The Premenstrual Syndromes: PMS and PMDD PDF

Preface

Somatic, affective, and behavioral symptoms can occur during the premenstrual phase of the menstrual cycle of nearly all ovulatory women. The nature and severity of these symptoms constitute a spectrum from minimal to disabling; however, the distinction between normal and pathological symptoms is one of the principal dilemmas in this area of research. The severity of interference with daily activities depends on various as yet poorly defined factors, but etiology probably includes genetic, neurochemical, and environmental factors. Are we really, in this era of high technology, limited to the use of simple paper-based rating scales to record the impact of symptoms on normal functioning, on school and work performance, and on ability to socialize? Yes, at present, this remains the most reliable way to distinguish between what is physiological and what constitutes a premenstrual disorder, premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD).

Awareness of such premenstrual problems amongst women, their partners, general practitioners, gynecologists, psychiatrists, other health professionals and, particularly, the media has increased dramatically over the past 30 years.

Even so, there are sceptics who say that premenstrual symptoms or disorders have been exaggerated and medicalized by the profession and the pharmaceutical industry, in order to ‘peddle' their hormones (progestagens and estrogen) or antidepressants (notably selective serotonin reuptake inhibitors, SSRIs). Complementary and alternative practitioners have also offered a range of treatments: some ineffective; others, poorly studied, but possibly effective. Premenstrual symptoms, similar to many affective and behavioral symptoms, exhibit a very high response to placebo, and significant symptoms can occur in at least 20% of women. The lack of consensus on the nature of this condition creates a void of knowledge, in which some women may unfortunately become targets for exploitation. However, it is of paramount importance that scientific research continues and that the medical community recognizes and cares for these disorders. It would be a great disservice to women and society if those in the medical community (who have insufficient knowledge and understanding) approach these problems with disdain.

Premenstrual syndrome is amongst a unique, small number of disorders where the patient frequently arrives at the specialist with their own diagnosis and it is the practitioner's role to exclude or confirm the diagnosis. The lack of an objective means of confirming the diagnosis and monitoring treatment is a great problem. This may be one of the reasons why the credibility of the diagnosis of PMS has been questioned. Although this is probably true for other psychological disorders, it is probably more so for PMS.

In the USA and in Australasia, PMS is recognized as a serious entity, but in the UK and continental Europe less so. The National Institute of Mental Health (NIMH) in Washington, DC, the American Psychiatric Association, and the American College of Obstetricians and Gynecologists (ACOG) respect the validity of these disorders in that research program grants, evidencebased clinician guidance, and patient information are well-established and widely disseminated. By contrast, in the UK, all PMS/PMDD research has been led by the pharmaceutical industry and only now, for the first time, is the Royal College of Obstetricians and Gynaecologists developing evidence-based guidance for treatment. The situation in the rest of Europe probably falls somewhere between these two extremes. A patient/consumer group in the UK, The National Association of Premenstrual Syndrome, has been the focus of activity in the field and has a relatively scientific view of most matters relating to PMS. In the UK and rest of Europe, the only licensed preparations for managing PMS are progesterone and various progestins, yet we will see in the following chapters that there is incontrovertible evidence that these are ineffective. Many other effective but unlicensed approaches are used in the UK and Europe: we have a situation where everything that is licensed is ineffective and everything that works is unlicensed! By contrast, in the USA, Canada, and Australasia, both the SSRI class of drugs as well as a novel oral contraceptive pill (for women who also want hormonal contraception), are licensed and prescribed extensively with guidelines for psychiatrists and gynecologists (ACOG) recommending either SSRIs or the newer drospirenone-containing oral contraceptive pill as first-line therapies for severe PMS or PMDD.

Clinical and basic science researchers in wide-ranging fields of study, including gynecology, psychology, psychiatry, endocrinology, genetics, brain imaging, and neurophysiology, have been interested in the exploration of this disorder for over 70 years, with an escalation of interest around the mid 1970s until today. This is the first multi-author textbook of its kind to focus solely on the premenstrual disorders of PMS and PMDD. Contributions have been received from individuals from most the units in Europe and the USA who have extensively researched and treated premenstrual tension, PMS, and PMDD.

The three editors have been involved in research into PMS for decades. They comprise a UK professor of obstetrics and gynecology from Keele University (PMSOB) who is currently also vice president of the Royal College of Obstetricians and Gynaecologists; a research and clinical psychiatrist from the NIMH in Washington, DC (PJS), and a well-established professor of obstetrics and gynecology from UCLA (AJR).

When setting about this book, we decided to choose authors who could represent virtually every major unit actively investigating aspects of PMS and PMDD in the UK, continental Europe, and the USA. It is hoped that no subject area has been left uncovered and no research group from these geographical areas overlooked.

Within the book there will be areas that are repeated or are contradictory, as views differ and it was felt inappropriate to edit out these views simply to be uniform. The reader will be able to appreciate ideological contrast and differing perceptions and experiences between psychiatrists and gynecologists, Europeans and Americans, clinicians and basic scientists, geneticists and endocrinologists. There is also, not surprisingly, agreement and disagreement within members of the same specialist areas. This adds to the richness of the debate and gives a fuller understanding of the current landscape. They are very much chapters written as the individuals see the issues, and often the emphasis will differ markedly. For instance, few authors from the USA contemplate giving estrogen, even though the evidence would support it. Few US authors would contemplate surgery. In the UK, there are strong advocates of ovulation suppression with transcutaneous estrogen therapy and, though only rarely and in severely affected patients, UK clinicians would be more willing to offer a surgical option – meaning, of course, the curative but very invasive decision to allow patients who request surgery to undergo hysterectomy and bilateral salpingooophorectomy. The research on this dramatic approach, however, has come from Canada and the USA as well as from the UK.

US psychiatrists, particularly, favor the use of the term PMDD and the use of SSRIs in management. The oral contraceptive pill is more readily advocated by US gynecologists, whereas the use of the levonorgestrel intrauterine system (LNG IUS, Mirena) is used extensively by UK gynecologists, not as a primary treatment method but to protect the endometrium from estrogeninduced hyperplasia during ovulation suppression using transcutaneous estrogen therapy. The use of psychotropic therapy and, more specifically, the SSRIs has been led by US and Canadian psychiatrists and Swedish researchers.

I think it is true to say that the study and publication of work on SSRI therapy predated any serious understanding of the neurobiology of PMS/PMDD, but this is now such a fascinating area that involves animal research, biochemical study, brain imaging with functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) scanning, and finally genetics. This combination of research, which is all being currently undertaken, will give us the best chance of succeeding in reaching a valid explanation for the etiology and then the cure of the premenstrual disorders within the early part of the 21st century.

The science of the premenstrual disorders and, hopefully, this textbook should stimulate and whet the appetite of anyone who has not already embarked on the investigation of this area.