The role of central serotonergic dysfunction in the aetiology of premenstrual dysphoric disorder: therapeutic implications

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.

Biological rhythms in premenstrual syndrome and premenstrual dysphoric disorder: a systematic review

BACKGROUND

Women with premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) typically experience a range of psychological and physiological symptoms that negatively affect their quality of life. Disruption in biological rhythms, including alterations of the sleep-wake cycle, have been implicated in PMS/PMDD, though literature is still growing to substantiate these findings. The objective of this study is to systematically review the available literature on biological rhythms disruption in PMS/PMDD.

METHODS

A literature search was conducted on four databases (Pubmed, Embase, Medline, and Web of Science) on December 3rd, 2021. This search yielded a total of 575 articles that assessed the relationship between biological rhythms and PMS/PMDD/premenstrual symptoms.

RESULTS

After the exclusion of irrelevant articles and hand-searching references, 25 articles were included in this systematic review. Some studies showed that women with PMS/PMDD present lower melatonin levels, elevated nighttime core body temperature, and worse subjective perception of sleep quality when compared to women without PMS/PMDD. Other biological rhythms parameters showed either no differences between groups (wrist actimetry) or conflicting results (objective sleep parameters, cortisol, prolactin, and thyroid stimulating hormone).

CONCLUSION

Current research demonstrates that women with PMS/PMDD experience lower melatonin levels, higher body temperature, and worse subjective perception of sleep quality. This review outlines some possible mechanisms behind these findings and proposes recommendations for future research. This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42020149921.

A 1-week sleep and light intervention improves mood in premenstrual dysphoric disorder in association with shifting melatonin offset time earlier

To test the hypothesis that 1 week of combined sleep and light interventions (SALI), which phase-advance (shift earlier) melatonin circadian rhythms, improves mood significantly more than phase-delay (shift later) SALI. After a 2-month diagnostic evaluation for premenstrual dysphoric disorder (PMDD per DSM-5 criteria) in a university clinical research setting, 44 participants enrolled in baseline studies were randomized in the luteal phase at home to (A) a phase-advance intervention (PAI): 1 night of late-night wake therapy (LWT: sleep 9 pm-1 am) followed by 7 days of the morning (AM) bright white light (BWL), or (B) a phase-delay intervention (PDI): 1 night of early-night wake therapy (EWT: sleep 3-7 am) plus 7 days of the evening (PM) BWL. After a month of no intervention, participants underwent the alternate intervention. Outcome measures were mood, the melatonin metabolite, 6-sulfatoxymelatonin (6-SMT), and actigraphy (to assess protocol compliance). At baseline, atypical depression correlated positively with phase delay in 6-SMT offset time (r = .456, p = .038). PAI advanced 6-SMT offset from baseline more than PDI (p < .05), and improved raw mood scores more than PDI (p < .05). As hypothesized, percent improvement in mood correlated positively with a phase advance from baseline in 6-SMT offset time (p < .001). Treatment with 1 night of advanced/restricted sleep followed by 7 days of AM BWL (PAI) was more efficacious in reducing PMDD depression symptoms than a PDI; mood improvement occurred in association with phase advance in 6-SMT offset time. Combined SALIs offer safe, efficacious, rapid-acting, well-tolerated, non-pharmacological, non-hormonal, affordable, repeatable home interventions for PMDD. Clinical Trials.gov NCT # NCT01799733.

Effects of exogenous melatonin on sleep and circadian rhythms in women with premenstrual dysphoric disorder

We previously found normal polysomnographic (PSG) sleep efficiency, increased slow-wave sleep (SWS), and a blunted melatonin secretion in women with premenstrual dysphoric disorder (PMDD) compared to controls. Here, we investigated the effects of exogenous melatonin in five patients previously studied. They took 2 mg of slow-release melatonin 1 h before bedtime during their luteal phase (LP) for three menstrual cycles. At baseline, patients spent every third night throughout one menstrual cycle sleeping in the laboratory. Measures included morning urinary 6-sulfatoxymelatonin (aMt6), PSG sleep, nocturnal core body temperature (CBT), visual analog scale for mood (VAS-Mood), Prospective Record of the Impact and Severity of Menstrual Symptoms (PRISM), and ovarian plasma hormones. Participants also underwent two 24-hour intensive physiological monitoring (during the follicular phase and LP) in time-isolation/constant conditions to determine 24-hour plasma melatonin and CBT rhythms. The same measures were repeated during their third menstrual cycle of melatonin administration. In the intervention condition compared to baseline, we found increased urinary aMt6 (p < 0.001), reduced objective sleep onset latency (p = 0.01), reduced SWS (p < 0.001), and increased Stage 2 sleep (p < 0.001). Increased urinary aMt6 was correlated with reduced SWS (r = -0.51, p < 0.001). Circadian parameters derived from 24-hour plasma melatonin and CBT did not differ between conditions, except for an increased melatonin mesor in the intervention condition (p = 0.01). Ovarian hormones were comparable between the conditions (p ≥ 0.28). Symptoms improved in the intervention condition, as measured by the VAS-Mood (p = 0.02) and the PRISM (p < 0.001). These findings support a role for disturbed melatonergic system in PMDD that can be partially corrected by exogenous melatonin.

Premenstrual Dysphoric Disorder

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

Premenstrual Dysphoric Disorder

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

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

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

Perceived Barriers to Weight loss Programs for Overweight or Obese Women

BACKGROUND

In order to develop appropriate obesity control and treatment strategies, the key point is to understand the barriers perceived by overweight or obese people in trying to follow weight-loss programs. This study examined perceived barriers to weight-loss programs among overweight or obese women.

METHODS

In this descriptive-analytical study, 204 overweight or obese women aged 31.97± 10.62 yr, were selected randomly from the nutritional counseling centers in 2008 in Tabriz, Iran. The mean BMI was 33.83 ±5.75 kg/ m2. A structured questionnaire including questions on barriers to weight-loss diet and physical activity was filled out for each participant by face-to-face interview. Height and weight measured objectively and demographic details were obtained. Data analysis carried out using multiple regression and factor analysis.

RESULTS

The most important perceived barriers to weight-loss diets were 'situational barriers', stress, depression, and food craving. High educational level was independent determinant of situational barriers (β=0.329, P=0.048). Employee women had a higher mean score on stress and depression than students and housewives. Lack of time and exercising lonely were the most important items of "External barriers" and Lack of motivation was the most important item of "internal barriers" to physical activity. Employment and being student were highly associated with external barriers (β=1.018, P<0.001 and β=0.541, P= 0.002). Moreover, older women who had low educational level, perceived more internal barriers.

CONCLUSION

Weight reducing strategies should take into account the specific perceived barriers to weight-loss diets faced by overweight or obese women, particularly situational barriers, stress and depression and food craving; and lack of time and lack of motivation as barriers to physical activity.

Pilot investigation of the circadian plasma melatonin rhythm across the menstrual cycle in a small group of women with premenstrual dysphoric disorder

Women with premenstrual dysphoric disorder (PMDD) experience mood deterioration and altered circadian rhythms during the luteal phase (LP) of their menstrual cycles. Disturbed circadian rhythms may be involved in the development of clinical mood states, though this relationship is not fully characterized in PMDD. We therefore conducted an extensive chronobiological characterization of the melatonin rhythm in a small group of PMDD women and female controls. In this pilot study, participants included five women with PMDD and five age-matched controls with no evidence of menstrual-related mood disorders. Participants underwent two 24-hour laboratory visits, during the follicular phase (FP) and LP of the menstrual cycle, consisting of intensive physiological monitoring under “unmasked”, time-isolation conditions. Measures included visual analogue scale for mood, ovarian hormones, and 24-hour plasma melatonin. Mood significantly (P≤.03) worsened during LP in PMDD compared to FP and controls. Progesterone was significantly (P = .025) increased during LP compared to FP, with no between-group differences. Compared to controls, PMDD women had significantly (P<.05) decreased melatonin at circadian phases spanning the biological night during both menstrual phases and reduced amplitude of its circadian rhythm during LP. PMDD women also had reduced area under the curve of melatonin during LP compared to FP. PMDD women showed affected circadian melatonin rhythms, with reduced nocturnal secretion and amplitude during the symptomatic phase compared to controls. Despite our small sample size, these pilot findings support a role for disturbed circadian rhythms in affective disorders. Possible associations with disrupted serotonergic transmission are proposed.

Reduced phase-advance of plasma melatonin after bright morning light in the luteal, but not follicular, menstrual cycle phase in premenstrual dysphoric disorder: an extended study

The authors previously observed blunted phase-shift responses to morning bright light in women with premenstrual dysphoric disorder (PMDD). The aim of this study was to determine if these findings could be replicated using a higher-intensity, shorter-duration light pulse and to compare these results with the effects of an evening bright-light pulse. In 17 PMDD patients and 14 normal control (NC) subjects, the authors measured plasma melatonin at 30-min intervals from 18:00 to 10:00 h in dim (<30 lux) or dark conditions the night before (Night 1) and after (Night 3) a bright-light pulse (administered on Night 2) in both follicular and luteal menstrual cycle phases. The bright light (either 3000 lux for 6 h or 6000 lux for 3 h) was given either in the morning (AM light), 7 h after the dim light melatonin onset (DLMO) measured the previous month, or in the evening (PM light), 3 h after the DLMO. In the luteal, but not in the follicular, phase, AM light advanced melatonin offset between Night 1 and Night 3 significantly less in PMDD than in NC subjects. The effects of PM light were not significant, nor were there significant effects of the light pulse on melatonin measures of onset, duration, peak, or area under the curve. These findings replicated the authors' previous finding of a blunted phase-shift response to morning bright light in the luteal, but not the follicular, menstrual cycle phase in PMDD compared with NC women, using a brighter (6000 vs. 3000 lux) light pulse for a shorter duration (3 vs. 6 h). As the effect of PM bright light on melatonin phase-shift responses did not differ between groups or significantly alter other melatonin measures, these results suggest that in PMDD there is a luteal-phase subsensitivity or an increased resistance to morning bright-light cues that are critical in synchronizing human biological rhythms. The resulting circadian rhythm malsynchonization may contribute to the occurrence of luteal phase depressive symptoms in women with PMDD.

Lifetime discrimination associated with greater likelihood of premenstrual dysphoric disorder

OBJECTIVES

To evaluate whether the stressor of perceived discrimination was associated with premenstrual dysphoric disorder (PMDD) and premenstrual symptoms among minority women. This study builds on previous research that found perceived discrimination was positively associated with other psychiatric illnesses.

METHODS

Participants were 2718 Asian, Latina, and black premenopausal women aged 18-40 years who completed the World Mental Health Composite International Diagnostic Interview for the National Latino and Asian American Survey or the National Survey of American Life. Perceived discrimination was assessed with the Everyday Discrimination Scale. DSM-IV-based diagnostic algorithms generated a provisional lifetime diagnosis of PMDD.

RESULTS

Eighty-three percent of the participants reported experiencing discrimination (due to race, gender, age, height or weight, or other reasons) in their lifetimes. The frequency of perceived discrimination was positively associated with PMDD (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.05-1.10) and premenstrual symptoms (OR 1.04, 95% CI 1.02-1.05), independent of demographic covariates and social desirability. Women reporting gender discrimination (OR 5.18, 95% CI 1.80-14.90), race discrimination (OR 4.14, 95% CI 1.54-11.11), and other forms of discrimination (OR 6.43, 95% CI 2.11-19.65) were significantly more likely than women without experiences of discrimination to have PMDD. Subtle discrimination was more strongly associated with PMDD (OR 1.12, 95% CI 1.01-1.23) than was blatant discrimination (OR 1.04, 95% CI 0.94-1.15).

CONCLUSIONS

This study is the first to demonstrate that perceived discrimination is associated with PMDD and premenstrual symptoms. These findings suggest that the prevalence of these conditions may be lessened by reducing discrimination in women's lives.

Neurosteroids and GABA-A Receptor Function

Neurosteroids represent a class of endogenous steroids that are synthesized in the brain, the adrenals, and the gonads and have potent and selective effects on the GABAA-receptor. 3α-hydroxy A-ring reduced metabolites of progesterone, deoxycorticosterone, and testosterone are positive modulators of GABA(A)-receptor in a non-genomic manner. Allopregnanolone (3α-OH-5α-pregnan-20-one), 5α-androstane-3α, 17α-diol (Adiol), and 3α5α-tetrahydrodeoxycorticosterone (3α5α-THDOC) enhance the GABA-mediated Cl(-) currents acting on a site (or sites) distinct from the GABA, benzodiazepine, barbiturate, and picrotoxin binding sites. 3α5α-P and 3α5α-THDOC potentiate synaptic GABA(A)-receptor function and activate δ-subunit containing extrasynaptic receptors that mediate tonic currents. On the contrary, 3β-OH pregnane steroids and pregnenolone sulfate (PS) are GABA(A)-receptor antagonists and induce activation-dependent inhibition of the receptor. The activities of neurosteroid are dependent on brain regions and types of neurons. In addition to the slow genomic action of the parent steroids, the non-genomic, and rapid actions of neurosteroids play a significant role in the GABA(A)-receptor function and shift in mood and memory function. This review describes molecular mechanisms underlying neurosteroid action on the GABA(A)-receptor, mood changes, and cognitive functions.

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.

Duloxetine treatment for women with premenstrual dysphoric disorder: a single-blind trial

Premenstrual dysphoric disorder (PMDD) affects 3-8% of women of reproductive age and is characterized by severe mood symptoms that cause important functional impairment. Serotonergic antidepressants appear to be an effective treatment for this disorder. The purpose of this study was to collect evidence on the efficacy and tolerability of duloxetine, a dual reuptake inhibitor of serotonin and norepinephrine, in the treatment of PMDD. We conducted a pilot, single-blind, non-controlled, fixed-dose trial. After two cycles for diagnosis confirmation, including a single-blind placebo cycle, 20 women with PMDD were treated continuously for three menstrual cycles with 60 mg/d duloxetine. The primary measure of the efficacy of treatment with duloxetine was the significant reduction in premenstrual symptoms demonstrated by the comparison between the mean Daily Record of Severity of Problems (DRSP) scores at baseline to endpoint (p=0.0002). Statistically significant symptom reduction was observed in the first treatment cycle and throughout all the treatment phase. Clinical response, defined as a reduction 50% of baseline premenstrual symptoms, occurred in 65% of subjects (intention-to-treat population). Significant improvements were demonstrated by secondary measures, including reduction in self-rated functional impairment (p=0.01) and improvement in quality of life (p=0.04). The main side-effects associated with duloxetine were dry mouth, nausea, drowsiness, insomnia, decreased appetite, decreased libido, and sweating. Duloxetine was effective and generally well tolerated in the treatment of PMDD. Further large-scale, double-blind, placebo-controlled studies are needed to evaluate duloxetine as an additional treatment strategy for the management of PMDD.

Patients with premenstrual dysphoric disorder have increased startle response across both cycle phases and lower levels of prepulse inhibition during the late luteal phase of the menstrual cycle

Patients with premenstrual dysphoric disorder (PMDD) experience their most intense symptoms during the late luteal phase. The aim of the current study was to compare acoustic startle response and prepulse inhibition in PMDD patients and controls during the follicular and late luteal phases of the menstrual cycle. Following two months of prospective daily ratings on the Cyclicity Diagnoser scale, 30 PMDD patients and 30 asymptomatic controls, between the ages of 20 and 46, were included in the study. The eyeblink component of the acoustic startle reflex was assessed using electromyographic measurements of m. orbicularis oculi. Twenty pulse-alone trials (115 dB 40 ms broad-band white noise) and 40 prepulse-pulse trials were presented. The prepulse stimuli consisted of a 115 dB 40 ms noise burst preceded at a 100 ms interval by 20 ms prepulses that were 72, 74, 78, or 86 dB. PMDD patients had a significantly higher startle response than controls during both phases of the menstrual cycle (p<0.05). PMDD patients exhibited lower levels of prepulse inhibition with 78 dB and 86 dB prepulses compared to control subjects in the luteal (p<0.01) but not in the follicular phase. Whereas control subjects displayed increased PPI during the late luteal phase compared to the follicular phase (p<0.01), PPI magnitude remained unchanged in PMDD patients between cycle phases. Relative to controls, PMDD patients displayed increased startle reactivity across both menstrual cycle phases and deficits in prepulse inhibition of acoustic startle during the late luteal phase. These findings are consistent with an altered response to ovarian steroids among PMDD patients.

Placebo-controlled trial comparing intermittent and continuous paroxetine in premenstrual dysphoric disorder

Serotonin reuptake inhibitors (SRIs) do not have to be administered continuously to be effective for premenstrual dysphoric disorder (PMDD), but can be given during luteal phases only. This is of practical importance, but also of theoretical interest since it suggests that the onset of action of SRIs is shorter in PMDD than in, for example depression. In this study, both continuous and intermittent SRI administration was compared with placebo, with the special purpose of analyzing if different PMDD symptoms respond differently depending on the treatment regimen. To this end, women meeting slightly modified DSM-IV criteria for PMDD (mean+/-SD age, 37+/-6.3 years) were treated for three menstrual cycles with paroxetine continuously, paroxetine during the luteal phase only, or placebo, the population completing at least one treatment cycle comprising 55-56 subjects per group. Continuous treatment with paroxetine reduced premenstrual symptoms effectively with a response rate of 85%. The effect size was highest for irritability (1.4) and lowest for lack of energy (0.5). Intermittent treatment was as effective as continuous treatment in reducing irritability, affect lability, and mood swings, but had a somewhat weaker effect on depressed mood and somatic symptoms. The study indicates that the response rate when treating PMDD with SRIs is high, and that irritability is a key target symptom. Symptoms such as irritability, affect lability, and mood swings appear to be more inclined to respond rapidly to SRIs, enabling intermittent treatment, than are, for example, the somatic symptoms.

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.

The interaction of neuroactive steroids and GABA in the development of neuropsychiatric disorders in women

A growing literature suggests that hormonal fluctuations occurring across the menstrual cycle, during and after pregnancy, and during the menopausal transition are associated with onset of affective disorders or exacerbation of existing disorders. This influence of the neuroendocrine system on psychiatric disorders is thought to be mediated by an abnormality in central nervous system response to neuroactive steroids such as estradiol, progesterone, and the progesterone derivative allopregnanolone (ALLO). This interplay is considerably complex as neuroactive steroids modulate the function of multiple neurotransmitter systems throughout various stages of development. While one could choose to study any number of steroid-neurotransmitter interactions, our group in addition to others has focused our investigative efforts on unraveling the contribution of neuroactive steroids to psychiatric syndromes and disorders via their modulation of gamma aminobutyric acid (GABA), the brain's major inhibitory neurotransmitter. The goal of this article is two-fold: to synthesize the clinical and preclinical research focusing on the interplay between neuroactive steroids and GABA as they relate to neuropsychiatric and substance use disorders in women and to integrate data from our laboratory using proton magnetic resonance spectroscopy into this context.

Mood changes correlate to changes in brain serotonin precursor trapping in women with premenstrual dysphoria

The cardinal mood symptoms of premenstrual dysphoria can be effectively treated by serotonin-augmenting drugs. The aim of the study was to test the serotonin hypothesis of this disorder, i.e. of an association between premenstrual decline in brain serotonin function and concomitant worsening of self-rated cardinal mood symptoms. Positron emission tomography was used to assess changes in brain trapping of 11C-labeled 5-hydroxytryptophan, the immediate precursor of serotonin, in the follicular and premenstrual phases of the menstrual cycle in eight women with premenstrual dysphoria. Changes in mood and physical symptoms were assessed from daily visual analog scale ratings. Worsening of cardinal mood symptoms showed significant inverse associations with changes in brain serotonin precursor trapping; for the symptom "irritable", r(s)=-0.83, and for "depressed mood" r(s)=-0.81. Positive mood variables showed positive associations, whereas physical symptoms generally displayed weak or no associations. The data indicate strong inverse associations between worsening of cardinal symptoms of premenstrual dysphoria and brain serotonin precursor (11C-labeled 5-hydroxytryptophan) trapping. The results may in part support a role for serotonin in premenstrual dysphoria and may provide a clue to the effectiveness of serotonin-augmenting drugs in this disorder but should, due to small sample size and methodological shortcomings, be considered preliminary.

Emotional influences on food choice: sensory, physiological and psychological pathways

Sensory, physiological and psychological mechanisms are reviewed that underlie emotional influences on food choice. Both moods and emotions are considered. Eating a meal will reliably alter mood and emotional predisposition, typically reducing arousal and irritability, and increasing calmness and positive affect. However, this depends on the meal size and composition being close to the eater's habit, expectations and needs. Unusual meals--e.g. too small, unhealthy--may negatively affect mood. Sweetness, and sensory cues to high energy density, such as fatty texture, can improve mood and mitigate effects of stress via brain opioidergic and dopaminergic neurotransmission. However, adaptation in these pathways, perhaps enhanced by inherited sensitivity, with chronic exposure to such sensory qualities, could lead to overeating of energy-dense foods and consequent obesity. Sweet, fatty foods low in protein may also provide alleviation from stress in vulnerable people via enhanced function of the serotonergic system. Moreover, in rats, such foods seem to act as part of a feedback loop, via release of glucocorticoid hormones and insulin, to restrain activity of the hypothalamic pituitary adrenal axis during stress. However, this effect is also associated with abdominal obesity. In humans, a number of psychological characteristics predict the tendency to choose such foods when stressed, such as restrained or emotional eating, neuroticism, depression and premenstrual dysphoria, all of which could indicate neurophysiological sensitivity to reinforcing effects of such foods. Greater understanding of such predictive traits and the underlying mechanisms could lead to tailoring of diet to meet personal emotional needs.

Menstrual cycle symptoms are associated with changes in low-grade inflammation

BACKGROUND

A close link between mood, low-grade inflammation and obesity has been demonstrated even in healthy subjects. We investigated the relationship between changes in physical and psychological symptoms and inflammatory markers during the menstrual cycle both in normal weight and in overweight women.

MATERIALS AND METHODS

Eight healthy normal weight (body mass index 21.6 +/- 1.9 kg m(-2)) and seven overweight (body mass index 30 +/- 2.4 kg m(-2)) young women with normal ovarian function and with no premenstrual syndrome were assessed 15 times throughout their menstrual cycle. At each time point fasting blood was drawn and symptoms were recorded using the Freeman Daily Symptom Record.

RESULTS

Independent of weight status, the serum concentrations of highly sensitive C-reactive protein (hs-CRP) and the total scores, in addition to the individual four factors (mood, behaviour, pain and physical symptoms), of the Daily Symptom Record varied significantly during the menstrual cycle (all P < or = 0.04) and paralleled each other. During the menstrual cycle, repeated hs-CRP serum concentrations correlated to the corresponding total symptom score and the factors mood, behaviour and physical symptoms, independent of both weight status and changes in circulating gonadal steroids (all P < or = 0.04). These associations were not observed for tumour necrosis factor-alpha serum levels. The mean hs-CRP concentrations were associated with the mean total symptom score, independent of weight status (r = 0.56, P = 0.04).

CONCLUSION

Healthy young women showed psychological and physical symptoms during the menstrual cycle which changed in association with alterations in low-grade inflammation and which were independent of body weight or plasma levels of gonadal steroids.

Estrogen enhances light-induced activation of dorsal raphe serotonergic neurons

The serotonergic system has been implicated in the modulation of physiological processes including circadian rhythms, learning, memory, mood and food intake. In females, cessation of ovarian function produces deleterious changes in all of these processes and estrogen treatment often ameliorates these conditions. Estrogen may produce these effects by acting on the midbrain raphe, an estrogen-sensitive region that receives direct projections from sensory systems. Here we examined the ability of estradiol to modulate neuronal responses of neurons within raphe nuclei to photic stimulation. Ovariectomized rats treated with estradiol or cholesterol were killed 1 h after the normal onset of light (Zeitgeber time 0) or after a 2-h phase advance (Zeitgeber time 22). In a second study, estradiol-treated ovariectomized rats under constant dark conditions were exposed to light 2 h before the subjective onset of circadian time [(CT)22] and killed 1 h later (CT23). The brains from all animals were processed for Fos and/or serotonin (5-HT) immunocytochemistry. Comparisons showed that the phase shift increased Fos immunoreactivity in all dorsal raphe nucleus (DRN) regions. Although estradiol did not alter the overall number of Fos-positive nuclei, it significantly increased the number of Fos/5-HT double-labelled cells in the medial and lateral DRN. In contrast, neither a phase shift nor estradiol altered the number of Fos-immunoreactive cells or the proportion of Fos-positive 5-HT cells in the median raphe nucleus. Results reveal that the DRN 5-HT system responds to changes in the light : dark cycle and that these responses are modulated by estrogen.

Is premenstrual dysphoria a variant of panic disorder? A review

Patients with premenstrual dysphoric disorder (PMDD) and patients with panic disorder (PD) both experience high rates of panic attacks in laboratory panic provocation studies. Recently, this shared elevated rate of challenge-induced panic has received increasing attention. Researchers have suggested that PMDD and panic disorder may share a pathophysiological or psychobiological link. The purpose of this paper is to review the findings from PMDD challenge studies and the theories advanced to connect PMDD to panic disorder. Taken together, the results of the PMDD challenge studies confirm that agents that incite panic in PD patients do so as well in PMDD women. This shared elevated challenge-induced panic cannot be accounted for by explanations such as a history of PD in PMDD women. None of the physiological theories as currently expressed--suffocation false alarm, gamma-aminobutyric acid (GABA), noradrenergic, serotonergic, and cholecystokinin--yet provides a compelling candidate to account for shared elevated challenge-induced panic in PD and PMDD patients. Psychological perspectives on panic emphasize that bodily sensations themselves can cause fear. Researchers have yet to apply several influential psychological approaches--conditioning, catastrophic misinterpretation, and anxiety sensitivity--to PMDD patients. Because psychological factors influence anxious responding in challenge studies, the search for the biological abnormality best accounting for PMDD panic might benefit from a reframing of the question to one that considers the psychological perspective as well.

Luteal phase administration of agents for the treatment of premenstrual dysphoric disorder

This review focuses on current information about luteal phase administration (i.e. typically for the last 2 weeks of the menstrual cycle) of pharmacological agents for the treatment of premenstrual dysphoric disorder (PMDD). Compared with continuous administration, a luteal phase administration regimen reduces the exposure to medication and lowers the costs of treatment. Based on evidence from randomised clinical trials, SSRIs are the first-line treatment for PMDD at this time. Of these agents, sertraline, fluoxetine and paroxetine (as an extended-release formulation) are approved by the US FDA for luteal phase, as well as continuous, administration. Clinical trials of these agents and citalopram have demonstrated that symptom reduction is similar with both administration regimens. When used to treat PMDD, SSRI doses are consistent with those used for major depressive disorder. The medications are well tolerated; discontinuation symptoms with this intermittent administration regimen have not been reported. Other medications that have been examined in clinical trials for PMDD or severe premenstrual syndrome (PMS) using luteal phase administration include buspirone, alprazolam, tryptophan and progesterone. Buspirone and alprazolam show only modest efficacy in PMS (in some but not all studies), but there may be a lower incidence of sexual adverse effects with these medications than with SSRIs. Symptom reduction with tryptophan was significantly greater than with placebo, but the availability of this medication is strictly limited because of safety concerns. Progesterone has consistently failed to show efficacy for severe PMS/PMDD in large, randomised, placebo-controlled trials.

Management of premenstrual dysphoric disorder

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

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.

Flux coupling in the human serotonin transporter

The serotonin (5-hydroxytryptamine; 5HT) transporter (SERT) catalyzes the movement of 5HT across cellular membranes. In the brain, SERT clears 5HT from extracellular spaces, modulating the strength and duration of serotonergic signaling. SERT is also an important pharmacological target for antidepressants and drugs of abuse. We have studied the flux of radio-labeled 5HT through the transporter stably expressed in HEK-293 cells. Analysis of the time course of net transport, the equilibrium 5HT gradient sustained, and the ratio of the unidirectional influx to efflux of 5HT indicate that mechanistically, human SERT functions as a 5HT channel rather than a classical carrier. This is especially apparent at relatively high [5HT](out) (> or =10 microM), but is not restricted to this regime of external 5HT.

Current update of hormonal and psychotropic drug treatment of premenstrual dysphoric disorder

This review discusses the current status of diagnosis and treatment of premenstrual dysphoric disorder (PMDD), with an emphasis on studies that have been published in the medical literature during the 2001 to 2002 interval. Serotonergic antidepressants are effective for PMDD, and are currently considered the first-line treatment. Recent clinical trials have shown that selective serotonin reuptake inhibitors, taken only during the symptomatic luteal phase, are also effective for PMDD. One study reported efficacy for a slow-release formulation of fluoxetine that was taken two times during the menstrual cycle. Oral contraceptives still lack definitive evidence of efficacy as a treatment for PMDD, although a new contraceptive formulation has appeared promising for the mood and behavioral symptoms of the disorder. The results of a meta-analysis of the published trials of progesterone and progestins further indicate that these hormones are not effective in the management of PMDD.

Selective serotonin reuptake inhibitors for premenstrual dysphoric disorder: the emerging gold standard?

There have been a large number of studies conducted investigating the use of selective serotonin reuptake inhibitors (SSRIs) in the treatment of patients with premenstrual dysphoric disorder (PMDD). The 12 randomised, controlled trials with continuous dose administration of SSRIs and the eight randomised, controlled trials with luteal phase dose administration (from ovulation to menses) are reviewed. All the treatment studies on fluoxetine, sertraline, paroxetine and citalopram have reported positive efficacy. Fluoxetine and sertraline have the largest literature, with a smaller number of studies endorsing paroxetine and citalopram. Mixed efficacy results have been reported with fluvoxamine. In general, adverse effects from the use of SSRIs in women with PMDD are the usual mild and transient adverse effects from SSRIs including anxiety, dizziness, insomnia, sedation, nausea and headache. Sexual dysfunction and weight gain can be problematic long-term adverse effects of SSRIs, but these effects have not been systematically evaluated with long-term SSRI use in women with PMDD. Serotonergic antidepressants have differential superiority over nonserotonergic antidepressants in the treatment of PMDD. Treatments that enhance serotonergic action improve premenstrual irritability and dysphoria with a rapid onset of action, suggesting a different mechanism of action than in the treatment of depression. It is possible that neurosteroids, such as progesterone metabolites, are involved in the rapid action of serotonergic antidepressants in PMDD. Future research needs to address less frequent dose administration regimens, such as 'symptom-onset' dose administration, and the recommended length of treatment.

Review of fluoxetine and its clinical applications in premenstrual dysphoric disorder

The largest number of antidepressant treatment trials in premenstrual syndrome and premenstrual dysphoric disorder (PMDD) have been conducted with fluoxetine. Fluoxetine and other selective serotonin re-uptake inhibitors (SSRIs) clearly reduce premenstrual emotional and physical symptoms and improve premenstrual psychosocial functioning. Fluoxetine was the first SSRI to be approved by the FDA as a treatment for the emotional and physical symptoms of PMDD. Fluoxetine 20 mg has been reported to be effective for emotional and physical premenstrual symptoms with continuous daily dosing (every day of the menstrual cycle) and with luteal phase daily dosing (from ovulation to menses). In addition, premenstrual emotional symptoms have been reported to improve with fluoxetine 10 mg in luteal phase daily dosing and with 90 mg 2 and 1 weeks prior to menses. Fluoxetine is generally a well-tolerated treatment for PMDD and discontinuation effects have not been reported with intermittent dosing regimens.