Menstrually related disorders: What we do know, what we only believe that we know, and what we know that we do not know

Menstrually related disorders (MRD) are quite prevalent. Attention is mostly focused upon the premenstrual syndromes (PMS), which are a subject of controversy tinted by opinions, beliefs, and biases. Recently, substantial progress has occurred in the diagnosis, evaluation, and treatment of MRD, but their etiology and pathophysiology are still unknown and are a matter for several hypotheses. Data on MRDs were recently extensively cataloged and reviewed elsewhere. Here the emphasis is on some opinions from the departure point that: (1) The existence of MRD is undoubtful if beliefs and biases are put aside, and (2) symptoms of MRD are diversified and the dysphoric ones are associated with other dysphoric disorders and states. The biology of MRDs should be elucidated by emphasizing the multidimensional interactional processes involving the hypothalamic-pituitary-gonadal (HPG) system, neurotransmitters, and other hormonal axes, as well as other biological systems and circuits. The biological systems are interwoven with environmental and psychological inputs. Much of the available data can be understood within a model of dynamically evolving, diversified vulnerabilities, which may be expressed as symptoms when a trigger is applied. That trigger is probably related to ovulation and/or the HPG system but might also be related to another stress- or state-related mechanism. Treatment of MRD might be targeted at the symptoms or vulnerability variables (as is the case with antidepressants) or at the ovulation-related trigger (as is the case with ovulation suppressors). Knowledge about MRD will be enhanced by studies of the mechanisms of interaction between environment and hormonal and brain systems, by studies of processes of homeostasis and its dysregulation, and by an in-depth evaluation of the mechanisms of treatment response and nonresponse.