The Prevalence of Menstrual Cycle Disorders and Menstrual Cycle-Related Symptoms in Female Athletes: A Systematic Literature Review.

BACKGROUND: Menstrual cycle (MC) disorders and MC-related symptoms can have debilitating effects on the health and performance of female athletes. As the participation of women in sports continues to increase, understanding the prevalence of a range of MC disorders and MC-related symptoms may guide preventive strategies to protect the health and optimise the performance of female athletes. OBJECTIVE: To examine the prevalence of MC disorders and MC-related symptoms among female athletes who are not using hormonal contraceptives and evaluate the assessment methods used to identify MC disorders and MC-related symptoms. METHODS: This systematic review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Six databases were searched until September 2022 for all original research that reported the prevalence of MC disorders and/or MC-related symptoms in athletes not using hormonal contraceptives, which included the definitions of the MC disorders examined, and the assessment methods used. MC disorders included amenorrhoea, anovulation, dysmenorrhoea, heavy menstrual bleeding (HMB), luteal phase deficiency (LPD), oligomenorrhoea, premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). MC-related symptoms included any affective and physical symptoms related to the MC that do not cause significant personal, interpersonal or functional impairment. The prevalence data across eligible studies were combined, and all studies were qualitatively synthesised to evaluate the assessment methods and tools used to identify MC disorders and MC-related symptoms. The methodological quality of studies was assessed using a modified Downs and Black checklist. RESULTS: Sixty studies involving 6380 athletes were included. A wide range of prevalence was observed for all types of MC disorders, with a dearth of data on anovulation and LPD. Based on pooled data, dysmenorrhoea (32.3%; range 7.8-85.6%) was the most prevalent MC disorder. Studies reporting MC-related symptoms mostly examined the premenstrual and menstruation phases, where affective symptoms appeared more prevalent than physical symptoms. A larger proportion of athletes reported symptoms during the initial days of menstruation compared with the premenstrual phase. MC disorders and MC-related symptoms were retrospectively assessed using self-report methods in 90.0% of studies. Most studies (76.7%) in this review were graded as moderate quality. DISCUSSION: MC disorders and MC-related symptoms are commonplace among female athletes, warranting further research examining their impact on performance and preventive/management strategies to optimise athlete health. To increase the quality of future studies, researchers should adopt standardised definitions of MC disorders and assessment methods such as a combination of calendar counting, urinary ovulation tests and a mid-luteal phase serum progesterone measurement when assessing menstrual function. Similarly, standardised diagnostic criteria should be used when examining MC disorders such as HMB, PMS and PMDD. Practically, implementing prospective cycle monitoring that includes ovulation testing, mid-luteal blood sampling (where feasible) and symptom logging throughout the MC could support athletes and practitioners to promptly identify and manage MC disorders and/or MC-related symptoms. TRIAL REGISTRATION: This review has been registered in the PROSPERO database (CRD42021268757).

Premenstrual disorders: Premenstrual syndrome and premenstrual dysphoric disorder.

Recently, the term premenstrual disorders (PMDs), which includes premenstrual syndrome and premenstrual dysphoric disorder as a continuum, has been proposed. Although the precise etiology of PMDs remains unknown, the involvement of hormonal fluctuations is clear. The brain transmitters, serotonin and γ-amino butyric acid, also seem to be involved. Serotonin reuptake inhibitors and oral contraceptives are the current mainstay of treatment, but these are insufficient. Even the currently used prospective two-period symptom diary is not widely used in actual clinical practice, creating a major problem of discrepancy between research and clinical practice. In this review, I would like to outline the latest information and problems in the etiology, diagnosis, and treatment of PMDs, with an emphasis on promising new therapies.

Unfolding the mystery of premenstrual syndrome (PMS): an overview.

Physical, emotional, and psychological symptoms are common among women in their reproductive years, particularly during their menstrual cycle's luteal phase and the week before their period. Approximately 5-8 percent of women suffer with premenstrual syndrome, with the majority of those suffering from premenstrual dysphoric disorder (PMDD). Because of the complexity and multifaceted nature of the aetiology, it is yet unknown. Premenstrual syndrome (PMS) is diagnosed entirely on the basis of signs and symptoms, with no particular diagnostic tests available to confirm the diagnosis. Only a small number of therapeutic modalities are backed by clinical data, yet there are many accessible. After providing a brief overview of the disease, the author goes on to discuss the various hypotheses as to why PMS occurs. With an emphasis on tailored treatment based on symptom profile, it examines the wide range of non-pharmacological and pharmaceutical methods that are accessible today.

Premenstrual syndrome and premenstrual dysphoric disorder / Premenstruális szindróma és premenstruális dysphoriás zavar

Premenstrual syndrome (PMS) is one of the most common problems for women of reproductive age. The physical, mental and behavioural symptoms recur during the luteal phase of the cycle in daily life and cause a deterioration in the quality of life, affecting the patient's social, work and family relationships. Symptoms typically disappear spontaneously within a few days after the onset of menstruation. The onset and severity of PMS are determined by the cyclical functioning of the hypothalamic-pituitary-ovarian axis and the combined presence of other physiological (e.g., chronobiological and circadian) and psychological stressors, which interact with each other. The diagnosis of PMS and premenstrual dysphoric disorder (PMDD) is based on the following criteria, as recommended by the International Society for Premenstrual Disorders (ISPMD): in PMS, the woman has 1-4 symptoms, which may be physical, behavioural or affective/psychological, or at least five symptoms, which may be physical or behavioural. However, if a woman has 5 or more symptoms, and one of these is affective (e.g., irritability, mood swings, anger) in addition to physical or behavioural symptoms, a more accurate diagnosis of PMDD can be made. Since, in addition to the general and gynecological history, the prospective scales (e.g., Prospective record of the impact and severity of menstrual symptoms - PRISM; Daily record of severity of problems - DRSP) completed daily by the physician are helpful in confirming the diagnosis of PMS and PMDD, it is important to take into account the severity of symptoms, the woman's plans for conception or contraceptive needs, her other associated medical conditions, her response to previous treatment methods, and her history of other medical conditions when formulating a treatment plan. Therapeutic options include regular aerobic exercise, stress relief, cognitive behavioural therapy, drug treatments (selective serotonin reuptake inhibitors - SSRIs, combined oral estrogen-progestin contraceptives - COCs, GnRH agonists), -depending on the severity of PMS and PMDD.

Premenstrual syndrome and premenstrual dysphoric disorder / Premenstruális szindróma és premenstruális dysphoriás zavar

Premenstrual syndrome (PMS) is one of the most common problems for women of reproductive age worldwide, along with painful menstruation and genital inflammation. The physical, mental and behavioural symptoms recur during the luteal phase of the cycle and cause a deterioration in the quality of life, affecting the patient's social, work and family relationships. Symptoms typically disappear spontaneously within a few days after the onset of menstruation. A severe form of PMS is premenstrual dysphoric disorder (PMDD), which requires psychiatric management. The onset and severity of PMS with multifactorial pathogenesis is triggered by psychoneuroendocrine mechanisms that are influenced by the cyclical functioning of the hypothalamic-pituitary-ovarian axis, altering the neurotransmitter or neuropathway functions of the brain, e.g., the serotoninergic system. The psychoneuroendocrine mechanisms contribute to the development of physical, psychological and behavioural symptoms, which are also influenced by the combined presence of other physiological (genetical background, metabolic and chronic inflammatory processes, chronobiological and circadian disorders) and psychological stressors and their interaction.

Suicide Risk and the Menstrual Cycle: a Review of Candidate RDoC Mechanisms.

PURPOSE OF REVIEW: Risk for suicidal behavior may fluctuate across the menstrual cycle. Here, we use the RDoC framework to review potential mechanisms by which the cycle may increase acute suicide risk. RECENT FINDINGS: The menstrual cycle impacts the majority of RDoC constructs linked to suicide risk, particularly among hormone-sensitive women, such as those with premenstrual dysphoric disorder or premenstrual exacerbation of a psychiatric disorder. Despite this, there are no published studies examining suicidal ideation, planning, or behavior longitudinally across the cycle. More work is needed to understand how hormone sensitivity may relate to both trait and state suicide risk. Intensive multilevel investigations of cyclical hormone effects on suicide risk through specific RDoC mechanisms are suggested. This is a fertile research area and may provide key insights regarding the mechanisms of acute suicide risk.

A case of repeated mixed mood episodes with psychotic symptoms associated with the premenstrual period in a patient with polycystic ovarian syndrome.

Studies have demonstrated that estrogen plays an important role in psychotic and mood disorders in women. Estrogens have a protective effect against the development of these disorders, while hypoestrogenic states may be a risk factor for the development or exacerbation of mental illness. Additionally, women with menstrual cycle abnormalities such as those with a history of anovulation may be more susceptible to monthly estrogen level fluctuation-related mood and psychotic symptoms. We present the case of a young woman with polycystic ovarian syndrome, who experienced three episodes of premenstrual mixed mood and psychotic symptoms.

Stress fracture and premenstrual syndrome in Japanese adolescent athletes: a cross-sectional study.

OBJECTIVES: To investigate the relationship between the occurrence of stress fracture and premenstrual syndrome (PMS)/premenstrual dysphoric disorder (PMDD) in Japanese adolescent athletes. DESIGN: Cross-sectional study. SETTING: Osaka, Japan. PARTICIPANTS: A school-based survey on menstruation and school life was conducted using a sample of 1818 Japanese female students who belonged to two public high schools in Japan. Among them, we recruited 394 athletes who had regular menstrual cycles (25-38 days) and completed a questionnaire about their premenstrual symptoms and their competitive career. MAIN OUTCOME MEASURE: Premenstrual symptoms and the occurrence of stress fracture. RESULTS: The prevalences of moderate-to-severe PMS and PMDD were 8.9% and 1.3%, respectively, which were the same as in collegiate athletes in a previous study. Premenstrual symptoms disturbed 'Work efficiency or productivity, home responsibilities', 'Relationships with coworkers or family' and 'Athletic performance in training or competition' more severely than menstrual pain (p=0.031, p=0.004 and p<0.001, respectively). 66 athletes (16.8%) reported having experienced a stress fracture. The severity of 'Overeating or food cravings', 'Physical symptoms' and 'Performance in training or competition' in athletes with previous stress fractures were much higher than in those without a history of stress fractures (p=0.015, p=0.008 and p=0.006, respectively). In terms of premenstrual symptoms, 'Physical symptoms' was associated with an increased risk of stress fractures in athletes (OR 1.66, 95% CI 1.06 to 2.62). CONCLUSIONS: The results from this study indicated that premenstrual symptoms may affect athletic performance and has the risk of stress fractures in adolescent athletes.

Affective temperaments and emotional traits are associated with a positive screening for premenstrual dysphoric disorder.

OBJECTIVES: Preliminary evidence indicates that premenstrual dysphoric disorder (PMDD) may be frequently co-morbid with bipolar spectrum disorders. In addition, the manifestations of PMDD seem similar to a subthreshold depressive mixed state. Nevertheless, the associations between PMDD and affective temperaments and emotional traits have not been previously investigated. METHODS: A consecutive sample of 514 drug-free Brazilian women (mean age: 22.8; SD=5.4years) took part in this cross-sectional study. Screening for PMDD was obtained with the validated Brazilian Portuguese version of the Premenstrual Symptoms Screening Tool (PSST). Affective temperaments and emotional dimensions were evaluated with the Affective and Emotional Composite Temperament Scale (AFECTS). In addition, socio-demographic and data on menstrual cycle were collected. RESULTS: According to the PSST, 83 (16.1%) women screened positive for PMDD, while 216 (42.0%) women had no/mild premenstrual symptoms. The cyclothymic temperament was independently associated with PMDD (OR=4.57; 95% CI: 2.11-9.90), while the euthymic temperament had an independent association with a lower likelihood of a positive screening for PMDD (OR=0.28; 95% CI: 0.12-0.64). In addition, anger and sensitivity emerged as emotional dimensions significantly associated with PMDD. CONCLUSIONS: A positive screening for PMDD was associated with a predominant cyclothymic temperament, while an euthymic temperament was associated with a lower likelihood for a positive screening for PMDD. These data deserve replication in prospective studies.

Association of premenstrual syndrome and premenstrual dysphoric disorder with bulimia nervosa and binge-eating disorder in a nationally representative epidemiological sample.

OBJECTIVE: Bulimia nervosa (BN) and binge-eating disorder (BED) are associated with significant health impairment. Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) comprise both psychological (disturbances in mood and affect) and physiological (bloating and changes in appetite) symptoms that may trigger binge-eating and/or purging. METHOD: Female participants were drawn from the Collaborative Psychiatric Epidemiological Surveys, conducted from 2001 to 2003. Weighted multivariable logistic regression modeled the association between lifetime PMS and PMDD and lifetime odds of BN or BED. RESULTS: Among 8,694 participants, 133 (1.0%) had BN and 185 (1.8%) BED. Additionally, 366 (4.2%) had PMDD and 3,489 (42.4%) had PMS. Prevalence of PMDD and PMS were 17.4 and 55.4% among those with BN, 10.7 and 48.9% among those with BED and 3.4 and 59.1% among those with subthreshold BED. After adjustment for age, race/ethnicity, income, education, body mass index, age at menarche, birth control use, and comorbid mental health conditions, PMDD was associated with seven times the odds of BN (OR 7.2, 95% CI 2.3, 22.4) and PMS with two times the odds of BN (OR 2.5, 95% CI 1.1, 5.7). Neither PMDD nor PMS were significantly associated with BED. DISCUSSION: Women with PMS and PMDD have a higher odds of BN, independent of comorbid mental health conditions. PMS and PMDD may be important comorbidities to BN to consider in clinical settings, and future research should investigate whether PMS and PMDD affect the onset and duration of bulimic symptoms as well as the potential for shared risk factors across disorders. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:641-650).

Nociceptive processing in women with premenstrual dysphoric disorder (PMDD): the role of menstrual phase and sex hormones.

OBJECTIVE: Premenstrual dysphoric disorder (PMDD) is associated with increased pain, but there has been a lack of well-controlled research assessing pain responsivity, sex hormones, and their relationships in this group. This study was designed to address this gap in the literature. MATERIALS AND METHODS: Healthy, regularly cycling participants (14 PMDD, 14 non-PMDD) attended pain testing sessions during the mid-follicular, ovulatory, and late-luteal phases of the menstrual cycle (order counterbalanced) and salivary estradiol, progesterone, and testosterone were assessed at each testing session. Pain sensitivity was measured from electrocutaneous threshold/tolerance, ischemic threshold/tolerance, sensory and affective ratings of electrocutaneous and ischemic stimuli, and the nociceptive flexion reflex threshold (NFR, a measure of spinal nociception). RESULTS: Women with PMDD had higher sensory pain ratings of electrocutaneous stimuli and trends for lower ischemic thresholds and higher affective pain ratings of electrocutaneous stimuli. However, there were no group differences observed in NFR threshold. Testosterone levels were also lower during the mid-follicular and ovulatory phases in PMDD. Correlations between pain outcomes and estradiol and testosterone indicated that these hormones are hypoalgesic, with estradiol having a greater hypoalgesic effect within the PMDD group. DISCUSSION: Overall, women with PMDD may have a phase-independent hyperalgesia, with pain amplification likely occurring at the supraspinal level rather than the spinal level, given the lack of group differences in NFR threshold. Because testosterone was hypoalgesic and lower in women with PMDD, and there were strong associations between pain and estradiol in PMDD, sex hormones may play a role in PMDD-related hyperalgesia.

Gonadotrophic hormone and reinforcement sensitivity systems in women with premenstrual dysphoric disorder.

AIM: Behavior inhibition and behavior approach system (BIS/BAS) determine the sensitivity to aversion and rewarding stimuli, respectively. This study aimed at evaluating the BIS/BAS of premenstrual dysphoric disorder (PMDD) and effect of estrogen and progesterone on the BIS/BAS. METHODS: Women with PMDD without treatment and control subjects were recruited from the community. The PMDD diagnosis was based on psychiatric interviewing and the result of two-menstrual-cycle follow up. A total of 67 women with PMDD and 75 control subjects were recruited and entered the final analysis. They were evaluated with BIS/BAS scale and for estrogen and progesterone levels in both premenstrual and follicular phases. RESULTS: The results revealed that BAS score was higher among women with PMDD in both premenstrual and follicular phases. Progesterone level negatively correlated with fun-seeking, and its change in the menstrual cycle also negatively correlated to a change in fun-seeking score among women with PMDD. Women with PMDD had a higher score in BIS in the premenstrual phase and the BIS score correlated to depression, anxiety, and hostility among them. CONCLUSION: These results suggest reward sensitivity of women with PMDD is vulnerable to the effect of progesterone change in the menstrual cycle. Furthermore, the sensitivity to aversive stimuli plays an important role involving core symptoms of PMDD. The reinforcement sensitivity of PMDD deserves further detailed study.