Gynecologic Issues The incidence of depression peaks, and the gender difference prevails, during the reproductive years (45). Connections between female reproductive functions and mood changes have been posited for centuries. When it first became possible to determine circulating hormone levels, researchers expected to find specific relationships between psychological and physiological changes. These expectations were uniformly discounted. There is no serum hormone level associated with premenstrual dysphoria, postpartum depression, or depression at menopause (46). There is a subgroup of women who are vulnerable, not to absolute circulating hormone levels, but to hormonal changes (47–50). There is a correlation between the degree of hormonal change, pre-and postpartum, and the incidence of postpartum mood disorder. Women who are vulnerable to hormonal changes may experience severe premenstrual mood symptoms, postpartum depression, and, possibly, depression in association with hormonal inﬂuences such as hormonal contraceptive methods, menopause, and hormone treatments (51).
Premenstrual Syndrome Depending on the methodology used to gather the data, most women report mood and behavioral changes associated with the menstrual cycle. Although there are both ups and downs associated with the cycle, it is the more problematic parts of the cycle that are characterized, as premenstrual syndrome, or PMS. An estimated 3% to 5% of ovulating women appear to suffer from symptoms so marked that they qualify for a diagnosis of premenstrual dysphoric disorder (PMDD) (52–54).
PMDD is included in DSM-IV-TR as an example of a depressive disorder, not otherwise specified, and as a category requiring additional research (9). Provisional diagnostic criteria are provided to standardize this research.
In most cycles over the past year, the patient had at least five of the following symptoms for most of the time during the premenstrual week, with symptoms remitting completely in the postmenstrual week (54):
Depressed mood, hopelessness, self-deprecation  Anxiety, tension  Affective lability  Anger, irritability, interpersonal conﬂict  Decreased interest in usual activities  Difficulty concentrating  Decreased energy  Appetite changes or cravings  Changes in sleep  Feeling overwhelmed or out of control  Physical symptoms such as breast tenderness, headache, bloating
The symptoms markedly interfere with work, family, or academic responsibilities; are not exacerbations of another existing disorder; and are corroborated by at least 2 months of prospective daily ratings (54).
Premenstrual syndrome, as differentiated from premenstrual dysphoric disorder, has been characterized by more than 100 different physical and psychological signs and symptoms, making it difficult to define scientifically. Methodological problems further complicate the situation; in the United States, the prevalence of attitudes linking the menstrual cycle to adverse mood and behavioral changes is so high that it skews women’s perceptions, the way they report symptoms to researchers, and the factors to which they attribute negative feelings. No specific circulating hormone levels or markers are associated with premenstrual symptoms (55). When prospective daily ratings are obtained systematically, the symptoms of most women who seek care for PMS are not related to the menstrual cycle (56,57). Therefore, careful assessment is essential. Before the diagnosis of PMS or PMDD can be established, a woman must record symptom ratings daily for at least two full cycles. Records of emotions and behaviors should be kept separate from menstrual records to avoid confounding patients’ perceptions. At the same time, the patient must be screened for other psychiatric disorders, including depression and personality disorders, and for domestic abuse and other life circumstances that may contribute to her psychological state (58).
No treatment for PMS has been validated by empirical studies (59). Studies of St. John’s wort, possibly the most popular alternative treatment, are contradictory (60). A number of lifestyle changes and other benign interventions alleviate symptoms for some patients with PMS (61):