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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.

Day 2 of Cycle During Worst Time		Day 10 of Cycle During Best Time
underside surface view notice marked decreased prefrontal cortex and temporal lobe activity		underside surface view notice marked overall improvement
During Worst Time		During Best Time
top down active view		top down active view
underside active view		underside active view
side active view notice marked increased cingulate activity		side active view notice calming of cingulate hyperactivity

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