psychological processes with the presence and severity of premenstrual symptoms, identifying the areas of agreement and disagreement. An exploratory study which measured menstrual distress, state and trait anxiety, and depressive mood in women suffering from the premenstrual syndrome (PMS group, n = 15) revealed that their symptoms were restricted to the second half of the menstrual cycle. This cycle-related pattern of responses was not found in women who did not fulfil the criteria for inclusion in the PMS group (MD group, n = 5). Furthermore, the trait-anxiety scores of the MD group were clearly higher than those of the PMS and control groups. The results suggest that women with premenstrual symptoms do not form a homogeneous group, and that further studies should incorporate a strict definition of the premenstrual syndrome in order to distinguish this syndrome from conditions in which the symptoms are not limited to the second half of the menstrual cycle.     

Inhibition of ovulation with oral progestins--effectiveness in premenstrual syndrome

Forty-eight women with premenstrual problems were recruited for therapy with either medroxyprogesterone (MPA) or norethisterone (NET), both compared with placebo, in a double-blind cross-over study. Thirty-five (73%) completed the study. At an oral dose of 15 mg daily for 21 days each cycle, both MPA and NET suppressed ovulation, although reduction of urinary total oestrogen excretion was significantly greater with NET. Breakthrough bleeding occurred in 74% of the cycles treated with MPA but only in 22% of those with NET. Symptoms were monitored daily by visual analogue scales. Both progestins significantly reduced breast discomfort, compared with placebo. While MPA significantly improved individual psychological symptom scores by the second active treatment cycle and pooled psychological symptom scores in both active cycles, NET was no more effective than the placebo. Similar numbers from both groups withdrew because of adverse effects. Among the women treated with MPA, the response to active and placebo therapy was related to the pretreatment psychological symptom profile. The results suggest that the beneficial effect of therapy with MPA in women with premenstrual problems was a consequence of disruption of menstrual cyclicity rather than a result of ovulation suppression.     

Modification of symptoms of the premenstrual syndrome during ovarian suppression with goserelin (Zoladex) depot – potential for research and clinical investigation

Eleven women with premenstrual problems were treated in an open study for up to 6 months with goserelin (Zoladex) 3.6mg by monthly subcutaneous depot. Twice weekly assay of urinary estronc glucuronide and pregnanediol demonstrated absence of ovulation and suppression of estrogen excretion to within or below the early follicular phase range. Physical and psychological symptoms, measured by daily self assessment, were significantly improved during therapy. However, some subjects continued to record intermittent episodes of swelling and adverse mood in the absence of changes in ovarian activity. Three women reported marked but transient worsening of anxiety and/or depression soon after the onset of ovarian suppression, one later withdrawing from the study. Return of ovulatory menstruation was preceded by recurrence of symptoms at pretreatment levels, although breast discomfort which was consistently improved during therapy showed a more sustained improvement. Although conclusions are limited by the lack of a placebo control, the results support a link between the hormonal events of the menstrual cycle and mood and physical symptoms. However, they demonstrate that the relationship is not clear-cut.     

Menstrual and premenstrual issues in female military cadets: a unique population with significant concerns

CONTEXT: There is a strong need to determine what effect, if any, menstruation has on the performance of duty as a Cadet at the United States Military Academy (USMA) at West Point, and to determine what impact, if any, the USMA environment has on the menstrual cycle. STUDY OBJECTIVES: To study menstrual function and premenstrual symptoms in a structured, rigorous military environment; determine the perceived impact of menstrual and premenstrual symptoms on academic, physical, and military activities; and evaluate the difficulties inherent to menstruation in a military setting. DESIGN, SETTING, AND PARTICIPANTS: A survey about high school menstrual and premenstrual function, and the Premenstrual Assessment Form (PAF), were completed by all 158 freshman female Cadets in July 1991. In May 1992, 83 participants completed a survey assessing menstrual and premenstrual symptoms, including interference with activities during the year. MAIN OUTCOME MEASURES: Menstrual regularity, premenstrual symptoms, interference with activities. RESULTS: Participants reported menstrual patterns and premenstrual symptoms in high school similar to other females their age. Most (62%) predicted a change in menstruation at the USMA, half were worried that physical symptoms would interfere with activities, one-fourth were worried that premenstrual symptoms would interfere with activities, and one-fourth were worried that obtaining and changing menstrual materials would interfere with activities. Almost all respondents (91%) reported changes in menstruation during the year, most commonly less regular, less frequent, shorter, lighter, and less crampy periods. Menstrual and premenstrual symptoms interfered with physical activities (66.2%, 61.4% respectively) more so than academic (50.6%, 45.7% respectively) or military activities (39.8%, 47.0% respectively). Female Cadets described significant difficulties with changing (62.6%), obtaining (51.8%), and disposing of (38.5%) menstrual materials. CONCLUSIONS: The data demonstrate major changes in menstrual function in over 90% of female Cadets; a significant perceived impact of menstrual and premenstrual symptoms on academic, physical, and military activities; and difficulties in obtaining, changing, and disposing of menstrual materials in a military setting. These findings have implications for females in the military, as well as for young women generally.     

A new monophasic oral contraceptive containing drospirenone. Effect on premenstrual symptoms

OBJECTIVE: To determine whether a new monophasic oral contraceptive containing drospirenone/ethinyl estradiol reduces premenstrual symptoms. STUDY DESIGN: In an open-label study measuring intrasubject changes in premenstrual symptoms and comparing effects between women who were new users of oral contraceptives and those who switched from previous contraceptives, ethinyl estradiol (30 micrograms) and drospirenone (3 mg) were administered for 13 menstrual cycles to 326 healthy women aged 18-35 years. Subjects completed the 23-item Women's Health Assessment Questionnaire at baseline and at the end of the sixth cycle. RESULTS: At the end of cycle 6, premenstrual and menstrual symptom scores on the negative affect and water retention scales were reduced significantly relative to baseline, as was increased appetite during the premenstrual and menstrual phases. Similar improvements were seen among new users of hormonal contraceptives and those who switched from previous contraceptives. Impaired concentration scale scores were not significantly reduced from baseline, and assessments of undesired hair changes and feelings of well-being did not change appreciably. CONCLUSION: An oral contraceptive containing drospirenone/ethinyl estradiol may reduce the premenstrual symptoms of negative affect, water retention and increased appetite.