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Lecture 6: Premenstrual Syndrome Dr. Antoinette Lee The University of Hong Kong Outline Definitions and Related Conditions Assessment and Diagnosis Etiologies Nature of the Problem among Chinese Females Treatment What is Premenstrual Syndrome? (I) History of PMS: Frank (1931): Premenstrual Tension (PMT) Dalton (1953): Premenstrual Syndrome (PMS) Court cases NIMH (1983): research standard for PMS American Psychiatric Association (1987): Late Luteal Phase Dysphoric Disorder (LLPDD) as a provisional research category What is Premenstrual Syndrome? American Psychiatric Association (1994): Premenstrual Dysphoric Disorder (PDD) as a “mood disorder not otherwise classified” Lay arena What is Premenstrual Syndrome? (II) Definition of PMS “the cyclic recurrence in the luteal phase of the menstrual cycle of a combination of distressing physical, psychological, and/or behavioral changes of a sufficient severity to result in deterioration of interpersonal relationships and/or interference with normal activities” Reid and Yen (1981) What is Premenstrual Syndrome? Distinguish from: Other physical (e.g. mastalgia) or psychological (e.g. depression bulimia) problems Premenstrual exacerbation of pre-existing conditions Diagnosis of PMS (Ling, 2000) A. Does not meet DSM-IV criteria for PMDD but does meet ICD-10 criteria for PMS B. Symptoms occur only in the luteal phase, peak shortly before menses, and cease with menstrual flow or soon after C. Presence of 1 or more of the following symptoms: Mild psychological discomfort Bloating and weight gain Breast tenderness Swelling of hands and feet Aches and pains Poor concentration Sleep disturbance Change in appetite (III) Related Conditions 1.) Premenstrual Dysphoric Disorder (PMDD) In Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (APA, 1994) Under “mood disorders not otherwise classified Mood symptoms as the primary complaint DSM-IV Research Criteria for Premenstrual Dysphoric Disorder A. In most menstrual cycles during the past year, five (or more) of the following symptoms were present most of the time during the last week of the luteal phase, began to remit within a few days after the onset of the follicular phase, and were absent in the week postmenses, with at least one of the symptoms being either (1), (2), (3), or (4). DSM-IV Research Criteria for Premenstrual Dysphoric Disorder 1. 2. 3. 4. 5. 6. markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts affective marked anxiety, tension, or feeling of being “keyed up,” or “on edge” marked affective lability (e.g. feeling suddenly sad or tearful or increased sensitivity to rejection) persistent and marked anger or irritability or increased interpersonal conflicts decreased interest in usual activities (e.g. work, school, friends, hobbies) subjective sense of difficulty in concentrating DSM-IV Research Criteria for Premenstrual Dysphoric Disorder 7. lethargy, easy fatigability, or marked lack of energy 8. marked change in appetite, overeating, or specific food cravings 9. hypersomnia or insomnia. 10. a subjective sense of being overwhelmed or out of control 11. other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of “bloating”, weight gain DSM-IV Research Criteria for Premenstrual Dysphoric Disorder B. The disturbance markedly interferes with work or school or with usual social activities or relationships with others (e.g., avoidance of social activities, decreased productivity and efficiency at work or school). C. The disturbance is not merely the exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, dysthymic disorder, or a personality disorder (although it may be superimposed on any of these disorders). DSM-IV Research Criteria for Premenstrual Dysphoric Disorder D. Criteria A, B, and C must be confirmed by prospective daily ratings during at least two consecutive symptomatic cycles. (The diagnosis may be made provisionally prior to this confirmation.) (APA, 1994) Content Validity of Premenstrual Dysphoric Disorder Hartlage & Arduino (2002) investigated the mood-related symptoms reported by 26 women seeking treatment for premenstrual disorders and found that premenstrual irritability or anger were more frequent than depressed mood. Irritability and affect lability as the most characteristics features of PMDD rather than depressed mood or anxiety (Landen, M. & Eriksson, E. 2003) (III) Related Conditions 2.) Premenstrual Tension Syndrome In the International Classification of Diseases, 10th edition (ICD-10) (WHO, 1992) Coded under “Diseases of the Genitourinary System” (N94.3) The Menstrual Cycle Symptoms of PMS More than 150 symptoms associated with PMS No “hallmark symptom” Variable constellation of symptoms Across individuals and over time Symptoms of PMS Moos (1968): 7 clusters of symptoms Pain Concentration Behavioral change Autonomic reactions Water retention Negative affect Arousal Symptoms of PMS Abraham (1983): 4 subgroups of PMS: PMT-A Anxiety, irritability, mood swings Estrogen-progesterone imbalance, serotonin, psychological factors PMT-H Water retention, bloating, breast tenderness PMT-D Depressed mood, cognitive impairment, insomnia PMT-C Carbohydrate cravings, fatigue Insulin sensitivity, stress, depressed mood Diagnosis and Assessment of PMS 1.) Self-report measures Prospective daily rating At least 2 menstrual cycles Moos Menstrual Distress Questionnaire (MDQ): Moos (1968) 47 items 8 subscales Premenstrual Assessment Form (PAF): Endicott and Halbreich (1982) Diagnosis and Assessment of PMS Calendar of Premenstrual Experiences (COPE) Prospective Record of Impact and Severity of Menstrual Symptoms (PRISM) Calendar of Premenstrual Experiences Begin our calendar on the first day of your menstrual cycle. Enter the calendar date below the cycle day. Day 1 is your first day of bleeding. Shade the box above the cycle day if you have bleeding (). Put an X for spotting (). If more than one symptom is listed in a category, i.e., nausea, diarrhea, constipation, you do not need to experience all of these. Rate the most disturbing of the symptoms on the 1-3 scale. Weight: Weigh yourself before breakfast. Record weight in the box below date. Symptoms: Indicate the severity of your symptoms by using the scale below. Rate each symptom at about the same time each evening. 0 = None (symptom not present) 2 = Moderate (interferes with normal activities) 1 = Mild (noticeable but not troublesome) 3 = Severe (intolerable, unable to perform normal activities) Other Symptoms: If there are other symptoms you experience, list and indicate severity. Medications: List any medications taken. Put an X on the corresponding day(s). Calendar of Premenstrual Experiences Bleeding Cycle day Date Weight SYMPTOMS Acne Bloatedness Brest tenderness Dizziness Fatigue Headache Hot flashes Nausea, diarrhea, constipation Palpitations Swellings (hands, ankles, breast) Angry outburst, arguments, violent tendencies Anxiety, tension, nervousness 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Calendar of Premenstrual Experiences Bleeding Cycle day Date Weight SYMPTOMS Confusion, Difficulty concentrating Crying easily Depression Food cravings (sweets, salts) Forgetfulness Irritability Increased appetite Mood swings Overly sensitive Wish to be alone Other symptoms 1.__________ 2.__________ Medications 1.__________ 2.__________ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Calendar of Premenstrual Experiences The COPE Calendar is scored by adding the total number of points from days 3-9 of the menstrual cycle (The follicular phase score) and the total number of points from the last 7 days of the cycle (luteal phase score). PMS: follicular phase score < 40 and luteal phase score > 42 Follicular phase scores > 40(regardless of luteal phase scores) suggest the possibility of underlying psychiatric disorder Although not strictly required for the diagnosis, almost all patients with PMS will have at least a 30% increase in scores from follicular to luteal phase. If this is not observed, the diagnosis should be reconsidered. Typical PRISM Calendar Record Indicating Depression BleedinggХ Х Х Х Х Х Х Х Х Х Menstrual Cycle 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 Date: SYMPTOMS Irritable 2 3 1 1 2 2 2 2 Fatigue 2 2 1 2 2 1 2 2 Inward Anger 2 3 2 2 2 2 2 1 Labile Mood (crying) 3 3 1 1 2 2 Depressed 3 1 1 2 1 2 Restless 1 1 1 1 Anxious 3 2 3 3 3 1 Insomnia Lack of Control 2 2 2 1 2 2 2 1 2 2 2 2 3 2 1 2 2 1 3 1 2 2 1 1 1 2 3 3 2 2 1 1 3 2 1 2 2 2 3 2 2 1 2 1 1 2 2 2 3 2 1 Appetite: updown 2 1 2 2 C C C 2 2 3 1 1 2 2 2 C 3 3 2 2 1 2 1 1 Abdominal Bloating C 1 1 1 1 2 Bowels: const. (c ) loose (l) 1 2 1 2 2 2 2 2 2 2 Brest Tenderness Drive: up down 2 1 2 2 1 2 2 1 1 2 1 1 2 1 1 2 1 2 2 2 1 2 2 2 1 1 1 2 1 2 2 3 1 2 2 2 2 2 1 2 1 1 1 2 2 1 1 1 2 2 3 2 1 2 2 1 2 3 1 1 2 2 1 2 1 2 2 Edema or Rings Tight 3 2 2 1 2 C 1 1 1 2 C C Chills (C ) / Sweats (S) Headaches 1 2 2 2 2 2 2 3 2 2 2 2 2 2 Crave: sweets, salt 1 2 2 2 2 2 Feel Unattractive 2 2 2 2 2 3 1 2 2 1 1 2 2 2 2 2 2 2 2 2 2 Guilty 2 2 2 2 2 2 2 2 2 2 2 Unreasonable behavior Low Self=Image 2 2 Nausea 1 1 2 2 2 Menstrual Cramps 2 2 2 1 2 1 2 2 1 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 1 2 2 3 3 2 2 2 2 2 2 2 2 1 1 2 Typical PRISM Calendar Record Indicating PMS BleedinggХ Х Х Х Х Х Х Х Х Х Menstrual Cycle 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 Date: SYMPTOMS Irritable 3 2 Fatigue 2 2 2 2 1 1 2 1 1 2 3 2 3 3 1 1 1 1 2 2 2 3 2 2 2 Inward Anger 1 1 Labile Mood (crying) 2 2 Depressed 2 1 1 2 Restless 3 1 Anxious 2 1 Insomnia 2 1 2 1 1 2 2 2 2 2 2 Abdominal Bloating 3 2 1 Bowels: const. (c ) loose (l) L L C Appetite: updown 1 2 2 2 3 2 2 2 3 2 2 Brest Tenderness 2 2 1 1 2 C C C 2 3 3 1 1 1 2 3 3 3 2 3 1 1 2 3 3 3 3 3 1 2 2 2 2 2 2 2 L L Drive: up down 2 2 2 1 Lack of Control 1 Edema or Rings Tight 1 2 1 2 2 3 3 2 1 2 C C Chills (C ) / Sweats (S) Headaches 3 2 2 1 1 2 2 3 1 2 2 Crave: sweets, salt Feel Unattractive 2 Guilty 1 Unreasonable behavior 2 2 Low Self=Image 2 Nausea 1 2 Menstrual Cramps 1 2 2 2 3 2 1 2 2 3 3 2 1 1 2 3 2 2 1 2 3 2 2 1 2 2 1 2 2 2 1 2 2 Diagnosis and Assessment of PMS 2.) Clinical Diagnosis APA and ICD criteria Differential diagnoses Lack of a biological marker 3.) Role of laboratory tests Limited to screening for medical conditions in screening for differential diagnoses Diagnosis and Assessment of PMS 4.) Differential Diagnoses E.g. hypothyroidism, hyperthyroidism, , breast disorders, pelvic diseases, major depression, bipolar disorder, anxiety disorders, personality disorders, anorexia nervosa, bulimia nervosa Prevalence of PMS Cross-study and cross-cultural comparisons heavily limited by inconsistent definition and assessment criteria + other methodological issues PMS: 2-5% PMDD: 3-5% (APA, 1994), 2-10% (Yonkers and Davis, 2000) 20-40%: some kind of premenstrual symptoms (American College of Obstetricians and Gynecologists, 1989) 24% of women from psychiatric population meet diagnostic criteria for PMDD (Casper, 1998) Etiologies No definitive etiology for PMS or PMDD Possible etiologies include biological, psychological, and social factors (1) Biology (i) Hormonal imbalance Estrogen, progesterone Absolute level and ratio (ii) Neurotransmitter Serotonin, norepinephrine, GABA Efficacy of SSRIs Psychosocial Context of PMS (2) Psychological and Social Factors (i) Relationship with Psychiatric Disorders 59% of LLPDD patients had a current diagnosis of one or more anxiety disorders, 56% had a lifetime occurrence (Veeninga et al., 1994) Level of anxiety and depression higher than controls 63% of PMS patients had at least one episode of depression or anxiety disorder (Anderson, 1986) PMS contribute to suicidal attempts among female psychiatric patients (Zhou and Fan, 1998) Psychosocial Context of PMS (ii) Stress PMS and life events Stressful life events predisposes individuals to PMS or PMS influences perception of stressors? (iii) Personality Neuroticism and trait anxiety (iv) Attitudes and Expectations Psychosocial Context of PMS (v) Role Quality The impact of multiple roles: scarcity hypothesis vs enhancement hypothesis Role occupancy & role quality vs number of roles PMS related to role conflict and dissatisfaction Psychosocial Context of PMS (6) Feminist Theories PMS as a male-created illness to depict women as the weaker gender Medicalization of normal fluctuations (7) Social Constructionism PMS socially constructed to serve certain social purposes PMS in Chinese Societies Johnson (1987): a culture-bound Sx 92% of women in Hong Kong reported some premenstrual symptoms (Chang et al., 1995) 60% of urban women in China experience negative menstrual changes (Yu et al., 1996) PMS in Chinese Societies Abdominal pain (33%), backache (30%), and bloating (23%) common in the menstrual phase validity of instruments questionable local forms of perimenstrual distress? PMS in Chinese Societies Reduced number of pregnancies Traditional conservative attitudes towards menstruation and sexuality Status of women Modernization Lack of a locally valid research and clinical instrument A Local Study of Perimenstrual Distress Sample: 538 young females in HK Mean age: 20.18 (SD=7.17) 5 premenstrual symptoms with highest endorsement: Irritability (22%) Hypersomnia (21%) Fatigue (20%) Body dissatisfaction (20%) Easy to lose temper (20%) 5 menstrual symptoms with highest endorsement: Abdominal cramps (46%) Fatigue (43%) Abdominal pain (41%) Hypersomina (32%) Take naps (32%) Perimenstrual Distress and Female Roles 339 females in HK (Mean age = 37.3, SD = 9.39) SYMPTOM ENDORSEMENT: Premenstrual Menstrual 5 or more symptoms: 19.6% 27.5% 10 or more symptoms: 9.8% 11.6% 20 or more symptoms: 2.8% 4.3% Single women without children had the highest level of menstrual distress Level of menstrual distress: wife + worker > wife + mother worker > wife + mother worker > wife + mother + worker wife and mother roles appeared to exert a protective function against menstrual distress A study of the relationship between the menstrual cycle and suicide attempts N = 52 women admitted to the ER in Turkey because of a suicide attempt and 50 healthy female controls Inclusion criteria: Fertility Regular menstrual cycles of 28 3 days Lack of intake of oral contraceptive or other gonadal hormones and psychotropic drugs Mean age of patients = 26.51 (SD=7.82) A study of the relationship between the menstrual cycle and suicide attempts Subjects were divided into four groups according to menstrual cycle phase: Menstrual follicular phase (MPF, days 1-7) Non-menstrual follicular phase (NMPF, days 8-11) Mid cyclic phase (MCP, days 12-16) Luteal phase (LP, days 17-28 3) Subjects were given the Stat-Trait Anxiety Inventory (STAI) and Hamilton Depression Rating Scale (HDRS) Socio-demographic and clinical characteristics were also obtained Precent of suicide attempts according to the menstrual cycle phases 45 40 35 30 % 25 20 15 10 5 0 MFP NMFP MCP LP Note: The frequency of suicide attempts among the four phases of the menstrual cycle was sig. different (p<.001) Caykoylu A et al., Psychiatry Clin Neurosci 2004; 58:460-464 HDRS and STAI scores of patients according to the menstrual cycle phases 50 45 Score 40 HDRS score 35 STAI (Trait) score 30 STAI (State) score 25 20 15 10 5 0 MFP NMFP MCP LP Note: No statistical difference in HDRS and STAI scores was found between MPF and other phases Caykoylu A et al., Psychiatry Clin Neurosci 2004; 58:460-464 The hormone levels of patients and controls at different menstrual phases Estrogen (pg/mL) Patients Controls Progesterone (ng/mL) 8 80 7 70 6 60 5 50 4 40 3 30 2 20 1 10 0 0 MFP NMFP MCP LP MFP NMFP MCP LP Note: No statistical difference of hormone levels in the different phases was found between patients and controls Caykoylu A et al., Psychiatry Clin Neurosci 2004; 58:460-464 A study of the relationship between the menstrual cycle and suicide attempts No significant difference of socio -demographic and clinical characteristics was observed between MFP and the other phases the frequency of suicide attempts in MFP may originate from other factors independent of clinical and socio-demographic ones A study of the relationship between the menstrual cycle and suicide attempts Possible explanations: The low levels of gonadal hormones in MFP may induce a suicide attempt in predisposed women Suicide attempts may occur as a consequence of increased impulsivity brought about by the low serotonergic function due to gonadal hormone levels are low PMS and Menopause Premenstrual syndrome was the main predictor of climacteric symptoms, followed by perimenopausal state and negative life events (Binfa et al., 2004) Influence of psycho-social factors and women's reproductive on the risk of suffering climacteric symptoms 4 * 3.5 ** Odds ratio 3 * 2.5 2 1.5 1 0.5 0 Life events n = 300 Family dysfunction *p<.05 level of significance ** p<.001 level of significance Premenstrual syndrome Perimenopause Binfa et al., Maturitas 2004; 48: 425-431 Treatment of PMS 1.) Drug treatment (a) Hormonal therapy Estrogen, oral contraceptives, ovulation suppressant (b) Other medications Analgesic, diuretics, antidepressant, anxiolytics SSRIs emerging as the most effective treatment option (Steiner, 2000) SSRIs: intermittent administration of fluoxetine (Prozac) (Steiner et al., 1997) and sertraline (Zoloft) (Yonkers et al. , 1997) for tx of PMDD Calcium was presented as an inexpensive and healthy option in a recent study (Pearlstein & Steiner, 2000) Treatment of PMS 2.) Psychotherapy Cognitive-behavioral therapy, stress management, relaxation training 3.) Lifestyle changes (a) Exercise Moderate aerobic and stretching exercises Improvement of blood circulation, muscle relaxation, and mood Treatment of PMS (b) Nutritional/dietary changes Avoid: Caffeinated Drinks & Stimulants Alcohol Treatment of PMS Avoid: High Sodium Foods Treatment of PMS Avoid: Refined Sugar Treatment of PMS Avoid: Dairy Products Treatment of PMS Avoid: High Fat Foods Treatment of PMS Consume more of: Complex Carbohydrates Treatment of PMS Consume more of: Soy and Beans Treatment of PMS Consume more of: Leafy Green Vegetables and Root Vegetables