Premenstrual Syndromes : PMS and PMDD - Rutuja :: The site ...

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Hormonal therapies overview
Candace Brown and Frank Ling
INTRODUCTION
The importance of PMS/PMDD has been summarized
in previous chapters and we will begin by briefly summarizing
this. Premenstrual syndrome (PMS) is a condition
of recurrent physical and psychological symptoms
that occurs in a cyclic fashion during the 1- to 2-week
period preceding a woman’s menstrual period. Most
surveys have found that as many as 85% of menstruating
women report one or more mild premenstrual
symptoms. Severe symptoms that meet the criteria for
PMS, however, are much less common, with only 10%
of women reporting significant impairment in their
lifestyles. 1 Premenstrual dysphoric disorder (PMDD), a
variant of PMS that entails more severe psychological
symptoms and impairment of functioning, occurs in
2–9% of women of reproductive age. 2 This chapter will
focus on hormonal treatments that have been used in
both PMS and PMDD, since only recent studies have
examined the latter.
Although the etiology of PMDD is incompletely
understood, the leading hormonal theory is related to
fluctuating sex steroid levels. Although there is a temporal
relationship between symptoms of PMDD, female
sex hormones, and phases of the menstrual cycle, women
with PMDD show no consistent diagnosis-related differences
in basal levels of ovarian hormones. 3 We have
already seen that the likely etiology of PMS/ PMDD is
the effect of postovulatory progesterone in sensitive
women. This progesterone sensitivity is probably due
to abnormal neurotransmitter function. Thus, in general
terms, treatment can be achieved by means of
correction of the neurotransmitter status, for example,
by use of selective serotonin reuptake inhibitors (SSRIs)
or by suppression of ovulation. Chapter 14 deals with
the concept of treatment by ovarian suppression. In
this chapter we outline the role of hormone therapy.
There is inevitably some overlap and differences of
opinion.
Suppression of ovarian function with pharmacotherapy
4–6 or through surgical menopause 7,8 eliminates the
symptoms of PMDD. Moreover, symptoms are eliminated
during pregnancy and are absent during nonovulatory
cycles and after menopause. 9 The most likely
explanation is that women with PMDD are in some
way vulnerable to the normal physiological changes
associated with the menstrual cycle. 3 This hypothesis
was supported in one study where women with PMDD
developed depressed mood in response to challenge
with physiological levels of estrogen and progesterone
compared with controls. 10
Androgens have also been suggested in the etiology
of PMS/PMDD because of the prominence of irritability
in the symptom profile. Elevated testosterone levels
have been reported in women with severe premenstrual
irritability, 11 and a positive correlation has been observed
between free testosterone concentrations and irritability.
12 Moreover, some success has been reported in
treating PMDD with androgen antagonists. 11 There are
other studies where complex interactions with serotonin
and even lower testosterone levels have been
shown, leading to the use of testosterone for treatment.
Finally, metabolites of progesterone, allopregnanolone
and pregnanolone, may be decreased in women
with PMDD. These metabolites may have a positive
effect on the central nervous system similar to that of
GABA (�-aminobutyric acid), and deficiencies may give
rise to premenstrual symptoms. 13
ORAL CONTRACEPTIVES
Combined oral contraceptive pills (OCPs) prevent
ovulation and replace endogenous fluctuations of ovarian