Cognitive functioning in premenstrual syndrome

Attention, response inhibition, impulsivity, and decision-making within luteal phase in women with premenstrual dysphoric disorder

Cognitive impairment is a key feature of depressive disorder. Various forms of cognitive function have yet to be investigated in women with premenstrual dysphoric disorder (PMDD) during early luteal (EL) and late luteal (LL) phases. Therefore, we evaluated response inhibition and attention in PMDD in these two phases. We also examined the associations between cognitive functions, impulsivity, decision-making style, and irritability. There is a total of 63 female participants with PMDD and 53 controls, as determined through psychiatric diagnostic interviewing and a weekly symptoms checklist. The participants completed a Go/No-go task, Dickman's impulsivity inventory, Preference for Intuition and Deliberation scale, and the Buss-Durkee Hostility Inventory: Chinese Version-Short Form at the EL and LL phases. The women with PMDD had poorer attention in the Go trials at the LL phase and poorer response inhibition in the No-go trials at the EL and LL phases. Repeated measures analysis of variance revealed an LL exacerbation of deficit in attention among PMDD group. In addition, impulsivity negatively correlated with response inhibition at the LL phase. Preference for deliberation correlated with attention at the LL phase. Women with PMDD experienced LL declined attention and impaired response inhibition across the luteal phase. Response inhibition is linked to impulsivity. The deficit in attention links preference for deliberation among women with PMDD. These results reveal the different courses in different domains of cognitive impairment in PMDD. Further studies are required to elucidate the mechanism underlying cognitive dysfunction in PMDD.

Early and Late Luteal Executive Function, Cognitive and Somatic Symptoms, and Emotional Regulation of Women with Premenstrual Dysphoric Disorder

Objective: Cognitive and somatic symptoms were vital factors in developing personalized treatment of depressive disorder. The study aimed to evaluate the following: (1) the cognitive and somatic symptoms of premenstrual dysphoric disorder (PMDD) in the early luteal (EL) and later luteal (LL) phase; and (2) their association with depression and functional impairment of PMDD. Methods: We prospectively evaluated executive function, emotion regulation, cognitive and somatic symptoms, and depression in the EL and LL phases in women with PMDD. Sixty-three women with PMDD and 53 healthy controls completed Simon’s task and questionnaire to assess emotion regulation, inattention, fatigue, insomnia, and depression. Results: Women with PMDD had a poor performance in Simon’s task during the LL phase. They were less likely to exercise cognitive reappraisal during EL and LL phases. Their cognitive reappraisal positively correlated with executive function and negatively associated with depression. In the LL phase, they also experience higher inattention, insomnia, and fatigue, which correlate with the depression and functional impairment of PMDD. Inattention is the most associated factor of PMDD and functional impairment in controlling depression. Conclusion: Executive function was impaired in women with PMDD during the LL phase. Its performance correlated positively with emotion regulation and negatively with depression. The association between inattention and PMDD functional impairment indicates that evaluation and intervention for cognitive impairment were essential in treating women with PMDD. Further studies were required to elucidate the possible etiology underlying these associations.

Hormonal contraceptives and the risk of suicide: a systematic review and meta-analysis

OBJECTIVE

To assess the effect of hormonal contraceptive use over the risk of suicide.

METHOD

Systematic review and meta-analysis of observational studies retrieved from five search engines until September 2019, comparing the use of any hormonal contraceptive versus non-hormonal contraceptive use or no use. Primary outcome was consumed suicide, and secondary outcomes were suicidal attempt and ideation. Random effects meta-analyses with the inverse variance method were used to evaluate the effects of exposure over outcomes. Effect was calculated as risk ratio (RR) with their corresponding 95% confidence interval (CI). Risk of bias was assessed with the Newcastle-Otawa Scale.

RESULTS

There were no randomized controlled trials concerning suicide and hormonal contraceptive use. Only three cohort studies (n = 184,721 women), that evaluated the primary outcome (consumed suicide), were included in the meta-analysis. Hormonal contraceptive use was associated to a higher risk of consumed suicide (RR = 1.36, 95% CI 1.06 to 1.75, P =  0.015, I² = 0%). There were no secondary outcomes in at least two cohorts.

CONCLUSION

This meta-analysis found a positive association between hormonal contraceptive use and consumed suicides. Prior to their use, populations at suicidal risk should be properly evaluated.

Cognition, The Menstrual Cycle, and Premenstrual Disorders: A Review

Sex hormones, such as estrogens, progesterone, and testosterone, have a significant influence on brain, behavior, and cognitive functioning. The menstrual cycle has been a convenient model to examine how subtle fluctuations of these hormones can relate to emotional and cognitive functioning. The aim of the current paper is to provide a narrative review of studies investigating cognitive functioning in association with the menstrual cycle in biological females, with a focus on studies that have investigated cognitive functioning across the menstrual cycle in females with premenstrual mood disorders, such as premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). In line with previous reviews, the current review concluded that there is a lack of consistent findings regarding cognitive functioning across the menstrual cycle. Most studies focused on changes in levels of blood estrogen, and neglected to explore the role of other hormones, such as progesterone, on cognitive functioning. Cognitive research involving premenstrual disorders is in its infancy, and it remains unclear whether any cognitive disturbances that are identified may be attributed to negative experience of mood and psychological symptoms or be a more direct effect of hormonal dysregulation or sensitivity. Suggestions for future research are provided.

Progesterone and human cognition

Progesterone is a neurosteroid and a neuroactive steroid, produced primarily by the corpus luteum and the placenta. In some animal models, progesterone affects cognitive performance, and its potential role in human cognition is especially germane to women. This role can be investigated through associations between peripheral concentrations of progesterone in blood or saliva and neuropsychological test results, through differences in cognitive profiles between women using menopausal hormone therapy with and without a progestogen, and through clinical trials. In naturally cycling reproductive-age women and pregnant women, there is no consistent relation between progesterone levels and cognition. In postmenopausal women within 6 years of menopause and not using hormone therapy, progesterone levels are positively associated with verbal memory and global cognition, but reported associations in older postmenopausal women are null. Some observational studies of postmenopausal women using hormone therapy raise concern of a small deleterious cognitive effect of progestogen (medroxyprogesterone acetate was most often reported in these studies), but this association may due to confounding factors. Small, short-term clinical trials of progesterone show no meaningful effect on cognition. The quality of evidence is low, but overall findings do not reveal consistent, clinically important effects of progesterone on cognitive function in women.

Sex and menstrual cycle influences on three aspects of attention

Sex differences and menstrual cycle influences have been investigated in a variety of cognitive abilities, but results regarding attention are comparably sparse. In the present study, 35 men and 32 naturally cycling women completed three attention tasks, which are commonly used in neuropsychological assessment situations. All participants completed two sessions, which were time-locked to the follicular (low progesterone) and luteal cycle phase (high progesterone) in women. The results reveal higher operation speed during sustained attention in men, but no sex differences in selected and divided attention. Menstrual cycle influences were observed on accuracy in all three tasks. During divided and sustained attention, for which a male advantage was previously reported, accuracy was higher during the early follicular compared to the mid-luteal cycle phase. Furthermore, during selected and sustained attention the learning effect from the first to the second test session was higher in women who started the experiment in their luteal cycle phase. These results suggest a possible role of progesterone in modulating the ability to focus on certain stimulus aspects, while inhibiting others and to sustain attention over a longer period of time.

Subtle persistent working memory and selective attention deficits in women with premenstrual syndrome

As a recurrent, cyclical phenomenon, premenstrual syndrome (PMS) affects a significant proportion of women of the reproductive age, and leads to regular monthly days of functional impairment. Symptoms of PMS include somatic and psychological symptoms, such as headaches, sleep disturbances, social withdrawal and mood changes, during the late luteal phase of the menstrual cycle, which alleviate during the follicular phase. This study investigated neurocognitive functioning in women with moderate to severe PMS symptoms (n=13) compared to women with mild/no PMS (n=27) through administration of a battery of neuropsychological tests during the asymptomatic follicular phase of the menstrual cycle. Relative to women with mild/no PMS symptoms, women with moderate to severe PMS showed significantly poorer accuracy and more errors of omission on the N-0-back, as well as more errors of omission on the N-2-back task, indicating the presence of impairment in selective attention and working memory. This study provides evidence of persistent, subtle working memory and selective attention difficulties in those with moderate to severe PMS during the follicular phase of the menstrual cycle.

Daily symptom ratings for studying premenstrual dysphoric disorder: A review

BACKGROUND

To review how daily symptom ratings have been used in research into premenstrual dysphoric disorder (PMDD), and to discuss opportunities for the future.

METHODS

PsycINFO and Medline were systematically searched, resulting in the inclusion of 75 studies in which (1) participants met the diagnostic criteria for late luteal phase dysphoric disorder (LLPDD) or PMDD and (2) diaries were used to study LLPDD/PMDD.

RESULTS

To date, diaries have been used to gain insight into the aetiology and phenomenology of PMDD, to examine associated biological factors, and to assess treatment efficacy. We found low consistency among the diaries used, and often only part of the menstrual cycle was analysed instead of the whole menstrual cycle. We also observed that there was substantial variability in diagnostic procedures and criteria.

LIMITATIONS

This review excluded diary studies conducted in women with premenstrual syndrome, women seeking help for premenstrual complaints without a clear diagnosis, and women without premenstrual complaints.

CONCLUSIONS

Prospective daily ratings of symptoms and related variables provide a valuable and important tool in the study of PMDD. This paper addresses some options for improving the use of diaries and proposes the use of experience sampling and ecological momentary assessment to investigate within-person variability in symptoms in more detail.

The effect of serotonin 1A receptor polymorphism on the cognitive function of premenstrual dysphoric disorder

Estrogen and serotonin play vital roles in the mechanism of premenstrual dysphoric disorder (PMDD). Cognitive deficit in the premenstrual phase contributes to impaired life function among women with PMDD. The aim of this study was to evaluate the difficulties in cognitive control and working memory (WM) in PMDD and to explore the effects of gonadotropic hormone and polymorphism of serotonin 1A receptor (HTR1A; rs6295) on cognitive deficit in PMDD. Women with PMDD completed diagnostic interviewing, questionnaire assessment, the Go/Nogo task, 2-back and 3-back tasks, and gonadotropic hormone analysis in the premenstrual and follicular phases. Further, they were followed up for two menstrual cycles to confirm two consecutive symptomatic cycles. A total of 59 subjects with PMDD and 74 controls completed all evaluation, fulfilled the criteria, and entered into the final analysis. The results demonstrated cognitive control and WM decline in the premenstrual among women with PMDD. The G/G genotype of HTR1A (rs6295) was found to be associated with impaired WM in the premenstrual phase and premenstrual decline of cognitive function. It also contributed to the vulnerability of cognitive function to the menstrual cycle effect and PMDD effect. As the G/G genotype of HTR1A (rs6295) involves in reducing serotonin neurotransmission, our results provide insight into the serotonin mechanism of cognitive function among women with PMDD.

Decision-making impairments in breast cancer patients treated with tamoxifen

The selective estrogen receptor modulator tamoxifen (TAM) is most commonly prescribed for patients with hormone-sensitive breast cancer. Although TAM can bind to estrogen receptors in the nervous system, it is unknown whether it acts as an estrogen agonist or antagonist in the human brain. Several studies have reported the negative effects of TAM on cognitive function; however, its effects on decision-making function have not been previously explored. The present study aimed to investigate the decision-making function under ambiguity and risk in breast cancer patients treated with TAM. Participants included breast cancer patients taking TAM (TAM, n=47) and breast cancer patients not taking TAM (non-TAM, n=45) as well as their matched healthy controls (HC, n=50). All participants were given the Iowa Gambling Task (IGT) to assess their decision-making under conditions involving ambiguity, the Game of Dice Task (GDT) to assess their decision-making under conditions involving risk, and a battery of neuropsychological tests. Our results indicated that patients in the TAM group were significantly impaired as assessed by both the IGT and GDT and performed significantly worse on some aspects of various tasks involving memory and information processing. Furthermore, we found that decreased performance on verbal memory testing significantly correlated with IGT performance, and executive dysfunction was associated with poor GDT performance in breast cancer patients undergoing TAM treatment. This study demonstrates that breast cancer patients taking TAM have several decision-making impairments. These findings may support the idea that TAM resulting in cognitive changes plays an antagonistic role in the areas of the brain where estrogen receptors are present, including the prefrontal cortex, hippocampus and amygdala.

Neuropsychological performance and menstrual cycle: a literature review

Approximately 80% of all women of reproductive age experience psychological and physical changes associated with the premenstrual phase. Cognitive alterations are among the most common complaints. In this context, studies have assessed cognitive performance across the menstrual cycle in healthy women and also in women with premenstrual syndrome (PMS). The main objective of the present study was to review the literature on cognitive function in different phases of the menstrual cycle in women of reproductive age, both healthy and with PMS, in particular premenstrual dysphoric disorder (PMDD). We searched MEDLINE and LILACS databases. A total of 27 studies were selected. The studies used heterogeneous methodologies. Most studies suggested that healthy women show small fluctuations in cognitive performance across the menstrual cycle, with low performance scores in the luteal phase for visuospatial and motor skills, attention and concentration, verbal memory, visual memory, working memory, and reaction time. Among women with PMS or PMDD, low performance scores for visuospatial and motor skills, attention and concentration, verbal memory, working memory, reaction time and impulsivity were also detected in the luteal phase. Symptoms observed in PMS/PMDD patients showed low intensity, but greater when compared with healthy women. Evidence indicates fluctuations in cognitive performance in the different phases of the menstrual cycle in healthy and PMS women, with worse performance for women with PMS/PMDD in the luteal phase. However, methodological limitations prevent us from drawing solid conclusions. Further studies are needed to investigate the impact of these cognitive fluctuations on patients' daily activities.

The effects of menstrual cycle phase on clinical measures of concussion in healthy college-aged females

The management of concussion and mild traumatic brain injury is an area of clinical uncertainty for many sports medicine professionals. While recent studies suggest sex differences in neurocognitive function may exist, our understanding of the effects of menstrual cycle phase and oral contraceptive pill (OCP) use in healthy females is limited. The purpose of this study was to investigate whether there were changes in neurocognitive function, postural stability and self-reported symptoms between the early and late stages of the menstrual cycle, and also to identify whether performance across menstrual cycle would differ between females using OCP and eumenorrheic females not using OCP. Healthy college-aged females completed a standard concussion test battery including computerised assessment of neurocognitive function, postural stability and symptom status. Participants completed the counterbalanced testing design during the early and late phases of their menstrual cycle. No significant main effects or interactions for any neurocognitive function or postural stability outcome measure were observed. Eumenorrheic females endorsed a higher number of symptoms and reported an increased symptom severity score compared to females using OCP. Menstrual cycle phase had no effect on the total severity or the number of symptoms endorsed. These results suggest preseason neurocognitive and postural stability baseline tests are stable across the menstrual cycle, regardless of OCP use. Therefore, decreased performance on these measures following a suspected concussion is likely not attributable to menstrual cycle phase or use of OCP.

The premenstrual syndrome revisited

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

Memory function in women with premenstrual complaints and the effect of serotonergic stimulation by acute administration of an alpha-lactalbumin protein

Serotonergic hypofunction may underlie at least part of the symptoms that are experienced by women with premenstrual complaints, including memory deficits. In the current study we investigated changes in memory functions in the premenstrual phase compared to the early postmenstrual phase in 16 women with premenstrual complaints. In addition, the effect of an acute serotonergic stimulation by administration of an alpha-lactalbumin protein on premenstrual memory performance was assessed using a double-blind placebo-controlled crossover design. It was found that both short-term and long-term memory for words (30-word learning task) and abstract figures (abstract visual learning task) were mildly impaired in the premenstrual phase. Administration of alpha-lactalbumin during the premenstrual phase could only partially attenuate the memory performance decrements that are seen in the premenstrual phase. Specifically, alphalactalbumin improved long-term memory for abstract figures, but not for words. There were no effects of menstrual phase or alpha-lactalbumin on planning functions (computerized Tower of London). The data suggest that serotonergic hypofunction may play a role in premenstrual memory decline, but serotonergic mechanisms cannot fully account for observed cognitive changes in the premenstrual phase.

Attentional validity effect across the human menstrual cycle varies with basal temperature changes

This study examined the correlation between covert attention and basal temperature change during menstrual cycle phase in 22 adult females. Previous work showing beneficial effects of estrogen on working memory led us to hypothesize that attentional function would be facilitated at the apparent time of ovulation. Menstrual phase was determined through questionnaires and objective measurements of basal body temperature (BBT) spikes over a 1 month period. The cued target detection (CTD) task was used to assess visuospatial attentional performance at three times during the menstrual cycle. The mean reaction times (RTs) to visual targets were measured as a function of menstrual cycle phase, cue type and target location. As predicted, the onset of ovulation showed decreased reaction times and a significant increase in the cue validity effect on the days immediately preceding and following ovulation. The magnitude of the attention validity effect was negatively correlated with the basal temperature rise. Women lacking basal temperature shifts failed to show these changes. Results support the conclusion that the natural fluctuations of body temperature, and possibly reproductive hormones, during the menstrual cycle may enhance the attentional component of cognitive performance.

Premenstrual dysphoric symptoms amongst Brazilian college students: factor structure and methodological appraisal

OBJECTIVES

The present study aims to assess the factor structure of the DSM-IV Premenstrual Dysphoric Disorder (PMDD) symptoms and its relationship with depressive symptoms.

METHODS

We evaluated retrospectively PMDD symptoms in 513 female college students, through a self-reporting questionnaire based on DSM-IV criteria, in addition to the Beck Depression Inventory (BDI). Principal component analysis on PMDD symptom data was performed to assess its dimensional structure.

RESULTS

In this non-clinical sample, the analysis indicated a higher importance of the dysphoric dimension, but physical symptoms as well as "being out of control" or "overwhelmed" should also be viewed as major symptoms of PMDD. Behavioural symptoms are of secondary importance. The mean BDI score of PMDD group was significantly higher (p < 0.05) than non-PMDD group.

CONCLUSION

The factor structure of the total sample was similar to the symptom structure suggested by DSM-IV diagnostic criteria. Depressive symptoms should be viewed as a confounding variable in PMDD.

Effects of antidepressants on quality of life in women with premenstrual dysphoric disorder

This review examines the effects of antidepressant medications on premenstrual dysphoric disorder (PMDD) and the diminished quality of life (QOL) that accompanies the disorder. PMDD is a chronic condition in women that emerges in the second half of the menstrual cycle and remits during the menstrual period. The affective and behavioural symptoms of PMDD adversely affect functioning and QOL to a disabling degree, particularly in the domains of family and personal relationships, work productivity and social activities. The serotonergic antidepressants, specifically the selective serotonin reuptake inhibitors (SSRIs), are effective for PMDD. Continuous and luteal-phase dosing regimens with SSRIs are similarly effective and well tolerated. Treatment of PMDD with a serotonergic antidepressant significantly improves functioning and QOL in all studies that have systematically examined QOL issues in this disorder. Although the data show that PMDD is effectively treated with serotonergic antidepressants and that functional impairment that accompanies the disorder is also improved with treatment, the social and economic burden of PMDD continues to be widely unrecognised. Greater awareness of the effectiveness of treatments and reliable measures of the direct and indirect healthcare costs of the disorder when it remains untreated are needed.

Estrogen and cognitive functioning in women

Research in basic neuroscience has provided biological plausibility for the hypothesis that estrogen replacement therapy (ERT) would protect against cognitive aging in healthy women. The weight of the evidence from randomized controlled trials of estrogen and cognition in women shows that this hormone preferentially protects verbal memory in postmenopausal women, whereas findings from observational studies are less consistent and show a more diffuse effect of estrogen on a range of cognitive functions. There is fairly consistent evidence from epidemiological studies that ERT significantly reduces the risk of Alzheimer's disease (AD) in women. On the other hand, findings from controlled treatment trials of women diagnosed with probable AD failed to show that physiological doses of ERT ameliorate existing deficits in cognitive functioning and/or prevent further deterioration in memory that inevitably occurs in these women over time. Finally, an accumulating body of evidence is beginning to suggest that the immediate postmenopausal period may constitute a critical window for treatment with ERT that maximizes its potential to protect against cognitive decline with aging and/or to reduce the risk of AD.

Characteristics of women with premenstrual dysphoric disorder (PMDD) who did or did not report history of depression: a preliminary report from the Harvard Study of Moods and Cycles

We examined the characteristics of 33 women with a diagnosis of premenstrual dysphoric disorder (PMDD) who did (n = 19) or did not (n = 14) report a history of major depression. Five hundred thirteen older premenopausal women (ages 36-44) from a community-based sample completed a prospective evaluation of PMDD with daily records. The diagnosis of PMDD was confirmed in 33 women (6.3%), and 14 subjects met criteria for PMDD with no history of depression. Demographic characteristics, cigarette smoking, and menstrual and reproductive history of subjects with PMDD who did or did not report a history of depression were compared. Women with PMDD and no history of depression were more educated and more frequently had a marital disruption (p < 0.05). No significant differences were observed with respect to reproduction-related characteristics or past cigarette smoking. These preliminary data suggest the existence of characteristics particularly related to women who meet criteria for PMDD and have no history of depression. Given the significant psychosocial impairment commonly associated with PMDD symptoms and the existing data that support its classification and adequate treatment as a distinct clinical entity, further studies are needed to better identify predictors of this syndrome unrelated to a lifetime history of depression.

A comparison of menstrual changes expected by pre-menarcheal adolescents and changes actually experienced by post-menarcheal adolescents in Mexico

This survey explored para-menstrual changes that Mexican pre-menarcheal girls expect to experience and paramenstrual changes actually experienced by post-menarcheal girls. The survey included 95 pre-menarcheal girls who reported what they expected to experience in the para-menstruum, and their answers were compared with para-menstrual changes reported by 98 post-menarcheal girls. There were more post-menarcheal than pre-menarcheal girls who reported negative physical changes, while more pre-menarcheal girls expected to experience negative changes related to cognitive-emotional expressions. Regarding positive para-menstrual changes, despite the fact that hardly any of the girls named them, more post-menarcheal girls reported positive changes than pre-menarcheal girls who expected the changes. The dominant menstrual discourse concerning menstruation focused on para-menstrual negative changes, which can lead pre-menarcheal girls to anticipate their periods with fear and to overlook positive changes that may occur in the para-menstruum.

Women's beliefs about the prevalence of premenstrual syndrome and biases in recall of premenstrual changes

The present study investigated the relationship between women's beliefs about the prevalence of premenstrual syndrome (PMS) and biases in recall of premenstrual changes. Forty-nine women completed the Moos Menstrual Distress Questionnaire (R. H. Moos, 1968) both retrospectively and prospectively. Afterward, they were asked about their beliefs concerning the prevalence of PMS. The women reported higher premenstrual changes when they completed the retrospective questionnaire. Seventy-five percent of the women believed that the majority of women have premenstrual changes. From this percentage, those who answered that the majority also experience PMS were more biased in their premenstrual changes in the retrospective assessment. Many women have a misperception about the meaning of PMS; consequently, they amplify their premenstrual changes in recall, reflecting women's cultural stereotypes rather than their actual experiences.