Pulsatile release patterns of luteinizing hormone and progesterone in relation to symptom onset in women with premenstrual syndrome*†

FERTILITY AND STERILITY

Vol. 64, No.2, August 1995

Printed on acid-free paper in U. S. A.

Copyright ( 1995 American Society for Reproductive Medicine

Pulsatile release patterns of luteinizing hormone and progesterone in relation to symptom onset in women with premenstrual syndrome*+ Linda L. Lewis, Ph.D.:j:§ Ellen M. Greenblatt, M.D.II~ C. Amanda Rittenhouse, Ph.D.:j:

Johannes D. Veldhuis, M.D.** Robert B. Jaffe, M.D.II

University of California, San Francisco, San Francisco, California, and University of Virginia, Charlottesville, Virginia

Objective: To explore the pulsatile-release characteristics of LH and P in women with premenstrual syndrome (PMS) compared with age-matched phase-matched controls. Design: Prospective, repeated measures, two-group study. Setting: Human volunteers in an academic research environment. Participants: Six women with rigorously defined prospectively determined PMS; six agematched phase-matched controls. Main Outcome Measures: Frequency, amplitude, concentration, and coincident pulsatile release characteristics of LH and P at three symptom-related points of the luteal phase. Results: No significant between-group differences in frequency, amplitude, or concentration were found. In pooled data, significant coincident pulsing between LH and P was demonstrated. The length of time between LH and P pulses systematically increased across the luteal phase, a finding not previously reported. In the PMS group only, significant coincident pulsing occurred at an unexpected zero time lag on the symptom-onset sampling day. Conclusion: A progressively increasing coupling interval may reflect the gradual decline of the corpus luteum. Presence of a zero time lag between LH and P at symptom onset in women with PMS may indicate an aberrance in corpus luteum response to LH stimulation. Fertil Steril 1995;64:288-92 Key Words: Premenstrual syndrome, luteinizing hormone, progesterone; coincident pulsatility

Interest in the luteal phase evolution of endocrine patterns in women with premenstrual syndrome Received September 8, 1994; revised and accepted March 10, 1995. * Presented in part at the 9th Biannual Meeting of the Society for Menstrual Cycle Research, Seattle, Washington, June 6 to 8, 1991. t Supported in part by grants 10686 and 11808 (to L.L.L.1 from the Robert Wood Johnson Foundation, Princeton, New Jersey; by grant 5 MOl RR00079 (to L.L.L.1 from the General Clinical Research Center, University of California, San Francisco, San Francisco, California; by grant BRSG 62-3558 (to L.L.L.1 from the School of Nursing, University of Washington, Seattle, Washington; and by grant RCDA 1K04HD0634 (to J.D.V.1 from the National Institute of Child Health and Development, National Institutes of Health, Bethesda, Maryland. t School of Nursing, Department of Physiological Nursing, University of California. § Reprint requests and present address: Linda L. Lewis, Ph.D., Department of Physiological Nursing, SM-28, University of Washington, Seattle, Washington 98195 (FAX: 206-543-47711. II School of Medicine, Department of Obstetrics and Gynecology and Reproductive Sciences, University of California. 288

Lewis et al. LH and P release patterns: PMS

(PMS) is prompted by the speculation that hypothalamic beta-endorphin (hf3E) plays a role in PMS (13). Studies have included evaluation of peripheral levels of ,B-endorphin (4) and, because of the modulating role of hf3E on GnRH, and subsequently on LH, pulsatility studies have been carried out in women with PMS (5, 6). More recently, Facchinetti et al. (7) examined LH and P pulsatile concordance at one point in the luteal phase in women with PMS. The examination ofLH and P concordance is particularly relevant because P is seen as a putative modulator of hf3E (in the presence of estrogen) (1, 8, 9). The purpose ofthis study was to explore the pulsatile release characteristics of LH and P at three symptom-related points of the luteal phase in

~ Present address: Department of Obstetrics and Gynecology, Toronto General Hospital, Toronto, Ontario Canada. * Department of Internal Medicine, Division of Endocrinology and Metabolism, School of Medicine, University of Virginia, Charlottesville, Virginia.

Fertility and Sterility

women with PMS compared with age-matched controls. The conventional approach for choosing testing days for menstrual cycle hormone analysis has been to divide the luteal phase a priori into equal segments (1); however, this approach does not consider the varying symptom-onset patterns of women with PMS (10-13). For this study, the blood sampling days were selected according to when each woman was projected to experience symptom onset (with post hoc verification), thus ensuring the analysis of luteal phase data collected before symptom onset, at the onset of symptoms, and during symptoms. Each subject's control cohort was age matched and phase matched (days after the LH surge). This approach made it possible to explore between-group differences in the evolution of luteal phase endocrine patterns as related to symptom patterns. MATERIALS AND METHODS Definition of PMS

For the purposes of this study, PMS was defined as a set of symptoms that occurs premenstrually, subsides within the first 2 to 3 days of menstruation, recurs on a cyclical basis in the premenstrual phase, is not systematically present in the postmenstrual phase, demonstrates a 2=:30% change in severity score from postmenstrual to premenstrual, and is severe enough to disrupt relationships with family, friends, and/or co-workers (2, 3, 10, 11). Participants

Women were recruited from the general public in a major metropolitan area on the west coast of the United States. Initial screening criteria included: ages 21 to 39 years; cycle length 25 to 35 days; no oral contraceptives or hormone therapy for the previous 3 months; both ovaries present; no abnormal medical or gynecological history, not pregnant or breast feeding, within 20% of ideal body weight, no regular use of mood altering or other central nervous system drugs. Premenstrual syndrome subjects had a history of PMS for 2=:6 months; control women had no history of PMS. Qualification for entry into the study was determined through prospective daily symptom assessment during two screening menstrual cycles. For women in the PMS group, symptom scores indicated a 30% increase from follicular to luteal phase (National Institutes of Mental Health guidelines) (2). Symptoms were severe enough to disrupt relationships with family, co-workers, and friends. A baseline for follicular phase symptom presence was drawn for this project from an earlier study (14). If five symptoms on the daily calendar were rated as Vol. 64, No.2, August 1995

"mild" to "moderate" during the follicular phase in both prospective screening cycles, the woman was excluded from the study. Qualification for entry into the control group required scores indicative of only sporadic minor complaints that were not cycle phase dependent. Final entry criteria included a hematocrit 2=: 36% and negative results upon a general physical and pelvic examination. All participants also had negative current psychiatric diagnoses determined through the Diagnostic Interview Schedule (15) administered during the follicular phase. Procedure

This study was approved by the Human Research Committee of the University of California, San Francisco. Informed consent was obtained before both the screening and blood testing phases. Volunteers were paid $300.00 for completion of the 3 days of blood testing. Prospective assessment of symptoms was accomplished through the daily use of the modified Daily Time Chart (16) for a total ofthree menstrual cycles. This Likert scale instrument evaluates the symptom presence and severity (1 = symptom not present; 6 = extreme) of 22 of the most common symptoms of PMS (e.g., depression, irritability, breast tenderness, abdominal bloating). During the second and third cycles of prospective symptom assessment, a urinary LH surge detection kit (OvuQUICK; Monoclonal Antibodies, Incorporated, Mountain View, CA) (17) was used by the women in their homes. The LH surge provided a marker for planning the timing of the blood studies in the women with PMS and for designating the comparative days of blood studies for each age-matched control. The choice of sample collection days for the cycle in which the blood studies occurred was estimated by reviewing the symptom patterns demonstrated in the two screening cycles. A post hoc examination of the symptom data in the testing cycle (cycle 3) assured that only the data from women whose blood study days fit the study design were included in data analysis. (The principal investigator [L.L.L.J was 80% accurate in predicting symptom onset; data sets from the inaccurately predicted subjects were not included in analyses.) For the women with PMS, sampling day 1 was a non symptom day (post LH surge). Sampling day 2 was 3 days later, during symptom onset. Sampling day 3 was 3 days later, during symptoms. The three sampling days for each age-matched control occurred the same number of days after LH surge as her PMS cohort. Women were admitted to the UCSF General Clinical Research Center between 7:30 and 8:00 A.M. An Lewis et a1. LH and P release patterns: PMS

289

indwelling peripheral catheter was placed at 8:30 A.M. and a 30-minute waiting period preceded baseline sampling. Caffeine and smoking were prohibited on the days of the study and meals were not spicy. Activity was minimal and the participants were discouraged from sleeping. Blood samples were collected every 10 minutes for 10 hours from 9:00A.M. to 7:00p.M. on each of the 3 testing days. The blood samples were centrifuged immediately and the serum was separated and frozen at -80°C. until RIA. All samples were assayed in duplicate and several quality control tubes were interspersed within every assay to monitor precision. Luteinizing hormone concentrations were determined by double antibody RIA for LH (18), using first antibody (rabbit) and tracer (HLH P289). The tracer was iodinated 25I) in the laboratory and the second antibody (sheep anti-rabbit gamma globulin) was supplied by the laboratory. The mean LH intra-assay coefficient of variation (CV) was 7.4%; the interassay CV was 6.9%. Progesterone concentrations were determined by direct serum liquid phase RIA, using AmerlexM Progesterone RIA Kits (Amersham Corporation, Arlington Heights, IL). The mean P intra-assay CV was 8.7%; the interassay CV was 6.1%.

e

[conversion factor to SI unit, 3.180]). The mean age was 34 years. Initially, inquiries were received from 905 women and 753 of the women were reached for screening. Of those women who self-identified with PMS (n = 670), 107 (16%) were included in the prospective screening phase of the study. Exclusions were based on issues related to medical history, premenstrual symptom history, night-shift worker, study availability, age, weight, and current medication regimens. Among the women who self-described with PMS and who entered the screening phase, 41% (n = 44) withdrew before completing the study (because of study fatigue, loss of interest, or testing availability change) and an additional 50% (n = 54) were rejected by the investigator because they did not fit the study's symptom criteria. Nine subjects with PMS entered the testing phase; three subjects had incomplete data sets. Only the six PMS subjects with complete data sets were included in analyses. Of the 83 women who self-identified with normal menstrual cycles, 42% (n = 35) were included in the prospective screening phase of the study. Only normal subjects who were the age-matched cohort (±2 years) of a PMS subject were entered into the testing phase; i.e., six normal subjects.

Statistical Analysis Sampling Days

The data were analyzed for pulse frequency and amplitude using the cluster analysis pulse detection algorithm (2 X 1 cluster configuration with a t statistic of2.0 for both upstroke and downstroke; the variance model used was intra-assay CV) (19). Deconvolution, a more precise procedure, was applied then to the data. The deconvolution procedure (20) takes into account the half-life of the hormone under study (here assumed to be 10.7 minutes for P) (21) and gives a clearer picture of a secretory pulse as opposed to a concentration pulse. For concordance purposes, P secretion was related to LH concentration peaks rather than LH secretory peaks because LH concentration was believed to represent a physiologically more relevant antecedent event for P secretion (22). Discrete event (peak maximum) coincidence was assessed by computer simulations and the hypergeometric probability density function (23). RESULTS Participants

The final groups of participants consisted of six women with rigorously defined PMS and six agematched (±2 years) phase-matched women without PMS (controls). All the participants were ovulatory during the tested cycle (luteal phase P :2: 6 nglmL 290

Lewis et al. LH and P release patterns: PMS

Upon post hoc examination of the symptom data during the testing cycle in the women with PMS, the range of actual sampling days was as follows: pre symptom days, LH surge + 5 to 7 days; symptom onset days, LH surge + 8 to 10 days. The range for during symptom days was LH surge + 11 to 13 days. Pulsatile Characteristics Between Groups

There were no significant between-group differences in LH pulse frequency, amplitude, and concentration, or in P pulse frequency, amplitude, and concentration. Data for pulse frequency are shown in Table 1. Coincident Pulsatile Release-Pooled Data

Significant coincidences (P < 0.05) were found between LH concentration peaks and P secretory peaks in the pooled data (n = 12) for each sampling day. The length of time between LH and P pulses systematically increased as the luteal phase progressed, from the sampling days of LH surge + 5 to 7 days, to LH surge + 8 to 10 days, to LH surge + 11 to 13 days. Data are presented in Table 2; the number of observed coincidences are depicted according to whether the coincidence between LH concentration peak and P secretory peak occurred with no time lag Fertility and Sterility

Table 1 Total Numbers of Detected Pulses by Group P secretory pulses

LH concentration pulses

Sampling days*

Table 3 Number of LH to P Coincident Pulsatile Releases Observed coincidences Sampling days

PMS group (n = 6) LH surge + 5 to 7 dayst LH surge + 8 to 10 days:j: LH surge + 11 to 13 days§ Control group (n = 6) LH surge + 5 to 7 days LH surge + 8 to 10 days LH surge + 11 to 13 days

32 36 31

34 32 32

26 21 35

38 40 31

* Samples collected every 10 minutes for 10 hours. t Before symptom onset. :j: At symptom onset. § During symptoms.

from LH concentration peak to P secretory peak (0 lag), a 10-minute lag from LH to P, or a 20-minute lag from LH to P. Coincident Pulsatile Release-by PMS and Control Group

When the pulsatile release coincidence studies were done by group, data from the women with PMS revealed no significant coincident pulsing during the 1st and 3rd sampling days. However, there was significant coincident pulsing of LH and P on the 2nd (LH + 8 to 10 days) sampling day (P < 0.03). Furthermore, this coincident pulsing represented a simultaneous release (zero time lag) between LH and P. By study design, the 2nd sampling day always occurred during the time of symptom onset. In the control group, there was significant coincident pulsing of LH and P on the 3rd (LH + 11 to 13 days) sampling day (Table 3). DISCUSSION

This study of the pulsatile release characteristics of LH and P in women with PMS was prompted by

Table 2 Pooled Data: Number of LH to P Coincident Pulsatile Releases* Observed coincidences Sampling days

Expected coincidencest

O:j:

10:j:

20:j:

LH surge + 5 to 7 days LH surge + 8 to 10 days LH surge + 11 to 13 days

5.9 (4.9) 5.8 (4.8) 5.9 (4.9)

10§ 8 5

5 10§ 9

5 5 10§

*N = 12. t Values in parentheses are variances. :j: Progesterone secretory event follows LH pulse by indicated lag time in minutes. § P < 0.05 for null hypothesis of purely random coincidences. Vol. 64, No.2, August 1995

PMS group (n = 6) LH surge + 5 to 7 days:j: LH surge + 8 to 10 days§ LH surge + 11 to 13 days~ Control group (n = 6) LH surge + 5 to 7 days LH surge + 8 to 10 days LH surge + 11 to 13 days

Expected coincidences*

ot

lOt

3.1 (2.5) 3.2 (2.7) 2.8 (2.3)

5 711 4

3 5 5

3 2 3

2.8 (2.3) 2.4 (2.0) 2.2 (1.9)

5 1 1

2 5 4

2 3 7**

20t

* Values in parentheses are variances. t Progesterone secretory event follows LH pulse by indicated lag time in minutes. :j: Before symptom onset. § At symptom onset. liP < 0.03 for null hypothesis of purely random coincidences. ~ During symptoms. ** P < 0.003 for null hypothesis of purely random coincidences.

the knowledge that opioids modulate gonadotropin release (24) and by a postulated role for hfjE in PMS (1,6, 7). Because central opioid levels cannot be measured accurately in humans, an indirect approach was taken in which the endocrine activity that is modulated by opioids was assessed. The study was designed to evaluate the evolution of LH and P pulsatility patterns at three symptom-related points in the luteal phase (presymptom, during symptom onset, and during symptoms). Neither the results of this study nor the work of Reame and colleagues (6) demonstrated significant between-group differences in LH and P pulsatile frequency, amplitude, or concentration in women with PMS compared with controls. However, two studies by Facchinetti and colleagues reported differences in the episodic secretion of LH and P (increased frequency and decreased amplitude in both LH (9, 11) and P (11) between women with PMS and controls. The presence of significant LH and P coincidences (P < 0.05) in the pooled sample of all participants in this study (n = 12) indicates that there is coincident pulsing, or coupling, between LH and P. This finding is consistent with the work of others (11, 13, 22) and supports the conclusion that the secretory activity of the corpus luteum is dependent on appropriate LH support (1). Interestingly, and not previously reported, the pooled data demonstrated that the length of time between LH and P pulses systematically increased across the luteal phase (P < 0.05). A. progressively increasing coupling interval may parallel the functional life span of the corpus luteum. The demonstration of a shorter than expected lag time (zero time lag) between LH and P during the symptom onset sampling day in women with PMS Lewis et al. LH and P release patterns: PMS

291

may be suggestive of an aberrancy in the LH to P coupling patterns in these women. Whether an aberrancy of this nature disrupts the influence of P on the release of central h(3E (1-3) and influences PMS symptom onset is unknown. By comparison, a significant zero time lag between LH and P at the LH surge + 8 to 10 sampling day was not seen in the control group. This raises questions about whether the corpora lute a of women with PMS during the onset of symptoms (LH surge + 8 to 10 days) differs in sensitivity to the luteotropic activity of LH compared with women without PMS at the same point in the luteal phase. The progressively increasing coupling interval throughout the luteal phase seen in the pooled data also was demonstrated in the control group. The significant coupling of LH and P at a 20-minute time lag on the last sampling day (LH surge + 11 to 13 days) supports the notion of a general pattern of progressively increasing coupling intervals. In summary, women with PMS did not differ from controls in LH and P pulsatile frequency, amplitude, and concentration. A concordance in LH and P pulsatility was noted in the pooled data, with a progressively lengthening coupling interval through the luteal phase. Women with PMS did, however, differ from the control group in the demonstration of a zero time lag between LH and P during the symptom onset point in the luteal phase. This finding prompts speculation about a greater corpus lutea sensitivity to LH stimulation at the time of symptom onset in women with PMS. Acknowledgments. We are indebted to the nursing staff of the General Clinical Research Center and to the Department ofPhysiological Nursing in the School of Nursing at the University of California, San Francisco, San Francisco, California and also to Monoclonal Antibodies, Inc. of Mountain View, California for donating the OvuQUICK kits. First antibody (rabbit) and tracer (HLH P289) were supplied by Alfred Parlow, University of California-Los Angeles, Los Angeles, California. REFERENCES 1. Yen SSC. The human menstrual cycle. In: Yen SCC, Jaffe RB, editors. Reproductive endocrinology. 3rd ed. Philadelphia: Saunders, 1991:273-308. 2. Halbreich U, Endicott J. Possible involvement of endorphin withdrawal or imbalance in specific premenstrual syndromes and postpartal depression. Med Hypotheses 1981;8:1045-58. 3. Reid RL. Etiology: medical theories. In: Keye WR, editor. The premenstrual syndrome. Philadelphia: Saunders, 1988:66-93. 4. Chuong CJ, Hsi BP, Gibbons WE. Periovulatory beta-endorphin levels in premenstrual syndrome. Obstet Gynecol 1994; 83:755-60. 5. Facchinetti F, Genazzani AD, Martignoni E, Fioroni L, Sances G, Genazzani AR. Neuroendocrine correlates of premenstrual syndrome: changes in the pulsatile pattern of plasma LH. Psychoneuroendocrinology 1990; 15:269-77.

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6. Reame NE, Marshall JC, Kelch RP. Pulsatile LH secretion in women with premenstrual syndrome (PMS): evidence for normal neuroregulation in the menstrual cycle. Psychoneuroendocrinology 1992; 17:205-13. 7. Facchinetti F, Genazzani AD, Martignoni E, Fioroni L, Nappi G, Genazzani AR. Neuroendocrine changes in luteal function in patients with premenstrual syndrome. J Clin Endocrinol Metab 1993;76:1123-7. 8. Soules MR, Steiner RA, Clifton RK, Cohen NL, Aksel S, Bremner WJ. Progesterone modulation of pulsatile luteinizing hormone secretion in normal women. J Clin Endocrinol Metab 1984;58:378-83. 9. Filicori M, Butler JP, Crowley WF. Neuroendocrine regulation of the corpus luteum in the human. J Clin Invest 1984;73:1638-47. 10. Hamilton JA, Parry B, Alagna S, Blumenthal S, Herz E. Premenstrual mood changes: a guide to evaluation and treatment. Psychiatr Ann 1984;4:426-35. 11. Brown MA, Lewis LL. Cycle-phase changes in perceived stress in women with varying levels of premenstrual symptomatology. Res Nurs Health 1993; 16:423-9. 12. Rubinow DR, Roy-Byrne P. Premenstrual syndromes: overview from a methodologic perspective. Am J Psychiatry 1984;2:163-72. 13. Woods NF, Lentz MJ, Mitchell ES, Kogan H. Arousal and stress response across the menstrual cycle in women with three perimenstrual symptom patterns. Res Nurs Health 1994; 17:99-110. 14. Lewis LL. Premenstrual syndrome: endocrine and psychosocial variables in relation to symptom severity [dissertation]. Chicago (IL): University of Illinois at Chicago, 1987. 15. Robins LN, Helzer JE, Croughan J, Ratcliff KS. National Institute of Mental Health Diagnostic Interview Schedule. Arch Gen Psychiatry 1981;38:381-9. 16. Halbreich U, Endicott J, Schacht S, Nee J. The diversity of premenstrual changes as reflected in the Premenstrual Assessment Form. Acta Psychiatr Scand 1982;65:46-56. 17. Vermesh M, Kletzky OA, Davajan V, Israel R. Monitoring techniques to predict and detect ovulation. Fertil Steril 1987;47:259-64. 18. Midgley AR. Radioimmunoassay: a method for human chorionic gonadotropin and human luteinizing hormone. Endocrinology 1966; 79:10-8. 19. Veldhuis JD, Johnson ML. Cluster analysis: a simple, versatile and robust algorithm for endocrine pulse detection. Am J Physiol 1986;250:E486-93. 20. Veldhuis JD, Iranmanesh A, Johnson ML, Lizarraide G. Twenty-four hour rhythms in plasma concentrations of adenohypophyseal hormones are generated by distinct amplitude and/or frequency modulation of underlying pituitary secretory bursts. J Clin Endocrinol Metab 1990; 71:1616-23. 21. Little B, Tait JF, Tait AS, Erlenmeyer F. The metabolic clearance rate of progesterone in men and ovariectomized women. J Clin Invest 1966;45:901-12. 22. Veldhuis JD, Evans WS, Kolp LA, Rogol AD, Johnson ML. Physiological profiles of episodic progesterone release during the mid-luteal phase of the human menstrual cycle: an analysis of circadian and ultradian rhythms, discrete pulse properties, and correlations with simultaneous LH release. J Clin Endocrinol Metab 1988;66:414-21. 23. Veldhuis JD, Johnson ML, Seneta E. Analysis of the co-pulsatility of anterior pituitary hormones. J Clin Endocrinol Metab 1991; 73:569-76. 24. Ferin M, Van Vugt R, Wardlaw S. The hypothalamic control of the menstrual cycle and the role of endogenous opioid peptides. Recent Prog Horm Res 1984;40:41-85.

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