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Lecture 6: Premenstrual Syndrome

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:

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Lecture 6: Premenstrual Syndrome

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  1. Lecture 6: Premenstrual Syndrome Dr. Antoinette Lee The University of Hong Kong

  2. Outline • Definitions and Related Conditions • Assessment and Diagnosis • Etiologies • Nature of the Problem among Chinese Females • Treatment

  3. 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

  4. What is Premenstrual Syndrome? • American Psychiatric Association (1994): Premenstrual Dysphoric Disorder (PDD) as a “mood disorder not otherwise classified” • Lay arena

  5. 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)

  6. What is Premenstrual Syndrome? • Distinguish from: • Other physical (e.g. mastalgia) or psychological (e.g. depression bulimia) problems • Premenstrual exacerbation of pre-existing conditions

  7. 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

  8. (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

  9. 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).

  10. DSM-IV Research Criteria for Premenstrual Dysphoric Disorder • 1. markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts affective • 2. marked anxiety, tension, or feeling of being “keyed up,” or “on edge” • 3. marked affective lability (e.g. feeling suddenly sad or tearful or increased sensitivity to rejection) • 4. persistent and marked anger or irritability or increased interpersonal conflicts • 5. decreased interest in usual activities (e.g. work, school, friends, hobbies) • 6. subjective sense of difficulty in concentrating

  11. 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

  12. 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).

  13. 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)

  14. 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)

  15. (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)

  16. The Menstrual Cycle

  17. Symptoms of PMS • More than 150 symptoms associated with PMS • No “hallmark symptom” • Variable constellation of symptoms • Across individuals and over time

  18. Symptoms of PMS • Moos (1968): 7 clusters of symptoms • Pain • Concentration • Behavioral change • Autonomic reactions • Water retention • Negative affect • Arousal

  19. 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

  20. 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)

  21. Diagnosis and Assessment of PMS • Calendar of Premenstrual Experiences (COPE) • Prospective Record of Impact and Severity of Menstrual Symptoms (PRISM)

  22. 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).

  23. Calendar of Premenstrual Experiences

  24. Calendar of Premenstrual Experiences

  25. 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.

  26. Typical PRISM Calendar Record Indicating Depression

  27. Typical PRISM Calendar Record Indicating PMS

  28. 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

  29. 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

  30. 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)

  31. 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

  32. 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)

  33. 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

  34. 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

  35. 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

  36. 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)

  37. 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?

  38. 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

  39. 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%)

  40. 5 menstrual symptoms with highest endorsement: • Abdominal cramps (46%) • Fatigue (43%) • Abdominal pain (41%) • Hypersomina (32%) • Take naps (32%)

  41. 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

  42. 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

  43. 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)

  44. 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

  45. 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

  46. 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

  47. The hormone levels of patients and controls at different menstrual phases Estrogen (pg/mL) Progesterone (ng/mL) 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

  48. 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

  49. 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

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