VIII.

Disorders Associated with Pregnancy and Menstruation

62. PREMENSTRUAL SYNDROME AND PREMENSTRUAL DYSPHORIC DISORDER

Doris C. Cmdersefi, M.D.
1. What is premenstrual syndrome (PMS)?
Premenstrual syndrome describes a cluster of nonspecific psychological, behavioral and somatic symptoms, which occur in the luteal phase of the menstrual cycle. The timing of the symptoms, between ovulation and the onset of menses, distinguishes PMS from other psychiatric conditions experienced by women of reproductive age. PMS symptoms include depression, imtability, and rejection-sensitivity. Bloating (related to fluid retention), increased appetite, weight gain, breast tenderness or swelling, and headache also are commonly reported. The symptoms are generally severe enough to interfere with performance and interpersonal relationships.

2. What is premenstrual dysphoric disorder (PMDD)? In 1994, the diagnosis of PMDD was classified in the DSM IV under Mood Disorders Not
Otherwise Specified. PMDD replaced late luteal phase dysphoric disorder, a diagnosis included in the DSM 111-R(1987). Whereas many women experience premenstrual psychological and physical discomfort, a much smaller percentage develop symptoms severe enough to meet diagnostic criteria for PMDD. Due to poor reliability of retrospective symptom reports, DSM IV clinical criteria stipulate that the diagnosis of PMDD be made prospectively, over at least two consecutive menstrual cycles. The luteal phase symptomatology must be of sufficient severity to interfere with functioning and must be distinguished from the exacerbation of co-occurring medical or psychiatric disorders.

DSM IV Criteria f o r Premenstrual Dysphoric Disorder

A. In most menstrual cycles during the past year, five (or more) of the following symptoms were present for most of the time during the last week of the luteal phase, began to remit with a few days after the onset of the follicular phase, and were absent in the week postmenses, with at least one of the symptoms being either (I), (2), (3), or (4): (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (1 1)

markedly depressed mood, feelings of hopelessness, or self-deprecatingthoughts marked anxiety, tension, feelings of being keyed up, or on edge marked affective lability (e.g., feeling suddenly sad or tearful or increased sensitivity to rejection) persistent and marked anger or irritability or increased interpersonal conflicts decreased interest in usual activities (e.g., work, school, friends, hobbies) subjective sense of difficulty concentrating lethargy, easy fatigability, or marked lack of energy marked change in appetite, overeating, or specific food cravings hypersomnia or insomnia a subjective sense of being overwhelmed or out of control other physical symptoms, such as breast tenderness or swelling, headaches,joint or muscle pain, a sensation of bloating, weight gain

Table continued on following page

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Premenstrual Syndrome and Premenstrual Dysphoric Disorder

DSM IV Criteria,forPremenstrual Dysphoric Disorder (Continued)

B. The disturbance markedly interferes with work or school or with usual social activities and relationships with others (e.g., avoidance of social activities, decreased productivity and efficiency at work or school). C. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depression, panic disorder, dysthymic disorder, or a personality disorder (although it may be superimposed on any of these disorders). D. Criteria A, B, and C must be confirmed by prospective daily ratings during at least two consecutive symptomatic cycles. (The diagnosis may be made provisionally prior to this confirmation.) Note: In menstruating females, the luteal phase corresponds to the period between ovulation and the onset of menses, and the follicular phase begins with menses. In nonmenstruating females (e.g., those who have had a hysterectomy),the timing of the luteal and follicular phases may require measurement of circulating reproductive hormones.
From The American PsychiatricAssociation: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington DC, APA, 1994, pp 717-718; with permission.

3. How common are these conditions among menstruating women? Epidemiological surveys estimate that approximately 75% of women with regular menstrual cycles report minor or isolated premenstrual symptoms, and 20-50% of women experience PMS. According to DSM IV, PMDD afflicts approximately 3-5% of all menstruating women. It is important to consider the high incidence of comorbid psychiatric conditions in this age
group. Premenstrual aggravation of a primary mood disorder may be mistakenly diagnosed as PMS or PMDD unless careful prospective rating scales are employed to distinguish these conditions. Of significance, about 70% of women with bipolar disorder have dysphoric PMS, and 30-60% of women with premenstrual dysphoria have a history of major depression. This tremendous symptom overlap contributes to the ongoing difficulty in establishing whether PMS or PMDD are truly independent disorders versus premenstrual magnification of preexisting affective disorders.

4. Are there specific risk factors for developing PMS? Yes. A prior history of clinical depression confers some heightened risk for developing PMS. A history of postpartum depression andlor mood changes related to oral contraceptive use also increases
the risk for developing the condition. Finally, a family history of PMS is an independent risk factor.

5. Describe the proposed etiology for PMS.

Despite extensive research in this area, no precise etiology for PMS has been identified. A number of theories continue to be entertained and vigorously explored. Because of the heterogeneity associated with PMS, the majority of investigators agree that the etiology is likely mulifactorial. Prospective evaluations of stressful life events in women with PMS have failed to demonstrate a link between environmental stress and symptom severity. Biological factors appear to play a more substantial role in the development of this condition. There exists a high familial incidence of PMS, supporting some genetic contribution. Women with afflicted mothers and/or sisters are at greater risk for developing PMS. Finally, monozygotic twin concordance rates for PMS exceed those observed in dizygotic twins.

6. What is the postulated role of endogenous sex hormones in the pathogenesis of PMS? Earlier theories were based on the premise that abnormal levels of gonadal steroids contributed to the development of premenstrual symptoms. The diminished secretion of progesterone in the luteal phase of the menstrual cycle was previously implicated as a potential etiologic factor in the development of PMS. However, many well-designed studies do not support this theory. Luteal phase progesterone supplementation is no more effective than placebo in the treatment of PMS. Hypoestrogenism also has been proposed as a factor in the pathogenesis of PMS. In the periovulatory phase of the menstrual cycle, a subtle, transient decline in circulating estradiol is observed and is temporally related to mood changes and hot flushes in some women.

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The importance of gonadal steroids is most clearly illustrated by studies in which women with PMS are given gonadotropin releasing hormone (GnRH) agonists. The resulting ovarian shutdown is accompanied by a dramatic reduction in PMS symptoms. Interestingly, these women showed no differences in levels of ovarian steroids, estrogen to progesterone ratios, gonadotropins, or ovarian steroid binding globulins when compared to control subjects. This suggests that hormone cyclicity, not absolute levels of circulating sex hormones, is a more important factor in the development of PMS. Genetically predisposed women may possess supersensitivity to the normal, monthly fluctuations in these hormones. The absence of symptomatology before puberty, during pregnancy, and post menopause (i.e., periods of anovulation) lends support to this premise. Results of a more recent study conducted by Schmidt et al. challenge the notion that premenstrual symptoms are related to luteal phase fluctuations of estrogen and progesterone. Women meeting (prospectively confirmed) criteria for PMS were given the antiprogesterone agent, RU 486 (mifepristone). Despite premature termination of the luteal phase, the research subjects experienced their usual premenstrual syndrome well into the synthetically-induced follicular phase of their menstrual cycles. This suggests that hormonal events preceding the luteal phase may trigger PMS. Alternatively, PMS may represent a cyclic disorder, independent of the menstrual cycle and associated hormonal changes.

7 . What other endogenous substances have been implicated?

Both progesterone and estrogen affect endorphin levels. Disturbances in endogenous opioid systems are associated with PMS-like symptoms including, but not limited to, irritability, sleep disruption, and headache. Furthermore, opiate antagonists tend to magnify PMS symptoms in susceptible women, suggesting a possible link between endorphin abnormalities and the expression of PMS. Variability in thyroid hormone measures has been noted in women with PMS. However, no specific thyroid disorders have been diagnosed in this population. Mastalgia is a symptom commonly reported by women with PMS. For this reason, prolactin is suspected to be a factor in the development of the syndrome. The involvement of prolactin is also supported by two research findings. Women with PMS demonstrate a blunted prolactin response to tryptophan challenge in both the follicular and luteal phases of the menstrual cycle. Additionally, a blunted prolactin response to the administration of buspirone during the follicular phase has been observed in these women. Central nervous system deficiencies of the prostaglandin PGE- 1 are associated with headache, fatigue, and a craving for sweets. The accumulation of prostaglandin PGE-2a in the uterine myometrium plays a role in the development of dysmenorrhea. These findings lead some investigators to conclude that disturbances in prostaglandin synthesis and/or functioning likely contribute to PMS. Follicular stimulating hormone (FSH), lutenizing hormone (LH), melatonin, cortisol, and testosterone also have been identified as potential etiological agents. Again, no definitive link between PMS and any of these substances have been established.

8. Are the neurotransmitters associated with mood regulation thought to play a role in the etiology of PMS? Contemporary hypotheses point to a link between fluctuations in ovarian steroids and dysregulation of central neurotransmission in women predisposed to PMS. Investigators have established that estrogen, progesterone, and metabolites of these parent compounds alter noradrenergic, serotonergic, and GABA (gamma-aminobutyric acidergic) neurotransmission. In animal studies, hypothalamic estrogen induces a diurnal pattern of serotonin (5HT) rhythm. Administration of serotonin agonists, such as m-chlorophenylpyperazine(m-CPP) may induce mood elevation, whereas serotonin antagonism is associated with some behavioral changes (also observed in women with PMS), including irritability and social withdrawal. Human clinical data also supports that PMS may be related to the apparent effects of ovarian hormones on central serotonin neurotransmission. Studies have determined that, premenstrually, women with PMS possess heightened sensitivity of 5HT- l a receptors. Reduced whole blood concentrations of serotonin have been observed in the luteal phase of women meeting criteria for PMS.

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Premenstrual Syndrome a n d Premenstrual Dysphoric Disorder

Decreased platelet serotonin uptake also has been noted in this same population, but not in healthy controls. Some investigators suspect that women with PMS who report food cravings in the late luteal phase of their cycles and engage in carbohydrate binging may be attempting to self-medicate a mood disturbance by boosting tryptophan levels and, ultimately, central serotonin supplies.

9. What is the differential diagnosis for PMS?

PMS andlor PMDD should be considered diagnoses of exclusion. Of all the women presenting with complaints of premenstrual symptoms, 2S-75% will actually meet criteria for another underlying medical or psychiatric condition.

Differential Diagnosis of Premenstrual Symptoms

MEDICAL PSYCHIATRIC

Migraines Seizures Endocrinopathies Irritable bowel syndrome Chronic fatigue syndrome Anemia Pelvic inflammatory disease Endometriosis Perimenopause Idiopathic edema Fibrocystic breast disease

Affective disorders Anxiety disorders Eating disorders Substance abuse

10. What steps should be taken to confirm the diagnosis of PMS or PMDD? Begin with thorough psychiatric, medical, and family histories. A physical examination, including pelvic examination, should be pursued routinely in women presenting with both physical and psychological complaints. As emphasized previously, premenstrual magnification of both medical and psychiatric disorders are common and should be ruled out before a diagnosis of PMS or PMDD is assigned. No specific laboratory testing is recommended to make the diagnosis. However, in women complaining of fatigue or depression, a complete blood count to rule out anemia in addition to thyroid screening is recommended. If breast tenderness is severe and/or the menstrual cycle irregular, a prolactin level can be obtained. For women in their 40s, consider the possibility of perimenopause. Estradiol levels and FSH screening are recommended. In one study, it was found that fewer than SO% of women seeking treatment for presumed PMS actually had a cycle-dependent constellation of symptoms. This illustrates the importance of prospective daily rating to confirm that the symptoms are isolated to the Weal phase and recur with most cycles. Once other medical and psychiatric illnesses are ruled out, at least two months of prospective daily rating should be pursued.
Prospective Daily Rating Scales
Daily Record of Severity of Problems Patient Self-Report Scale (PSRS) Moos Menstrual Distress Questionnaire (MMDQ) Patient Record of Increased Symptoms with Menses (PRISM) Premenstrual Experience Assessment (PEA) Premenstrual Assessment Form (PAF) Calendar of Premenstrual Experiences (COPE)

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If the prospective charting reveals luteal-phase symptoms in the absence of follicular phase complaints, the diagnosis of PMS (or PMDD, depending on the severity of reported symptoms) can be made. However, persistent follicular phase symptomatology without dramatic magnification in the luteal phase should prompt the clinician to continue a search for occult medical andlor psychiatric conditions. Finally, persistent follicular phase complaints accompanied by significant luteal phase worsening points to the presence of an underlying disorder and comorbid PMS, or simply premenstrual magnification of an untreated medical or psychiatric condition. Identify all confounding conditions, and treat them aggressively.

11. Once the diagnosis is confirmed, what treatment strategies can be employed? Given the lack of a precise etiology, the treatment of PMS and PMDD generally focuses on attempts to ameliorate isolated symptoms. Treatment should begin with conservative interventions, including psychoeducation, support, and healthy lifestyle changes. The process of prospective rating allows a woman to participate in her own treatment, thereby reducing apprehension by providing greater predictability. When a woman is able to establish a pattern of recumng symptoms, it allows her to anticipate the more difficult days of her cycle and make plans to minimize stress during that time period. Cognitive, behavioral, and relaxation therapies have been found to decrease the severity of PMS. Additionally, physical (aerobic) exercise promotes endorphin release, which is believed to have a positive effect on mood and promote relaxation. Increased exercise should be encouraged in the late luteal phase of the menstrual cycle for women who complain of lethargy, tension, anxiety, and depression. A nutritional assessment can be helpful. Excessive alcohol consumption can exacerbate mood and sleep disturbances in women with PMS. Eliminating caffeine is suggested for women complaining of irritability, anxiety, and breast pain. Finally, reducing sodium intake, at least in the luteal phase of the cycle, may minimize bloating due to fluid retention. Wurtman et al. found that low-protein, high-carbohydrate diets consumed during the luteal phase led to a greater reduction in postmeal depression, tension, anger, confusion, and fatigue in PMS patients compared to their controls. Evening primrose oil (linoleic acid) has been reported to relieve premenstrual symptoms of depression, bloating, headache, breast pain, and irritability. A review of the literature reveals seven placebo-controlled trials, five of which were randomized. Inconsistent scoring and response criteria employed in these studies limit their usefulness. However, two of the better-designed studies failed to demonstrate the efficacy of this proposed remedy.

12. What is the role of vitamin and mineral supplementationin the treatment of PMS?
Vitamin and mineral supplementation is frequently recommended as part of the overall treatment strategy for women with PMS despite the fact that no actual vitamin or mineral deficiencies have been reported in this patient population. Many earlier studies were methodologically flawed due to poor subject selection and the failure to use valid prospective rating scales for establishing an accurate diagnosis. More recently, a handful of well-designed clinical trials have demonstrated efficacy for some nutritional supplements. Results of a double-blind, placebo-controlled studyI4confirmed that calcium is effective in alleviating both the physical and psychological symptoms of PMS. By the third treatment cycle, subjects receiving 1200 mg of calcium daily experienced a significant reduction in muscle aches, depression, food cravings, and fluid retention. The researchers hypothesized that the same hormones involved in calcium regulation also interact with reproductive hormones. Premenstrual symptoms may reflect a calcium deficiency in some women. Vitamin B6 (pyridoxine) is a cofactor in the synthesis of dopamine and serotonin. It has been reported to reduce depression, irritability, fatigue, edema, and headache in some premenstrual women. The scientific data concerning the value of B6 (pyridoxine) supplementation is mixed. Pooled data from ten randomized, double-blind trials revealed that approximately 30% of subjects experience a beneficial response. Two-thirds showed ambiguous results or no benefit compared to placebo. Effective doses range from 50 mg to 100 mg per day. Patients should be warned of the risk of developing an irreversible peripheral neuropathy if the recommended doses are exceeded.

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Premenstrual S y n d r o m e a n d Premenstrual Dysphoric Disorder

Magnesium deficiencies are associated with depletion of central nervous system dopamine, and also increased peripheral aldosterone. Magnesium is involved in prostaglandin synthesis and affects glucose-induced insulin secretion. Well-designed trials support magnesium supplementation during the luteal phase, (360 mg to 1080 mg per day) to minimize fluid retention, depression, and fatigue. Vitamin E modulates prostaglandin synthesis, and 400 IU daily may be helpful for reducing premenstrual depression and pain, although scientific data on efficacy is mixed.
13. What pharmacological treatments are helpful in the treatment of PMS or PMDD?
Nonpsychotropic Agents For Severe, Disabling Symptoms of PMS and PMDD
MEDICATION DOSE CYCLE PHASE TARGET SYMPTOM(S)

Ibuprofen Bromocriptine Spironolactone Naltrexone Atenolol Clonidine

600 mg bid-tid 2.5 mg bid-tid 25 mg-100 mg qd 25 mg bid SO mg qd 17 mcgkg qd*

As needed Luteal As needed Days 9- I 8 Entire cycle Entire cycle

Dysmenorrhea, headache Breast pain, edema Edema, weight gain Imtability, anxiety, depression Irritability Imtability, hostility, anxiety

* Divided doses are recommended.

Nonsteroidal anti-inflammatory drugs (NSAIDs), when given several days before the onset of menses, reduce pelvic pain, cramping, and headaches. For severe breast pain, the dopamine agonist (and prolactin inhibitor) bromocriptine can be prescribed. One double-blind, randomized, crossover trial supports the use of bromocriptine to alleviate premenstrual edema, weight gain, and bloating. It is reported to be less effective in relieving mood symptoms. Nausea is a common side effect, especially at higher doses, and may preclude its use. Several well-designed trials support the use of the potassium-sparing, aldosterone antagonist spironolactone to reduce severe edema and bloating. Some investigators believe the antiandrogenic properties of this diuretic are responsible for improving mood in addition to alleviating somatic symptoms. Diuretics should be used judiciously because of the risk of secondary aldosteronism and rebound edema. The opiate antagonist naltrexone may reduce luteal phase irritability, anxiety, depression, lethargy, bloating, and headaches in women suffering from PMS or PMDD. Nausea, dizziness, and appetite suppression are potential side effects.? The beta-blocker atenolol has been reported to alleviate premenstrual irritability. Similarly, the alpha-blocker clonidine has demonstrated efficacy i n the treatment of premenstrual symptoms including irritability, hostility, and anxiety.
14. Which psychotropic agents are used to treat PMS and PMDD? The use of psychotropic drugs in the treatment of PMS is based on the premise that a dysregulation in the hypothalamic-pituitary-gonadal axis affects central neurotransmitter physiology. Some Psychiatric Medications Currently Used in the Treutment of PMS and PMDD
MEDICATION DOSE CYCLE PHASE

Dextroamphetamine Alprazolam Buspirone Fluoxetine Sertraline Citalopram

10 mg-20 mg qd .25 mg-2.0 mg qd 15 mg-60 mg qd 20 mg qd 50 mg-100 mg qd 10 mg-30 mg qd

As needed in luteal phase As needed in luteal phase Continuous or luteal phase Continuous or luteal phase Continuous or luteal phase Continuous or luteal phase
Table continued on following page

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Some Psychiatric Medications Ciirrentlv Used in the Treatment of PMS and PMDD (Continued)
MEDICATION

DOSE

CYCLE PHASE

Paroxetine Clomipramine Nortriptyline Nefazadone Mirtazapine

10 mg-30 mg qd 25 mg-75 mg qd 50 mg-100 mg qd 100 mg-600 mg qd 7.5 mg-15 mg qd

Continuous Continuous Continuous Continuous Continuous

Note: For women with early age onset of PMS, documented mood or anxiety disorders, or severe symptoms of PMDD, intermittent SSRI dosing is not recommended. For pronounced premenstrual lethargy and hyperphagia, time-limited treatment with low-dose dextroamphetamine can be helpful. Anxiolytics are effective in alleviating prominent luteal phase anxiety, nervous tension and irritability. Specifically, alprazolam has been studied and found effective when prescribed in the week preceding menses. Average doses range from .75 mg to 2.25 mg per day. The medication should be tapered with the onset of menses. Caution must be exercised when prescribing stimulants or benzodiazepines in women with histories of substance abuse. Buspirone, a nonhabituating alternative, is also used to treat the anxiety and irritability associated with PMS and PMDD. Continuous dosing (15 mg to 60 mg per day), is recommended.

15. What about antidepressants? Currently, no antidepressant agents are FDA-approved for the treatment of PMS or PMDD. However, numerous controlled studies have established that a variety of antidepressant medications dramatically reduce or ameliorate premenstrual symptoms. These agents are particularly useful for women diagnosed with comorbid depressive and anxiety disorders, or who have failed to respond to more conservative treatment interventions, including other pharmacotherapies.
16. What is the evidence for successful treatment with SSRIs? Selective serotonin reuptake inhibitors (SSRIs) have been researched extensively in the treatment of these conditions. Carefully controlled studies demonstrate that fluoxetine is superior to placebo in abolishing behavioral, psychological, and, interestingly, somatic symptoms. Fluoxetine administered at 20 mg per day appears to be as effective as 60 mg per day, and research subjects reported fewer side effects on the lower dose. One long-term study (i.e., 1 year of treatment with fluoxetine) showed continued benefit. Similar controlled studies of sertraline have established its efficacy in the treatment of PMS and PMDD. Open trials of paroxetine,Is mirtazapine, and nefazadone' support the efficacy of these antidepressants as well. However, controlled, double-blind studies are needed to verify these promising preliminary results. Additionally, serotonergic antidepressants including desipramine, clomipramine, and nortriptyline have been used successfully, however with less tolerability than the SSRIs. Flexible dosing regimens (e.g., drug administration limited to the luteal phase) have been studied for fl~oxetine,'~ sertraline,8 and citalopram. In the absence of psychiatric comorbidity, half-cycle dosing is as effective as continuous dosing for the treatment of premenstrual symptoms. The psychopharmacologic reasons for the efficacy of intermittent dosing are not known. These intriguing findings suggest the mechanism underlying PMS or PMDD may differ from that of affective disorders. Alternatively, the efficacy observed with the use of SSRIs may be a function of some action independent of the antidepressant effect.

17. Describe hormonal therapies used to treat premenstrual symptoms. Oral contraceptives have have been proposed as a therapy for PMS based on the theory that the monophasic preparations supply steady doses of estrogen and progesterone throughout the menstrual cycle, thereby eliminating the natural hormonal fluctuations thought to contribute to premenstrual symptoms. Available studies reveal that about 25% of women improve, 50% report no change, and 25% experience an exacerbation of symptoms. Women with significant dysmenorrhea or heavy

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Premenstrual Syndrome and Premenstrual Dysphoric Disorder

bleeding may benefit most from this intervention. Triphasic preparations, which provide hormonal cyclicity, should be avoided in women with PMS and PMDD. The decline in progesterone during the luteal phase has been suspected as a potential trigger for premenstrual symptoms. Unfortunately, numerous clinical trials, including large, randomized, placebo-controlled studies, have failed to demonstrate the efficacy of progesterone.h Estrogen, administered continuously, may blunt the normal late luteal phase decline of this hormone and, at least theoretically, prevent associated premenstrual mood and somatic symptoms. Given subcutaneously or transdermally, estrogen is more effective than placebo. However, potential side effects include nausea, breast tenderness, and weight gain, precluding its use in some women. Furthermore, unless a woman has undergone hysterectomy, oral progestins also must be prescribed to prevent uterine hyperplasia. Progestins can induce PMS-like symptoms in some women. For women with severe PMDD, refractory to other available treatments, suppression of the hypothalamic-pituitary-ovarian axis to halt ovulation provides dramatic relief. Danazol, a synthetic androgen, works by inhibiting progesterone binding and estrogen synthesis. It suppresses the midcycle surges of FSH and LH, creating an anovulatory state. It has been reported to reduce premenstrual depression, irritability, anxiety, edema, and breast tenderness. Potential androgenic side effects include hirsutism, acne, and weight gain. About 10% of women develop hepatic dysfunction on this synthetic steroid.8 Similar symptomatic relief has been observed with gonadotropin-releasinghormone (GnRH) agonists like leuprolide. This agent produces a chemical menopause through downregulation of GnRH receptors, followed by the cessation of the cyclic release of estrogen and progesterone. Although highly effective, these latter two treatments are expensive. Additionally, danazol and leuprolide create hypoestrogenic environments with the associated risks of menopause, including symptoms of hot flashes and vaginal dryness, osteoporosis, and cardiac disease. For this reason, prolonged treatment (i.e., greater than 6 months) is not advised at this time. Hormonal Therapies For Premenstrual Symptoms
MEDICATION DOSE CYCLE PHASE

Oral contraceptives* Estrogen patches Danazol Leuprolide

Variable 200 ,ug q 3 d 200400 mg 3.75 mg im

Continuous Continuous Onset of symptoms to menses q 4 weeks (< 6 months)

* Monophasics = Brevicon, Loestrin, Demulen

Researchers are exploring the possibility of using GnRH agonists in conjunction with steadydose estrogen and progestin hormone replacement therapy. Preliminary findings are encouraging. 18. Is surgery an option? Surgical menopause (i.e., ovariectomy) is a very lust resort, and should be explored only if all other interventions are ineffective, diagnostic accuracy has been established, and future pregnancies are not desired.
BIBLIOGRAPHY
I . American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington DC, American Psychiatric Association, 1994. 2. Blackstrom T, Hansson-Malstrom Y, Lindhe B, et al: Oral contraceptives in premenstrual syndrome: A randomized comparison of triphasic and monophasic preparations. Contraception 46:253-268, 1992. 3. Chuong CJ, Coulam CB, Bergstralh EJ, et al: Clinical trial of naltrexone in premenstrual syndrome. Obstet

Gynecol72:332-336, 1988. 4. Dubovsky SL, Giese A: Selected issues in the psychopharmacologic treatment of women with psychiatric disorders. J Pract Psycho1 Behav Health 277-282, 1997. 5. Facchinetti F, Borella P, Sances G, et al: Oral magnesium successfully relieves premenstrual mood changes. Obstet Gynecol 78:177-181, 1991.

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35 1

6. Freeman EW, Rickels K, Sondheimer SJ, Polansky M: Ineffectiveness of progesterone suppository treatment for premenstrual syndrome. JAMA 264:349-353, 1990. 7. Freeman EW, Rickels K, Sondheimer SJ, et al: Nefazadone in the treatment of premenstrual syndrome: A preliminary study. J Clin Psychopharmacol 14:180-1 86, 1994. 8. Halbreich U, Rojanksy N, Palter S: Elimination of ovulation and menstrual cyclicity (with danazol) improves dysphoric premenstrual syndromes. Fertil SterilS6:10661069, 199I. 9. Moden-Vrtovec H, Vujc D: Bromocriptine in the management of premenstrual syndrome. Clin Exp Obstet Gynecol 19:242-248, 1992. 10. Menkes DB, Taghavi E, Mason PA, Howard RC: Flnoxetines spectrum of action in premenstrual syndrome. Int Clin Psychophmacol8:95-102, 1993. 11. Schmidt PJ, Nieman LK, Grover GN, et al: Lack of effect of induced menses on symptoms in women with premenstrual syndrome. New Engl J Med 324: 1174, 1991 . 12. Steiner M, Wilkins BA: Diagnosis and assessment of premenstrual dysphoria. Psychiatric Ann 25(9):571575, 1996. 13. Steiner M, Korzekwa M, Lamont J, et al: Intermittent fluoxetine dosing in the treatment of women with premenstrual dysphoria. Psychopharmacol Bull 33(4):771-774, 1997. 14. Thys-Jacobs S, Starkey P, Bernstein D, Tian J: Calcium carbonate and the premenstrual syndrome: Effects of premenstrual and menstrual symptoms. Premenstrual Syndrome Study Group. Am J Obstet Gynecol 179:444452, 1998. 15. Yonkers KA, Gullion C, Williams A, et al: Paroxetine as a treatment for premenstrual dysphoric disorder. J Clin Psychopharmacol 16:3-8, 1994. 16. Young SA, Hurt PH, Benedek DM, Howard RS: Treatment of premenstrual dysphoric disorder with sertraline during the luteal phase: A randomized, double-blind, placebo-controlled crossover trial. J Clin Psychiatry 59:76-80, 1998.

63. PSYCHIATRIC DISORDERS AND PREGNANCY

Doris C. GurtderseM, M.D

1. How common are eating disorders in pregnant women? Few reports of anorexia nervosa associated with pregnancy are found in the literature. To some extent, the two conditions are mutually exclusive. The endocrine abnormalities associated with anorexia nervosa substantially diminish fertility. The paucity of published information on bulimia in pregnancy may reflect the failure of physicians to identify the problem, despite an incidence of up to 13% in women of childbearing age.

2. How are pregnant women with eating disorders diagnosed and managed?
T h e possibility of an eating disorder should b e considered in any woman whose pregravid weight is subnormal or who fails to gain weight as pregnancy progresses. Any patient who casually mentions that she has an eating problem should be carefully questioned. An eating disorder should be suspected in patients who are excessively preoccupied with weight gain and body image during pregnancy. A history of persistent vomiting before o r during pregnancy should be investigated. A psychosocial history may reveal comorbidity with other psychiatric conditions, such as depression or chemical dependency in bulimic women. Hospitalization is recommended for the eating-disordered pregnant patient with excessive weight loss, severe metabolic disarray, or prominent symptoms of depression. Psychotherapy and nutritional counseling should complement prenatal care. Enlisting the support of families to monitor weight gain and nutrition is helpful. Ideally, eating disorders should be identified before conception. The afflicted woman should be advised to delay pregnancy until the eating disorder is truly in remission.