Images of PMS

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Is Premenstual Syndrome Real? You Bet!

Over the past years we have scanned many women with PMS just before the onset period, during the worst time of their cycle, and then again a week after the onset of their period, during the best time. Most often when PMS is present we see dramatic differences between the scans. When a woman feels good, her deep limbic system is calm and cool and she has good activity in her temporal lobes and prefrontal cortex. Right before her period when she feels the worst her deep limbic system is often overactive and she has poor activity in her temporal lobes and prefrontal cortex!

I have seen two PMS patterns, clinically and on SPECT, that respond to different treatments. One pattern is focal increased deep limbic activity often accompanied by temporal lobe hypoperfusion that correlates with cyclic mood changes. When the limbic system is more active on the left side it is often associated with anger, irritability and expressed negative emotion. When it is more active on the right side it is often associated with sadness, emotional withdrawal, anxiety and repressed negative emotion. Left-sided abnormalities are more a problem for other people (outwardly directed anger and irritability), while right-sided overactivity is more an internal problem. Focal deep limbic and temporal lobe findings, worse during the premenstrual period, often respond best to lithium or anticonvulsant medications, such as Depakote, Neurontin, Lamictal or Tegretol. These medications tend to even out moods, calm inner tension, decrease irritability and help people feel more comfortable in their own skin.

The second PMS pattern that I have noted is increased deep limbic activity in conjunction with increased cingulate gyrus activity. The cingulate, as we will see, is the part of the brain associated with shifting attention. Women with this pattern often complain of increased sadness, worrying, repetitive negative thoughts and verbalizations (nagging) and cognitive inflexibility. This pattern usually responds much better to medications which enhance serotonin availability in the brain, such as Zoloft, Paxil or Prozac. Here are several examples.

Haley

Haley is a 12-year-old girl who presented to the clinic with violent mood swings, aggressive behavior, prolonged tantrums, depression and oppositional behavior. Her symptoms primarily occur several days before and after the onset of her menstrual cycle. By the first week after the start of her period she is markedly improved, more compliant, more positive and easier to get along with. In order to help understand the underlying physiological abnormalities in her brain a SPECT series was performed during the worst time of her cycle (day 3 of her menstrual cycle) and during the best time of her cycle (day 10).

Haley’s study during the worse part of her cycle was very abnormal with marked overactivity of the cingulate gyrus (associated with obsessive thinking and problems shifting attention), significant decreased temporal lobe activity (associated with aggressive thoughts, hypersensitivity to others, memory problems and mood instability) and marked decreased prefrontal cortex activity (associated with problems of impulsivity, attention span and self-supervision).

The SPECT study during the best time of her cycle markedly improved with decreased cingulate activity and improved function in the temporal lobes and prefrontal cortex. HL had a positive response to medication geared toward stabilizing the temporal lobes (Neurontin), calming cingulate hyperactivity (Zoloft) and enhancing prefrontal cortex function (Adderall). During the worst time of her cycle she also takes Risperdal to calm the aggressive behavior.

Andrea

Andrea is a 25-year-old female who has been diagnosed with severe PMS and ADD. Seven to ten days before the onset of her menstrual cycle she experiences moodiness, irritability, hypersensitivity to others, anxiety and increased alcohol consumption. These symptoms decrease significantly several days after the onset of her menstrual period.

Michelle

On three separate occasions Michelle, a 35-year-old nurse, left her husband. Each time she left him it happened within the ten days before the onset of her menstrual period. The last time she left him, her irritability, anger and irrational behavior escalated to the point where she attacked him with a knife over a minor disagreement. The next morning, her husband was on the phone to my office. When I first met Michelle, it was several days after her menstrual period had started and things had significantly settled down. The severe temper outbursts were usually over by the third day after her period started. In my office she appeared to be a gentle, soft-spoken woman. It was hard for me to imagine that this woman had only days before gone after her husband with a carving knife. Because her actions were so serious, I decided to perform two brain SPECT studies on her. The first one was done four days before the onset of her next period — during the roughest time in her cycle — and the second one was done eleven days later — during the best time of her cycle.

My colleagues and I have observed that left-sided brain problems often correspond with a tendency toward significant irritability, even violence. On Michelle’s premenstrual brain study before the onset of her period her limbic system (the mood control center) near the center of her brain was significantly overactive, especially on the left side. This "focal" limbic finding (on one side as opposed to both sides) often correlates with cyclical tendencies toward depression and irritability. There was a dramatic change in her second scan taken eleven days later when Michelle was feeling better. The limbic system was normal!

J.J.

JJ is a 44 year old woman who experiences severe symptoms before the onset of her period. These symptoms include moodiness, anger, sugar cravings, insomnia and anxiety. These symptoms abate several days after the onset of her period.

Chris

Chris was a thirty-eight-year-old married female referred for evaluation of suicidal thoughts, depression and temper flares. She also experienced problems with anxiety, excessive tension and overeating. These problems occurred primarily during the last 10 days of her menstrual cycle and abated two to three days after the onset of menses. On three separate occassions she left her husband within the 10 days prior to the onset of her period, on one occasion, she attacked him physically. The patient and her husband confirmed the cyclic changes to her symptomatology. Both the patient and her husband kept a symptom log over the next month and she gave consent to participate in the study.

On day 27 (of a 29 day cycle) Chris called the clinic, saying that she was having problems with suicidal thoughts and depression. She was scanned the same day. Her SPECT study revealed significant increased activity in the anterior cingulate gyrus and marked decreased activity in the left temporal lobe and prefrontal cortex bilaterally. She was then scanned on day 8 of the next menstrual cycle when she was symptom free. Her follow-up scan revealed improved temporal lobe and prefrontal cortex function but persistent cingulate hyperactivity.

Due to the clear temporal lobe pathology Chris was placed on divalproate which stabilized her temper outbursts and suicidal thoughts. Sertraline was then added a month later due to persistent premenstrual sadness. Twenty-four cycles later she remains symptom free.

Danielle

Danielle was a thirty-three-year-old married female referred for evaluation of suicidal thoughts, depression, anxiety and irritability. These problems occurred predominantly during the last week her menstrual cycle and significantly let up several days after the onset of menses. She had experience a post-partum depression after the birth of one child but not after the birth of her other 2 children. The patient and her husband confirmed the cyclic changes to her symptomatology. Both the patient and her husband kept a symptom log over the next month and she gave consent to participate in the study.

On day 25 (of a 28 day cycle) Danielle called the clinic, complaining of severe agitation and moodiness. She was scanned the same day. Her SPECT study revealed significant increased activity in the anterior and central cingulate gyrus and increased activity in the left basal ganglia and deep left temporal lobe. Also, there was decreased activity in the prefrontal cortex and left temporal lobe. She was then scanned on day 10 of the next menstrual cycle when she was symptom free. Her follow-up scan revealed improved a calming of the cingulate, basal ganglia and temporal lobe hyperactivity and improved activity in the prefrontal cortex and temporal lobes.

Divalproate, sertraline and fluoxetine were ineffective in treating her symptoms, but she had a positive response to lithium carbonate at a dose of 1,200 milligrams a day, with a blood level of 0.6 mcg/dl. Three years later she remains symptom free during the premenstrual period.

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