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Severity of symptom 100 90 80 70 60 50 40 30 20 10 Depression Clumsy Irritable Bleeding most likely to be present (J Endicott, unpublished data): 1. Premenstrual worsening of her ongoing condition, which is present throughout her cycle. 2. PMDD with patterns of changes that clearly meet criteria. 3. PMS that is clearly present but does not meet the severity or impairment criteria for PMDD. 4. Symptoms and impairment that show no evidence of being linked to phases of the menstrual cycle. The reason such a diagnostic evaluation is important is that it will identify the diagnosis and guide the treatment of the condition (Figure 4.2) The Premenstrual Symptoms Screening Tool The Premenstrual Symptoms Screening Tool (PSST) is a simple user-friendly screening tool devised by Steiner et al 22 to identify women who suffer from severe PMS/PMDD and who are likely to benefit from treatment. The PSST reflects and translates categorical DSM-IV criteria into a rating scale with degrees of severity and impact of premenstrual symptoms. It is less time consuming and more practical than two cycles of prospective charting and, hence, is an important starting point for further assessment. Following screening, the clinician still must rule out other psychiatric QUANTIFICATION OF PMS AND PMDD 29 0 1 6 11 16 21 26 31 36 41 46 51 56 Day of cycle Figure 4.1 Daily visual analog scale scores for psychological symptoms derived from electronic data capture of VAS measurement on PDA. 30 and medical conditions and, if in doubt, more comprehensive assessment measures including prospective charting should be initiated (Figure 4.3). This chart has the potential to provide a simple easyto-used chart for clinical purposes but probably not for research. Even for clinical purposes, most clinicians believe it still needs to be validated against the DRSP. When using any chart for either research or clinical purposes, ideally, symptoms should be rated prospectively in order to avoid the inaccuracies inherent in retrospective rating, including the incorrect recall of symptom timing and exaggeration of symptom severity. Symptoms recorded over several cycles will illustrate any inter-cycle variability in the nature and severity of symptoms. Statistical measures have to be used to establish if a cyclical change exists or not. Quantifying severity with VAS and other techniques poses problems. In 1983 the National Institute of Mental Health workshop on PMS/PMDD stated that premenstrual changes should show at least 30% increase from the intensity of symptoms measured in the follicular phase (i.e. on days 5–10 of the menstrual cycle), compared with those measured in the premenstrual phase (on the 6 days before menstruation). Many of those involved in that workshop consider the 30% change in the ratings of symptoms has been shown to be too liberal and a poor discriminator when comparing women with self-reported severe PMS, women using contraceptives whose natural cyclicity has been
30 THE PREMENSTRUAL SYNDROMES Table 4.1 Techniques used to quantify premenstrual syndrome Reference Method Comment aHamilton 196013 Hamilton Rating Scale for Observer-rated instrument to assess 17/21 Depression (HAM-D) items in premenstrual mood disturbance aBeck et al 19612 Beck Depression Inventory (BDI) 21-item self-report questionnaire; symptoms rated 0–3 to give an overall depression score Moos 19683 Moos Menstrual Distress Questionnaire (MDQ) 47 symptoms rated on a six-point scale aMcNair et al 197114 Profile of Mood States (POMS) 65 symptoms rated on 0–4 scale combined to give summary scores for five dimensions aWeissman and Social Adjustment Scale (SAS) Self-report instrument containing Bothwel 197615 56 questions in seven different sections Endicott et al 1976 8 Global Assessment Scale (GAS) Has not been used extensively aGuy 197616 Clinical Global Impression Seven-point observer/patient-rated Scale (CGIS) global scale aDerogatis and Symptom Checklist-90 (SCL-90) General index of psychological and physical Cleary 197717 symptoms plus additional nine subscales O’Brien et al 19794 Visual analog scale (VAS): 100 mm line at either end of which are Premenstrual Mood Index opposing adjectives representing the symptoms Steiner et al 19809 Self-Rating Scale for Premenstrual Syndrome A 36-item yes/no rating scale Steiner et al 19809 Premenstrual Tension Assess symptoms in 10 different domains. Syndrome – Observer (PMTS-O) and Self-Rating (PMTS-SR) 36 symptoms with severity ranging from 0 to 4 Halbreich et al 198210 Premenstrual Assessment Retrospective questionnaire based on Form (PAF) psychological and behavioral symptoms Reid 198511 Prospective Record of the Daily chart records a large number of Impact and Severity of Menstrual Symptoms (PRISM) symptoms rated 1–3 Rubinow et al 19846 Visual analog scale (VAS) 100 mm line at either end of which are opposing adjectives representing the symptoms Magos et al 198618 Modified Moos Menstrual Ten items derived from MDQ, usually Distress Questionnaire (MDQ) subjected to Trigg’s trend analysis Casper and Visual analog scale (VAS) 100 mm line at either end of which are Powell 19865 opposing adjectives representing the symptoms Magos and Premenstrual Tension-Cator Five symptoms rated 0–3S Studd 198819 (PMT-Cator) (Continued)
Page 2: The Premenstrual Syndromes
Page 5 and 6: © 2007 Informa UK Ltd First publis
Page 7 and 8: vi CONTENTS 10. Pathophysiology I:
Page 9 and 10: viii LIST OF CONTRIBUTORS Uriel Hal
Page 12 and 13: Preface Somatic, affective, and beh
Page 14 and 15: 1 History of the premenstrual disor
Page 16 and 17: and estrogen/progesterone imbalance
Page 18 and 19: Dalton’s PMS, new, more precise t
Page 20 and 21: Many other therapeutic areas have b
Page 22 and 23: 2 The diagnosis of PMS/PMDD - the c
Page 24 and 25: section of gynecological disorders,
Page 26 and 27: Universal acceptance of a diagnosti
Page 28 and 29: Extremely severe Severe None Severi
Page 30 and 31: Table 2.5 Differential diagnosis of
Page 32: 17. Halbreich U, Borenstein J, Pear
Page 35 and 36: 22 THE PREMENSTRUAL SYNDROMES pharm
Page 37 and 38: 24 THE PREMENSTRUAL SYNDROMES IS PM
Page 39 and 40: 26 THE PREMENSTRUAL SYNDROMES 18. S
Page 41: 28 THE PREMENSTRUAL SYNDROMES METHO
Page 45 and 46: 32 THE PREMENSTRUAL SYNDROMES DAILY
Page 47 and 48: 34 THE PREMENSTRUAL SYNDROMES Table
Page 49 and 50: 36 THE PREMENSTRUAL SYNDROMES to ot
Page 51 and 52: 38 THE PREMENSTRUAL SYNDROMES prosp
Page 53 and 54: 40 THE PREMENSTRUAL SYNDROMES exami
Page 55 and 56: 42 THE PREMENSTRUAL SYNDROMES healt
Page 57 and 58: 44 THE PREMENSTRUAL SYNDROMES deter
Page 59 and 60: 46 THE PREMENSTRUAL SYNDROMES 35. B
Page 62 and 63: 6 Comorbidity of premenstrual syndr
Page 64 and 65: inhibitor, medications routinely us
Page 66 and 67: symptoms as well as worsening of co
Page 68 and 69: 7 The clinical presentation and cou
Page 70 and 71: ecause ovulation is less frequent a
Page 72 and 73: to try self-help strategies that ar
Page 74: 40. WHO. International Classificati
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Page 79 and 80: 66 THE PREMENSTRUAL SYNDROMES Anter
Page 81 and 82: 68 THE PREMENSTRUAL SYNDROMES REFER
Page 83 and 84: 70 THE PREMENSTRUAL SYNDROMES store
Page 85 and 86: 72 THE PREMENSTRUAL SYNDROMES contr
Page 87 and 88: 74 THE PREMENSTRUAL SYNDROMES Serot
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Page 91 and 92: 78 THE PREMENSTRUAL SYNDROMES level
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80 THE PREMENSTRUAL SYNDROMES 110.
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10 Pathophysiology I: role of ovari
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different neuromodulatory profile f
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studied, reflecting in part interes
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disturbed in these patients. Compar
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mid-luteal phases of the menstrual
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hyposensitivity or altered circadia
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52. Osterlund MK, Halldin C, Hurd Y
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135. Facchinetti F, Genazzani AD, M
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11 Pathophysiology II: neuroimaging
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orbitofrontal cortex (OFC), and ant
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EVIDENCE OF ALTERED GABAERGIC FUNCT
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the preclinical data indicating tha
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19. Nordstrom AL, Olsson H, Halldin
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110 THE PREMENSTRUAL SYNDROMES ster
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112 THE PREMENSTRUAL SYNDROMES ESTR
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114 THE PREMENSTRUAL SYNDROMES tria
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118 THE PREMENSTRUAL SYNDROMES GABA
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122 THE PREMENSTRUAL SYNDROMES PERC
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124 THE PREMENSTRUAL SYNDROMES (10
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126 THE PREMENSTRUAL SYNDROMES depr
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128 THE PREMENSTRUAL SYNDROMES and
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15 Psychotropic therapies Meir Stei
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Table 15.2 Intermittent dosing (lut
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Table 15.3 Intermittent vs continuo
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clinical evidence that concomitant
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46. Yamada K, Kanba S. Effectivenes
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142 THE PREMENSTRUAL SYNDROMES Tabl
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144 THE PREMENSTRUAL SYNDROMES redu
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146 THE PREMENSTRUAL SYNDROMES PMDD
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17 Clinical evaluation and manageme
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prior to menses) compared with the
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anxiety, or bipolar disorders, post
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premenstrual cognitive disturbance,
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PMS, and bilateral oophorectomy alo
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69. Studd J, Leather AT. The need f
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162 THE PREMENSTRUAL SYNDROMES GABA
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164 THE PREMENSTRUAL SYNDROMES the
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166 THE PREMENSTRUAL SYNDROMES psyc
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172 THE PREMENSTRUAL SYNDROMES In t
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174 THE PREMENSTRUAL SYNDROMES incl
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176 THE PREMENSTRUAL SYNDROMES by g
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178 THE PREMENSTRUAL SYNDROMES REFE
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Index Note to index: PMS is used fo
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levonorgestrol, with estradiol 156
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