Lasting response to ovariectomy in severe intractable premenstrual syndrome

Global burden and trends in female premenstrual syndrome study during 1990-2019

PURPOSE

Premenstrual syndrome (PMS) is prevalent worldwide and considered a crucial issue regarding women's health. In the present study, the Global Burden of Disease (GBD) Study 2019 dataset was utilized to assess the distributional trends in PMS burden and prevalence in regional, national, and sociodemographic index (SDI) categories.

METHODS

The analytical methods and approaches used in the 2019 GBD study were adopted to investigate the incidence rates and disability-adjusted life years (DALY) related to PMS in 204 countries or regions. Age-standardized incidence rates (ASIR), 95% uncertainty intervals (95% UI), and annual percentage changes (EAPC) were calculated from the data.

RESULTS

The global incidence and disability-adjusted life years of PMS exhibited a declining trend in the year 2019. Regions with medium-low SDI had the greatest burden of PMS, with the regions of South Asia (ASR = 7337.9 per 10,000) exhibiting the greatest Age-standardized incidence rates, while the high-income North American states presented the fastest upward trends in Age-standardized disability-adjusted life year rates. At the national level, 107 nations exhibited a decreasing trend in PMS incidence ASR, while 97 nations exhibited an increasing trend, with the United States presenting the greatest increase.

CONCLUSIONS

The present study highlighted that even though the global PMS incidence and disability-adjusted life years have decreased from the year 1990 to 2019, PMS remains a prevalent health concern for women worldwide. While addressing preventive measures and treatment, it is also important to consider the regional and national differences in PMS to develop further effective and targeted health policies.

Unfolding the mystery of premenstrual syndrome (PMS): an overview

Physical, emotional, and psychological symptoms are common among women in their reproductive years, particularly during their menstrual cycle's luteal phase and the week before their period. Approximately 5-8 percent of women suffer with premenstrual syndrome, with the majority of those suffering from premenstrual dysphoric disorder (PMDD). Because of the complexity and multifaceted nature of the aetiology, it is yet unknown. Premenstrual syndrome (PMS) is diagnosed entirely on the basis of signs and symptoms, with no particular diagnostic tests available to confirm the diagnosis. Only a small number of therapeutic modalities are backed by clinical data, yet there are many accessible. After providing a brief overview of the disease, the author goes on to discuss the various hypotheses as to why PMS occurs. With an emphasis on tailored treatment based on symptom profile, it examines the wide range of non-pharmacological and pharmaceutical methods that are accessible today.

Premenstrual disorders: Premenstrual syndrome and premenstrual dysphoric disorder

Recently, the term premenstrual disorders (PMDs), which includes premenstrual syndrome and premenstrual dysphoric disorder as a continuum, has been proposed. Although the precise etiology of PMDs remains unknown, the involvement of hormonal fluctuations is clear. The brain transmitters, serotonin and γ-amino butyric acid, also seem to be involved. Serotonin reuptake inhibitors and oral contraceptives are the current mainstay of treatment, but these are insufficient. Even the currently used prospective two-period symptom diary is not widely used in actual clinical practice, creating a major problem of discrepancy between research and clinical practice. In this review, I would like to outline the latest information and problems in the etiology, diagnosis, and treatment of PMDs, with an emphasis on promising new therapies.

The pharmacotherapeutic management of premenstrual dysphoric disorder

INTRODUCTION

Premenstrual dysphoric disorder (PMDD) is a prevalent psychiatric condition associated with substantial mental distress, impaired psychosocial functioning, high rates of co-morbid psychiatric conditions, and elevated risk of suicide.

AREAS COVERED

We provide an update on epidemiology, pathophysiology, clinical presentation, and diagnosis of PMDD, with a focus on the pharmacological management of this condition.

EXPERT OPINION

Given the high rates of false positives from retrospective assessments, prospective daily symptom monitoring for a minimal of two symptomatic menstrual cycles is critical to accurately confirm (or rule out) the diagnosis of PMDD. Serotonin-based antidepressants are well-established first-line treatments of PMDD. Second-line treatment includes the use of combined, monophasic oral contraceptives. In mild to moderate cases, independent meta-analyses have shown efficacy of Chasteberry extract (Vitex agnus cactus). Preliminary results with compounds blocking the synthesis of allopregnanolone are promising.

Resident intruder paradigm-induced PMDD rat model of premenstrual irritability: behavioral phenotypes, drug intervention, and biomarkers

BACKGROUND

Premenstrual dysphoric disorder (PMDD) is high in women of childbearing age with obvious premenstrual irritability. However, reliable animal models are still lacking.

MATERIALS AND METHODS

PMDD rat model of premenstrual irritability was induced by the resident-intruder paradigm (RIP). Behavioral characteristics were determined by the aggressive behavior test, elevated plus maze, open-field test, and breast width measurement. The estrous cycle in rats was artificially manipulated by bilateral ovariectomy and exogenous hormone injection to verify the model phenotype's dependence on the estrous cycle. Fluoxetine and Baixiangdan capsules were administered by gavage to determine the symptom improvement effect of PMDD irritability. Biomarkers in serum and brain were detected using ELISA, and GABRA4 was detected in the brain by RT-PCR and Western blot.

RESULTS

Rat models demonstrated similar clinical characteristics as PMDD, such as premenstrual irritability and anxiety, and the above symptoms were estrous cycle-dependent. In addition, the levels of progesterone (P) and ALLO hormones decreased in the serum, hippocampus, amygdala, and frontal lobe in the NR phase. The contents of 5-HT in the brain were significantly increased, while NE and GABA contents were considerably reduced. Moreover, mRNA and protein expression of GABRA4 levels in model rats' amygdala, hippocampus, and frontal lobe were significantly increased, while drug intervention downregulated its expression in these tissues.

CONCLUSION

Premenstrual irritability rat model of PMDD demonstrates a behavioral phenotype consistent with the clinical symptoms of PMDD and micro index. The increased levels of 5-HT, NE, and expression of GABRA4, as well as the decrease of GABA, P, and ALLO levels, may be critical biomarkers of the abnormal changes that occur during the pathogenesis of PMDD.

Full Remission of Long-Term Premenstrual Dysphoric Disorder-Like Symptoms Following Resection of a Pituitary Adenoma: Case Report

Patient: Female, 44-year-old

Final Diagnosis: Pituitary adenoma

Symptoms: Depression and anxiety

Medication:—

Clinical Procedure: —

Specialty: Neurosurgery • Psychiatry

Effects of GABA active steroids in the female brain with a focus on the premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) afflicts 3%-5% of women of childbearing age, and is characterised by recurrent negative mood symptoms (eg, irritability, depression, anxiety and emotional lability) during the luteal phase of the menstrual cycle. The aetiology of PMDD is unknown, although a temporal association with circulating ovarian steroids, in particular progesterone and its metabolite allopregnanolone, has been established during the luteal phase. Allopregnanolone is a positive modulator of the GABA_A receptor: it is sedative in high concentrations but may precipitate paradoxical adverse effects on mood at levels corresponding to luteal phase concentrations in susceptible women. Saccadic eye velocity (SEV) is a measure of GABA_A receptor sensitivity; in experimental studies of healthy women, i.v. allopregnanolone decreases SEV. Women with PMDD display an altered sensitivity to an i.v. injection of allopregnanolone compared to healthy controls in this model. In functional magnetic resonance imaging (fMRI) studies, women with PMDD react differently to emotional stimuli in contrast to controls. A consistent finding in PMDD patients is increased amygdala reactivity during the luteal phase. Post-mortem studies in humans have revealed that allopregnanolone concentrations vary across different brain regions, although mean levels in the brain also reflect variations in peripheral serum concentrations. The amygdala processes emotions such as anxiety and aggression. This is interesting because allopregnanolone is detected at high concentrations within the region into which marked increases in blood flow are measured with fMRI following progesterone/allopregnanolone administration. Allopregnanolone effects are antagonised by its isomer isoallopregnanolone (UC1010), which significantly reduces negative mood symptoms in women with PMDD when administered s.c. in the premenstrual phase. This was shown in a randomised, placebo-controlled clinical trial in which the primary outcome was change in symptom scoring on the Daily Rating of Severity of Problems (DRSP): the treatment reduced negative mood scores (P < .005), as well as total DRSP scores (P < .01), compared to placebo in women with PMDD. In conclusion, the underlying studies of this review provide evidence that allopregnanolone is the provoking factor behind the negative mood symptoms in PMDD and that isoallopregnanolone could ameliorate the symptoms as a result of its ability to antagonise the allopregnanolone effect on the GABA_A receptor.

Eating disorders in premenstrual dysphoric disorder: a neuroendocrinological pathway to the pathogenesis and treatment of binge eating

BACKGROUND

This case report details the presentation, treatment and post-operative outcome of an adult female with co-occurring binge eating disorder and premenstrual dysphoric disorder (PMDD).

CASE PRESENTATION

The patient, self-presenting for treatment, reported having struggled with severe, debilitating physical and psychological PMDD symptoms for nearly a decade. After having taken part in a number of unsuccessful first- and second line treatments in primary and secondary care, the patient was referred to tertiary care at the Department of Gynecology at Oslo University Hospital in Norway. Chemical menopause using a gonadotropin-releasing hormone (GnRH) agonist was induced, predicting the desired response (i.e. resolution of PMDD symptoms) to bilateral salpingo-oophorectomy (BSO). At three- and six months post BSO follow-up, the patient reported complete resolution of all reported PMDD symptoms including marked increase in appetite (i.e. hyperphagia), specific food cravings and auxiliary binge eating.

CONCLUSIONS

To our knowledge, this is the first case documenting the recovery from an eating disorder following surgical ovarian suppression. Our findings lend supports to existing studies linking binge eating to hormonal changes in the mid-luteal phase of the menstrual cycle, and may help advance new treatment options for a selected, severely impaired group of females struggling with excessive appetite and binge eating due to fluctuations in ovarian activity.

Premenstrual Dysphoric Disorder Symptoms Following Ovarian Suppression: Triggered by Change in Ovarian Steroid Levels But Not Continuous Stable Levels

OBJECTIVE

Premenstrual dysphoric disorder (PMDD) symptoms are eliminated by ovarian suppression and stimulated by administration of ovarian steroids, yet they appear with ovarian steroid levels indistinguishable from those in women without PMDD. Thus, symptoms could be precipitated either by an acute change in ovarian steroid levels or by stable levels above a critical threshold playing a permissive role in expression of an underlying infradian affective "pacemaker." The authors attempted to determine which condition triggers PMDD symptoms.

METHOD

The study included 22 women with PMDD, ages 30 to 50 years. Twelve women who experienced symptom remission after 2-3 months of GnRH agonist-induced ovarian suppression (leuprolide) then received 1 month of single-blind (participant only) placebo and then 3 months of continuous combined estradiol/progesterone. Primary outcome measures were the Rating for Premenstrual Tension observer and self-ratings completed every 2 weeks during clinic visits. Multivariate repeated-measure ANOVA for mixed models was employed.

RESULTS

Both self- and observer-rated scores on the Rating for Premenstrual Tension were significantly increased (more symptomatic) during the first month of combined estradiol/progesterone compared with the last month of leuprolide alone, the placebo month, and the second and third months of estradiol/progesterone. There were no significant differences in symptom severity between the last month of leuprolide alone, placebo month, or second and third months of estradiol/progesterone. Finally, the Rating for Premenstrual Tension scores in the second and third estradiol/progesterone months did not significantly differ.

CONCLUSIONS

The findings demonstrate that the change in estradiol/progesterone levels from low to high, and not the steady-state level, was associated with onset of PMDD symptoms. Therapeutic efforts to modulate the change in steroid levels proximate to ovulation merit further study.

A Comprehensive Review of Treatment Options for Premenstrual Syndrome and Premenstrual Dysphoric Disorder

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome that involves a combination of emotional and physical symptoms that result in significant functional impairment. Because of the debilitating nature of PMDD, multiple treatment options have been considered. This review provides a comprehensive overview of these therapeutic regimens to help health care professionals provide adequate treatment for PMDD and premenstrual syndrome. The treatments that are reviewed are organized into the following categories: psychiatric, anovulatory, supplements, herbal, nonpharmacological, and other. Selective serotonin reuptake inhibitors have been established as the first-line treatment for PMDD. Although luteal phase or continuous dosing can be used, additional research is needed to more thoroughly compare the efficacies and differential symptom response of continuous, semi-intermittent, luteal phase, and symptoms-onset dosing. The psychiatric medications venlafaxine, duloxetine, alprazolam, and buspirone have also been found to be useful treatments for PMDD. Various anovulatory-related treatments have demonstrated efficacy; however, the use of some of these treatments remains limited due to potential side effects and/or the availability of cheaper alternatives. Although a variety of supplement and herbal-related treatments have been proposed, with some warranting further research, at this time only calcium supplementation has demonstrated a consistent therapeutic benefit. In conclusion, serotoninergic antidepressants have been established as the first-line treatment option for PMDD; however, there are a variety of additional treatment options that should be considered if a patient fails to achieve an adequate therapeutic response with a selective serotonin reuptake inhibitor.

Hormone therapy for reproductive depression in women

An email survey of patients attending a PMS and Menopause Centre produced 238 patients whose principal presenting symptom was depression. Seventy-seven percent claimed to have had severe or moderate depression, 17% had had at least one psychotic episode and 14% had attempted suicide. Fifty-eight percent had seen a psychiatrist. Seventy-one percent had received antidepressants and 17% had received mood stabilising drugs. Twelve percent had been admitted to a psychiatric hospital and 3.8% had received electroconvulsive therapy. Sixty-eight percent had premenstrual syndrome as a teenager and 145 women (89%) out of 165 women who had been pregnant had no depression during pregnancy but 110 (66%) developed postnatal depression. Ninety-seven women (58%) who had been pregnant had suffered both premenstrual depression and postnatal depression. All were treated with transdermal estrogens and 93% also had transdermal testosterone. One hundred and seventy-one patients had a uterus and received cyclical progestogen to protect the endometrium and 63% of these developed the premenstrual syndrome-type symptoms of progesterone intolerance during the progestogen days. Thirty-five percent of patients claimed to be cured and 55% had a considerable improvement with estrogen therapy. Only 3.7% reported that there was no improvement. For 94%, the hormone therapy was a life-changing event for the better. None were worse. Forty patients had hysterectomy and bilateral oophorectomy for progesterone intolerance or heavy uterine bleeding and 38 replied that it was life changing for the better with less or no depression. It is concluded that premenstrual and postnatal depressions appear in the same vulnerable women. These women are typically well during pregnancy and are a sub group of reproductive depression which also develops climacteric depression in the transition phase. These types of depression are the product of hormonal changes and respond well to transdermal hormone therapy.

Personal view: Hormones and depression in women

Depression is more common in women, occurring at times of hormonal fluctuations as premenstrual depression, postnatal depression and perimenopausal depression. These are all related to changes in hormone levels and constitute the diagnosis of reproductive depression. There is a risk that severe premenstrual depression can be misdiagnosed as bipolar disorder and that women will be started on inappropriate antidepressants or mood-stabilizing therapy. The most effective treatment for severe premenstrual syndrome is by suppression of ovulation and suppression of the cyclical hormonal changes by transdermal estrogens or by GnRH analogs. Postnatal depression is more common in women with a history of premenstrual depression and also responds to transdermal estrogens. Transdermal testosterone gel can be also used in women who suffer loss of energy and loss of libido which may be due to the inappropriate prescription of antidepressants. There is also a role for the Mirena IUS and laparoscopic hysterectomy and oophorectomy in women who are progestogen-intolerant. The hormonal causation of certain common types of depression in women and the successful treatment by estrogens should be understood by psychiatrists and gynecologists.

Treatment of premenstrual dysphoric disorder

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

The effect of uterine artery embolization on premenstrual symptoms in patients with symptomatic fibroids or adenomyosis

PURPOSE

To evaluate whether uterine artery embolization (UAE) can reduce the premenstrual symptoms in women undergoing UAE for fibroid tumors or adenomyosis.

MATERIALS AND METHODS

Among 141 women who underwent UAE for symptomatic fibroid tumors or adenomyosis at a single institution between March 2011 and February 2013, 54 premenstrual symptoms in 39 patients were prospectively analyzed. Premenstrual symptoms were rated by the patient on a scale of 0 to 10, with 0 representing no symptom and 10 representing the baseline severity. The change in premenstrual symptom score was calculated by subtracting the baseline score from the post-UAE score. At 3-6 months after UAE, each woman also completed a symptom severity questionnaire to assess the severity of menstrual bleeding to compare the changes in premenstrual symptoms scores between women with and without menorrhagia.

RESULTS

Back pain, headache, and gastrointestinal symptoms (eg, constipation, indigestion, lower abdominal pain) were significantly improved after UAE (P < .05). Muscle pain, fatigue, nervousness, breast tenderness, and systemic edema were also improved, but not significantly so. The mean premenstrual symptom score change in patients with menorrhagia was significantly greater than in those without menorrhagia (-6.4 vs -3.7; P = .044).There was no correlation between the degree of menorrhagia score change and the degree of premenstrual symptom score change (P = .186).

CONCLUSIONS

UAE could be a method to alleviate some premenstrual symptoms in patients with uterine fibroid tumors or adenomyosis.

Low-dose acetazolamide in the treatment of premenstrual dysphoric disorder: a case series

The treatment of premenstrual dysphoric disorder (PMDD) is far from satisfactory, as there is a high proportion of patients who do not respond to conventional treatment. The antidiuretic sulfonamide, acetazolamide, inhibits carbonic anhydrase and potentiates GABAergic transmission; the latter is putatively involved in PMDD. We therefore tried acetazolamide in a series of women with intractable PMDD. Here, we describe a series of eight women diagnosed with DSM-IV-TR PMDD, five of whom had comorbidity with a mood disorder and one with an anxiety disorder, who were resistant to treatment and responded with symptom disappearance after being added-on 125 mg/day acetazolamide for 7-10 days prior to menses each month. Patients were free from premenstrual symptoms at the 12-month follow-up. We suggest that acetazolamide may be used to improve symptoms of PMDD in cases not responding to other treatments. GABAergic mechanisms may be involved in counteracting PMDD symptoms.

ISPMD consensus on the management of premenstrual disorders

The second consensus meeting of the International Society for Premenstrual Disorders (ISPMD) took place in London during March 2011. The primary goal was to evaluate the published evidence and consider the expert opinions of the ISPMD members to reach a consensus on advice for the management of premenstrual disorders. Gynaecologists, psychiatrists, psychologists and pharmacologists each formally presented the evidence within their area of expertise; this was followed by an in-depth discussion leading to consensus recommendations. This article provides a comprehensive review of the outcomes from the meeting. The group discussed and agreed that careful diagnosis based on the recommendations and classification derived from the first ISPMD consensus conference is essential and should underlie the appropriate management strategy. Options for the management of premenstrual disorders fall under two broad categories, (a) those influencing central nervous activity, particularly the modulation of the neurotransmitter serotonin and (b) those that suppress ovulation. Psychotropic medication, such as selective serotonin reuptake inhibitors, probably acts by dampening the influence of sex steroids on the brain. Oral contraceptives, gonadotropin-releasing hormone agonists, danazol and estradiol all most likely function by ovulation suppression. The role of oophorectomy was also considered in this respect. Alternative therapies are also addressed, with, e.g. cognitive behavioural therapy, calcium supplements and Vitex agnus castus warranting further exploration.

Potential strategies to avoid progestogen-induced premenstrual disorders

Non-hormonal approaches to premenstrual syndrome (PMS) treatment such as selective serotonin reuptake inhibitors are by no means effective for all women and frequently we must resort to endocrine therapy. During many of the hormonal approaches, PMS-like symptoms can be introduced or re-introduced during the necessary cyclical or continuous progestogen component of the therapy. This is seen with combined oral contraception, progestogen only contraception, progestogen therapy for heavy menstrual bleeding and endometriosis, sequential hormone replacement therapy and any therapeutic strategy for premenstrual syndrome where it is necessary to provide endometrial protection, including estrogen suppression of ovulation or add-back during gonadotrophin releasing hormone suppression. The link to progestogen is very often missed by health professionals. When the pattern of symptoms mimics the cyclicity of PMS, it is termed progestogen-induced premenstrual disorder. The need to use progestogen to protect the endometrium from the proliferative actions of estrogen can pose insurmountable difficulties in managing premenstrual disorders. In the absence of any really useful evidence, nearly all practice in this area depends on clinician experience. We cannot afford to wait for adequate research evidence to be produced - it never will - and so we must rely on empirical findings, clinical experience, theoretical strategies and common sense.

Reproductive hormonal treatments for mood disorders in women

There has been a century-long view in medicine that reproductive function in both men and women is intimately involved with mood regulation. The 19th century witnessed a proliferation of medical reports documenting beneficial effects on mood and behavior after medical or surgical manipulations of women's reproductive functíon. More recently, the results of several studies suggest that gonadal steroids do regulate mood in some women. Thus, there is considerable interest in the potential role of reproductive therapies in the management of depressive illness, including both classical and reproductive endocrine-related mood disorders. Future studies need to determine the predictors of response to hormonal therapies compared with traditional antidepressant agents, and to characterize the long-term safety and benefits of these therapies.

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.

When should surgical treatment be considered for premenstrual dysphoric disorder?

Premenstrual mood disorders afflict a substantial number of women of reproductive age. Medical treatments provide excellent symptomatic relief to many women but at times a poor therapeutic response or adverse effects attributable to these therapies lead women to seek alternative solutions. Oophorectomy (with concomitant hysterectomy) followed by low-dose estrogen therapy has been shown to be an effective alternative for such cases of menstrual-cycle-related mood disorder.

Treatment of premenstrual disorders by suppression of ovulation by transdermal estrogens

The understanding of the cause and treatment of premenstrual disorders is confused but it is essentially the result of cyclical ovarian activity, usually ovulation, and an effective treatment should be by suppressing ovulation. This can be done by an oral contraceptive but as these women are progestogen intolerant the symptoms may persist becoming constant rather than cyclical. Alternatively, transdermal estradiol by patch, gel or implant effectively removes the cyclical hormonal changes, which produce the cyclical symptoms. A shortened seven-day course of a progestogen is required each month for endometrial protection but it can reproduce premenstrual syndrome-type symptoms in these women. Gonadotropin-releasing hormone with ‘add-back’ is effective in the short term. Laparoscopic hysterectomy and bilateral oophorectomy with adequate replacement of estrogen and testosterone should be considered in the severe cases with progestogenic side-effects.

Reproductive depression

Reproductive depression is the depression in women that is related to the hormonal changes of the menstrual cycle, pregnancy and the menopause and is manifested clinically as premenstrual depression, postnatal depression and climacteric depression. These three components occur in the same vulnerable women in that a woman with depression in the menopausal transition will usually have a history of premenstrual syndrome (PMS; premenstrual dysphoric disorder [PMDD]), would have been in a good mood during pregnancy and then develop postnatal depression. When the periods return the depression becomes cyclical as PMS. These three conditions are effectively treated with transdermal estrogens which should be the first-choice therapy rather than antidepressants. Estrogens can be used together with antidepressants. The critical time to prevent long-term mood problems is the correct treatment of postnatal depression. In women with low energy and libido, often a side effect of antidepressants, the addition of transdermal testosterone is useful. These women with reproductive depression are often progesterone/progestogen intolerant and a smaller dose or duration of progestogen is a necessary compromise. Alternatively a Mirena IUS or rarely a hysterectomy is required.

The effect of hysterectomy or levonorgestrel-releasing intrauterine system on premenstrual symptoms in women treated for menorrhagia: secondary analysis of a randomized controlled trial

OBJECTIVE

To study the effect of hysterectomy or levonorgestrel-releasing intrauterine system (LNG-IUS) on premenstrual symptoms in women treated for menorrhagia.

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

Five university hospitals in Finland.

SAMPLE

A cohort of 236 women, aged 35-49 years (mean 43 years) referred for menorrhagia between 1994 and 1997. Women were not diagnosed with premenstrual syndrome.

METHODS

Women were randomized to treatment by hysterectomy (n=117) or LNG-IUS (n=119). Analyses were performed using the intention-to-treat and actual treatment principles. Women using estrogen therapy and women who underwent bilateral salpingo-oophorectomy were excluded from the analyses.

MAIN OUTCOME MEASURES

The occurrence of premenstrual symptoms evaluated by questionnaires at baseline and at follow-up visits six and 12 months after the treatment and five years after the randomization.

RESULTS

Premenstrual symptoms decreased significantly in both groups by six months (p≤0.028) without significant differences between the groups, except that in the LNG-IUS group the decrease of breast tenderness was seen first by 12 months (p=0.048). Even though 42% of the women assigned to treatment with LNG-IUS were hysterectomized during the follow-up period, the results of intention-to-treat and actual treatment analyses were comparable.

CONCLUSIONS

Both hysterectomy and LNG-IUS seem to alleviate premenstrual symptoms of women treated for menorrhagia, while the effect of these treatments on premenstrual syndrome remains unsettled.

Towards a consensus on diagnostic criteria, measurement and trial design of the premenstrual disorders: the ISPMD Montreal consensus

Premenstrual disorders (PMD) are characterised by a cluster of somatic and psychological symptoms of varying severity that occur during the luteal phase of the menstrual cycle and resolve during menses (Freeman and Sondheimer, Prim Care Companion J Clin Psychiatry 5:30-39, 2003; Halbreich, Gynecol Endocrinol 19:320-334, 2004). Although PMD have been widely recognised for many decades, their precise cause is still unknown and there are no definitive, universally accepted diagnostic criteria. To consider this issue, an international multidisciplinary group of experts met at a face-to-face consensus meeting to review current definitions and diagnostic criteria for PMD. This was followed by extensive correspondence. The consensus group formally became established as the International Society for Premenstrual Disorders (ISPMD). The inaugural meeting of the ISPMD was held in Montreal in September 2008. The primary aim was to provide a unified approach for the diagnostic criteria of PMD, their quantification and guidelines on clinical trial design. This report summarises their recommendations. It is hoped that the criteria proposed here will inform discussions of the next edition of the World Health Organisation's International Classification of Diseases (ICD-11), and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) criteria that are currently under consideration. It is also hoped that the proposed definitions and guidelines could be used by all clinicians and investigators to provide a consistent approach to the diagnosis and treatment of PMD and to aid scientific and clinical research in this field.

Update on research and treatment of premenstrual dysphoric disorder

Many women in their reproductive years experience some mood, behavioral. or physical symptoms in the week prior to menses. Variability exists in the level of symptom burden in that some women experience mild symptoms, whereas a small minority experience severe and debilitating symptoms. For an estimated 5%-8% of premenopausal women, work or social functioning are affected by severe premenstrual syndrome. Many women in this group meet diagnostic criteria for premenstrual dysphoric disorder (PMDD). Among women who suffer from PMDD, mood and behavioral symptoms such as irritability, depressed mood, tension, and labile mood dominate. Somatic complaints, including breast tenderness and bloating, also can prove disruptive to women's overall functioning and quality of life. Recent evidence suggests that individual sensitivity to cyclical variations in levels of gonadal hormones may predispose certain women to experience these mood, behavioral, and somatic symptoms. Treatments include: antidepressants of the serotonin reuptake inhibitor class, taken intermittently or throughout the menstrual cycle; medications that suppress ovarian cyclicity; and newer oral contraceptives with novel progestins.

Non-contraceptive benefits of oral contraceptives

BACKGROUND

There is increasing awareness of the opportunity that many contraceptive interventions may provide for additional health benefits. However, treatment of medical problems with oral contraceptives (OCs) is often an 'off-label' practice.

OBJECTIVE

The aim of this review is to summarize available data on non-contraceptive benefits of OCs.

METHODS

Review of the literature.

RESULTS

OCs have been shown to reduce the risk of ovarian, endometrial, and colorectal cancer. It has been suggested that OCs may be used in treatment of endometriosis, menorrhagia, and uterine leiomyomas. Pelvic inflammatory disease, dysmenorrhea, premenstrual syndrome, and acne have been shown to improve under OCs.

CONCLUSION

OCs are important for global and female health. Besides contraception, non-contraceptive effects of OCs are evidence based, well established, and commonly used in clinical practice.

Role of calcium metabolism in premenstrual syndrome

Premenstrual syndrome has been the subject of many myths and misconceptions over the centuries. It is a very common problem affecting millions of young women during their reproductive lives and is characterized by numerous recurrent, cyclical emotional and physical symptoms during the luteal phase of the menstrual cycle. The etiology of this disorder has remained poorly understood until only recently. Alterations in calcium homeostasis have long been associated with many affective disorders. Cyclical fluctuations of the ovarian steroid hormones across the menstrual cycle influence calcium metabolism, affect intestinal calcium absorption and modulate 1,25-dihydroxyvitamin D synthesis. Evidence now strongly suggests that abnormalities in calcium and vitamin D metabolism, specifically calcium and vitamin D deficiency, are responsible for these luteal-phase symptoms. Calcium and vitamin D supplementation may offer a simple solution to millions of women affected with premenstrual syndrome.

Premenstrual syndrome

Most women of reproductive age have some physical discomfort or dysphoria in the weeks before menstruation. Symptoms are often mild, but can be severe enough to substantially affect daily activities. About 5-8% of women thus suffer from severe premenstrual syndrome (PMS); most of these women also meet criteria for premenstrual dysphoric disorder (PMDD). Mood and behavioural symptoms, including irritability, tension, depressed mood, tearfulness, and mood swings, are the most distressing, but somatic complaints, such as breast tenderness and bloating, can also be problematic. We outline theories for the underlying causes of severe PMS, and describe two main methods of treating it: one targeting the hypothalamus-pituitary-ovary axis, and the other targeting brain serotonergic synapses. Fluctuations in gonadal hormone levels trigger the symptoms, and thus interventions that abolish ovarian cyclicity, including long-acting analogues of gonadotropin-releasing hormone (GnRH) or oestradiol (administered as patches or implants), effectively reduce the symptoms, as can some oral contraceptives. The effectiveness of serotonin reuptake inhibitors, taken throughout the cycle or during luteal phases only, is also well established.

Differences in free estradiol and sex hormone-binding globulin in women with and without premenstrual dysphoric disorder

CONTEXT

Over the years, different hypotheses involving the ovarian steroid hormones have been proposed to explain the luteal phase occurrence of severe premenstrual syndrome symptoms. Although it had been strongly suspected that differences in the concentrations of the ovarian steroids may underlie the mood and psychological imbalance of this disorder, the evidence for this hypothesis has been inconsistent and remains controversial.

OBJECTIVE

Our objective was to measure the ovarian steroid hormones across the menstrual cycle in women with and without luteal phase symptoms consistent with premenstrual dysphoric disorder (PMDD).

DESIGN

We measured estradiol (E2), progesterone, and SHBG in women with and without PMDD using a cross-sectional and prospective experimental design. Participating women underwent 2-month self-assessment symptom screening and 1-month hormonal evaluation.

RESULTS

Overall means for LH, progesterone, E2, peak E2, and free E2 were not different between groups. Across the menstrual cycle, overall percent free E2 was significantly lower and SHBG significantly greater in the PMDD group compared with controls (1.39 +/- 0.26 vs. 1.50 +/- 0.28, P = 0.03; 61.4 +/- 25.1 vs. 52.4 +/- 21.3 nmol/liter, P = 0.046, respectively). During the luteal phase, free E2 was significantly lower in the PMDD group compared with controls (PMDD 7.6 +/- 7.0 vs. controls 8.9 +/- 8.4 pmol/liter; P = 0.032). For both follicular and luteal phases, SHBG was significantly higher in the PMDD group (follicular phase 60.5 +/- 31.7 vs. 51.4 +/- 38.2 nmol/liter, P = 0.047; luteal phase 65.1 +/- 32.3 vs. 55.1 +/- 38.9 nmol/liter, P =0.03). In both groups, SHBG significantly increased from the follicular to luteal phase.

CONCLUSION

Luteal phase concentrations of free E2, percent free E2, and SHBG differ significantly between women with and without PMDD.

Le syndrome prémenstruel: revue générale

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.

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.

The premenstrual syndrome revisited

More women - and their families - are affected by the physical and psychological irregularities due to premenstrual symptoms than by any other condition. Up to 90% of women of childbearing age report perceiving one or more symptoms during the days before menstruation, symptoms which can alter their behaviour and wellbeing and which, therefore, can affect their family, social and work circle. However, and notwithstanding this general prevalence, the clinical entity that in a large number of cases results from these symptoms, commonly known as the premenstrual syndrome, still lacks defined and validated contents so that recommendations of treatments backed by adequate experimental and clinical evidence are only slowly appearing. In the present paper, we review recent experimental data as to a possible aetiology of the premenstrual problem. We propose a Premenstrual Profile, i.e. a new register of symptoms, to be used for the differential diagnosis of the three forms of the premenstrual alteration. Finally, we review the evidence-based recommendations from reliable sources as regards the treatment of "normal" and "abnormal" premenstrual symptoms.

Are there differential symptom profiles that improve in response to different pharmacological treatments of premenstrual syndrome/premenstrual dysphoric disorder?

Current evidence suggests that the accepted treatments for premenstrual syndrome (PMS)/premenstrual dysphoric disorder (PMDD) have similar overall efficacy. While these treatments are more effective than placebo, response rates associated with them are far from satisfactory (<60%), such that, irrespective of treatment modality, there remain a significant number of women who are unresponsive to current conventional pharmacological therapy. The available data on response rates of specific types of premenstrual symptoms to, or symptom profiles that are most amenable to, each treatment modality are limited and not well defined because most studies were not designed to assess specific symptom profiles. Those studies that have attempted to evaluate which symptom profiles respond to specific therapies have revealed variations within the individual modalities, as well as between the different modalities. It appears that suppression of ovulation ameliorates a broad range of behavioural as well as physical premenstrual symptoms. SSRIs are most effective for irritability and anxiety symptoms, with lesser efficacy for 'atypical' premenstrual symptoms. GABAergic compounds are most efficacious for anxiety and anxious/depressive symptoms, while dopamine agonists, particularly bromocriptine, are perhaps most efficacious for mastalgia. Overall treatment response rates may improve if treatments are targeted at well-defined subgroups of patients. Re-analysis of available datasets from randomised clinical trials may shed more light on the notion that targeting women with specific premenstrual symptom profiles for specific treatment modalities would improve response rates beyond the current ceiling of approximately 60%. Such information would also improve understanding of the putative pathophysiological mechanisms underlying PMS and PMDD, and may point to a more specific diagnosis of these conditions.

Ovariotomy for menstrual madness and premenstrual syndrome--19th century history and lessons for current practice

Ovariotomy--the removal of normal ovaries, known as Battey's Operation--began in 1872 and became the fashionable treatment of menstrual madness, neurasthenia, nymphomania, masturbation and "all cases of insanity". This practice was supported by distinguished gynecologists and psychiatrists, becoming one of the great medical scandals of the 19th century. In modern times, if menstrual madness is considered to be premenstrual dysphoric disorder (PMDD), and ovariotomy, the surgical equivalent of ovulation suppression of GnRH analogues, it can be argued that the surgery would have been effective for this limited indication, although the side effects of long-term estrogen deficiency would have made the treatment unacceptable. Currently, the successful hormonal treatment of PMDD is one of suppression of ovulation and removal of the cyclical hormonal changes in the luteal phase, probably progesterone, which is the essential cause of PMDD. Such therapy would be by GnRH analogues, transdermal estradiol and, in a few cases, the surgical option of hysterectomy and bilateral salpingo-oophorectomy with adequate hormone replacement. A study of medical history can help us prevent the mistakes of over-enthusiasm but positive lessons can be learned.

The role for vitamin B-6 as treatment for depression: a systematic review

BACKGROUND

Major depression is the leading cause of disability worldwide, and among the 10 most frequent indications for using alternative medicine therapies, especially dietary supplements.

OBJECTIVE

To assess the evidence evaluating vitamin B-6 supplementation as treatment for depression.

METHODS

Medline, Psychinfo, AMED, and Cochrane Controlled Trials Register were searched from database inception through September 2001. All randomized controlled trials, controlled clinical trials, intervention studies, case-control studies, reviews, and case reports examining the evidence behind vitamin B-6 in depression among humans were selected. No limits were placed for demographics or co-morbidities. Only English language papers were abstracted and assessed for trial quality. Two abstractors independently evaluated each study, then reconciled findings. As data were available, between group treatment effect size was noted or, as needed, calculated. When studies reported outcome effects using multiple measures, data were abstracted to permit the greatest possible comparisons among papers.

RESULTS

Ten articles met inclusion criteria; three reviews, one case report, five RCTs, and one intervention study. There was no common outcome measure among all studies, eliminating opportunity for direct comparison of effect sizes. As an alternate means of comparison, effects were plotted as they related to the null hypothesis.

CONCLUSION

Viewed as a whole, meaningful treatment effect of vitamin B-6 for depression in general was not apparent. However, examination of papers addressing depression in pre-menopausal women only, reveals a consistent message about the value of using vitamin B-6 supplementation. Further study of vitamin B-6 as independent and adjuvant therapy for hormone related depression in women is indicated.

Algorithm for treatment of premenstrual syndromes (PMS): experts' recommendations and limitations

The number of women who seek treatment for Premenstrual Syndromes (PMS) is continually increasing. To meet their needs there are many treatment modalities that have been introduced to clinical practice. In order to assist the clinician in choosing treatment for his/her patients, treatment recommendations by experts in the field are not only available but they may also be prioritized and sequenced as treatment algorithm. Such an algorithm for treatment of women with PMS is presented here. The algorithm is the author's summary and common denominator of several experts' consensus building group processes. The strengths as well as shortcomings of the experts' opinions processes are discussed. Substantial clinically-relevant research and assessments are still needed.

Premenstrual Syndrome, Premenstrual Dysphoric Disorder, and Beyond: A Clinical Primer for Practitioners

The management of adverse premenstrual symptoms has presented a difficult challenge for clinicians. However, based on numerous well-designed research studies over the last decade, we now have diagnostic criteria for the severe form of the syndrome, premenstrual dysphoric disorder, and a variety of evidence-based therapeutic strategies. This review presents a comprehensive, practical description of what the clinician needs to know to diagnose and treat adverse premenstrual symptoms at all levels of severity. Diagnostic criteria are described in detail, including a discussion of the distinction between premenstrual dysphoric disorder and premenstrual syndrome (PMS). The rationale for including prospective symptom calendars as a routine part of the diagnostic evaluation of severe symptoms is presented. The differential diagnosis of cyclic symptoms, including depression and anxiety disorders, menstrual migraine, and mastalgia, and an approach for the management of each of these problems are presented. A treatment approach is recommended that matches the treatment to the degree of problems the woman is experiencing. Serotonin reuptake inhibitors are the treatment of choice for severe symptoms, and most women with PMS/premenstrual dysphoric disorder will respond to intermittent, luteal phase-only therapy. Ovulation suppression should be reserved for women who do not respond to other forms of therapy. The role of oophorectomy is limited, and guidelines for its use are presented.

Adrenal response to adrenocorticotropic hormone stimulation in patients with premenstrual syndrome

Several studies have been performed during recent years to investigate the existence of a possible endocrine cause for premenstrual syndrome (PMS); the results reported are often discordant. Great interest has been raised around allopregnanolone, which could be involved in the determination of mood disorders reported by PMS patients. During the luteal phase, lower levels of this hormone have been detected in PMS patients. The aim of our study was to evaluate estradiol, progesterone, dehydroepiandrosterone (DHEA), DHEA sulfate (DHEAS), androstenedione, total and free testosterone, cortisol, pregnenolone and allopregnanolone levels in 20 patients suffering from PMS and to compare them with those found in 20 fertile healthy women in the follicular and the luteal phases. Adrenocorticotropic hormone (ACTH) tests after dexamethasone suppression were performed in 10 patients of each group during the follicular and the luteal phases. In the PMS group, significantly lower allopregnolone levels were found in the luteal phase, while progesterone was lower in the PMS group in both phases. In the PMS group, higher free testosterone levels were found during the luteal phase and higher DHEA levels in both the follicular and the luteal phases. The present data confirm reduced allopregnanolone levels in the luteal phase in PMS patients, together with higher levels of DHEA and free testosterone. It is possible to conclude that, in addition to the previously described reduced luteal secretion of allopregnanolone, the adrenal gland production of this steroid in PMS sufferers is also impaired in the luteal phase. Considering the specific actions of these hormones on the control of mood and behavior, this specific hormonal milieu may contribute to the cyclic occurrence of anxiety, aggressiveness and irritability reported by PMS patients.

A biopsychosocial approach to premenstrual dysphoric disorder

Though epidemiological data is difficult to collect, existing evidence indicates that there is a small but significant population of women in whom premenstrual symptoms, and particularly affective symptoms, severely impair functioning. Although PMDD is predominantly regarded as a biologically based illness, there is strong evidence that variables such as life stress, history of sexual abuse, and cultural socialization are important determinants of premenstrual symptoms. In diagnosing and treating PMDD patients, attention to biological and sociocultural variables is recommended.

The role of hormones and hormonal treatments in premenstrual syndrome

Premenstrual syndrome (PMS) is a menstrual cycle-linked condition with both mental and physical symptoms. Most women of fertile age experience cyclical changes but consider them normal and not requiring treatment. Up to 30% of women feel a need for treatment. The aetiology is still unclear, but sex steroids produced by the corpus luteum of the ovary are thought to be symptom provoking, as the cyclicity disappears in anovulatory cycles when a corpus luteum is not formed. Progestogens and progesterone together with estrogen are able to induce similar symptoms as seen in PMS. Symptom severity is sensitive to the dosage of estrogen. The response systems within the brain known to be involved in PMS symptoms are the serotonin and GABA systems. Progesterone metabolites, especially allopregnanolone, are neuroactive, acting via the GABA system in the brain. Allopregnanolone has similar effects as benzodiazepines, barbiturates and alcohol; all these substances are known to induce adverse mood effects at low dosages in humans and animals. SSRIs and substances inhibiting ovulation, such as gonadotrophin-releasing hormone (GnRH) agonists, have proven to be effective treatments. To avoid adverse effects when high dosages of GnRH agonists are used, add-back hormone replacement therapy is recommended. Spironolactone also has a beneficial effect, although not as much as SSRIs and GnRH agonists.

Management of premenstrual dysphoric disorder

Premenstrual dysphoric disorder is a complex disorder characterized by severe physical and psychological symptoms. The pathophysiology and effective treatment of premenstrual dysphoric disorder are presented. Evidence for the effective treatment of premenstrual dysphoric disorder by correction of neuroendocrine abnormalities or suppression of cyclical ovarian activity is reviewed.

Pharmacotherapy of premenstrual syndromes and premenstrual dysphoric disorder: current practices

Premenstrual syndromes (PMS) and especially premenstrual dysphoic disorder (PMDD) affect a large segment of the population of women of reproductive age. Treatment is necessary in approximately 2-10% of women with PMS and PMDD because of the degree of impairment and distress experienced. Treatment modalities are increasingly based on hypotheses concerning possible underlying biological mechanisms: mostly ovulation-related hormonal changes and serotonergic abnormalities. Two treatment modalities distinguish themselves as highly effective: suppression of ovulation and specific serotonin re-uptake inhibitor (SSRI) antidepressants. Suppression of ovulation is effective for a wide range of PMS, while SSRIs are effective for PMDD with some degree of efficacy for physical symptoms. The SSRIs are also efficacious when administered intermittently--only during the luteal phase of the menstrual cycle.

Menopause and perimenopause: the role of ovarian hormones in common neuroendocrine syndromes in primary care

The climacteric and menopause are characterized by erratic fluctuations and decline in ovarian steroid hormones that have broad impact on physical and psychological phenomena leading to a number of clinical syndromes encountered in primary care settings. This endocrine transition is abrupt in women and is not often adequately assessed using objective measures, leading to potential overuse of various medications to treat the physiological and psychological consequences of decline in ovarian hormones. This article reviews such issues and explains how primary care physicians may incorporate the endocrine changes more effectively in their evaluation and treatment of midlife women.

Current management of premenstrual syndrome and premenstrual dysphoric disorder

About 5% of women of reproductive age experience affective or physical premenstrual symptoms that markedly influence work, social activities, or relationships. Prospective charting of symptoms for at least two menstrual cycles is required to facilitate an accurate diagnosis of premenstrual syndrome or premenstrual dysphoric disorder. The optimal treatment plan begins with lifestyle modifications, followed by pharmacotherapy. Evidence from numerous controlled trials has clearly demonstrated that low-dose serotonin reuptake inhibitors, using intermittent or continuous administration, have excellent efficacy with minimal side effects. Modification of the menstrual cycle should be considered only after all other treatment options have failed.

Treating premenstrual dysphoric disorder using serotonin agents

Premenstrual syndrome (PMS) affects 20%-50% of all women. Premenstrual dysphoric disorder (PMDD), which can be conceptualized as a more severe variant of PMS, can affect 3%-9% of all women. Because a significant number of women suffer from premenstrual disorders and afflicted women may spend up to half the month suffering from symptoms, it is important to identify and provide effective treatment for such women. Historically, it has been difficult to distinguish premenstrual disorders from other depressive disorders, given the high comorbidity of the two disorders. Most studies attempt to remove this confounding factor by excluding women with concurrent depressive disorders. Despite the difficulties and limitations inherent in studying treatments for premenstrual disorders, most investigations support the use of serotonin agents in treating PMDD.

Depression and anxiety disorders

Depressive and anxiety disorders are common problems facing obstetrician-gynecologists. Although psychiatric disorders are equally common in men and women, women are at least twice as likely to present with depressive disorders and most anxiety disorders. The depressive disorders include major depression, dysthymia, seasonal affective disorder, and premenstrual dysphoric disorder. The anxiety disorders are panic disorder (with and without agoraphobia), generalized anxiety disorder, social phobia, obsessive compulsive disorder, and PTSD. One must diagnose and manage depressive and anxiety disorders during pregnancy, the purpureum, and while breastfeeding. General treatment principles include assessing suicide risk, psychotherapy, pharmacologic treatment, and an appropriate medical work-up for depressive and anxiety disorders. The SSRIs are the first-line treatment for most depressive and anxiety disorders because of data supporting their efficacy, the minimal need for dosage titration, the overall favorable side-effect profile, and the length of available clinical experience. Newer antidepressants, such as venlafaxine, bupropion, nefazodone, and mirtazapine, are options for patients unresponsive to, or intolerant of, the SSRIs. Treatment considerations include acute, maintenance, and continuation therapy, dosage regimens, adverse effects, and drug interactions. Specific guidelines are available for referring patients to a mental health specialist.