Patrick O'Brien

Towards a consensus on diagnostic criteria, measurement and trial design of the premenstrual disorders : the ISPMD Montreal consensus

Premenstrual disorders (PMD) are characterised by a cluster of somatic and psychological symptoms of varying severity that occur during the luteal phase of the menstrual cycle and resolve during menses (Freeman and Sondheimer, Prim Care Companion J Clin Psychiatry 5:30–39, 2003; Halbreich, Gynecol Endocrinol 19:320–334, 2004). Although PMD have been widely recognised for many decades, their precise cause is still unknown and there are no definitive, universally accepted diagnostic criteria. To consider this issue, an international multidisciplinary group of experts met at a face-to-face consensus meeting to review current definitions and diagnostic criteria for PMD. This was followed by extensive correspondence. The consensus group formally became established as the International Society for Premenstrual Disorders (ISPMD). The inaugural meeting of the ISPMD was held in Montreal in September 2008. The primary aim was to provide a unified approach for the diagnostic criteria of PMD, their quantification and guidelines on clinical trial design. This report summarises their recommendations. It is hoped that the criteria proposed here will inform discussions of the next edition of the World Health Organisation’s International Classification of Diseases (ICD-11), and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) criteria that are currently under consideration. It is also hoped that the proposed definitions and guidelines could be used by all clinicians and investigators to provide a consistent approach to the diagnosis and treatment of PMD and to aid scientific and clinical research in this field.

ISPMD consensus on the management of premenstrual disorders

The second consensus meeting of the International Society for Premenstrual Disorders (ISPMD) took place in London during March 2011. The primary goal was to evaluate the published evidence and consider the expert opinions of the ISPMD members to reach a consensus on advice for the management of premenstrual disorders. Gynaecologists, psychiatrists, psychologists and pharmacologists each formally presented the evidence within their area of expertise; this was followed by an in-depth discussion leading to consensus recommendations. This article provides a comprehensive review of the outcomes from the meeting. The group discussed and agreed that careful diagnosis based on the recommendations and classification derived from the first ISPMD consensus conference is essential and should underlie the appropriate management strategy. Options for the management of premenstrual disorders fall under two broad categories, (a) those influencing central nervous activity, particularly the modulation of the neurotransmitter serotonin and (b) those that suppress ovulation. Psychotropic medication, such as selective serotonin reuptake inhibitors, probably acts by dampening the influence of sex steroids on the brain. Oral contraceptives, gonadotropin-releasing hormone agonists, danazol and estradiol all most likely function by ovulation suppression. The role of oophorectomy was also considered in this respect. Alternative therapies are also addressed, with, e.g. cognitive behavioural therapy, calcium supplements and Vitex agnus castus warranting further exploration.

Menopause and perimenopause

Menopause is the time when a woman’s menstrual periods stop permanently. Menopause is confirmed after 1 year of no periods. The average age of menopause is 51 years, but the normal range is 45 years to 55 years. The years leading up to this point are called perimenopause. This term means “around menopause.” This phase can last for up to 10 years. During perimenopause, shifts in hormone levels can affect ovulation and cause changes in the menstrual cycle. What are some of the common changes that occur in the menstrual cycle during perimenopause? During a normal menstrual cycle, the levels of the hormones estrogen and progesterone increase and decrease in a regular pattern. Ovulation occurs in the middle of the cycle, and menstruation occurs about 2 weeks later. During perimenopause, hormone levels may not follow this regular pattern. As a result, you may have irregular bleeding or spotting. Some months, your period may be longer and heavier. Other months, it may be shorter and lighter. The number of days between periods may increase or decrease. You may begin to skip periods. How can I tell if bleeding is abnormal? Any bleeding after menopause is abnormal and should be reported to your health care professional. Although the menstrual period may become irregular during perimenopause, you should be alert for abnormal bleeding, which can signal a problem not related to perimenopause. A good rule to follow is to tell your health care professional if you notice any of the following changes in your monthly cycle: • Very heavy bleeding • Bleeding that lasts longer than normal • Bleeding that occurs more often than every 3 weeks • Bleeding that occurs after sex or between periods

Psychological Disorders in Obstetrics and Gynaecology for the MRCOG and Beyond: Substance use disorders

Although the prevailing view for many decades was that drug dependent patients simply suffered from character weakness, the persuasive data emerging from modern brain imaging techniques and the application of molecular biology methods to animal models of compulsive drug use indicate that this position is no longer tenable. The integration of a number of new technologies has allowed investigators to combine behavioral and neurobiological approaches to more completely evaluate multiple aspects of this difficult problem. The following 16 chapters detail advances in the biology of substance use disorders, concentrating on those occurring during the 1990s, the decade of the brain. The section concentrates on advances most relevant to neuropsychopharmacology, integrating neurobiology, behavioral biology, and pharmacology. Knowledge of the pathophysiology of drug use disorders has greatly increased with the identification and cloning of receptors for the major drugs of abuse. There is also a much greater understanding of the brain circuits involved, including those common to different classes of drugs. The efficacy of treatment has also increased through the availability of effective medications for alcohol, heroin, and nicotine, as well as behavioral approaches used with cocaine abusers. Also, there is greater acceptance of the chronic disease model, which focuses on functional improvement as the realistic goal of treatment, rather than ‘‘cures.’’ The terminology used in this section deserves some comment. There is general agreement that there are degrees of