week 21/22

• Premenstrual syndrome (PMS)


  A common cyclical disorder that causes distress in women
• Premenstrual dysphoric disorder (PMDD)


  A more severe classifiable mental disorder that responds well to treatment, including with SSRIs
• Menopause


  A time of psychosocial change as well as hormonal change which may be a vulnerable period for women with pre-existing mental disorders
• HRT is not an appropriate treatment for clinical depression or for the prevention of dementia
• Menstrual cycle


  • 28 days in a cycle
  • Ovulation occurs 14 days before first day of next period
  • Fluctuation in level of progesterone and oestrogen affects the whole body including central nervous system
  • In CNS, these hormones act via steroid receptors and have an effect of neurotransmission including: gabba, serotonin, dopamine and glutamate
• Studies have shown that oestrogen and progesterone and their metabolites will affect brain areas that regulate: mood, behaviour and cognitive abilities
• Menopause


  • Physiological phase: defined retrospectively by 12 months of stopped periods which are not due to any other reasons
  • During the period of hormonal changes leading up to menopause is when most menopausal symptoms are experienced which can go on for several years
  • Reduction of oestrogen → sharp rise of FSH → gradually reduces and flattens out with LH in the later years
  • Central effects of decreased oestrogen: Vasomotor symptoms e.g. hot flushes, and sweats, MSK symptoms e.g. joint pain, muscle pain, and Sexual difficulties e.g.low sexual desire
  • Local effects of low oestrogen include Urogenital symptoms e.g. vaginal dryness and atrophy
• Experience of menopause varies across different people
• Vulnerability for development of a depressive illness corresponds to main hormonal transitions across the female lifespan
• Brain is one of the primary targets of oestrogen to regulate a variety of behaviours and physiological functions including: reproduction, energy, homeostasis and memory
• Premenstrual syndrome (PMS)


  • Repetitive, cyclical, physical and behavioural symptoms
  • Occur in luteal phase of menstrual cycle
  • Resolve at within a few days or less of start of period
  • To meet criteria for diagnosis there are 2 factors: Symptoms are not an exacerbation of another disorder, Symptoms interfere with some aspect of the woman's life
  • Physical changes, breast changes and minor changes in mood occurring in the luteal phase are common, occurring in 80% of women and not considered to be a disorder
• Premenstrual dysphoric disorder (PMDD)


  • Affects less than 5% of women
  • More severe than PMS
  • Mood symptoms predominate - Significant distress, impact across areas of life (work, relationships etc)
  • Classified under genitourinary disorder in ICD11
  • Subcategory of depression in DSM 5
  • No diagnostic blood tests, circulating hormones are normal
  • Increased risk of postnatal depression
  • Aetiology may include genetic factor (twin studies, specific genes implicated)
• Clinical presentations in PMS and PMDD


  • Mood symptoms - Tearfulness, Irritability, Low mood and Tension
  • Physical symptoms - Overeating, Bloating, Lethargy, Headaches and Breast tenderness
  • Cognitive symptoms - Concentration, Memory and Sleep
  • Impact - Impacts adversely – work, life, family
• Risk factors for PMDD

  • Age 20-30
  • Comorbid psychiatric disorders
  • Genetic
  • Psychosocial stress
  • Smoking
  • Obesity
• Diagnosis and investigations of PMDD


  • Menstrual history and dairy of symptoms essential
  • Daily record of severity of problems
  • Should be symptom free for at least one week per cycle
  • Most symptoms occur in luteal phase and be cyclical
  • Bloods TSH and FBC
  • Consider screening for depression if non cyclical
• PMS/PMDD treatment interventions


  • Mild PMS - Lifestyle changes • Exercise • Reduce alcohol • Diet • CBT
  • Moderate pms - SSRIS e.g. Sertraline or fluoxetine either continuous or luteal phase • Combined oral contraceptive pill • CBT
  • Sever PMS and PMDD - All above • GnRH agonist to suppress ovulation • Surgical treatment (oophorectomy)
• PMDD- pharmacological treatment


  • Antidepressants that slow the reuptake of serotonin provide effective treatment for premenstrual dysphoric disorder (PMDD)
  • These drugs alleviate the symptoms of PMDD more quickly than those of major depression, which means that women don't necessarily have to take the drugs every day
  • Hormone therapies provide additional options but are generally considered second-line treatments
  • The response to SSRI's is more rapid than for depression and has good outcomes in 60- 70 per cent
• Menopause


  • The average age in the UK 51-52
  • Women post surgery
  • No blood tests are needed >45
  • Symptoms include hot flushes, mood changes, brain fog, vaginal symptoms, bloating and joint pains
  • Women with past PND and PMS at more at risk mood changes
• HRT- relief of symptoms

  • Depression and anxiety are common in peri- menopause
  • Relapse in depression and schizophrenia common
  • Oestrogen and progesterone → Risks- cancer, heart disease ,thrombosis, cardiovascular disease → Benefits-symptom relief, quality of life, osteoporosis → Tablets, patches, gel → CBT and lifestyle
• Menopause and dementia


  • HRT may have cognitive benefits to some women
  • There appears to be a window of opportunity for intervention in the perimenopause and early menopause
  • A recent study found that women who are carriers of the APOE Alzheimers gene treated with HRT had improved memory and cognition
  • There is no evidence that HRT can cure or prevent dementia
• Social cultural factors menopause


  • Are we over treating with HRT?
  • Co morbid depression common
  • Differences in experience symptoms seen globally
  • Positive view of aging can affect experience of menopause
  • Cessation of periods and possibility of conception seen as positive
  • Social status of women in some cultures increases as they grow older
  • Comorbid depression is common - it is a time of change, including Loss events, Psychosocial stress, Change of roles of women in society
  • Cognitive therapy before menopause improves experience of menopause
  • Media interest in HRT may affect perceptions and decisions