Elsevier

Hormones and Behavior

Volume 54, Issue 1, June 2008, Pages 185-193
Hormones and Behavior

Changes in mood, cognitive performance and appetite in the late luteal and follicular phases of the menstrual cycle in women with and without PMDD (premenstrual dysphoric disorder)

https://doi.org/10.1016/j.yhbeh.2008.02.018Get rights and content

Abstract

Although it's been reported that women with premenstrual dysphoric disorder (PMDD) have increased negative mood, appetite (food cravings and food intake), alcohol intake and cognitive deficits premenstrually, few studies have examined these changes concurrently within the same group of women or compared to women without PMDD. Thus, to date, there is not a clear understanding of the full range of PMDD symptoms. The present study concurrently assessed mood and performance tasks in 29 normally cycling women (14 women who met DSM-IV criteria for PMDD and 15 women without PMDD). Women had a total of ten sessions: two practice sessions, 4 sessions during the follicular phase and 4 sessions during the late luteal phase of the menstrual cycle. Each session, participants completed mood and food-related questionnaires, a motor coordination task, performed various cognitive tasks and ate lunch. There was a significant increase in dysphoric mood during the luteal phase in women with PMDD compared to their follicular phase and compared to Control women. Further, during the luteal phase, women with PMDD showed impaired performance on the Immediate and Delayed Word Recall Task, the Immediate and Delayed Digit Recall Task and the Digit Symbol Substitution Test compared to Control women. Women with PMDD, but not Control women, also showed increased desire for food items high in fat during the luteal phase compared to the follicular phase and correspondingly, women with PMDD consumed more calories during the luteal phase (mostly derived from fat) compared to the follicular phase. In summary, women with PMDD experience dysphoric mood, a greater desire and actual intake of certain foods and show impaired cognitive performance during the luteal phase. An altered serotonergic system in women with PMDD may be the underlying mechanism for the observed symptoms; correspondingly, treatment with specific serotonin reuptake inhibitors (SSRIs) remains the preferred treatment at this time.

Introduction

Premenstrual syndrome (PMS) is a recurrence of negative behavioral (e.g. fatigue), psychological (e.g. irritability) and physical symptoms (e.g. headaches) that occur during the luteal phase of the menstrual cycle and remit by the follicular phase (Dickerson et al., 2003). While the overwhelming majority of premenopausal women experience some level of premenstrual symptoms (Dickerson et al., 2003), only 8% of these women suffer from premenstrual symptoms to such a degree that it interferes with normal functioning and are diagnosed with premenstrual dysphoric disorder (PMDD; Bhatia and Bhatia, 2002, Wittchen et al., 2002). PMDD is characterized primarily by a cluster of mood symptoms, especially depression, tension, anxiety, irritability, and fatigue, with five or more symptoms present during the luteal phase (American Psychiatric Association, 1994). The diagnosis of PMDD can only be made by having women prospectively monitor their symptoms for at least two consecutive symptomatic menstrual cycles (Di Giulio and Reissing, 2006, Futterman and Rapkin, 2006). These symptoms have to occur during the last week of the luteal (premenstrual) phase, diminish with the onset of menses, and cease during the follicular phase. These dramatic cyclical changes in mood in women with PMDD have been well documented both clinically and in research studies (e.g. De Ronchi et al., 2005, Evans et al., 1998, Freeman et al., 1985, Halbreich et al., 1982, Landen et al., 2007, Rapkin et al., 1989).

In addition to increases in dysphoric mood during the luteal phase, women with PMDD also report impairments in cognitive abilities such as concentration, memory and motor coordination that interfere with their productivity and efficiency (American Psychiatric Association, 1994, Diener et al., 1992). However, the extent to which various aspects of psychomotor or cognitive performance are actually impaired during the luteal phase in women with PMDD has not been extensively studied and the results have been inconsistent, with studies reporting no differences (e.g. Rapkin et al., 1989) or only subtle differences on isolated tasks (e.g. Man et al., 1999, Posthuma et al., 1987, Resnick et al., 1998). For instance, although Keenan et al., 1992a, Keenan et al., 1995) assessed a range of neuropsychological tasks, women with PMDD were only impaired on a verbal learning task compared to a group of control women and this impairment was not related to menstrual cycle phase. In another well-controlled study that evaluated a range of tasks, the only performance impairment observed was that women with PMDD showed more psychomotor slowing during the luteal phase compared to control women (Resnick et al., 1998). Another study (Morgan and Rapkin, 2002) that also assessed a full series of neurocognitive tasks reported no performance differences between women with PMDD and control women, despite a relatively large sample size. In a previous study conducted in our laboratory (Evans et al., 1998), we assessed changes in mood and performance as a function of menstrual cycle phase in women with confirmed PMDD after placebo or alprazolam administration. When placebo was administered, motor coordination (via a balance task) and performance on the Digit Symbol Substitution Task (DSST) were impaired in the luteal phase. Limitations of that study included only administering placebo one day in each phase and the lack of a control group. Regardless, one major distinction between the Evans et al. (1998) study and all the other studies mentioned above is that task performance was assessed multiple times over the day, not just once. The fact that most previous studies only assessed performance on a single occasion each phase may be one reason for the inconsistencies observed across studies. It is possible that most individuals might be able to perform relatively well if only required to do the task once for a brief period of time, whereas individuals may be less likely to sustain their performance if they required to perform for extended periods of time, particularly when experiencing PMDD symptoms during the luteal phase. Therefore, one goal of this study was to extend previous research by comprehensively assessing changes in cognitive performance in women with PMDD across the menstrual cycle and to include a control group of women without PMDD.

Lastly, women with PMDD also report changes in appetite, food intake and specific food cravings during the luteal phase (American Psychiatric Association, 1994), and these changes appear to be correlated with premenstrual mood changes, primarily depression (e.g. Both-Orthman et al., 1988, Dye and Blundell, 1997, Wurtman et al., 1989). Despite this, few studies have carefully assessed food cravings or food intake in women. In fact, most studies relied on retrospective reports of PMDD and retrospective food cravings, typically using a single question that did not specify food type (e.g. Both-Orthman et al., 1988, Bancroft et al., 1993). With respect to changes in food intake, the majority of studies have relied on retrospective food diaries, rather than measuring actual food intake. In fact, only two studies actually measured food intake in women with and without PMS while they resided as inpatients, and the foods provided to participants consisted of high carbohydrate (CHO) and high protein foods, with fat content held constant (Brzezinski et al., 1990, Wurtman et al., 1989). In both studies, only women with PMS showed a significant increase in food intake during the luteal phase compared to the follicular phase, and this was attributed to an increase in CHO intake. In another study (Evans et al., 1999) we assessed food cravings and food intake in 19 women with PMDD and showed that craving for foods, specifically those containing fat, were significantly increased in the luteal phase compared to the follicular phase, while desires for CHO alone did not change as a function of menstrual cycle phase. In that same study, when placebo was administered there was no corresponding increase in actual food consumption at lunch during the luteal phase. Unfortunately, limitations of that study included only administering placebo one day in each phase and the lack of a control group. Therefore, another goal of the present study was to carefully assess whether food cravings (across a range of food items), food intake, as well as macronutrient intake, vary between the luteal and follicular phases in these two groups of women.

Taken together, although PMDD is characterized by a spectrum of symptoms and complaints (mood, performance, appetite), the full spectrum has not been assessed in a comprehensive manner. Therefore, to expand on previous research in this area, the purpose of the present study was to concurrently assess the relationship between changes in mood, cognitive performance, food craving, as well as actual food consumption, as a function of menstrual cycle phase in women meeting DSM-IV criteria for PMDD compared to a matched group of Control women. All participants were prospectively monitored throughout the study, and menstrual cycle phase was verified via ovulation kits and hormone levels of estradiol and progesterone. Women were tested on four different days each phase, and on each day a variety of mood and performance tasks was assessed multiple times to simulate a modified workday and food cravings and food intake at lunch were measured. We hypothesized that women with PMDD would show impaired mood and cognitive task performance, along with increased cravings and intake of food and alcohol, in the late luteal phase compared to the follicular phase, or compared to Control women. This study aims to give a comprehensive description of PMDD that may aid in the development of treatments that address the full range of PMDD symptoms.

Section snippets

Subjects

The 29 women (15 Control and 14 with PMDD) who participated in this study responded to an advertisement in a local newspaper for female volunteers suffering from premenstrual syndrome (see Table 1). Women had a mean age of 30, were predominately White, had a mean of 16 years of education, were normal weight (BMI  25) and had normal menstrual cycles. Overall, women were light drinkers and reported little or no other drug use. There were no significant differences on any of these demographic

Hormone levels

All women had ovulatory menstrual cycles that ranged from 23 to 33 days. When examining hormone levels as a function of group and phase, estradiol levels were not significantly different in the luteal phase compared to the follicular phase in the PMDD and Control women (96.35 ± 8.99 pg/ml vs. 74.28 ± 10.68 pg/ml; p  0.05). Regarding progesterone levels, there was a main effect of phase [F(1,21) = 113.82, p = 0.0001]. Specifically, progesterone levels in the luteal phase were significantly higher than in

Discussion

As hypothesized, the current study found that women with PMDD in their luteal phase: (1) had increased dysphoric mood; (2) had impaired cognitive performance; (3) had an increased desire for food items high in fat (both savory and sweet); and (4) ate more calories (particularly fat) at lunch compared to when they were in their follicular phase and/or compared to women without PMDD.

In the present study, women were carefully prospectively screened and those women in the PMDD group met full DSM-IV

Acknowledgments

This research was supported by Grants R01 DA009114 and K02 DA00465 from the National Institute on Drug Abuse. The authors gratefully acknowledge the assistance of the research and clinical staff.

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