Genetic and environmental factors in the aetiology of menstrual, premenstrual and neurotic symptoms: a population-based twin study

Unveiling the Neurotransmitter Symphony: Dynamic Shifts in Neurotransmitter Levels during Menstruation

The menstrual cycle is an intricate biological process governed by hormonal changes that affect different facets of a woman's reproductive system. This review provides an overview of neurotransmitter alterations during different menstrual cycle phases and their effects on physiology and psychology. During the follicular phase, rising estrogen levels increase serotonin synthesis, enhancing mood, cognition, and pain tolerance. Estrogen may also influence dopamine levels, promoting motivation and reward sensitivity. GABA, involved in anxiety regulation, may be modulated by estrogen, inducing relaxation. Ovulation involves fluctuating dopamine and serotonin levels, potentially affecting motivation and positive mood. In the luteal phase, rising estrogen and progesterone may reduce serotonin availability, contributing to mood dysregulation, while enhanced GABAergic neurotransmission promotes sedation. Menstruation is characterized by declining estrogen and progesterone, potentially leading to mood disturbances, fluctuating GABAergic and dopaminergic neurotransmitter systems, relaxation, fatigue, motivation, and pleasure variations. Understanding neurotransmitter alterations during the menstrual cycle unveils the neurobiological mechanisms behind menstrual-related symptoms and disorders, facilitating targeted interventions. Pharmacological approaches targeting neurotransmitter systems, nutritional interventions, and lifestyle modifications show promise in managing menstrual symptoms. Future research should focus on further understanding neurotransmitter dynamics, personalized medicine, unexplored neurotransmitter roles, and integrating psychosocial factors. This knowledge will enhance well-being and quality of life for individuals experiencing menstrual-related challenges.

Diagnostic validity of premenstrual dysphoric disorder: revisited

The World Health Organization (WHO) and American Psychiatric Association (APA) have recognised premenstrual dysphoric disorder (PMDD) as an independent diagnostic entity, legitimising the distress and socio-occupational impairment experienced by affected women. However, the biological validity of this diagnosis remains inexplicit. This illness has also been criticised for a feminist-led, sympathetic reaction to the modern cultural challenges of urban, literate, employed, high-functioning women. This article systematically reviews existing literature on PMDD using the criteria established by Robins and Guze for the validity of a psychiatric diagnosis (clinical description, laboratory study, exclusion of other disorders, follow-up study, and family study). Despite the early recognition of premenstrual syndrome (PMS) in the 1950s, the research has encountered challenges due to two groups of proponents viewing it with psychologising bias and medicalising bias. PMDD is currently understood as the most severe form of PMS, characterised by the presence of psychological features. Recent evidence suggests that PMDD perhaps has neurodevelopmental underpinnings (attention deficit hyperactive disorder, adverse childhood experiences) affecting the fronto-limbic circuit that regulates the emotions. In addition, the affected individuals exhibit an increased sensitivity to gonadal hormonal fluctuations as observed during premenstrual, pregnancy, and perimenopausal phases of life. The prevalence is comparable between high-income countries and low- and middle-income countries (LAMIC), refuting the notion that it mostly affects modern women. Instead, a greater prevalence is observed in LAMIC. Despite the fact that educated women possess knowledge regarding the importance of getting help, there is a prevalent issue of inadequate help-seeking behaviour. This can be attributed to the perception of seeking help as an isolating experience, which is influenced by profound internalised stigma and discrimination in the workplace. Future studies must aim to develop culturally validated assessment tools and more research to understand the life course of the illness, in addition to systematically examining for more biological validators (animal models, genetics, imaging, neurotransmitters).

Towards understanding the biology of premenstrual dysphoric disorder: From genes to GABA

Premenstrual dysphoric disorder (PMDD) is a severe mood disorder, with affective symptoms that rise and fall in concert with the hormonal fluctuations of the menstrual cycle. PMDD's pathophysiology is poorly understood. This review describes recent research on potential biological contributors to PMDD, with a focus on neuroactive steroids, genetics, neuroimaging and cellular studies. Studies suggest that a key contributor is abnormal central nervous system (CNS) response to fluctuations in neuroactive steroid hormones. Imaging studies are limited but support alterations in serotonergic and GABA transmission. Genetic studies suggest heritability, yet specific genetic contributors have not been characterized. Finally, recent cutting-edge cellular studies indicate an underlying vulnerability to the effect of sex hormones at a cellular level. Overall the findings across studies do not yet fit together into a complete description of the underlying biology of PMDD. It is possible that PMDD consists of biological subtypes, and future research may benefit from a subtyping approach.

Study protocol of DIVERGE, the first genetic epidemiological study of major depressive disorder in Pakistan

INTRODUCTION

Globally, 80% of the burdenof major depressive disorder (MDD) pertains to low- and middle-income countries. Research into genetic and environmental risk factors has the potential to uncover disease mechanisms that may contribute to better diagnosis and treatment of mental illness, yet has so far been largely limited to participants with European ancestry from high-income countries. The DIVERGE study was established to help overcome this gap and investigate genetic and environmental risk factors for MDD in Pakistan.

METHODS

DIVERGE aims to enrol 9000 cases and 4000 controls in hospitals across the country. Here, we provide the rationale for DIVERGE, describe the study protocol and characterise the sample using data from the first 500 cases. Exploratory data analysis is performed to describe demographics, socioeconomic status, environmental risk factors, family history of mental illness and psychopathology.

RESULTS AND DISCUSSION

Many participants had severe depression with 74% of patients who experienced multiple depressive episodes. It was a common practice to seek help for mental health struggles from faith healers and religious leaders. Socioeconomic variables reflected the local context with a large proportion of women not having access to any education and the majority of participants reporting no savings.

CONCLUSION

DIVERGE is a carefully designed case-control study of MDD in Pakistan that captures diverse risk factors. As the largest genetic study in Pakistan, DIVERGE helps address the severe underrepresentation of people from South Asian countries in genetic as well as psychiatric research.

Primary dysmenorrhoea in adolescents and young women: A twin family study of maternal transmission, genetic influence and associations

AIMS

The extent to which maternal transmission of primary dysmenorrhoea is genetically determined in adolescents and young women has yet to be determined. We aimed to assess heritability and associations relevant to primary pain syndromes using a twin family study.

METHODS

Participants were young menstruating female twins, and their oldest sisters and mothers, whose families were registered with Twins Research Australia and previously participated in a twin family study of primary paediatric pain disorders. Questionnaire packs were mailed, assessing current maximum and average menstrual pain intensity, current pain interference with activities and retrospective dysmenorrhea secondary symptoms.

RESULTS

The sample comprised 206 twin individuals (57 monozygous (MZ) and 46 dizygous (DZ) pairs) aged 10-22 years, eldest siblings (n = 38) aged 13-28 years and mothers (n = 101) aged 32-61 years. The estimated regression coefficient of the relationship between mother-daughter and twin-sibling dyads indicated significant associations for the measures of dysmenorrhea and supported heritability. Adjusted for age, the within twin-pair correlation for MZ twins was generally more than twice that of DZ twins. Heritability estimates were maximal pain intensity 0.67 (P = 3.8 × 10^-11 ), average pain intensity 0.63 (P = 3.7 × 10^-10 ), pain interference 0.57 (P = 1.8 × 10^-8 ) and retrospective symptoms 0.57 (P = 1.8 × 10^-8 ). Twin individuals with a lifetime (three-month) history of iron deficiency and those with painless restless legs syndrome (RLS) were significantly more likely to have more intense pain associated with menstruation.

CONCLUSION

Primary dysmenorrhea in adolescents and young women was shown to be relatively strongly genetically influenced and associated especially with a history of iron deficiency and painless RLS which have potential therapeutic implications.

Using i-vectors from voice features to identify major depressive disorder

BACKGROUND

Machine-learning methods using acoustic features in the diagnosis of major depressive disorder (MDD) have insufficient evidence from large-scale samples and clinical trials. This study aimed to evaluate the effectiveness of the promising i-vector method on a large sample of women with recurrent MDD diagnosed clinically, examine its robustness, and provide an explicit acoustic explanation of the i-vectors.

METHODS

We collected utterances edited from clinical interview speech records of 785 depressed and 1,023 healthy individuals. Then, we extracted Mel-frequency cepstral coefficient (MFCC) features and MFCC i-vectors from their utterances. To examine the effectiveness of i-vectors, we compared the performance of binary logistic regression between MFCC i-vectors and MFCC features and tested its robustness on different utterance durations. We also determined the correlation between MFCC features and MFCC i-vectors to analyze the acoustic meaning of i-vectors.

RESULTS

The i-vectors improved 7% and 14% of area under the curve (AUC) for MFCC features using different utterances. When the duration is > 40 s, the classification results are stabilized. The i-vectors are consistently correlated to the maximum, minimum, and deviations of MFCC features (either positively or negatively).

LIMITATIONS

This study included only women.

CONCLUSIONS

The i-vectors can improve 14% of the AUC on a large-scale clinical sample. This system is robust to utterance duration > 40 s. This study provides a foundation for exploring the clinical application of voice features in the diagnosis of MDD.

Premenstrual disorders

Premenstrual disorders include premenstrual syndrome, premenstrual dysphoric disorder, and premenstrual worsening of another medical condition. While the underlying causes of these conditions continue to be explored, an aberrant response to hormonal fluctuations that occurs with the natural menstrual cycle and serotonin deficits have both been implicated. A careful medical history and daily symptom monitoring across 2 menstrual cycles is important in establishing a diagnosis. Many treatments have been evaluated for the management of premenstrual disorders. The most efficacious treatments for premenstrual syndrome and premenstrual dysphoric disorder include serotonin reuptake inhibitors and contraceptives with shortened to no hormone-free interval. Women who do not respond to these and other interventions may benefit from gonadotropin-releasing hormone agonist treatment.

Reproductive Affective Disorders: a Review of the Genetic Evidence for Premenstrual Dysphoric Disorder and Postpartum Depression

PURPOSE OF REVIEW

The purpose of this study is to review and summarize the literature exploring the genetic basis for premenstrual dysphoric disorder (PMDD) and postpartum depression (PPD).

RECENT FINDINGS

There is more evidence for a genetic basis for PPD than for PMDD, but only when PPD is defined as beginning in the immediate postpartum time period. Familial, genome-wide linkage and association studies, and candidate gene studies, most in the past 10 years, have examined the genetic etiology of reproductive affective disorders, including PMDD and PPD. The most commonly studied genes include SERT, COMT, MAOA, BDNF, and ESR1 and 2. This qualitative review of the recent literature finds limited evidence so far for the genetic basis for PMDD, with both familial and candidate gene studies having negative or conflicting results. Evidence is stronger for the genetic basis for PPD, with positive associations found in family studies and in several genes associated with major depression as well as genes involved in estrogen signaling but only when PPD onset is shortly after delivery. Epigenetic biomarkers on genes responsive to estrogen have also been found to predict PPD. Our findings underscore the need for additional studies with larger samples, as well as the crucial importance of timing in the definition of PPD for genetic studies.

The ESC/E(Z) complex, an effector of response to ovarian steroids, manifests an intrinsic difference in cells from women with premenstrual dysphoric disorder

Clinical evidence suggests that mood and behavioral symptoms in premenstrual dysphoric disorder (PMDD), a common, recently recognized, psychiatric condition among women, reflect abnormal responsivity to ovarian steroids. This differential sensitivity could be due to an unrecognized aspect of hormonal signaling or a difference in cellular response. In this study, lymphoblastoid cell line cultures (LCLs) from women with PMDD and asymptomatic controls were compared via whole-transcriptome sequencing (RNA-seq) during untreated (ovarian steroid-free) conditions and following hormone treatment. The women with PMDD manifested ovarian steroid-triggered behavioral sensitivity during a hormone suppression and addback clinical trial, and controls did not, leading us to hypothesize that women with PMDD might differ in their cellular response to ovarian steroids. In untreated LCLs, our results overall suggest a divergence between mRNA (for example, gene transcription) and protein (for example, RNA translation in proteins) for the same genes. Pathway analysis of the LCL transcriptome revealed, among others, over-expression of ESC/E(Z) complex genes (an ovarian steroid-regulated gene silencing complex) in untreated LCLs from women with PMDD, with more than half of these genes over-expressed as compared with the controls, and with significant effects for MTF2, PHF19 and SIRT1 (P<0.05). RNA and protein expression of the 13 ESC/E(Z) complex genes were individually quantitated. This pattern of increased ESC/E(Z) mRNA expression was confirmed in a larger cohort by qRT-PCR. In contrast, protein expression of ESC/E(Z) genes was decreased in untreated PMDD LCLs with MTF2, PHF19 and SIRT1 all significantly decreased (P<0.05). Finally, mRNA expression of several ESC/E(Z) complex genes were increased by progesterone in controls only, and decreased by estradiol in PMDD LCLs. These findings demonstrate that LCLs from women with PMDD manifest a cellular difference in ESC/E(Z) complex function both in the untreated condition and in response to ovarian hormones. Dysregulation of ESC/E(Z) complex function could contribute to PMDD.

Genetic and Environmental Structure of DSM-IV Criteria for Antisocial Personality Disorder: A Twin Study

Results from previous studies on DSM-IV and DSM-5 Antisocial Personality Disorder (ASPD) have suggested that the construct is etiologically multidimensional. To our knowledge, however, the structure of genetic and environmental influences in ASPD has not been examined using an appropriate range of biometric models and diagnostic interviews. The 7 ASPD criteria (section A) were assessed in a population-based sample of 2794 Norwegian twins by a structured interview for DSM-IV personality disorders. Exploratory analyses were conducted at the phenotypic level. Multivariate biometric models, including both independent and common pathways, were compared. A single phenotypic factor was found, and the best-fitting biometric model was a single-factor common pathway model, with common-factor heritability of 51% (95% CI 40-67%). In other words, both genetic and environmental correlations between the ASPD criteria could be accounted for by a single common latent variable. The findings support the validity of ASPD as a unidimensional diagnostic construct.

Sex differences in anxiety and depression clinical perspectives

Sex differences are prominent in mood and anxiety disorders and may provide a window into mechanisms of onset and maintenance of affective disturbances in both men and women. With the plethora of sex differences in brain structure, function, and stress responsivity, as well as differences in exposure to reproductive hormones, social expectations and experiences, the challenge is to understand which sex differences are relevant to affective illness. This review will focus on clinical aspects of sex differences in affective disorders including the emergence of sex differences across developmental stages and the impact of reproductive events. Biological, cultural, and experiential factors that may underlie sex differences in the phenomenology of mood and anxiety disorders are discussed.

Gene x environment interactions impact endometrial function and the menstrual cycle: PROGINS, life history, anthropometry, and physical activity

OBJECTIVES

We assessed the impact of a high frequency, functionally significant allelic variant of the progesterone receptor gene (PROGINS) on endometrial function and menstrual cycle characteristics. Further we asked whether PROGINS moderates the impact of life history characteristics, anthropometric measures, and physical activity on endometrial function.

METHODS

Fifty-two women were genotyped for the PROGINS variant, provided life history information, and had anthropometric measurements made. Women monitored their menstrual bleeding for three cycles, performed mid-cycle urinary ovulation tests, and recorded physical activity. A subset of women provided daily saliva samples and had mid-luteal endometrial thickness measurements taken during the third menstrual cycle. Salivary progesterone was assayed using ELISAs. The direct impact of PROGINS on endometrial and menstrual cycle characteristics was determined via independent t-tests with Bonferroni correction. Interactions between PROGINS and covariates were assessed by moderated regression.

RESULTS

PROGINS did not directly impact any indicator of endometrial function. However, PROGINS caused an increase in menstrual cycle length with increasing mid-luteal progesterone levels; the opposite relationship was present in noncarriers (P < 0.05). Additionally, PROGINS interacted with four of six anthropometric measures (BMI, waist circumference, height, and waist-hip ratio) to impact endometrial function, however, interactions between PROGINS and life history variables, or physical activity was limited.

CONCLUSIONS

The gene x environment interactions we report suggest that PROGINS alters endometrial sensitivity to maternal energetic condition. Thus, the possibility of genetically-based variation in sensitivity to energetic stress should be considered in future adaptive models of women's reproduction.

Menstrual cycle phase modulates emotional conflict processing in women with and without premenstrual syndrome (PMS)--a pilot study

Background

Premenstrual syndrome (PMS) is characterized by a cluster of psychological and somatic symptoms during the late luteal phase of the menstrual cycle that disappear after the onset of menses. Behavioral differences in emotional and cognitive processing have been reported in women with PMS, and it is of particular interest whether PMS affects the parallel execution of emotional and cognitive processing. Related to this is the question of how the performance of women with PMS relates to stress levels compared to women without PMS. Cortisol has been shown to affect emotional processing in general and it has also been shown that women with severe PMS have a particular cortisol profile.

Methods

We measured performance in an emotional conflict task and stress levels in women with PMS (n = 15) and women without PMS (n = 15) throughout their menstrual cycle.

Results

We found a significant increase (p = 0.001) in the mean reaction time for resolving emotional conflict from the follicular to the luteal cycle phase in all subjects. Only women with PMS demonstrated an increase in physiological and subjective stress measures during the luteal menstrual cycle phase.

Conclusions

Our findings suggest that the menstrual cycle modulates the integration of emotional and cognitive processing in all women. Preliminary data are supportive of the secondary hypothesis that stress levels are mediated by the menstrual cycle phase only in women with PMS. The presented evidence for menstrual cycle-specific differences in integrating emotional and cognitive information highlights the importance of controlling for menstrual cycle phase in studies that aim to elucidate the interplay of emotion and cognition.

Should psychiatrists be prescribing oestrogen therapy to their female patients?

Some studies have indicated that oestrogen therapy may be beneficial in the treatment of a number of neuropsychiatric disorders. However, it has been suggested that psychiatrists fail to prescribe oestrogen therapy to their patients, as they are 'not aware of' or 'do not believe' studies supporting their use. This paper reappraises the putative role of hormone treatments, particularly oestrogen therapy, in psychiatry.

Variant brain-derived neurotrophic factor (Valine66Methionine) polymorphism contributes to developmental and estrous stage-specific expression of anxiety-like behavior in female mice

BACKGROUND

Most anxiety and depressive disorders are twice as common in women compared with men, and the sex difference in prevalence typically emerges during adolescence. Hormonal changes across the menstrual cycle and during the postpartum and perimenopausal periods are associated with increased risk for anxiety and depression symptoms. In humans and animals, reduced brain-derived neurotrophic factor (BDNF) has been associated with increased expression of affective pathology. Recently, a single nucleotide polymorphism (SNP) in the BDNF gene (BDNF Valine66Methionine [Val66Met]), which reduces BDNF bioavailability, has been identified in humans and associated with a variety of neuropsychiatric disorders. Although BDNF expression can be directly influenced by estrogen and progesterone, the potential impact of the BDNF Val66Met SNP on sensitivity to reproductive hormone changes remains an open question.

METHODS

As a predictive model, we used female mice in which the human SNP (BDNF Val66Met) was inserted into the mouse BDNF gene. Using standard behavioral paradigms, we tested the impact of this SNP on age and estrous-cycle-specific expression of anxiety-like behaviors.

RESULTS

Mice homozygous for the BDNF Val66Met SNP begin to exhibit increased anxiety-like behaviors over prepubertal and early adult development, show significant fluctuations in anxiety-like behaviors over the estrous cycle, and, as adults, differ from wild-type mice by showing significant fluctuations in anxiety-like behaviors over the estrous cycle-specifically, more anxiety-like behaviors during the estrus phase.

CONCLUSIONS

These findings have implications regarding the potential role of this SNP in contributing to developmental and reproductive hormone-dependent changes in affective disorders in humans.

Genetic and environmental determinants of menstrual characteristics

BACKGROUND

The impact of women's menstrual cycle on her quality of life, health, work, and community is substantial. Menstrual disturbance is linked with general ill conditions such as migraine, asthma, and endocrinopathies. The clinical significance of medical interventions to prevent these conditions becomes clear if the role of genetic or environment is clarified.

AIMS

To identify the genetic and environmental contribution on menstrual characteristics.

SETTING AND DESIGN

This was a cross-sectional study in 2 Asian countries.

MATERIALS AND METHODS

2 cohorts of monozygotic and dizygotic twins born between (1945-1988, n = 122) and (1951-1993, n = 71) were taken. A standard questionnaire was designed inclusive of socio- demographic characteristics of subjects as well as menstrual history (duration, interval, amount, irregularity). Subjects were interviewed by phone.

STATISTICAL ANALYSIS

Quantitative variables were analyzed using Falconars' formula as well as maximum likelihood analysis. Structural modeling was then applied to twin correlations to provide estimates of the relative genetic and/or environmental factors contribution in determining the measured trait.

RESULTS

Menstrual characteristics were found to be under environmental influence where the best fitting model for menstrual interval and duration was common environment. CDF plotting confirmed the results for both variables. Proband-wise concordance analysis for amount of menstruation, amenorrhea, and irregular menstruation revealed no genetic influence. The best fitting model for menstrual irregularity was CE (C73%, E27%). The same model was defined for amenorrhea (C48%, E52%).

CONCLUSIONS

Environmental factors are most likely responsible to determine the menstrual flow, its integrity, and regularity. These factors need to be studied further.

Premenstrual dysphoric disorder: evidence for a new category for DSM-5

Premenstrual dysphoric disorder, which affects 2%–5% of premenopausal women, was included in Appendix B of DSMIV, "Criterion Sets and Axes Provided for Further Study." Since then, aided by the inclusion of specific and rigorous criteria in DSM-IV, there has been an explosion of research on the epidemiology, phenomenology, pathogenesis, and treatment of the disorder. In 2009, the Mood Disorders Work Group for DSM-5 convened a group of experts to examine the literature on premenstrual dysphoric disorder and provide recommendations regarding the appropriate criteria and placement for the disorder in DSM-5. Based on thorough review and lengthy discussion, the work group proposed that the information on the diagnosis, treatment, and validation of the disorder has matured sufficiently for it to qualify as a full category in DSM-5. A move to the position of category, rather than a criterion set in need of further study, will provide greater legitimacy for the disorder and encourage the growth of evidence-based research, ultimately leading to new treatments.

Genetics of early cancer detection behaviours in Australian female twins

Early detection of cervical and breast cancers is an important component of women's health strategy. Screening programmes, health professional interventions and preventive behaviours such as breast self-examination provide the means to this end. Our twin study sought to identify the relative influence of environmental and genetic factors on liability to early cancer detection behaviours, including use of cervical smear tests, mammograms, and breast examination. Additive genetic and random environmental effects models gave the best, most parsimonious fit to the data for each early cancer detection behaviour. The heritability of liability to Pap smear use was 66%, mammogram use 50%, breast examination by a doctor or nurse 38% and breast self-examination 37%. Genetic influences were behaviour-specific; there was no evidence for a common genetic influence on the four behaviours. Potential covariates investigated included age, amount of contact between co-twins, educational level and personality traits such as harm avoidance, novelty seeking, reward dependence, neuroticism, anxiety, depression, self-esteem, perceived control, interpersonal dependency and ways of coping. None were significant. The study was carried out before the implementation of national screening programmes with media campaigns to increase participation rates. Hence follow-up investigation, including data on regularity of behaviours, would be informative

Genetic and Non-Genetic Factors Affecting Birth-Weight and Adult Body Mass Index

Birthweight affects neonatal mortality and morbidity and has been used as a marker of foetal undernutrition in studies of prenatal effects on adult characteristics. It is potentially influenced by genetic and environmental influences on the mother, and effects of foetal genotype, which is partially derived from the maternal genotype. Interpretations of variation in birthweight and associated characteristics as being due to prenatal environment ignore other possible modes of materno-foetal transmission. Subjects were adult twins recruited through the Australian Twin Registry, aged 17 to 87 years, and the sample comprised 1820 men and 4048 women. Twins reported their own birthweight as part of a health questionnaire. Body Mass Index (BMI) was calculated from self-reports of height and weight. Correlations between co-twins' birthweights were high for both monozygotic (r = 0.77) and dizygotic (r = 0.67) pairs, leading to substantial estimates of shared environmental effects (56% of variance) with significant additive genetic (23%) and non-shared environmental (21%) components. Adult BMI was mainly influenced by genetic factors, both additive (36% of variance) and nonadditive (35%). The correlation between birthweight and BMI was positive, in that heavier babies became on average more obese adults. A bivariate model of birthweight and adult BMI showed significant positive genetic (rg = 0.16, p = 0.005) and environmental (re = 0.08, p = 0.000011) correlations. Intra-uterine environmental or perinatal influences shared by cotwins exercise a strong influence on birthweight, but the factors which affect both birthweight and adult BMI are partly genetic and partly non-shared environmental.

SRD5A1 genotype frequency differences in women with mild versus severe premenstrual symptoms

The aims of this small pilot study were to explore the association between premenstrual symptom severity and two genes from the gamma-aminobutyric acid (GABA) pathway: steroid-5-alpha-reductase, alpha polypeptide 1 (SRD5A1) and gamma-aminobutyric acid receptor subunit alpha-4 (GABRA4). Saliva samples were obtained from a convenience sample of 19 Caucasian females ages 18-25 years, ten cases and nine controls. Deoxyribonucleic acid (DNA) was isolated, and genotyping performed on ten single nucleotide polymorphisms (SNPs). Ten percent of cases and 44% of controls had the cytosine/cytosine (C/C) genotype for the SRD5A1 SNP, rs501999 indicating that this genotype may protect women against severe premenstrual symptoms. Replication of this study using an adequately powered sample size is warranted.

Hormones, heart disease, and health: individualized medicine versus throwing the baby out with the bathwater

It is increasingly axiomatic that depression has widespread adverse physiological effects and, conversely, that a variety of physiological systems impact the risk for developing depression. This convergence of depression and altered physiology is particularly dramatic during midlife--a time during which reproductive failure presages dramatic increases in prevalence of both heart disease and depression. The potentially meaningful and illuminating links between estrogen deficiency, cardiovascular disease (CVD), and depression have largely been obscured, first by assertions, subsequently repudiated, that the perimenopause was not a time of increased risk of depression, and more recently by the denegration of hormone replacement therapy by initial reports of the Women's Health Initiative. Increasingly, however, research has led to unavoidable conclusions that CVD and depression share common, mediating pathogenic processes and that these same processes are dramatically altered by the presence or absence of estrogen (E2). This review summarizes data supporting these contentions with the intent of placing depression and estrogen therapy in their proper physiologic context.

Hormones, heart disease, and health: individualized medicine versus throwing the baby out with the bathwater

It is increasingly axiomatic that depression has widespread adverse physiological effects, and conversely that a variety of physiological systems impact the risk for developing depression. This convergence of depression and altered physiology is particularly dramatic during midlife-a time during which reproductive failure presages dramatic increases in prevalence of both heart disease and depression. The potentially meaningful and illuminating links between estrogen (E2) deficiency, cardiovascular disease (CVD), and depression have largely been obscured, first by assertions, subsequently repudiated that the perimenopause was not a time of increased risk of depression, and more recently by the denegration of hormone replacement therapy by initial reports of the Women's Health Initiative. Increasingly, however, research has led to unavoidable conclusions that CVD and depression share common and mediating pathogenic processes and that these same processes are dramatically altered by the presence or absence of E2. This review summarizes data supporting this contention with the intent of placing depression and E2 therapy in their proper physiologic context.

Estrogen receptor alpha (ESR-1) associations with psychological traits in women with PMDD and controls

Premenstrual Dysphoric Disorder (PMDD) is a mood disorder affecting about 5% of women and is associated with substantial morbidity. Albeit inconsistently, PMDD is described as being characterized by heritable personality traits. Although PMDD is a heritable disorder, it is unclear whether any of the heritable susceptibility to PMDD resides in heritable personality traits. In groups of carefully characterized women with PMDD (n=68) and controls (n=56), we attempted to determine whether diagnosis-related traits could be confirmed, as well as to determine whether such traits were associated with SNPs in estrogen receptor alpha (ESR-1) that we previously demonstrated were associated with PMDD. We observed 7/25 traits to be significantly different in patients and controls and further showed that 11/12 significant associations observed between these 7 traits and 16 ESR-1 SNPs involved the intron 4 SNPs previously shown to be the locus of the association with PMDD. While several interactions between genotype and diagnosis were observed, the effect of genotype in most instances was in the same direction in patients and controls. These data demonstrate affective state-independent personality traits that distinguish patients with PMDD from controls and further support the relevance of ESR-1 polymorphic variants in the regulation of non-reproductive behaviors.

Analysis of the serotonin transporter promoter rs25531 polymorphism in premenstrual dysphoric disorder

OBJECTIVE

The objective of this study was to investigate whether the functional rs25531 promoter polymorphism in the serotonin transporter gene is associated with premenstrual dysphoric disorder.

STUDY DESIGN

The study sample comprised 53 women with clinically diagnosed premenstrual dysphoric disorder (age range, 27-46 years; mean, 37.7 years) and 52 healthy control subjects (age range, 22-48 years; mean, 36.2 years). The rs25531 polymorphism was genotyped in both groups. Because of its close proximity to rs25531, the 5-HTTLPR promoter polymorphism was also genotyped. Genotype and allele frequencies for rs25531 and for the composite 5-HTTLPR/rs25531 marker were analyzed by chi(2) test.

RESULTS

There was no significant association between any genotype and clinical category and no significant allele distribution profiles for rs25531 or 5-HTTLPR/rs25531 in either the premenstrual dysphoric disorder or the control groups.

CONCLUSION

These findings do not support a major role for rs25531, either in isolation or combined with 5-HTTLPR, in contributing to susceptibility to premenstrual dysphoria.

Sex-specific association of depression and a haplotype in leukotriene A4 hydrolase gene

OBJECTIVE

To assess whether genetic variants involved in inflammation play a role in the sex difference in depression. Depression is, in part, genetically determined and inflammation has been implicated. Women are twice as likely to develop depression as men.

METHODS

We examined the association, separately in men and women, between seven single nucleotide polymorphisms (SNPs) in the arachidonate 5-lipoxygenase-activating protein (ALOX5AP) gene and 12 SNPs in the leukotriene A4 hydrolase (LTA4H) gene and depression in 1368 white subjects (30.4% female) referred for cardiovascular evaluation. Depression was defined as a score of >or=10 in the Patient Health Questionnaire 9. Single marker analysis was assessed by the chi(2) test. Haplotype-specific associations were performed, using likelihood ratio tests. Empirical significance levels were determined by permutation tests.

RESULTS

Depressed individuals, comprising 14.5% of the total, were more likely to be female, current smokers, have a history of diabetes and myocardial infarction. None of the SNPs in the ALOX5AP gene, either singly or in combination, was associated with depression. The 12 SNPs in the LTA4H gene were not individually associated with depression. However, a six-SNP haplotype in LTA4H gene, named HapE, showed a significant protective effect on depression in women, but not in men, after correcting for cardiovascular effects. The interaction between HapE and sex on depression was statistically significant.

CONCLUSION

This study provides the first evidence for a sex-specific association of a novel haplotype in the LTA4H gene on depression. Although replication is needed, our study suggests that genetic variations may underlie sex differences in depression.

Premenstrual syndrome and premenstrual dysphoric disorder: quality of life and burden of illness

Premenstrual symptoms are distressing for up to 20% of reproductive-aged women and are associated with impairment in interpersonal or workplace functioning for at least 3-8%. Typical symptoms of premenstrual syndrome and the severe form, premenstrual dysphoric disorder, include irritability, anger, mood swings, depression, tension/anxiety, abdominal bloating, breast pain and fatigue. The symptoms recur monthly and last for an average of 6 days per month for the majority of the reproductive years. For women with premenstrual dysphoric disorder, the symptoms can be as disabling as major depressive disorder. It has been estimated that affected women experience almost 3000 days of severe symptoms during the reproductive years. Until two decades ago, there were no effective treatments for severe premenstrual syndrome. Even in 2000, almost three-quarters of women in the USA with premenstrual disorders either did not seek help or sought treatment unsuccessfully from at least three clinicians for over 5 years. This review will focus on the epidemiology, diagnosis, treatment outcomes, quality of life and burden of illness for premenstrual disorders.

Premenstrual mood symptoms: study of familiality and personality correlates in mood disorder pedigrees

We sought to determine whether premenstrual mood symptoms exhibit familial aggregation in bipolar disorder or major depression pedigrees. Two thousand eight hundred seventy-six women were interviewed with the Diagnostic Interview for Genetic Studies as part of either the NIMH Genetics Initiative Bipolar Disorder Collaborative study or the Genetics of Early Onset Major Depression (GenRED) study and asked whether they had experienced severe mood symptoms premenstrually. In families with two or more female siblings with bipolar disorder (BP) or major depressive disorder (MDD), we examined the odds of having premenstrual mood symptoms given one or more siblings with these symptoms. For the GenRED MDD sample we also assessed the impact of personality as measured by the NEO-FFI. Premenstrual mood symptoms did not exhibit familial aggregation in families with BP or MDD. We unexpectedly found an association between high NEO openness scores and premenstrual mood symptoms, but neither this factor, nor NEO neuroticism influenced evidence for familial aggregation of symptoms. Limitations include the retrospective interview, the lack of data on premenstrual dysphoric disorder, and the inability to control for factors such as medication use.

A reproductive subtype of depression: conceptualizing models and moving toward etiology

The lifetime risk for major depression in women is well known to be twice the risk in men and is especially high during the reproductive years between menarche and menopause. A subset of reproductive-age women experience depressive episodes that are triggered by hormonal fluctuations. Such "reproductive depressions" involve episodes of depression that occur specifically during the premenstrual, postpartum, and perimenopausal phases in women. These reproductive subtypes of depression can be conceptualized as a specific biological response to the effects of hormonal fluctuations in the brain. The different types of reproductive depressions are associated with each other, have unique risk factors that are distinct from nonreproductive depression episodes, and respond to both hormonal and nonhormonal interventions. This review uses a PubMed search of relevant literature to discuss clinical, animal, and genetic evidence for reproductive depression as a specific subtype of major depression. Unique treatment options, such as hormonal interventions, are also discussed, and hypotheses regarding the underlying biology of reproductive depression-including interactions between the serotonergic system and estrogen, as well as specific effects on neurosteroids-are explored. This review will provide evidence supporting reproductive depression as a distinct clinical entity with specific treatment approaches and a unique biology that is separate from nonreproductive depression.

Serotonin receptor 1A C(-1019)G polymorphism associated with premenstrual dysphoric disorder

OBJECTIVE

To assess whether the G allele of the serotonin receptor 1A C(-1019)G polymorphism is associated with premenstrual dysphoric disorder.

METHODS

The study sample comprised 53 women with clinically diagnosed premenstrual dysphoric disorder (age range 27-46 years, mean 37.7 years) and 51 healthy control subjects (age range 22-48 years, mean 36.2 years). The serotonin receptor 1A C(-1019)G polymorphism was genotyped and compared between the two groups.

RESULTS

In contrast to the postulated "high-risk" G/G genotype, there was a marked overrepresentation of the C/C genotype in the premenstrual dysphoric disorder group (P=.034; odds ratio 3.63, 95% confidence interval 1.22-10.78). The presence of at least one C allele was associated with a 2.5-fold increased risk of premenstrual dysphoric disorder (P=.053; odds ratio 2.46, 95% confidence interval 1.03-5.88).

CONCLUSION

Our hypothesis that the high-risk G allele is associated with the occurrence of premenstrual dysphoria was not proved in this study. However, due to the increased prevalence of the C variant, we suggest that the C(-1019) allele may contribute to the risk of premenstrual dysphoria.

LEVEL OF EVIDENCE

II.

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.

Risk for premenstrual dysphoric disorder is associated with genetic variation in ESR1, the estrogen receptor alpha gene

BACKGROUND

Premenstrual dysphoric disorder (PMDD) is a heritable mood disorder that is triggered by gonadal steroids during the luteal phase in susceptible women.

METHODS

We performed haplotype analyses of estrogen receptors alpha and beta (ESR1 and ESR2) in 91 women with prospectively confirmed PMDD and 56 control subjects to investigate possible sources of the genetic susceptibility to affective dysregulation induced by normal levels of gonadal steroids. We also examined associations with the valine (Val)158methionine (Met) single nucleotide polymorphism (SNP) of the gene for catechol-O-methyltransferase (COMT), an enzyme involved in estrogen metabolism and prefrontal cortical activation.

RESULTS

Four SNPs in intron 4 of ESR1 showed significantly different genotype and allele distributions between patients and control subjects. Significant case-control differences were seen in sliding-window analyses of two-, three-, and four-marker haplotypes but only in those haplotypes containing SNPs in intron 4 that were positive in the single-locus analysis. No significant associations were observed with ESR2 or with the COMT Val158Met polymorphism, although the significant associations with ESR1 were observed only in those with the Val/Val genotype.

CONCLUSIONS

These are the first positive (albeit preliminary) genetic findings in this reproductive endocrine-related mood disorder and involve the receptor for a hormone that is pathogenically relevant.

Serotonin transporter, tryptophan hydroxylase, and monoamine oxidase A gene polymorphisms in premenstrual dysphoric disorder

OBJECTIVE

The purpose of this study was to investigate whether common polymorphisms of key genes that control the serotonin (5-hydroxytryptamine) pathway are associated with premenstrual dysphoric disorder.

STUDY DESIGN

The study sample comprised 53 women with clinically diagnosed premenstrual dysphoric disorder (age range, 27-46 years; mean age, 37.7 years) and 52 healthy control subjects (age range, 22-48 years; mean age, 36.2 years). Eight polymorphisms that encode the 5-hydroxytryptamine transporter (LPR, VNTR-2, and 3' UTR G/T), tryptophan hydroxylase 1 (TPH1 G-6526A, G-5806T, and A218C), and monoamine oxidase A (monoamine oxidase A promoter VNTR-1 and exon 8 Fnu 4H1) were genotyped. Genotype and allelic frequencies were analyzed by chi-square test and stepwise logistic regression analysis.

RESULTS

There was no significant association between any genotype and clinical category and no significant allelic distribution profiles in either the premenstrual dysphoric disorder group or the control group.

CONCLUSION

These findings do not support a major role for common 5-hydroxytryptamine transporter, TPH1, and monoamine oxidase A polymorphisms in contributing to susceptibility to premenstrual dysphoric disorder.

Multivariate Genetic Analysis of Chronic Pelvic Pain and Associated Phenotypes

Chronic pelvic pain (CPP) is a common condition in women that is difficult to diagnose. Although heritability estimates have been published for some conditions potentially underlying pelvic pain, the heritability of CPP itself has never been investigated. Using data from 623 MZ and 377 DZ female twin pairs aged 29-50 from an Australian twin cohort, we found an increased CPP concordance among MZs compared to DZs, with tetrachoric correlations of 0.43 (95% CI: 0.26-0.58) and 0.11 (95% CI: -0.16-0.38), respectively. This corresponded to a heritability of 0.41 (95% CI: 0.25-0.56). Lack of correlations with environmental indicators suggested that violation of the equal environments assumption was not responsible for this effect. Multivariate Cholesky decomposition models incorporating CPP and significantly correlated phenotypes showed that the entire CPP heritability could be explained by genetic variance underlying endometriosis (38%), dysmenorrhoea (23%), fibroids (24%), and somatic distress (15%), the latter a possible indicator of increased nociception. CPP itself is unlikely to be a useful independent phenotype to conduct genetic aetiological studies; contributing conditions such as endometriosis and variation in nociception are likely to provide more useful phenotypes.

Premenstrual exacerbation of depressive disorders in a community-based sample in the United States

OBJECTIVE

No published epidemiologic study has examined premenstrual exacerbation of depressive disorders (PME-DD) in a representative sample. Knowledge gained should indicate the burden of illness, suggest whom to monitor, and facilitate diagnosis. The objectives were to 1) ascertain the prevalence and predictors of PME-DD; and 2) test competing hypotheses that PME-DD is related to a) severity or history of depression, b) menstrual cyclicity in females in general, or c) a methodological artifact.

METHODS

Menstruating females (N = 900) from ages 13 to 53 living in urban or rural Illinois completed semi-structured psychiatric diagnostic interviews and rated symptoms of depression daily for two menstrual cycles; 58 had major depressive, dysthymic, or subclinical depressive disorders, and the remaining 842 were the non-depressed portion of the representative sample.

RESULTS

Depressed females had 1.34 (95% confidence interval, 1.02-1.66) symptoms exacerbated premenstrually. The best model for predicting exacerbation contained only age. Older women more often had symptoms worsen. Symptoms during the follicular phase were most severe for clinically depressed, intermediate for subclinically depressed, and least severe for non-depressed participants, ps < 0.001. Consistent with the hypothesis that exacerbation is related to cyclicity in all females, the number of symptoms that became worse did not differ between groups, ps < 0.46. Given no symptoms in one cycle, the odds of having symptoms in the next cycle were 0.91. Only 56% of non-depressed females taking antidepressants were asymptomatic all month long; the remaining 44% still had symptoms premenstrually.

CONCLUSIONS

Premenstrual exacerbation of depressive disorders is associated with deteriorated functioning over and above that already experienced by depressed females. Patients may be susceptible regardless of severity of depression, number of episodes, or remission status.

How does premenstrual dysphoric disorder relate to depression and anxiety disorders?

Premenstrual dysphoric disorder (PMDD) is a severe variant of premenstrual syndrome that afflicts approximately 5% of all women of fertile age. The hallmark of this condition is the surfacing of symptoms during the luteal phase of the menstrual cycle, and the disappearance of symptoms shortly after the onset of menstruation. Whereas many researchers have emphasized the similarities between PMDD and anxiety disorders, and in particular panic disorder, others have suggested that PMDD should be regarded as a variant of depression. Supporting both these notions, the treatment of choice for PMDD, the serotonin reuptake inhibitors (SRIs), is also first line of treatment for depression and for most anxiety disorders. In this review, the relationship between PMDD on the one hand, and anxiety and depression on the other, is being discussed. Our conclusion is that PMDD is neither a variant of depression nor an anxiety disorder, but a distinct diagnostic entity, with irritability and affect lability rather than depressed mood or anxiety as most characteristic features. The clinical profile of SRIs when used for PMDD, including a short onset of action, suggests that this effect is mediated by other serotonergic synapses than the antidepressant and anti-anxiety effects of these drugs. Although we hence suggest that PMDD should be regarded as a distinct entity, it should be emphasized that this disorder does display intriguing similarities with other conditions, and in particular with panic disorder, which should be the subject of further studies. Also, the possibility that there are subtypes of PMDD more closely related to depression, or anxiety disorders, than the most common form of the syndrome, should not be excluded.

Prevalence and predictors of premenstrual syndrome among college-aged women in Saudi Arabia

BACKGROUND

Research on risk factors for premenstrual syndrome (PMS) is lacking for the Gulf countries of the Middle East, a region with unique cultural features that might influence expectations and self-perception of the disease. We examined the association of PMS frequency with possible risk factors for the disease.

METHODS

Using a self-report questionnaire, we surveyed all eligible young women (n=464) enrolled in the medical, nursing and medical technology/respiratory therapy educational programs at a university in Dammam. Women were asked about the frequency of symptoms during the previous six months. A stepwise multiple regression analysis was performed to determine which of several biopsychosocial and dietary factors influenced the premenstrual symptom score.

RESULTS

At least one premenstrual symptom was experienced by 448 women (96.6%), and 176 (37.5%) had a high symptom severity score. Premenstrual symptom frequency was significantly associated with a maternal history of premenstrual syndrome, self-perception of mental stress, physical activity, consumption of sweet-tasting foods, and coffee, but these factors only explained 14% of the variability in the multiple regression model.

CONCLUSIONS

We recommend that women vulnerable to mental stress take advantage of relaxation techniques and psychotropic therapies. Moreover, women with PMS might eliminate sweet-tasting food and caffeine-containing beverages, particularly coffee, from their diet.

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 etiology, biology, and evolving pathology of premenstrual syndromes

Menstrually related symptoms and disorders are multidimensional and affect diverse physiologic systems. Elucidation of the pathophysiologic mechanisms of these disorders should allow for a more precise diagnosis, and provide direction for targeted therapeutic interventions. Several biologic mechanisms that underlie menstrually related symptoms have been proposed. They focus mostly on gonadal hormones, their metabolites and interactions with neurotransmitters and neurohormonal systems, such as serotonin, GABA, cholecystokinin, and the renin-angiotensin-aldosterone system. Altered responses of these systems to gonadal hormone's fluctuations during the menstrual cycle, as well as an increased sensitivity to changes in gonadal hormones may contribute to menstrually related symptoms in vulnerable women. Disrupted homeostasis and deficient adaptation may be core underlying mechanisms. Future directions for clinically-relevant progress include identification of specific subgroups of menstrually-related syndromes, assessment of the genetic vulnerability and changes in vulnerability along the life cycle, the diversified mechanisms by which vulnerability is translated into pathophysiology and symptoms, the normalization process as well as syndromes-based and etiology-based clinical trials.

Serotonin transporter gene polymorphisms and platelet [3H] paroxetine binding in premenstrual dysphoria

The purpose of this study was to investigate if women with premenstrual dysphoria differ from controls with respect to the number of platelet serotonin transporters, and with respect to three polymorphisms in the gene coding for the serotonin transporter: a 44 base pair insertion/deletion in the promoter region, a variable number of tandem repeats in the second intron, and a single nucleotide polymorphism in the 3' untranslated region. Also, the possible relationship between the three polymorphisms and platelet serotonin transporter density was analyzed. The density of platelet [(3)H]paroxetine binding sites was significantly lower in women with premenstrual dysphoria than in controls, but patients and controls did not differ with respect to allele or genotype frequency for any of the three polymorphisms examined. A significant association between the number of platelet serotonin transporters and the promoter polymorphism was observed, subjects being homozygous for the short (deletion) variant having higher platelet serotonin transporter density than subjects carrying the long (insertion) allele. The results support the assumption that serotonin-related psychiatric disorders-such as premenstrual dysphoria-may be associated with a reduction in platelet [(3)H]paroxetine binding, but argue against the notion that this reduction is due to certain variants of the serotonin transporter gene being more common in patients than in controls.

Premenstrual Dysphoric Disorder: Recognition and Treatment

Premenstrual dysphoric disorder (PMDD) represents the more severe and disabling end of the spectrum of premenstrual syndrome and occurs in an estimated 2% to 9% of menstruating women. The most frequent PMDD symptoms among women seeking treatment consist of anger/irritability, anxiety/tension, feeling tired or lethargic, mood swings, feeling sad or depressed, and increased interpersonal conflicts. Women who develop PMDD appear to have serotonergic dysregulation that may be triggered by cyclic changes in gonadal steroids. The marked increase in the number of well-designed placebo-controlled studies in the past decade has established several selective serotonin reuptake- inhibiting antidepressants as effective first-line treatments for this disorder. Both continuous dosing and intermittent luteal dosing strategies lead to rapid improvement in symptoms and functioning. The present article provides a brief review of current information on the epidemiology, clinical presentation, neurobiology, and treatment of PMDD.

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.

Treatment of depression in women: a summary of the expert consensus guidelines

Women constitute two-thirds of patients suffering from common depressive disorders, making the treatment of depression in women a substantial public health concern. However, high-quality, empirical data on depressive disorders specific to women are limited, and there are no comprehensive evidence-based practice guidelines on the best treatments for these illnesses. To bridge the gap between research evidence and key clinical decisions, the authors developed a survey of expert opinion concerning treatment of four depressive conditions specific to women: premenstrual dysphoric disorder, depression in pregnancy, postpartum depression in a mother choosing to breast-feed, and depression related to perimenopause/menopause. The survey asked about 858 treatment options in 117 clinical situations and included a broad range of pharmacological, psychosocial, and alternative medicine approaches. The survey was sent to 40 national experts on women's mental health issues, 36 (90%) of whom completed it. The options, scored using a modified version of the RAND Corporation's 9-point scale for rating appropriateness of medical decisions, were assigned one of three categorical rankings-first line/preferred choice, second line/alternate choice, third line/usually inappropriate-based on the 95% confidence interval of each item's mean rating. The expert panel reached consensus (defined as a non-random distribution of scores by chi-square "goodness-of-fit" test) on 76% of the options, with greater consensus in situations involving severe symptoms. Guideline tables indicating preferred treatment strategies were then developed for key clinical situations. The authors summarize the expert consensus methodology they used and then, for each of the four key areas, review the treatment literature and summarize the experts' recommendations and how they relate to the research findings. For women with severe symptoms in each area we asked about, the first-line recommendation was antidepressant medication combined with other modalities (generally psychotherapy). These recommendations parallel existing guidelines for severe depression in general populations. For initial treatment of milder symptoms in each situation, the panel was less uniform in recommending antidepressants, and either gave equal endorsement to other treatment modalities (e.g., nutritional or psychobehavioral approaches in PMDD; hormone replacement in perimenopause) or preferred psychotherapy over medication (during conception, pregnancy, or lactation). In all milder cases, however, antidepressants were recommended as at least second-line options. Among antidepressants, selective serotonin reuptake inhibitors (SSRIs) were recommended as first-line treatment in all situations. The specific SSRIs that were preferred depended on the particular clinical situation. Tricyclic antidepressants were highly rated alternatives to SSRIs in pregnancy and lactation. In evaluating many of the treatment options, the experts had to extrapolate beyond controlled data in comparing treatment options with each other or in combination. Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide some direction for addressing common clinical dilemmas in women, and can be used to inform clinicians and educate patients regarding the relative merits of a variety of interventions.

Evaluation and Management of Premenstrual Syndrome and Premenstrual Dysphoric Disorder

OBJECTIVE

To review premenstrual disorders, their varied symptoms, possible etiology, and treatment options.

DATA SOURCES

Published articles identified through MEDLINE (1966-2001) using the search terms premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) and the additional terms treatment and etiology. Additional references were identified from the bibliographies of the retrieved articles.

DATA SYNTHESIS

PMS refers to a group of menstrually related disorders that are estimated to affect up to 40% of women of childbearing age. The varied symptoms of PMS include mood swings, tension, anger, irritability, headache, bloating, and increased appetite with food cravings. PMS symptoms occur during the luteal phase of the menstrual cycle and remit with the onset of menstruation or shortly afterward. Approximately 5% of women with PMS suffer from PMDD, a more disabling and severe form of PMS in which mood symptoms predominate. Because no tests can confirm PMS or PMDD, the diagnosis should be made on the basis of a patient-completed daily symptom calendar and the exclusion of other medical disorders. The causes of PMS and PMDD are uncertain, but are likely associated with aberrant responses to normal hormonal fluctuations during the menstrual cycle. For most women, symptoms can be relieved or reduced through lifestyle interventions, such as dietary changes and exercise, and drug therapy with hormonal or psychotropic agents. For PMDD, selective serotonin reuptake inhibitors have recently emerged as first-line therapy. Certain dietary supplements, including calcium, also may be an option for some women.

CONCLUSION

PMS and PMDD are complex but highly treatable disorders. Pharmacists can improve the recognition and management of these common conditions by providing patient education on premenstrual symptoms and counseling women on lifestyle interventions and pharmacotherapy to relieve their discomfort.

Relationships of premenstrual dysphoric disorder to major depression and anxiety disorders: a re-examination

Clarifying the relationships of premenstrual dysphoric disorder (PMDD) to depressive and anxiety disorders may contribute to the understanding of risk factors and etiologies associated with the disorders. A current belief is that women with PMDD have a higher percentage of past psychiatric disorders than women without the disorder, an assumption that may be premature. This review carefully examines existing literature on the nature of the relationships between PMDD and major depression and anxiety disorders. A re-evaluation of the literature and the resulting implications for risk factors and etiology, as well as for obstetric and gynecological practice, are provided.

Genetic influences on endometriosis in an Australian twin sample. sueT@qimr.edu.au

OBJECTIVE

To investigate the prevalence of and twin pair concordance for endometriosis.

DESIGN

A questionnaire survey incorporating validation.

SETTING

An Australia-wide volunteer sample of female monozygotic (MZ) and dizygotic (DZ) twin pairs from the Australian National Health and Medical Research Council Twin Register.

PATIENT(S)

Twins were selected only on the basis of previous participation in twin research.

INTERVENTION(S)

Questionnaires were sent to 3,298 individuals. Information was requested from physicians named by consenting twins.

MAIN OUTCOME MEASURE(S)

Reported endometriosis, validated where possible by pathology or surgical report.

RESULT(S)

Three thousand ninety-six (94%) of the twins and 145 (82%) of the physicians responded to the survey. Two hundred fifteen twins reported endometriosis, for a prevalence rate of .07 among question respondents. Tetrachoric twin pair correlations for self-reported endometriosis (MZ: n = 854 and DZ: n = 493) were rMz = .46+/-.09 and rDz = .28 +/-.13. When available medical and pathology reports were included, they changed to rMz =.52 +/-.08 and rDZ = .19+/-.16, suggesting that 51% of the variance of the latent liability to endometriosis may be attributable to additive genetic influences.

CONCLUSION(S)

These findings support the hypothesis that genes influence liability to endometriosis.

Gender differences in psychiatric illness and treatments: a critical review

Controversy exists about the causation of gender differences long observed in the prevalence of mental disorders. Recent epidemiological, biochemical, and genetic research has shed further light upon both their etiologies and treatments. Both controversies and research are reviewed and critically examined.

Typology of common psychiatric syndromes. An empirical study

BACKGROUND

Diagnostic comorbidity is prevalent in psychiatry and may be inadequately captured by the DSM-III/III-R nosology.

METHODS

The lifetime presence of II psychiatric diagnoses was determined by structured personal interviews of a population-based sample of 1898 female twins. We used latent class analysis to derive an empirical typology.

RESULTS

Six classes provided the best fit to the data. Their mnemonics were: minimal disorder (60% of the sample), major depression-generalised anxiety disorder (19%), alcohol-nicotine (7%), highly comorbid major depression (5%) and eating disorders (3%). The validity of this typology was strongly supported by demographic, health, personality and attitudinal validators along with the significant monozygotic twin concordance for class membership. The typology superficially resembled DSM-III-R, but contained many differences. Major depression appeared in three forms (alone, with generalised anxiety disorder and with considerable comorbidity). Alcoholism-nicotine dependence and the various anxiety disorders formed discrete classes, but were also prominent in other classes. Bulimia and anorexia were exceptional in their appearance in a single class.

CONCLUSIONS

The DSM-III-R and closely related DSM-IV nosology did not capture the natural tendency of these disorders to co-occur. Fundamental assumptions of the dominant diagnostic schemata may be incorrect.