The multifactorial aetiology and management of premenstrual dysphoric disorder with leuprorelin acetate.

Up to 18% of women of reproductive age may experience symptoms during the luteal phase of the menstrual cycle known as premenstrual syndrome (PMS) or its more severe form, premenstrual dysphoric disorder (PMDD). A plethora of symptoms have been described, but both are commonly associated with other mood-related disorders such as major depression causing significant life impairment. Originally known as late luteal phase dysphoric disorder in the DSM-III-R (American Psychiatric Association 1987), the syndrome was renamed PMDD in the DSM-IV (American Psychiatric Association 1994). Between 3% and 8% of women meet the diagnostic criteria for PMDD. Currently, there is no consensus on its aetiology although it is thought to be multifactorial. Biological, genetic, psychological, environmental and social factors have all been suggested. However, an altered sensitivity to the normal hormonal fluctuations that influence functioning of the central nervous system is thought most likely. PMDD is identified in the DSM-5 by the presence of at least five symptoms accompanied by significant psychosocial or functional impairment. During evaluation, it is recommended that clinicians confirm symptoms by prospective patient mood charting for at least two menstrual cycles. Management options include psychotropic agents, ovulation suppression and dietary modification. Selective serotonin reuptake inhibitors (SSRIs) are considered primary therapy for psychological symptoms. Ovulation suppression is another option with the combined oral contraceptive pill (COCP) or GnRH (gonadotropin-releasing hormone) agonists. Rarely symptoms warrant a bilateral oophorectomy and a 6-month trial of GnRH agonists prior to surgery may be prudent to determine its potential efficacy. The authors present the case of a multiparous woman in her mid-30s experiencing severe symptoms during the luteal phase of her menstrual cycle. A trial of the contraceptive pill and SSRIs were unsuccessful. Treatment with leuprorelin acetate (Prostap) improved her symptoms. She therefore elected to undergo a bilateral oophorectomy with resolution of her symptoms. She started hormone replacement therapy (HRT). This case demonstrates the multifactorial aetiology of PMDD and the challenges in its management. Women with PMDD suffer functional impairments comparable with other depressive disorders and yet PMDD and its impact remain under-recognised. As the psychological nature and consequences of PMDD often seem indistinguishable from symptoms of other mental health difficulties, this condition presents distinct diagnostic challenges for healthcare professionals. It is crucial to establish the correct diagnosis using clearly defined criteria because if it is left untreated, it can cause considerable impairment to the woman's quality of life.

Associated factors with Premenstrual syndrome and Premenstrual dysphoric disorder among female medical students: A cross-sectional study.

AIM: The study aimed to determine potential risk factors associated with Premenstrual Syndrome and Premenstrual Dysphoric Disorder. METHODS: Three hundred two female student participants who were 18-45 years old completed a questionnaire including demographic characteristics, lifestyle factors, and a Vietnamese Premenstrual Syndrome Screening Tool. We then followed up participants during at least two menstrual cycles using the Daily Record of Severity of Problems. The Premenstrual Syndrome and Premenstrual Dysphoric Disorder diagnosis was established using The Carolina Premenstrual Assessment Scoring System, based on the American College of Obstetrics and Gynecology and Diagnostic and Statistical Manual of Mental Disorders. RESULTS: According to the Carolina Premenstrual Assessment Scoring System, 35 out of 302 students (11.6%; 95%CI: 8.2-15.7%) met the diagnosis of PMS (31 students) or PMDD (4 students). We found that age at menarche (PR = 0.77, 95%CI: 0.63-0.96), having negative Rh blood type (PR = 4.43, 95%CI: 1.95 to 10.08), being moderately depressed or higher (PR = 2.81, 95%CI: 1.24 to 6.36), and consuming caffeine more than three times per week were statistically associated with having Premenstrual Syndrome or Premenstrual Dysphoric Disorder after adjusting for other variables. CONCLUSION: The prominent risk factors for Premenstrual Syndrome and Premenstrual Dysphoric Disorder were negative Rhesus blood type, menarche age, caffeine consumption, and self-reported depression.

¿Vulnerabilidad cognitiva a la depresión o sobreestimación de los síntomas disfóricos premenstruales? / Cognitive vulnerability to depression or overestimation of premenstrual dysphoric symptoms?

Es difícil estimar la verdadera presencia del trastorno disfórico premenstrual (TDPM). Las expectativas de las mujeres influyen en los síntomas del TDPM, lo que podría aumentar su vulnerabilidad a la depresión. Este estudio pretendió estimar la presencia de TDPM en un grupo de mujeres comparando su autodiagnóstico con la evaluación clínica; diferenciar los síntomas y su intensidad entre TDPM y su forma subsindrómica, así como determinar sus consecuencias sociolaborales y relacionales. Se analizan las diferencias entre TDPM y trastorno depresivo mayor (TDM) identificando una posible vulnerabilidad cognitiva a la depresión. En un diseño ex-post facto, participaron 105 mujeres, 85 de la población general (Medad= 23,60; DT 3,05) y 20 mujeres con TDM, (Medad= 25,15; DT 3,51). Para el autodiagnóstico, completaron varios autoinformes y los indicadores de criterios TDPM A, B, C (APA) y D (por autor). El diagnóstico clínico se realizó mediante entrevista semiestructurada siguiendo los criterios del DSM-5. El TDPM se sobreestimó cuando fue autoinformado (51,76%) contrastando con la evaluación clínica (5,88%). La vulnerabilidad cognitiva a la depresión para el TDPM no fue apoyada. (AU)

True premenstrual dysphoric disorder (PMDD) is hard to diagnose. It has been suggested that women’s expectations influence the symptoms of this disorder, which could increase their vulnerability to depression. This study aimed to estimate PMDD in a group of women by comparing their self-diagnosis with clinical evaluation; differentiate between PMDD symptoms and their intensity and its subthreshold form, determining its social-employment and relational consequences, finding differences in symptoms and vulnerability to depression; and identifying possible cognitive vulnerability to depression in PMDD. 105 women participated, 85 from the general population and 20 women with Major Depressive Disorder were selected. For the self-diagnosis, they filled out several self-reports and PMDD Criteria Indicators A, B, C (APA) and D (by author). The clinical diagnosis was made using a semi-structured interview following DSM-5 criteria. PMDD was overestimated when it was self-reported (51,76%) compared to clinical evaluation (5,88%). Therefore, retrospective and self-reported evaluation could bias what they remember and overestimate the indicators of the disorder and their severity. Cognitive vulnerability to depression for PMDD was not supported. (AU)

Patient Experiences of Health Care Providers in Premenstrual Dysphoric Disorder: Examining the Role of Provider Specialty.

Background: Premenstrual dysphoric disorder (PMDD) is a severe mood disorder that affects ∼5% of menstruating individuals. Although symptoms are limited to the luteal phase of the menstrual cycle, PMDD causes significant distress and impairment across a range of activities. PMDD is under-recognized by health care providers, can be difficult to diagnose, and lies at the intersection of gynecology and psychiatry. Thus, many patients are misdiagnosed, or encounter challenges in seeking care. The aim of this study was to examine patients' experiences with different health care specialties when seeking care for PMDD symptoms. Methods: We examined data from the 2018 Global Survey of Premenstrual Disorders conducted by the International Association for Premenstrual Disorders (IAPMD). Patients rated their health care providers (general practitioners, psychiatrists, gynecologists, psychotherapists) in three key areas related to treatment of premenstrual mood complaints: interpersonal factors, awareness and knowledge of PMDD, and whether the patient was asked to track symptoms daily. Intraclass correlations examined between- and within-person variance. Multilevel regression models predicted ratings on each provider competency item, with ratings nested within individuals to examine the within-patient effect of provider type on outcomes. Results: The sample included 2,512 patients who reported seeking care for PMDD symptoms. Regarding interpersonal factors, psychotherapists were generally rated the highest. On awareness and knowledge of PMDD, gynecologists and psychiatrists were generally rated the highest. Gynecologists were more likely than other providers to ask patients to track symptoms daily. Conclusions: These findings suggest that different providers have different strengths in assessing and treating PMDD. Further, graduate and medical training programs may benefit from increased curricular development regarding evidence-based evaluation and treatment of PMDD.

The impact of competitive sports on menstrual cycle and menstrual disorders, including premenstrual syndrome, premenstrual dysphoric disorder and hormonal imbalances.

OBJECTIVES: With the considerable increase of female participation in youth sports, it has become crucial for medical professionals, coaches and parents to improve their competitiveness by understanding the conditions for which these females are at elevated risk and mitigating possible health consequences. The aim of this study was to evaluate the effect competitive sports have on the disorders of the menstrual cycle, to investigate the frequency of PMS (premenstrual syndrome)/PMDD (premenstrual dysphoric order) in professional female athletes and to identify risk factors predisposing for PMS and PMDD. Additionally, the levels of selected hormones such as serum estradiol, FSH, LH and prolactin were investigated to identify any hormonal perturbances that might have influence or be the risk factors for menstrual dysfunctions. MATERIAL AND METHODS: The study group consisted of 75 professional athletes (girls and young women at the age of 16-22) who lived on the territory of Silesia. The control group consisted of 50 girls and young women at the same age, who did not practice any sport. The research tools included daily diary of PMS symptoms created in line with The American College of Obstetricians and Gynecologists (ACOG) recommendations and ICD-10 diagnostic criteria, daily diary of PMDD symptoms created according to DSM-V diagnostic criteria of the American Psychiatric Association (APA) and premenstrual symptoms screening tool (PSST). RESULTS: The analysis of menstrual cycle disorders showed statistical significance for heavy menstrual bleeding (p = 0.01) and longer breaks between menstrual bleeds (p = 0.01). PMDD was diagnosed in 8% and PMS in more than 42% of respondents. The incidence of PMDD was not at significant variance between the groups (9.33% in contrast to 6.0%), while incidence of PMS was statistically different in both groups (p = 0.045) (49.33% vs 32.0%). A significant correlation between PMS, average age (p = 0.00001) and menarche age (p = 0.03) in young active athletes has been shown. The risk of PMS increased with age (by 1.71 with each year) (p = 0.0007). CONCLUSIONS: A number of other risk factors predisposing for PMS and PMDD has also been identified. The findings of these researches will enable the athletic care network to provide better care for young female athletes.

Association between Generalized Anxiety Disorder and Premenstrual Dysphoric Disorder in a Diagnostic Interviewing Study.

BACKGROUND: Premenstrual dysphoric disorder (PMDD) demonstrates predictable, cyclic, affective and somatic symptoms that are aggravated in the late luteal phase and are resolved by menstruation. Generalized anxiety disorder (GAD) is characterized by excessive and persistant worry. The present study aims to evaluate the association between PMDD and GAD. The fluctuations of behavior inhibition, anxiety, depression, and irritability were also evaluated during the menstrual cycle among women with PMDD and healthy women. Methods: There were 100 women diagnosed with PMDD based on a psychiatric interview and on a prospective evaluation in three menstrual cycles. A total of 96 healthy women were recruited as controls. Each individual's GAD diagnosis, behavior inhibition, behavior activation, depression, anxiety, and irritability were assessed in both luteal and follicular phases. Results: The odds ratio of women with GAD having PMDD was 7.65 (95% CI: 1.69-34.63) in relation to those without it. This association was partially mediated by behavior inhibition and irritability and was completely mediated by depression. Women with PMDD and GAD had higher anxiety during the luteal phase and higher PMDD severity, depression, and irritability than those without GAD in the follicular phase. There is no difference in anxiety, depression, or irritability between the luteal and follicular phases among women with PMDD and GAD. Conclusions: Women with GAD were more likely to have PMDD. Anxiety, depression, and irritability symptoms in women with PMDD and GAD were not relieved in the follicular phase. Thus, GAD should be assessed for women with PMDD. Their anxiety, depression, and irritability should be intervened not only in the luteal phase, but also in the follicular phase. Depression, irritability and behavior inhibition mediated the association between PMDD and GAD. Intervening with these mediators to attenuate GAD and PMDD comorbidity should be researched in the future.

Supporting the needs of college students with autism spectrum disorder.

OBJECTIVE: Young adults with autism spectrum disorder (ASD) are enrolling in colleges at increasing rates. This case highlights the need for college mental health clinicians to be aware of features of ASD in emerging adults. Participants: A case of a young woman with dysphoria and anxiety who also met ASD criteria during a diagnostic evaluation. Methods: The author describes diagnostic criteria for ASD, common psychiatric co-morbidities, and commonly used campus services. Results: The student in this case was diagnosed with ASD during the course of treatment for dysphoria and anxiety. Knowledge of this diagnosis led to better self-understanding and discovery of new supports. Conclusions: College mental health clinicians will increasingly encounter students with ASD whose social and communication challenges impact their success in post-secondary educational environments. Clinicians should be knowledgeable of ASD features, common mental health challenges, and how best to support students.

Lifestyle Factors Associated with Premenstrual Syndrome: A Cross-sectional Study of Japanese High School Students.

STUDY OBJECTIVE: To investigate the relationships between premenstrual syndrome (PMS) and lifestyle, sleep, and dietary habits among Japanese high school students. DESIGN: Cross-sectional study. SETTING: Two public high schools in Sendai, the largest city in northeastern Japan. PARTICIPANTS: A school-based survey was conducted among 1818 female Japanese high school students in 2015, and 1022 students with regular menstrual cycles (25-38 days) completed the questionnaire. INTERVENTIONS AND MAIN OUTCOME MEASURES: Relationships between PMS and lifestyle, sleep, and dietary habits. RESULTS: The rates of moderate to severe PMS and premenstrual dysphoric disorder were 9.7% (99/1022) and 2.2% (22/1022), respectively. A total of 121 students (11.9%) were classified as having PMS-the PMS(+) group. Significant differences were observed between the PMS(+) group and those without PMS-the PMS(-) group-in age at menarche (P = .022), menstrual pain (P < .001), hypnagogic disorder (P < .001), long Internet use time (P < .001), eating breakfast (P = .018), chewing well (P = .037), and belonging to a sports club (P = .046). Multivariate analysis revealed that the risk factors for PMS were menstrual pain (odds ratio [OR], 4.74; 95% confidence interval [CI]: 2.83-7.95), hypnagogic disorder (OR, 2.22; 95% CI, 1.47-3.35), stress fracture (OR, 2.19; 95% CI, 1.21-3.98), and Internet use time (OR, 1.003; 95% CI, 1.001-1.005). Belonging to a sports club decreased the risk of PMS (OR, 0.57; 95% CI, 0.35-0.91). CONCLUSION: Sleep, dietary habits, belonging to a sports club, and screen time affect PMS among high school students.

Tobacco consumption and premenstrual syndrome: A case-control study.

OBJECTIVE: To assess whether tobacco smoking is associated with Premenstrual Syndrome (PMS) and its most severe form, Premenstrual Dysphoric Disorder (PMDD). DESIGN: Case-control study with incident cases using the Spanish public healthcare system. SETTING: 3 major public hospitals and one family counseling and planning center. POPULATION: Women consulting for troubles related to menstruation and for other motives such as screening for uterine cancer, contraception counseling or desire for pregnancy. METHODS: Logistic regression. MAIN OUTCOME MEASURES: Odds Ratios of PMS and PMDD. RESULTS: 285 incident PMS cases and 285 age-matched controls on the one hand, and 88 incident PMDD cases and 176 controls on the other hand participated in the study. The odds of premenstrual disorders was higher in current smokers compared with never smokers: Odds Ratio (OR) = 1.78, 95% Confidence Interval (CI): 1.20-2.63 for PMS and OR = 2.92, 95%CI: 1.55-5.50 for PMDD. For PMS, women who smoke 1 to 5 cigarettes/day presented an OR = 2.82, 95%CI: 1.57-5.06 and those who smoke more than 15 cigarettes/day an OR = 2.52, 95%CI: 0.99-6.40. Compared to non-smokers, current and ex-smokers who smoked < 3 pack-years presented an OR = 1.79, 95%CI: 1.04-3.08 for PMS, and an OR = 3.06, 95%CI: 1.27-7.35 for PMDD. Smokers of 3 to 8 pack-years presented an OR = 2.34, 95%CI: 1.33-4.13 for PMS and OR = 3.56, 95%CI: 1.55-8.17 for PMDD. These results were confirmed by the exposure-effect curve obtained from a cubic spline model. CONCLUSIONS: This study shows that smokers are more likely to develop PMS and PMDD.

Sex differences during emotion processing are dependent on the menstrual cycle phase.

Sex differences in the neural processing of emotion are of special interest considering that mood and anxiety disorders predominant in females. However, these sex-related differences were typically studied without considering the hormonal status of female subjects, although emotion processing in the brain was shown to differ between phases of the menstrual cycle. In this functional MRI study, we demonstrated the influence of the menstrual cycle phase on sex differences in brain activity and functional connectivity during negative and positive emotions, using two different paradigms: emotion perception and emotion experience. Twenty naturally cycling healthy women without premenstrual symptoms were scanned twice: during the mid-follicular and late-luteal menstrual phases, and compared to a matched group of twenty healthy men. During negative emotion perception, men showed increased neural activity in the right hippocampal formation relative to women in the mid-follicular phase, and increased activity in the right cerebellum relative to women in the late-luteal phase. During experience of amusement, reduced putamen-ventrolateral prefrontal cortex and putamen-dorsomedial prefrontal cortex functional connectivity were observed for women in the late-luteal phase relative to men and associated with levels of sex hormones. These neural and hormonal findings were complemented by behavioral reports of reduced amusement and increased sadness in late-luteal women. Our results demonstrate menstrual phase-dependent sex differences in emotion perception and experience and may suggest a biological tendency for a deficient experience of pleasure and reward during the late-luteal phase. These findings may further shed light on the underlying pathophysiology of premenstrual dysphoric disorder.

Trastorno disfórico premenstrual (TDPM) / Premenstrual dysphoric disorder (PMDD)

El presente artículo trata el tema del síndrome premenstrual y su versión más grave e incapacitante: el trastorno disfórico premenstrual. Buscamos presentar los síntomas, causas y tratamientos. Resaltando la existencia de enfoques diversos. Algunos de los cuales sorprenden por su falta en efectividad, mientras que otros por lo bueno del pronóstico. Palabras claves: Trastorno Disfóricos Premenstrual, síndrome premenstrual.

This article is about premenstrual syndrome and its most serious and incapacitating version: premenstrual dysphoric disorder. We are searching for the symptoms, causes and treatments. Highlighting the existence of diverse approaches. Some of which surprise for their lack of effectiveness, while others for the good of the forecast

The Menstrual Cycle Influences Emotion but Has Limited Effect on Cognitive Function.

From a psychological perspective, the menstrual cycle has been a research topic for more than 50 years. The most recent menstrual cycle research has been driven by an increased interest in sex differences in neuroscience, and the urge to understand sex disparities in prevalence, clinical presentation, and treatment response in psychiatric or neurologic disorders. Indeed, the menstrual cycle is an excellent model of ovarian steroid influence on emotion, behavior, and cognition. This review summarizes the emotion-related and cognitive findings of methodologically sound menstrual cycle studies. In particular, the review is devoted to the sex hormone-induced emotional disturbances in women with premenstrual dysphoric disorder, a subgroup of women responding with enhanced sensitivity to the normal fluctuations in endogenous hormone levels during the menstrual cycle. In addition, emotion processing and cognitive findings across the menstrual cycle in healthy women are also discussed. The overall conclusion is that that menstrual cycle differences in sexually dimorphic cognitive tasks are small and difficult to replicate. Emotion-related changes are more consistently found and are better associated with progesterone and the luteal phase, than with estradiol.

Premenstrual Dysphoric Disorder in a Patient With Traumatic Brain Injury: A Case Presentation.

We present a case of a 17-year-old girl who developed premenstrual dysphoric disorder (PMDD) after sustaining a severe traumatic brain injury (TBI), and we review the diagnosis of PMDD. The patient developed symptoms of severe depression surrounding her menses months after sustaining severe TBI and was diagnosed with PMDD by a psychiatrist. She ultimately required antipsychotics for optimal symptom resolution. PMDD is a severe form of premenstrual syndrome with symptoms including irritability, anxiety, and nonfatal suicidal behavior. We discuss other potential causes of mood disturbance that are important to screen for after TBI, including depression, anxiety, and hypothalamic-pituitary axis disorders. Rehabilitation medicine providers need to be aware of PMDD in postpubertal female patients with TBI because it can lead to nonfatal suicidal behaviors. LEVEL OF EVIDENCE: V.

Premenstrual Dysphoric Disorder.

Premenstrual dysphoric disorder (PMDD) comprises emotional and physical symptoms and functional impairment that lie on the severe end of the continuum of premenstrual symptoms. Women with PMDD have a differential response to normal hormonal fluctuations. This susceptibility may involve the serotonin system, altered sensitivity of the GABAA receptor to the neurosteroid allopregnanalone, and altered brain circuitry involving emotional and cognitive functions. Serotonin reuptake inhibitors are considered the first-line treatment. Second-line treatments include oral contraceptives containing drospirenone, other ovulation suppression methods, calcium, chasteberry, and cognitive-behavioral therapy.

Fish Consumption and Premenstrual Syndrome and Dysphoric Disorder in Japanese Collegiate Athletes.

STUDY OBJECTIVE: To determine the specific characteristics of premenstrual syndrome (PMS)/premenstrual dysphoric disorder (PMDD) in Japanese collegiate athletes, with a focus on their fish consumption. DESIGN: Cross-sectional study. SETTING: A university in Osaka, the largest city in western Japan. PARTICIPANTS AND INTERVENTIONS: The participants were 312 female collegiate students. The study group was composed of 200 students who were members of sport clubs, and the control (nonathletes) group was composed of 112 members of cultural clubs. MAIN OUTCOME MEASURES: Premenstrual symptoms and social activities. RESULTS: The prevalence of moderate to severe PMS and PMDD in the study group was the same as in nonathletes. The prominent feature of premenstrual symptoms in athletes was that the severities of 'physical symptoms' and 'performance in training or competition' were much greater than those of nonathletes (P = .003 and P = .002, Mann-Whitney U test). There was a greater effect of PMS and PMDD on athletes, affecting their physical symptoms and performance compared with nonathletes. In terms of dietary habits, 'fish or dried fish' consumption was associated with a decreased risk of poor performance in athletes (odds ratio, 0.61; 95% confidence interval, 0.40-0.92). CONCLUSION: The results from this study indicate that fish consumption might be positively associated with the relief of PMS/PMDD-induced athletic disturbance.

Menstrual Cycle and the Prevalence of Premenstrual Syndrome/Premenstrual Dysphoric Disorder in Adolescent Athletes.

STUDY OBJECTIVE: The purpose of this study was to assess the menstrual cycle, menstrual disorders and premenstrual syndrome/premenstrual dysphoric disorder (PMS/PMDD) in girls and young women participating in competitive sports. The impact of PMS/PMDD symptoms on the quality of life was also analyzed. DESIGN: The prospective study encompassed 125 girls and young women with the aim to determine the presence of menstrual disorders and the prevalence of PMS/PMDD. PARTICIPANTS: The studied group was composed of 75 female athletes aged 16 to 22 years. The control group included 50 healthy girls and young women who did not practice competitive sports. SETTING: The studied athletes and the controls prospectively evaluated their 2 consecutive menstrual cycles by using a questionnaire. INTERVENTIONS: The research tools were a purpose-built questionnaire, a daily log of PMS symptoms according to the American College of Obstetricians and Gynecologists' guidelines, and a daily log of PMDD symptoms based on the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria. MAIN OUTCOME MEASURES: To determine the impact of competitive sports on the menstrual cycle, menstrual disorders, and the prevalence of PMS/PMDD in girls and young women. RESULTS: Intensive physical exercise delayed menarche. PMDD was diagnosed in 8% and PMS in 42.4% of all respondents. The prevalence of PMDD did not differ significantly between the groups (9.33% versus 6.00%). PMS was significantly more frequent among athletes than among controls (49.33% versus 32%, P = .045). The prevalence of PMS correlated significantly with mean age (P = .00001) and age at menarche (P = .03) in athletes. PMS was more frequent in older athletes and in girls with older age at menarche. CONCLUSION: Competitive sports, older mean age, older age at menarche, length of sporting career, and intensity of training are conducive to PMS. The prevalence of PMS increases with the duration and intensification of competitive exercises.