By: Sejal Kotecha, DO
Director’s Note: Since May is Mental Health Awareness Month, we are featuring a review that addresses psychological and physical symptoms women experience during the premenstrual – or luteal – phase of their cycles. Dr. Sejal Kotecha, a former FACTS elective participant, summarized the article written by Hofmeister and Bodden titled, “Premenstrual Syndrome and Premenstrual Dysphoric Disorder.” [1] The article was published in American Family Physician in 2016. Dr. Kotecha’s summary highlights the etiology, diagnostic criteria, and symptoms of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD), benefits of tracking symptoms, and treatment options available for women with PMS or PMDD. As we celebrate National Women’s Health Week this week, we at FACTS hope similar research continues to advance authentic healthcare for women!
Introduction
Most people have likely heard a woman state she is “PMS-ing,” but what does that actually mean? Throughout a woman’s cycle, what causes mood changes or physical symptoms? Although a colloquial understanding may expect premenstrual symptoms to be present in most women, these symptoms can be debilitating for those diagnosed with premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). While much remains to be discovered about the etiology of PMS and PMDD, physiological differences noted by tracking symptoms during a woman’s cycle can be targeted with various treatments to improve quality of life and address health concerns.
“While much remains to be discovered about the etiology of PMS and PMDD, physiological differences noted by tracking symptoms during a woman’s cycle can be targeted with various treatments to improve quality of life and address health concerns.”
Epidemiology
Approximately 80% of women report at least one affective (psychological) or somatic (physical) symptom during the luteal phase of the cycle, but this does not typically interfere with daily living. Based on a French study [2] by Potter et al, 12% of women met the criteria for PMS, which requires the presence of symptoms in three previous cycles that demonstrably cause dysfunction in social, educational or professional performance. Symptoms can begin any time between menarche and menopause. The persistence of PMS fluctuates over time; in one study, 36% of women who were diagnosed with PMS still had it a year later. PMDD has a much lower prevalence of 1.3-5.3%. [2]
Etiology
Studies suggest that cyclic changes of estrogen and progesterone during the luteal phase trigger symptoms. Estrogen and progesterone affect serotonin, dopamine, and gamma-aminobutyric acid (GABA), which in turn affect the renin-angiotensin-aldosterone system (RAAS). Changes in these neurotransmitters cause psychological symptoms such as mood swings, while changes in RAAS influence physical symptoms such as bloating. Moreover, suboptimal progesterone levels due to a short luteal phase contribute to symptoms. Low levels of endorphins during the luteal phase are also associated with PMS. Patients with PMS or PMDD do not have higher levels of estrogen or progesterone than the general population.
“Estrogen and progesterone affect serotonin, dopamine, and GABA… Changes in these neurotransmitters cause psychological symptoms such as mood swings.”
Diagnostic Criteria
The criteria for PMS include having at least one affective symptom and one somatic symptom during the five days prior to menses in the last three consecutive cycles. Symptoms must end by four days into menses. Affective symptoms include angry outbursts, anxiety, confusion, depression, irritability, and social withdrawal. Somatic symptoms include abdominal bloating, breast tenderness or swelling, headache, joint or muscle pain, swelling of extremities, and weight gain.
“The criteria for PMS include having at least one affective symptom and one somatic symptom during the five days prior to menses in the last three consecutive cycles.”
A diagnosis of PMDD requires five affective or somatic symptoms in addition to clinically significant interference with work, school, social activities or relationships. These symptoms and disturbances are not solely attributable to another disorder such as major depression, dysthymia or a personality disorder, and are not caused by substance use, medications or another medical condition.
Treatment Options
Treatment options focus on relieving physical and psychiatric symptoms by modulating hormonal imbalances or the neurotransmitters affected by those hormones.
SSRI’s
Selective serotonin reuptake inhibitors (SSRI’s) are the first line treatment for PMS and PMDD. Administration can be continuous or timed to the luteal phase. Although dosage can be adjusted to tolerability, several side effects may limit use, including nausea, asthenia, fatigue, and sexual dysfunction. Higher doses can also alleviate some physical symptoms.
GnRH analogues
Gonadotropin releasing hormone (GnRH) analogues reduce symptoms by suppressing estradiol levels. While proven to be effective, side effects such as osteoporosis and cardiovascular risks may limit chronic use. Long-term users often require hormone “add-back” therapy, which can trigger a relapse of symptoms. However, some women may not experience PMS symptoms long term and could still benefit from this treatment option.
OCPs
Oral contraceptive pills (OCPs) are used to suppress the cyclic hormonal changes responsible for symptoms. Several studies have shown their effectiveness in reducing depressive symptoms, bloating, mastalgia, headache, weight gain, and swelling in the extremities with continuous use for three months. However, patients with PMDD display a high placebo response.
Naltrexone
Naltrexone is often used off-label based on clinicians’ experiences to alleviate symptoms. While naltrexone is traditionally used to treat opioid and alcohol use disorders, it can be used at low or high doses to enhance endorphin levels which are low during the luteal phase in women with PMS or PMDD. Improving endorphin levels is correlated with improved symptom severity, especially with high doses of naltrexone.
Discussion
Further research is necessary regarding the etiology and treatment of PMS and PMDD. There is need to explore why some women are more susceptible than others to experiencing symptoms of PMS and PMDD despite having similar hormone levels. Although twin studies have shown potential for a genetic component, no genes have been identified as a target for treatment. Treatment options such as naltrexone and vitamin D supplementation need additional testing to become more widely accepted. Future studies should also compare luteal phase versus continuous administration of SSRI’s.
Most research studies utilize the outdated rhythm method when drawing blood to test hormone levels and when implementing a particular treatment. This is a flawed approach, given that every woman will not ovulate exactly on day 14 of her cycle, and hormone levels may not be interpreted accurately. Utilizing fertility awareness-based methods (FABMs) to chart a cycle should be considered best practice, since the peak day (i.e., the day of ovulation) can be identified. This would enable accurate testing of hormone levels in the luteal phase, and treatments could be precisely targeted in an individual’s current cycle down to the day. If more studies utilized FABMs, progesterone would have potential for proven results as a treatment option and may be utilized more consistently for an inadequate luteal phase in PMS and PMDD.
“Utilizing fertility awareness-based methods (FABMs) to chart a cycle … would enable accurate testing of hormone levels in the luteal phase, and treatments could be precisely targeted in an individual’s current cycle down to the day.”
Prospective questionnaires are typically used to diagnose and monitor symptoms and establish whether they are truly cyclic in nature. FABM charting can also be used to monitor symptom changes alongside the biomarkers observed to track a woman’s cycle. This enables clinicians to identify more accurately the phase of the menstrual cycle in which symptoms occur and how that correlates with specific hormonal changes.
Monitoring whether PMS or PMDD truly exists in a patient is also relevant to fertility tracking, since a short luteal phase may cause PMS or PMDD in addition to infertility or recurrent pregnancy loss. Tracking cycles with FABM charting methods can offer additional insight with respect to premenstrual syndromes, as the menstrual cycle is considered the fifth vital sign.
References
[1] LHofmeister, S.; Bodden, S. (2016). Premenstrual Syndrome and Premenstrual Dysphoric Disorder. American Family Physician, 94(3), 236–240.?
[2] Potter J, Bouyer J, Trussell J, Moreau C. Premenstrual syndrome prevalence and fluctuation over time: results from a French population-based survey. J Womens Health (Larchmt). 2009;18(1):31-39.
ABOUT THE AUTHOR
Sejal Kotecha, DO
Sejal Kotecha, DO attended Nova Southeastern University in Fort Lauderdale, Florida and will begin residency in family medicine at Summa Health in Akron, Ohio. She has a passion for patient-centered education. She enrolled in the FACTS elective to better serve the vast patient needs in women’s health and family planning, enabling patients to feel supported, heard, and empowered in understanding their bodies.
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