Premenstrual syndrome and its psychiatric ramifications.

To the Editor: The article by Drs. Perveen Rasheed and Latifa Saad Al-Sowailem is interesting and the first of its kind that describes the prevalence and predictors of premenstrual syndrome in Saudi Arabia.1 However, we have reviewed the literature on premenstrual syndrome [PMS] and premenstrual dysphoric disorder [PMDD].2 Further, we have also reported five cases of PMS and its psychological connections to premenstrual dysphoric disorder.3 In a related development, Al-Habeeb also briefly reviewed the pertinent data and reported a case of premenstrual manic disorder, and based on four reported cases in the world literature, proposed tentative research diagnostic criteria.4 We observed that the two premenstrual syndromes with specific differentiating symptoms were etiologically attributed best to the dysregulation of central serotonergic and gabaergic systems and the noxious sex steroid hormonal milieu during normal cyclical ovulation. Further, the women with these syndromes, who need proper assessment, tests, and a correct diagnosis, respond effectively to selective serotonin-reuptake inhibitors, gonadotrophin-releasing hormone agonists, a novel contraceptive pill-Yasmin, cognitive-behavior therapy, life-style changes, and in addition, placebo. The oral contraceptive pill-Yasmin contains low-dose (30 microg) ethinylestradiol (EE) combined with a new progestogen, drospirenone (3 mg) (DRSP) and it offers better clinical efficacy for PMS/PMDD as a result of the unique pharmacological profile of this progestogen, which is a 17alpha-spirolactone derivative with antimineralocorticoid and antiandrogenic activity. Notably, DRSP resembles endogenous progesterone. Unlike other oral contraceptives, it has very minimal effects on skin, appetite, food craving, mood changes and breast tension and also improves general well-being together with a positive effect on oral contraceptive continuation.5,6 We concluded that premenstrual psychiatric spectrum syndromes coupled with multiple adverse consequences are important clinical entities in a woman’s reproductive life, and need timely intervention and further research, especially in Arabian Gulf countries.

With special reference to this study,1 we would like to make some comments that may have both research and clinical relevance. First, this study reported that mothers of probands were suffering from PMS [45.4%] and a family history of depression or mental illness was revealed in 46.9% of women with PMS. Here, our main concern is how mothers of the study group make sure that they were suffering from PMS. Did they themselves make this diagnosis, or after consulting a gynecologist? Similar questions may be evoked in relation to depression or other mental disorders reported in their families. Notably, both PMS and PMDD are diagnoses of exclusion. However, most importantly the implication of the former finding is that these college women might have learned of PMS symptoms from their mothers, as also reported in the literature.7–9 With regard to depression, it is commonly reported in families or patients with PMS who have co-morbid depression [86%] and an array of other psychiatric disorders and physical disorders.7,10 PMS has a reciprocal relationship with depression. Hence, clinicians should screen patients with PMS for co-morbid depression, which is known to have a detrimental effect on women’s mental and physical health.

Second, this study has taken into consideration the timing of premenstrual symptoms one week prior to the onset of menstruation and generally ending a couple of days before periods or at the commencement of periods. Indeed, this definition is not typical of PMS and one may ask the question: are the women whose symptoms remitted mid-menstruation rather than at the commencement of menstruation not suffering from PMS? Evidently, PMS symptoms typically remit mid-menstruation7,11 and therefore this study might have missed many true cases of PMS, though the reported prevalence [96.6%] is congruous with international studies. Conversely, this study might have picked up many false cases of PMS as well.

Third, the authors chose thirteen PMS symptoms and readers like myself would be interested to know whether these PMS symptoms, out of 100 reported PMS molimina, were the most frequently reported in the literature or were stable across premenstrual cycles.11 Also, what is the reliability and validity of the PMS symptoms questionnaire? However, this question may not have much relevance because in the absence of other gynecological, medical and psychiatric disorders,2,7 one or two symptoms are sufficient for the diagnosis of PMS. But from the perspective of future research on PMS, it would have been much better to append the questionnaire with the article. Space constraint in this journal might have discouraged this possibility. For informing prospective researchers, Budeiri and colleagues have comprehensively described various relevant scales used among patients with PMS.12 Recently, Steiner and colleagues have developed an effective screening tool for operationalizing DSM-IV criteria for PMDD and to understand clinically significant PMS.13

Fourth, PMS and PMDD have overlapping symptoms, similar etiological underpinnings and treatment modalities. According to this study, 37.9% of women [n= 176/464] had a high PMS score of 10–33. In view of this, a proportion of these college women, i.e., about 3% to 18%, might be suffering from PMDD,14 which has proposed research diagnostic criteria.15 These research diagnostic criteria for PMDD take into account the past year during which premenstrual symptoms [in most cycles] occur during late luteal phase and remit within a few days after the onset of the follicular phase and are absent in the week post-menses. Another syndrome related to PMS is seasonal PMS.

Finally, in light of these comments the findings of this study should be interpreted cautiously and generalization of the findings should be restricted. In Arabian Gulf countries, PMS is a fertile avenue for future research. So, I would like to suggest that an Arabian Gulf PMS/PMDD Research Group should be formed for exploring premenstrual obstretic-gynecological/psychiatric spectrum disorders, puerperal psychosis, postpartum depression, and other postpartum psychiatric disorders.