Letters to the Editor
Premenstrual Complaints Before and After 40 Years of Age
Dear Editor:
Premenstrual syndrome (PMS) may represent a continuum in a woman’s reproductive life, but the mood and physical changes differ in presentation and severity from menarche to menopause (1,2). Daily self-rating forms that record symptom pattern and severity are commonly used to confirm the diagnosis of PMS or premenstrual dysphoric disorder (PMDD) (3). Many studies have investigated the severity and chronological relation of symptoms to the menstrual cycle (4,5), but few studies have systematically looked at the impact of premenstrual symptoms in women as they approach perimenopause (2,6–8).
Although there is a definite overlap, it is expected that physical symptoms may be more dominant in women who are later in their reproductive years (8). Thus, we conducted a pilot study, using self-rating scales to compare the severity of presenting symptoms and levels of distress in women with PMDD under age 40 years (n = 12) vs women age 40 years and over (n = 12). We used 3 questionnaires applied to premenstrual complaints: the Symptom Questionnaire (SQ) (9), the Sheehan Disability scale (SDS) (10), and the Self-Assessment of Symptoms Questionnaire (SAS). The SQ and SDS are validated scales. We based the SAS on mood and physical symptoms commonly reported during the menopausal transition.
Subjects diagnosed with PMDD gave written informed consent. They completed the questionnaires during the luteal phase (once only), and they reported menstrual history and general demographic data. We conducted independent t-tests to determine the effect of age on distress levels, as measured by the questionnaires.
Our preliminary findings indicate that there are no significant differences between the 2 groups in the mean total scores of distress levels and functional impairment. However, independent t-tests demonstrated a significant between-group difference (P < 0.05) on certain individual items: the group aged under 40 years reported more impairment in social life and leisure activities and more feelings of irritability. The group aged 40 years and over reported more frequent waking at night as well as more early waking. Nevertheless, these results should be viewed with caution because there were few participants, the questionnaires were only completed once, and the measures were not designed specifically for PMDD. The study also did not control for the use of selective serotonin reuptake inhibitors (SSRIs). Seven of the subjects over age 40 years reported current use of SSRIs for PMS, which may have influenced the ratings of mood symptoms. However, taking this into account, our results still indicate that the highest mean score in both groups was irritability, which supports the view that irritability is one of the dominant factors of PMDD (11,12).
Our preliminary findings suggest that specific mood and physical symptoms may change throughout the reproductive years, rather than as a whole across the overall clinical picture. Once the diagnosis of PMDD is made, emphasis on certain symptoms throughout the different phases of a woman’s reproductive transition may assist in treatment recommendations.
We encourage a larger controlled study using standardized questionnaires to capture the premenstrual symptom profiles at various stages of the reproductive cycle.
References
1. Haynes P, Parry BL. Mood disorders and the reproductive cycle: affective disorders during the menopause and premenstrual dysphoric disorder. Psychopharmacol Bull 1998;34:313–8.
2. Novaes C, Almeida OP, de Melo NR. Mental health among perimenopausal women attending a menopause clinic: possible association with premenstrual syndrome? Climacteric 1998;1(4):264–70.
3. Freeman EW, Halbreich U. Premenstrual syndromes. Psychopharmacol Bull 1998;34:291–5.
4. Johnson SR, McChesney C, Bean JA. Epidemiology of premenstrual symptoms in a nonclinical sample. J Reprod Med 1988;33:340–6.
5. Bloch M, Schmidt PJ, Rubinow DR. Premenstrual syndrome: evidence for symptom stability across cycles. Am J Psychiatry 1997:154:1741–6.
6. Schmidt PJ, Roca CA, Rubinow DR. Clinical evaluation in studies of perimenopausal women: position paper. Psychopharmacol Bull 1998;34:309–11.
7. Rapkin AJ, Mikacich JA, Moatakef-Imani B, Rasgon N. The clinical nature and formal disagnosis of premenstrual, postpartum, and perimenopausal affective disorders. Curr Psychiatry Rep 2002;4:419–28.
8. Morse CA, Dudley E, Guthrie J, Dennerstein L. Relationships between premenstrual complaints and perimenopausal experiences. J Psychosom Obstet Gynaecol 1998;19:182–91.
9. Kellner R. A symptom questionnaire. J Clin Psychiatry 1987;48:268–74.
10. Leon AC, Olfson M, Portera L, Faber L, Sheehan DV. Assessing psychiatric impairment in primary care with the Sheehan Disability Scale. Int J Psychiatry Med 1997;27(2):93–105.
11. Hartlage SA, Arduino KE. Toward the content validity of premenstrual dysphoric disorder: do anger and irritability more than depressed mood represent treatment-seekers’ experiences? Psychol Rep 2002;90:189–202.
12. Steiner M, Born L. Diagnosis and treatment of premenstrual dysphoric disorder: an update. Int Clin Psychopharmacol 2000;15(Suppl 3):S5–S17.
Annie J Kuan, BA
Diana MG Carter, MD, FRCPC
Fred J Ott, OT
Vancouver, British Columbia
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