Leslie Born

Advances in the Diagnosis and Treatment of Premenstrual Dysphoria

The recent inclusion of research diagnostic criteria for premenstrual dysphoric disorder (PMDD) in the DSM-IV recognises the fact that some women in their reproductive years have extremely distressing emotional and behavioural symptoms premenstrually. Through the use of these criteria, PMDD can be differentiated from premenstrual syndrome (PMS) which has milder physical symptoms, i.e. breast tenderness, bloating, headache and minor mood changes. PMDD can also be differentiated from premenstrual exacerbation of a current psychiatric disorder or medical condition, although some women may meet criteria for a dual diagnosis.Epidemiological surveys have estimated that as many as 75% of women with regular menstrual cycles experience some symptoms of PMS. PMDD, on the other hand, is much less common. It affects only 3 to 8% of women in this group, but it is more severe and exerts a much greater psychological toll. These women report premenstrual symptoms that seriously interfere with their lifestyle and relationships. The aetiology of PMDD is largely unknown but the current consensus seems to be that normal ovarian function (rather than hormone imbalance) is the cyclical trigger for PMDD-related biochemical events within the CNS and other target organs.The serotonergic system is in close reciprocal relationship with the gonadal hormones and has been identified as the most plausible target for interventions. Thus, beyond the conservative treatment options such as lifestyle and stress management, and the more extreme interventions that eliminate ovulation altogether, the selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs) are emerging as the most effective treatment options for this population.Results from several randomised placebo-controlled trials in women with PMDD, with predominantly psychological symptoms of irritability, tension, dysphoria and lability of mood, have clearly demonstrated that the SSRIs have excellent efficacy and minimal adverse effects. More recently, several preliminary studies indicate that intermittent (premenstrually only) treatment with SSRIs is equally effective in these women and, thus, may offer an attractive treatment option for a disorder that is itself intermittent.

Treatment of Menopause-Related Mood Disturbances

More than 1.7 million American women are expected to reach menopause each year. Recent Canadian statistics show that a 50-year-old woman can now expect to live until her mid-80s, which implies living at least one-third of her life after menopause. The menopausal transition is typically marked by intense hormonal fluctuations, accompanied by vasomotor symptoms (eg, hot flashes, night sweats), sleeps disturbance, and changes in sexual function, as well as increased risk for osteoporosis, cardiovascular disease, and cognitive decline. More importantly, recent studies have demonstrated a significant association between menopausal transition and a higher risk for developing depression. In the post-Womens Health Initiative Study era, physicians and patients are questioning the safety and efficacy of long-term hormone therapy use. This article reviews the current literature on the benefits and risks of using hormone therapy for the treatment of menopause-related mood disturbances and alternate strategies currently available for the management of menopause-related problems, including antidepressants, complementary and alternative medicine, and selective estrogen receptor modulators.

The Relationship Between Menarche and Depression in Adolescence

Prior to adolescence, the rates of depression are similar in girls and boys, or are slightly higher in boys. However, with the onset of puberty, the gender proportion of depression dramatically shifts to a 2:1 female to male ratio. What is the relationship between menarche and the onset of major depression in early adolescence? A recent theoretical model proposes that vulnerability to depression may be rooted in normal female hormonal maturational processes and gender socialization. Information regarding the management of depression in adolescent and young adult women is provided, including gender differences in the presentation of depressive symptoms, instruments to facilitate assessment, and treatment options. Pubertal and other hormonal changes should be monitored prospectively along with individual, genetic, constitutional, and psychological characteristics. The burden of illness associated with onset of depression following menarche reinforces the importance of expeditious recognition and intervention.

Estrogens and Other Hormones in the Treatment of Premenstrual Syndromes

Premenstrual Syndrome (PMS) can be defined as a pattern of emotional, behavioral, and physical symptoms that occur premenstrually and remit after menses (World Health Organization 1996). These symptoms typically include minor mood changes such as irritability, tension, or depressed mood, and physical complaints such as breast tenderness, bloating, cramps, or headache. Premenstrual dysphoric disorder (PMDD) denotes PMS with prominent mood symptoms (irritability, tension, dysphoria, or affective lability) severe enough to markedly affect work, social activities, or relationships with others (American Psychiatric Association 1994). The etiology of PMS and PMDD is still largely unknown, though there is accumulating evidence that these disorders are primarily biological phenomena. For example, investigators have shown the elimination of premenstrual complaints with suppression of ovulation (Muse et al. 1984; Schmidt et al. 1998) or surgical menopause (Casper and Hearn 1990; Casson et al. 1990) and an absence of symptoms during nonovulatory cycles (Hammarback et al. 1991). Additionally, there is recent, convincing evidence of the heritability of premenstrual symptoms (Kendler et al. 1998). The role of the female sex hormones in premenstrual symptomatology has long been considered of central importance. That both estrogen and progesterone are important in the manifestation of premenstrual symptoms has been shown in studies of postmenopausal hormone replacement therapy (Hammarback et al. 1985; Henshaw et al. 1996) and in a recent animal model of PMS (Ho et al. 2001). Women who received estrogen alone did not show any cyclical worsening in mood or physical symptoms (Hammarback et al. 1985). 8