The prevalence of early life trauma in premenstrual dysphoric disorder (PMDD)

The role of the neuroinflammation and stressors in premenstrual syndrome/premenstrual dysphoric disorder: a review

Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are prevalent emotional disorders in females, characterized by cyclic variations in physiological stress responses and emotional symptoms that correspond with the menstrual cycle. Despite extensive research, the underlying causes of these disorders remain elusive. This review delves into the neurobiological mechanisms connecting stress-induced neuroinflammation with PMS/PMDD. Additionally, it traces the conceptual development and historical context of PMS/PMDD. The review further evaluates clinical evidence on the association between PMS/PMDD and stress, along with findings from both clinical and animal studies that link these disorders to inflammatory processes. Additionally, the neurobiological pathways by which inflammatory responses may play a role in the pathogenesis of PMS/PMDD were elucidated, including their interactions with the hypothalamic-pituitary-ovary (HPO) axis, serotonin-kynurenine (5-HT-KYN) system, GABAergic system, brain-derived neurotrophic factor (BDNF), hypothalamic-pituitary-adrena(HPA)axis and. Future research is encouraged to further investigate the pathogenesis of PMS/PMDD through the perspective of neuroinflammatory responses.

Cognition and behaviour across the menstrual cycle in individuals with premenstrual dysphoric disorder - A systematic review

BACKGROUND

Premenstrual Dysphoric Disorder (PMDD) is a cyclical mood disorder whereby symptoms are triggered by normal hormonal changes during the menstrual cycle. A better understanding of psychological changes that occur with PMDD can inform non-pharmacological and non-invasive treatment interventions.

METHODS

A systematic review was conducted of quantitative studies that measured any aspect of cognition or behaviour at a minimum of two time points in the menstrual cycle in those with and without PMDD. A narrative synthesis is reported.

RESULTS

94 outcome measures were extracted from 21 papers and a total participant sample of 1222. Risk of bias was noted in relation to lack of power analysis and inappropriate statistical methods. Cognitive performance was most often tested but evidence of change with PMDD was limited and inconsistent. Findings of studies exploring cognitive processes and content suggest that a negative attentional bias is central to the psychological experience of PMDD.

LIMITATIONS

A quantitative synthesis could not be conducted due to limited reporting of key data.

CONCLUSIONS

Cognitive process, content, and behaviour are likely to be more informative in understanding PMDD than absolute cognitive abilities. Future studies should aim to investigate such in real-time and within the context of daily living.

Cortisol and ACTH response to Dex/CRH testing and 24-hour urine free cortisol levels in women with and without premenstrual dysphoric disorder

Hyperactive and hyperreactive HPA axis functions are frequently reported in depressive disorders, particularly in major depression. However, research into HPA axis function in women with premenstrual dysphoric disorder (PMDD), which is also classified as a depressive disorder, has shown inconsistent results. This study aimed to characterize the HPA axis in women with PMDD using the combined dexamethasone suppression and CRH stimulation (Dex/CRH) test, alongside measurements of 24-hour urine free cortisol (UFC). We enrolled 26 women with prospectively confirmed PMDD and 25 asymptomatic controls (ACs), testing them during the mid-follicular and luteal phases of the menstrual cycle. The primary outcomes included serial plasma cortisol and ACTH levels, their area-under-the-curve (AUC), and 24-hour UFC levels. We utilized a mixed model to compare serial cortisol and ACTH levels, and the Wilcoxon Signed Rank test for comparing UFC levels and cortisol and ACTH AUC. No significant effects related to diagnosis or menstrual cycle phase were observed on plasma cortisol or ACTH levels (from time 0 to +75 minutes), nor on the AUCs of plasma cortisol or ACTH (p > 0.05 for all comparisons). Notably, the PMDD group displayed significantly lower 24-hour UFC levels compared to the AC group during both the follicular and luteal phases (p = 0.0004 and p = 0.0007, respectively). The observed hyposecretion of cortisol in the PMDD group suggests a pathophysiology distinct from other depressive disorders, possibly aligning more closely with stress disorders such as PTSD. The unique symptom profile of PMDD, marked by significant irritability and a more rapid response to antidepressant treatment than is typical in major depression, further supports considering an alternative classification.

Impact of childhood trauma history on premenstrual syndrome in women of reproductive age: A cross-sectional study

AIM

Premenstrual syndrome is a women's health problem affecting women of reproductive age. Early traumas may have negative effects on women's health. Childhood traumas are thought to be an important risk factor for the emergence of premenstrual syndrome. The aim of this study was to investigate the relationship between premenstrual syndrome and childhood traumas in women.

METHOD

This is a cross-sectional study. This study was conducted online between September 2023 and January 2024. The sample of the study consisted of 437 women of reproductive age, between the ages of 18-49, who did not have any obstacles to participating in the study. Personal Information Form, Premenstrual Syndrome Scale and Childhood Trauma Scale were used to collect the data. SPSS statistical program was used to analyze the data. [Correction added on 28 December 2024, after first online publication: In the preceding sentence, 'SPPS' has been corrected to SPSS.] RESULTS: The prevalence of premenstrual syndrome was 55.6%. Emotional neglect, physical abuse, emotional abuse and sexual abuse levels were found to be higher in women with premenstrual syndrome (p < 0.05). It was determined that childhood traumas increased the level of premenstrual syndrome in women (ß = 0.266). Childhood trauma explained 6.8% of the total change in premenstrual syndrome level (R2 = 0.068). Emotional neglect (ß = 0.163) and physical abuse (ß = 0.121) increased the level of premenstrual syndrome.

CONCLUSION

Childhood traumas were found to be an important factor affecting the occurrence of premenstrual syndrome and exacerbating its symptoms. Early detection of childhood traumas may prevent long-term problems that may occur in individuals.

Dimensional Affective Sensitivity to Hormones across the Menstrual Cycle (DASH-MC): A transdiagnostic framework for ovarian steroid influences on psychopathology

Fluctuations in progesterone (P4) and estradiol (E2) across the menstrual cycle can exert direct effects on biological systems implicated in neuropsychiatric disorders and represent a key biological source of variability in affective, cognitive, and behavioral disorders. Although these cyclical symptoms may be most readily identified when they occur exclusively in relation to the menstrual cycle, as in DSM-5 premenstrual dysphoric disorder, symptom changes of similar magnitude occur in a larger proportion of people with ongoing psychiatric disorders. Studies investigating cyclical regulation of brain and behavior often produce inconsistent results, which may be attributed to a lack of focus on specific hormonal events and individual differences in related sensitivities. We propose a transdiagnostic Dimensional Affective Sensitivity to Hormones across the Menstrual Cycle (DASH-MC) framework, postulating that atypical neural responses to several key hormonal events provoke specific temporal patterns of affective and behavioral change across the menstrual cycle. We review prospective and experimental evidence providing initial support for these dimensions, which include (1) luteal-onset negative affect caused by a sensitivity to E2 or P4 surges (mediated by neuroactive metabolites such as allopregnanolone), typified by irritability and hyperarousal; (2) perimenstrual-onset negative affect caused by a sensitivity to low or falling E2, typified by low mood and cognitive dysfunction; and (3) preovulatory-onset positive affect dysregulation caused by a sensitivity to E2 surges, typified by harmful substance use and other risky reward-seeking. This multidimensional, transdiagnostic framework for hormone sensitivity can inform more precise research on ovarian steroid regulation of psychopathology, including further mechanistic research, diagnostic refinement, and precision psychiatry treatment development. Additionally, given the high rates of hormone sensitivity across affective disorders, the DASH-MC may guide broader insights into the complex neurobiological vulnerabilities driving female-biased affective risk, as well as potential triggers and mechanisms of affective state change in psychiatric disorders.

Association of preconception premenstrual disorders with perinatal depression: an analysis of the perinatal clinical database of a single Japanese institution

BACKGROUND

Recent studies have identified premenstrual disorders (PMDs) as a risk factor for postpartum depression. However, routine screening for preconception PMDs is not yet common in Japan. This study investigated the association between preconception PMDs and perinatal depression in a single tertiary care setting.

METHODS

We analyzed data from pregnant women who gave birth at Kyoto University Hospital between April 2020 and October 2023. The Premenstrual Symptoms Screening Tool was administered at the first postconception visit to retrospectively assess PMD status before the current pregnancy. The Edinburgh Postnatal Depression Scale (EPDS) was administered during pregnancy and one month postpartum as a prospective measure of perinatal depression. EPDS cutoff values were set at 12/13 during pregnancy and 8/9 at one month postpartum.

RESULTS

Of the 781 women analyzed, 53 had preconception PMD. Univariate and multivariate logistic regression analyses revealed that preconception PMD was associated with an EPDS score of ≥ 13 during pregnancy, with a crude odds ratio (OR) of 5.78 (95% confidence interval [CI]: 2.70-11.75) and an adjusted OR of 3.71 (95% CI: 1.54-8.35). For an EPDS score of ≥ 9 at 1 month postpartum, the crude OR was 3.36 (95% CI: 1.79-6.12) and the adjusted OR was 2.16 (95% CI: 1.04-4.35).

CONCLUSIONS

Our findings indicate that preconception PMDs are a significant risk factor for both depression during pregnancy and postpartum depression. These results support the implementation of preconception PMD screening during antenatal checkups as a preventive measure and to identify women in need of early mental health care.

The prevalence of traumatic exposure in women with premenstrual dysphoric disorder (PMDD): a systematic review

BACKGROUND AND PURPOSE

Premenstrual dysphoric disorder (PMDD) is a debilitating illness that affects 3-8% of women worldwide. There are multiple factors underlying the aetiology of PMDD, ranging from neuroendocrine changes to psychosocial factors such as exposure to trauma. This systematic review aims to assess the prevalence of traumatic exposure in women with PMDD.

METHODS

A literature search of MEDLINE, EMBASE and PsycInfo was conducted following PRISMA guidelines. Of the 369 studies identified for abstract and full-text screening, 27 were included for review and 16 studies for the quantitative calculation of average prevalence and 95% confidence intervals. Data extracted included study details, sampling details, demographic details, type of traumatic exposure reported, diagnostic tools used, the prevalence of PMDD (total) and the prevalence of self-reported traumatic exposure in PMDD patients.

RESULTS

The reported prevalence of traumatic exposure in PMDD ranged from 18.03 to 90.5%. Using a random effects model, the pooled prevalence was 61% (95%CI, 46-74%). The level of heterogeneity (I2) was 95%, showing considerable variability in the data. Amongst only those studies with a control group, it was shown that those with PMDD are 1.99 times more likely to have a history of traumatic exposure than those without PMDD.

CONCLUSION

Our findings suggest that a history of traumatic exposure is highly represented in women living with PMDD. Trauma exposure may be a risk factor for PMDD and could inform this condition's aetiology. A trauma-informed approach should be considered when assessing and managing women presenting with PMDD.

The link between childhood traumatic events and the continuum of premenstrual disorders

Background

Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD), collectively known as Premenstrual Disorders (PMDs), cause significant distress and functional impairment, and premenstrual exacerbation (PME) affects a large proportion of women with psychiatric diagnoses. Childhood trauma is one factor that may contribute to PMD/PME risk. This study examines the relationship between childhood trauma and PMDs, PME, and non-PMD psychiatric illness.

Methods

This study is a secondary analysis of data from a prospective cohort. Participants completed self-assessments on childhood trauma using the Childhood Traumatic Event Scale (CTE-S) and on premenstrual symptoms using the Premenstrual Symptoms Screening Tool (PSST). Psychiatric diagnoses were assessed through structured clinical interviews. Participants were divided into four groups based on their PSST scores and psychiatric illness status: (1) Premenstrual Disorders (PMDs; moderate to severe PMS and PMDD), (2) PME, (3) psychiatric controls (PC; individuals with psychiatric illness but no significant premenstrual symptoms), and (4) healthy controls (HC; individuals with no psychiatric illness and no significant premenstrual symptoms). Statistical analyses, including ANOVA, Tukey's HSD test, Fisher's exact test, and logistic regression, were conducted to examine differences among the groups.

Results

Data from 391 participants were analyzed. Participants with PME and PC reported a higher quantity and severity of childhood traumatic events compared to HCs (p <.05). There was a weak but significant correlation between childhood trauma and premenstrual symptom burden across all groups (R = .18, p <.001). Within-group analysis revealed moderate correlations between childhood trauma and premenstrual symptoms driven by the PMD group (R = .42, p = .01).

Conclusions

The findings underscore the impact of childhood traumatic events on mental health and premenstrual symptoms and highlight the need for additional research to explore the underlying mechanisms linking childhood trauma to the continuum of premenstrual disorders, to improve the efficacy of trauma-focused interventions for affected individuals.

Bridging early life trauma to difficult-to-treat depression: scoping review

AIMS AND METHOD

Accumulating evidence suggests that early life trauma (ELT) initiates and perpetuates a cycle of depression, leading to challenges in management and achieving remission. This scoping review aimed to examine the intricate relationship between ELT and difficult-to-treat depression (DTD). An extensive literature search from 1 January 2013 to 21 October 2023 was conducted using the Cochrane Library, PubMed, Scopus, PsycINFO and OpenGrey.

RESULTS

Our review identified scientific literature illustrating the multifaceted link between ELT and DTD, highlighting the dual impact of ELT on therapeutic resistance and clinical complexity.

CLINICAL IMPLICATIONS

This complexity hampers management of patients with DTD, who are characterised by limited pharmacological responsiveness and heightened relapse risk. While exploring the ELT-DTD nexus, the review revealed a paucity of literature on the impact of ELT within DTD. Findings underscore the profound link between ELT and DTD, which is essential for comprehensive understanding and effective management. Tailoring treatments to address ELT could enhance therapeutic outcomes for patients with DTD. Future studies should use larger samples and well-defined diagnostic criteria and explore varied therapeutic approaches.

Early Life Trauma, Emotion Dysregulation and Hormonal Sensitivity Across Female Reproductive Life Events

PURPOSE OF REVIEW

To explore the relationship between early life trauma, hormonal sensitivity, and psychiatric disorders across female-reproductive life events, with a focus on the neurobiological mechanisms.

RECENT FINDINGS

Childhood trauma significantly increases the risk of subsequent mood disorders during periods of intense hormonal fluctuation such as premenstrual, pregnancy, postpartum, and perimenopause. Neurobiological changes resulting from early trauma influence emotion regulation, which emerges as a key predisposing, exacerbating, and perpetuating factor to hormonal sensitivity and subsequent psychiatric symptoms. We identified altered stress response and allopregnanolone imbalance, bias in cognitive processing of emotions, neuroimage correlates and sleep disturbances as potential underlying neurobiological mechanisms. This review integrates cumulative findings supporting a theoretical framework linking early life trauma to hormonal sensitivity and mood disorders. We propose that some women might be more susceptible to such hormonal fluctuations because of emotion dysregulation following significant early life trauma.

Clinical Correlates of Premenstrual Suicidal Ideation Among Women in Makkah Population

Introduction Suicidal ideation (SI), planning, and attempts have been found to be more common in women with premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). This study assessed the association between PMS, PMDD, and SI within the Makkah population, in Saudi Arabia. Methodology A descriptive cross-sectional study that simply characterizes the prevalence of a health outcome in a specified population was done on 733 women using an online questionnaire. Data about demographics, menstrual cycle, PMS, past psychiatric history, prior history of PMDD, and previous drug treatment for PMDD were collected. The chi-square and Fisher exact tests were applied. Results Of the participants, 540 (73.7%) had an age represented the age of 18-25 years old, 551 (75.2%) were single, 592 (80.8%) did not have children, 352 (48.0%) had a four-year college education, and 552 (75.3%) had a monthly income of less than 5000 SR. Exactly 704 (96.0%) were menstruating, 539 (73.5%) had regular menstrual cycles, 640 (87.3%) reported low shock trauma, 201 (27.4%) reported a history of anxiety, and 541 (73.8%) reported an impact of premenstrual disorders on mental health. Of them, 662 (90.3%) experienced premenstrual symptoms, 53 (7.2%) had a previous diagnosis of premenstrual symptoms, and 62 (8.5%) had a history of a suicide attempt. Those aged 18 to 25 years, who have no children, have a monthly income of less than 5000, are unemployed, have irregular menstruation, have medical interventions due to premenstrual symptoms, have a lifelong history of depression or anxiety, and have a history of high shock trauma had a significantly higher prevalence of a history of a suicide attempt. These factors were independent predictors on regression analysis. Conclusion The link between PMD and the likelihood of suicide attempts highlights how crucial it is to treat severe PMDs in the context of mental health.

The role of the hypothalamic-pituitary-adrenal axis in depression across the female reproductive lifecycle: current knowledge and future directions

The aim of this narrative review is to consolidate knowledge on the role of the hypothalamic-pituitary-adrenal (HPA) axis in depression pathophysiology at different reproductive stages across the female lifespan. Despite growing evidence about the impact of gonadal hormones on mood disorders, no previous review has examined the interaction between such hormonal changes and the HPA axis within the context of depressive disorders in women. We will focus on HPA axis function in depressive disorders at different reproductive stages including the menstrual cycle (e.g., premenstrual dysphoric disorder [PMDD]), perinatally (e.g., postpartum depression), and in perimenopausal depression. Each of these reproductive stages is characterized by vast physiological changes and presents major neuroendocrine reorganization. The HPA axis is one of the main targets of such functional alterations, and with its key role in stress response, it is an etiological factor in vulnerable windows for depression across the female lifespan. We begin with an overview of the HPA axis and a brief summary of techniques for measuring HPA axis parameters. We then describe the hormonal milieu of each of these key reproductive stages, and integrate information about HPA axis function in depression across these reproductive stages, describing similarities and differences. The role of a history of stress and trauma exposure as a contributor to female depression in the context of HPA axis involvement across the reproductive stages is also presented. This review advances the pursuit of understanding common biological mechanisms across depressive disorders among women. Our overarching goal is to identify unmet needs in characterizing stress-related markers of depression in women in the context of hormonal changes across the lifespan, and to support future research in women's mental health as it pertains to pathophysiology, early diagnosis, and treatment targets.

Childhood adversity predicts stronger premenstrual mood worsening, stress appraisal and cortisol decrease in women with Premenstrual Dysphoric Disorder

Background

Lifetime traumatic events are prevalent in women with Premenstrual Dysphoric Disorder (PMDD) and predict stronger premenstrual symptom intensities. Less is known about the unique effects of childhood adversity on PMDD. This study aims to investigate the menstrual cycle related course of mood, stress appraisal and cortisol activity over time and the effects of childhood adversity - by controlling for recent stressful life events - on the cyclicity of these outcomes.

Methods

Fifty-two women with PMDD completed questionnaires on childhood adversity and stressful life events during the past 12 months. Momentary negative and positive affect, stress appraisal, and saliva-cortisol were assessed within an Ambulatory Assessment (AA) design over four consecutive days during both the follicular and the late luteal phase. This AA was repeated after five months, resulting in two measurement bursts.

Results

Women with PMDD showed expected cycle related variations in mood and stress appraisal, whereby these effects weakened over time. No cortisol cyclicity was identified. Higher childhood adversity was linked to stronger increases in negative affect and stress appraisal, and stronger decreases in positive affect from the follicular toward the late luteal phase. Women with higher childhood adversity exhibited lower cortisol levels during the late luteal phase compared to the follicular phase whereas no such cyclicity was found in women with lower childhood adversity.

Conclusion

Childhood adversity appears to show independent deteriorating effects on premenstrual mood worsening and stress appraisal in women with PMDD. The observed cortisol cyclicity in women with higher childhood adversity may point to different neuroendocrine subtypes of PMDD in relation to childhood trauma and requires further systematic research.

Does Symptom-Onset Treatment With Sertraline Improve Functional Impairment for Individuals With Premenstrual Dysphoric Disorder?: A Randomized Controlled Trial

PURPOSE/BACKGROUND

Daily treatment with sertraline improves functional impairment among individuals with premenstrual dysphoric disorder (PMDD). We do not know whether treatment initiated at symptom onset also improves functional impairment.

METHODS/PROCEDURES

This 3-site, double blind, randomized, clinical trial compared sertraline (25-100 mg) to similar appearing placebo, both administered at symptom onset, for reduction of PMDD symptoms. Ninety participants were allocated to sertraline and 94 participants to placebo. Functional outcomes from the Daily Ratings of the Severity of Problems included (1) reduced productivity or efficiency at work, school, home, or daily routine; (2) interference with hobbies or social activities; and (3) interference with relationships. Items were measured from 1 (no interference) to 6 (extreme interference) and averaged for the final 5 luteal phase days. This secondary analysis examined whether improvement in functional domains was greater for those allocated to sertraline compared with placebo. Second, we used causal mediation analyses to explore whether specific PMDD symptoms mediated functional improvement.

RESULTS/FINDINGS

Only relationship functioning improved significantly with active treatment between baseline and the end of the second cycle (active group mean [SD] change, -1.39 [1.38]; placebo group mean change, -0.76 [1.20]; β = -0.40; SE, 0.15; P = 0.009). The total effect of treatment on interference was -0.37 (95% confidence interval [CI], -0.66 to -0.09; P = 0.011). Given the nonsignificant direct effect (0.11; 95% CI, -0.07 to 0.29; P = 0.24) and significant indirect effect (-0.48; 95% CI, -0.71 to -0.24; P < 0.001), amelioration of anger/irritability likely mediated reductions in relationship interference.

IMPLICATIONS/CONCLUSIONS

That anger/irritability mediates impairments in relationship functioning has face validity but should be replicated in other data sets.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT00536198 .

New Pharmacological Approaches to the Management of Premenstrual Dysphoric Disorder

Premenstrual symptoms are experienced by many female individuals during their fertile age. Premenstrual dysphoric disorder (PMDD), a sex-specific mood disorder, affects about 5% of female individuals during the luteal phase of the menstrual cycle. Treatment with selective serotonin reuptake inhibitors represents a valid solution to manage PMDD for many, but not all, patients. Owing to maladaptive neural reactivity to gonadal hormone fluctuations, that is, the putative mechanism postulated to underlie PMDD, drugs suppressing or stabilizing such variations have been tested. Recently, a clinically significant reduction in the severity of the mental symptoms of PMDD was observed upon treatment with a selective progesterone receptor modulator (SPRM), as demonstrated when comparing ulipristal acetate with placebo in a randomised controlled trial. Stable and low progesterone levels, with maintained low-medium oestradiol levels, define the endocrine profile of this treatment. Importantly, the efficacy of SPRM treatment was accompanied by negligible side effects. These promising results represent a headway to understanding the mechanisms behind PMDD symptomatology and opening up new solutions in the management of PMDD. They also call for studies on the long-term efficacy, safety, and viability of SPRMs in female individuals during their fertile age to further support the development of targeted management of female's mental ill-health in relation to the menstrual cycle. The present overview thus seeks to inform about current and new pharmacological approaches to the management of premenstrual dysphoric disorder.