Vitamin A levels in premenstrual syndrome*t

Transcription

1 FERTILITY AND STERILITY Copyright 1990 The American Fertility Society Printed on acid-free paper in U.S.A. Vitamin A levels in premenstrual syndrome*t C. James Chuong, M.D., M.P.H.:j: Earl B. Dawson, Ph.D. Edward R. Smith, Ph.D. Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas To determine whether changes in peripheral vitamin A levels are associated with symptoms of premenstrual syndrome (PMS), 10 PMS patients and 10 controls were studied. They gave blood at 2- or 3-day intervals through three menstrual cycles. The vitamin A was measured by fluorometry after cyclohexane extraction. In the controls, vitamin A values were 68.0 ± 3.2 JLg/dL (mean ± SE) during the luteal phase and 69.8 ± 4.2 JLg/dL during the follicular phase. No significant changes were noted between the two values. In the patients, the values were 73.9 ± 4.2 JLg/dL during the luteal phase, which was not significantly different from 72.7 ± 1.8 JLg/dL during the follicular phase. No significant changes were noted between the controls and the patients in either the luteal or the follicular phase. Vitamin A deficiency in PMS patients was not demonstrated in our study. Fertil Steril54:643, 1990 Many theories have been proposed to understand the pathophysiology of premenstrual syndrome (PMS) in the hope of finding an effective treatment. 1 The Biskinds were the first to propose the role of nutritional factors in PMS. 2 Over the last few years, nutritional supplements have been widely used as a treatment for PMS. 3-6 The use of these supplements is based on the assumption that PMS patients consume more refined sugar, refined carbohydrates, and dairy products, and less vitamins, such as vitamin A than do normal women. 7 Vitamin A was thought to alleviate PMS by opposing thyroid hyperfunction, 8 or by exerting a direct antiestrogenic, 9 or diuretic effect, 10 but, to date, none of these hypotheses have been substantiated. Reports on the success of vitamin A therapy Received March 26, 1990; revised and accepted June 22, * Presented in part at the 43rd Annual Meeting of The American Fertility Society, Reno, Nevada, September 28 to 30, t Supported in part by the University of Texas Medical Branch Intramural grant award , Galveston, Texas. :j: Reprint requests and present address: C. James Chuang, M.D., M.P.H., Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Baylor College of Medicine, One Baylor Plaza, Houston, Texas in the treatment ofpms have appeared in the literature.11 It was noted, however, that the placebo and vitamin A were not administered in a double-blind, cross-over fashion for each patient, and vitamin A deficiency was never demonstrated in these patients when compared with control subjects. Serum vitamin A levels may assist in assessing a vitamin A deficiency in PMS patients and serve as a guideline before and during vitamin A treatment. Therefore, the objective of this study is to determine whether changes in peripheral vitamin A levels are associated with PMS symptoms. MATERIALS AND METHODS The study was approved by the Institutional Review Board of the University of Texas Medical Branch, Galveston, Texas. Ten patients, 24 to 39 years of age, with regular menses for at least six previous cycles were studied. All were interviewed by the same investigator (C.J.C.) for detailed medical history. All were from a white middle-class population in Southeast Texas. Interview on the diet history and daily intake of various nutrients did not reveal evidence of extraordinary food intake. They had normal physical examinations by either Chuong et al. Vitamin A levels in premenstrual syndrome 643

2 the investigator or the referral physicians within 6 months before the study began. They were in general good health, and no significant medical conditions from history or on physical examination were noted. They had no history of psychiatric disorders, determined by the Schedule for Affective Disorders and Schizophrenia-Lifetime interview. The patients were instructed to start charting the Daily Diary on the 1st day of the menses throughout the entire menstrual cycle and to qualitatively measure their premenstrual complaints. The Daily Diary was designed by us to follow the diagnosis guidelines established by the National Institute of Mental Health. Each patient documented, within the last half of the cycle, at least 3 of the 18 symptoms, with at least 1 psychological and 1 somatic symptom for at least one preceding menstrual cycle. The 18 symptoms included (1) irritability; (2) tension or anxiety; (3) mood swings; (4) emotional liability; (5) restlessness; (6) decreased concentration; (7) depression; (8) aggression; (9) poor coordination; (10) craving for sweet or salty food; (11) lethargy; (12) generalized swelling; (13) breast tenderness; (14) abdominal bloating; (15) swelling of the face, hands, or feet; (16) weight gain; (17) headache; and (18) change in bowel habits. Patients were eliminated from the study if their symptoms were present in the first half of the cycle or if they persisted for >2 days after the onset of menses. Also excluded were pregnant patients, patients who had been taking drugs or medications, including oral contraceptives, thyroid preparations, antithyroid medications, or any forms of vitamin or nutritional supplements during the 8 weeks before the study. Before enrollment, we made a pretreatment assessment of symptoms by evaluating the symptoms recorded daily for 1 month, beginning on the 1st days of menses (day 1 of the cycle after the initial visit). Each subject was instructed to complete the Menstrual Distress Questionnaire 12 on days 7 and 25 of the menstrual cycle for one cycle. They were also instructed to complete the basal body temperature (BBT) chart during the same cycle. All of them demonstrated a biphasic pattern with evidence of ovulation and adequate luteal phase. The Menstrual Distress Questionnaire was described in previous studies. 12 Women whose scores on the Menstrual Distress Questionnaire were >80 on day 7 or <95 on day 25 of the menstrual cycle were excluded from the study. Using these entry criteria, the mean (±SE) Menstrual Distress Questionnaire score was 55.2 ± 2.3 on day 7 and ± 8.2 on day 25. Ten female volunteers from among our institution's employees served as the control group. They underwent the similar interview on medical and diet histories and physical examination process to those for the patient group. They were all in general good health and had regular predictable menses. None of them had premenstrual symptoms or severe dysmenorrhea. Subjects were excluded if they had been taking any drugs or medication, including vitamin or nutritional supplements during the 8 weeks before the study. They were also asked to keep a Daily Diary, to complete the Menstrual Distress Questionnaire, and the BBT chart in the same fashion as the patient group. None of them demonstrated significant premenstrual symptoms on the Daily Diary. They all demonstrated a biphasic pattern and adequate luteal phase on the BBT chart. The mean (±SE) Menstrual Distress Questionnaire score before the study was 53.1 ± 2.6 on day 7 and 51.5 ± 1.1 on day 25. Informed consent was obtained from all of the participants. They were instructed to complete the BBT chart daily and the Menstrual Distress Questionnaire on days 7 and 25 of each menstrual cycle during the 3-month study period. After an overnight fast, the blood samples for vitamin A, luteinizing hormone (LH) and follicle-stimulating hormone (FSH) assays were drawn between 8 A.M. and 10 A.M. Before the blood was collected, the women sat quietly for 30 minutes. They gave blood at 2- or 3-day intervals, starting on day 1 of the menstrual cycle through three cycles. Ten milliliters of blood was collected, permitted to clot, and centrifuged at 1000 X g for 15 minutes at 26 C. The serum was stored at -20oC until analyzed. The measurement of serum vitamin A levels was by the procedures previously describedy The serum was deproteinized by ethanol, and vitamin A was extracted from the aqueous phase by the addition of hexane, vortexing, and slow-speed centrifugation. The supernatant hexane layer was transferred to a quartz curette for fluorometric measurement of vitamin A (Turner Model 430 Spectrofluorometer; G K Turner, Palo Alto, CA). The serum vitamin A levels were determined by comparison with vitamin A standards in hexane (Sigma Chemical Co., St. Louis, MO) and the results expressed as Jig/dL. Luteinizing hormone and FSH were measured by double antibody radioimmunoassay. All reagents except the standards were obtained from the National Pituitary Agency. Luteinizing hormone and FSH standards were obtained from the World Health Organization. The intra-assay co- 644 Chuong et al. Vitamin A levels in premenstrual syndrome Fertility and Sterility

3 efficient of variation was 7.3% for LH and 6.8% for FSH, whereas the interassay variations were 12.3% and 15% for LH and FSH, respectively. All samples from the same patient were run in duplicate in the same assay for vitamin A, LH, and FSH. The day of LH surge was considered as the midpoint of the cycle and was designated day 0. All other measurements were expressed as the number of days before or after the LH surge. The hormonal measurement during the follicular phase (day LH -14 to -3) of each month for each subject was the mean of all data during the follicular phases of each month. The mean of the 3 months' values for each subject was then obtained. The hormonal measurement during the luteal phase (day LH +3 to+ 14) was calculated in a similar fashion. The two-way analysis of variance (ANOVA), using Procedure: General Linear Models from SAS 14 was used to test for significant intragroup changes of vitamin A levels between the follicular and luteal phases. Comparisons between the control and PMS groups during the follicular and luteal phases were also made by the ANOVA. The differences in the Menstrual Distress Questionnaire scores were determined by the two-sample or paired-sample t-tests. The level of significance was P < RESULTS There were no differences in age, body weight, marital status, reproductive history, menstrual history, or degree of dysmenorrhea between the patient and control groups (Table 1). The mean duration of PMS symptoms in the patient group was 60.5 months. To participate in the study, the Menstrual Distress Questionnaire score on day 7 had to be <80. The Menstrual Distress Questionnaire score on day 7 before the study for the PMS group was not significantly different from that of control subjects (55.2 ± 2.3 versus 53.1 ± 2.6 [mean ± SE]). The large difference in Menstrual Distress Questionnaire score on day 25 (125.7 ± 8.2 for PMS group and 51.5 ± 1.1 for control group), was expected, based on the criteria for inclusion in this study. A similar pattern of score changes were noted in each PMS and control subject each month during the study period. All the participants demonstrated a biphasic BBT pattern each month suggesting ovulation and adequate luteal phase. The LH and FSH are shown in their characteristic patterns, with the day of the LH peak designated day LH 0. The LH peak Table 1 Age, Body Weight, Marital Status, and Reproductive and Menstrual Histories of PMS Patients and Control Subjects Control PMS (n = 10) (n = 10) Age(y) Median Range 23 to to 39 Body weight Average (%ofibw") Range 84to to 126 (% ofibw") Number of obese 1 (124% ofibw") 2 (120% and 126% subjectsb ofibw") Marital status Single 5 3 Married 5 5 Divorced 0 2 Reproductive history Nulliparous 6 5 Parous 4 5 Menstrual history, median Menarch (y) Interval (d) Length (d) Dysmenorrhea None 2 1 Mild 4 3 Moderate 3 4 Severe 1 2 IBW, ideal body weight is according to the table of the Metropolitan Life Insurance Company. b Obesity is defined as body weight~ 20% above IBW. reached 92.3 ± 12.5 mlu/ml (mean± SE), whereas FSH was 24.2 ± 5.3 mlu/ml on day LH 0. In the controls, vitamin A values were 68.0 ± 3.2 ~g/dl (mean ± SE) during the luteal phase and 69.8 ± 4.2 ~g/dl during the follicular phase. No significant changes were noted between the two values. In the patients, the values were 73.9 ± 4.2 ~g/dl during the luteal phase, which was not significantly different from 72.7 ± 1.8 ~g/ dl during the follicular phase. No significant changes were noted between the controls and the patients in either the luteal or the follicular phase (Table 2). DISCUSSION Simkins, 8 during treatment of hyperthyroidism with massive doses of vitamin A, incidentally discovered that this therapy "cured" the symptoms of PMS in one patient. He thought the mechanism involved a decreased formation of circulatory estrogen (E). Argonz and Abinzano 9 subsequently reported the successful treatment of 30 patients with Chuong et al. Vitamin A levels in premenstrual syndrome 645

4 Table 2 Mean Vitamin A Levels Over Three Menstrual Cycles of PMS Patients and Control Subjects a Control Subject Follicular phase Luteal phase (14)b 75.2 (12) (12) 74.7 (13) (13) 52.1 (14) (14) 73.9 (13) (11) 80.5 (14) (13) 75.0 (10) (12) 58.9 (11) (15) 58.3 (8) (15) 71.2 (13) (16) 60.3 (13) 69.8 ± 4.2' 68.0 ± 3.2' a Mean vitamin levels are JLg/dL. b Values in parentheses are the number of observations. PMS Subject Follicular phase Luteal phase (15) 97.0 (14) (10) 65.5 (8) (10) 97.0 (15) (15) 65.7 (12) (14) 63.1 (14) (12) 72.2 (14) (13) 68.5 (11) (15) 70.4 (12) (12) 67.1 (12) (15) 72.5 (15) 72.7±1.8' 73.9 ± 4.2' 'Values are means± SE. PMS by means of 200,000 IU of vitamin A daily and postulated that vitamin A may be able to rectify an aberration in E metabolism. The effect of Vitamin A on the PMS symptoms was also hypothesized to be related to its diuresis effect, 10 as shown in subjects receiving 144,000 IU daily throughout several weeks. We are unable to find any reports on the relationship between vitamin A alone and PMS in the literature of the past 30 years. However, several studies on the effects of multiple vitamin and mineral supplements on PMS have been reported Vitamin A and zinc supplements were found to be effective in controlling premenstrual flare-up of oily skin and acne.16 All the study subjects were not on vitamin A supplements for at least 8 weeks before the study. We believed that 8 weeks without vitamin A would ensure the basal state in vitamin A metabolism because studies17 18 have shown that the turnover time for vitamin A in humans varies individually from 72 hours to 33 days. Vitamin A deficiency in PMS patients was not demonstrated by peripheral vitamin A levels in our study. Our findings cannot explain the beneficial effect of vitamin A in PMS patients in previous studies.8 11 Those patients were assumed to have vitamin A deficiency before the treatment was given. The dosages of vitamin A administered to these patients ranged from 200,000 to 400,000 IU /d, which was 4,000% to 8,000% of the U.S. Recommended Daily Allowance for adults. We suggest that the response to vitamin A in these studies was because of a pharmacological response rather than correction of a deficiency state. Another explanation for this discrepancy might be that vitamin A levels in the peripheral blood do not parallel to those in the central nervous system. It remains possible that the bioavailability of vitamin A in the central nervous system, which is related to the activities of several neurotransmitters, could decrease during the luteal phase in some PMS patients. As a result, the premenstrual symptoms occur. However, these changes of vitamin A levels in the central nervous system may not be reflected in the peripheral blood levels. Because of the rigorous initial entry criteria, such as at least two-month, medication-free (including any forms of vitamin or nutritional supplements) interval before testing, and the requirement of blood drawing at 2- or 3-day intervals for 3 months when no treatment could be given, the sample size in our study was limited. Yet, these subjects would be expected to show vitamin A deficiency during the luteal phase if the deficiency is related to PMS symptoms and can be shown in the peripheral circulation. It is suggested that the treatment of PMS has been hampered by a lack of laboratory evidence of the nutritional state of these patients. Stewart5 evaluated the nutritional state ofpms patients but not the controls and found evidence of deficiencies in vitamin B6 and magnesium; however, he did not evaluate vitamin A. Abraham19 did not find significantly different serum levels of vitamin A and several other nutrients between the follicular and luteal phases of the menstrual cycle in six PMS patients. However, only two blood samples during each phase were drawn, and no samples were obtained from the controls. Mira et al. 20 measured several vitamin and trace element levels in the serum ofpms patients and the controls on two occasions (premenstrual and postmenstrual) in Chuong et al. Vitamin A levels in premenstrual syndrome Fertility and Sterility

5 month and found no evidence for nutritional deficiencies including vitamin A. We now confirm and enlarge these previous observations by obtaining blood samples at 2- or 3-day intervals through three menstrual cycles from both patient and control groups. Further clarification ofthe role of vitamin A in central neurotransmitters activities and the relationship between the central and peri pherallevels of vitamin A is needed. Until these issues are addressed, vitamin A supplementation can only be considered as an empirical therapy for PMS. Acknowledgments. We wish to thank Ms. JoAnn Rabb for excellent editorial assistance in the preparation of the manuscript, as well as Mrs. Elaine Brown, Mr. Michael Harris, William A. Harris, B.A., and Ms. Sheila Jonas for technical assistance. REFERENCES 1. Reid RL, Yen SSC: Premenstrual syndrome. Am J Obstet Gynecol139:85, Biskind MS, Biskind GR, Biskind LH: Nutritional deficiency in the etiology of menorrhagia, metrorrhagia, cystic mastitis, and premenstrual tension. Surg Gynecol Obstet 78:49, Abraham GE, Rumley RE: Role of nutrition in managing the premenstrual tension syndromes. J Reprod Med 32:405, Abraham GE: Management of the premenstrual tension syndrome: Rationale for a nutritional approach. In A Year in Nutritional Medicine, Edited by J Bland. New Haven, Keats Publishing, 1986, p Stewart A: Clinical and biochemical effects of nutritional supplementation on the premenstrual syndrome. J Reprod Med 32:435, Kendall KE, Schnurr PP: The effects of vitamin B6 supplementation on premenstrual symptoms. Obstet Gynecol 70: 145, Goei GS, Ralston JL, Abraham GE: Dietary patterns of patients with PMT. J Appl Nutr 34:4, Simkins S: Use of massive doses of Vitamin A in the treatment of hyperthyroidism. J Clin Endocrinol Metab 7:572, Argonz J, Abinzano C: Premenstrual tension treated with vitamin A. J Clin Endocrinol Metab 10:1579, Bicknell F, Prescott F: The Vitamins in Medicine. London, Heinemann, 1946, pp 37 and Block E: The use of vitamin A in premenstrual tension. Acta Obstet Gynecol Scand 39:586, Moos RH: The development of a menstrual distress questionnaire. Psychosom Med 30:853, Selvaraj KJ, Susheela TP: Estimation of serum vitamin A by a microfluorometric procedure. Clin Chim Acta 27:165, SAS User Guide, SAS Institute, Gary, North Carolina, Piesse JW: Nutrition factors in the premenstrual syndrome. Int Clin Nutr Rev 4:54, Michaelson G, Juhlin L, Vahlquist A: Effects of oral zinc and vitamin A in acne. Arch Dermatol113:31, Smith FR, Goodman DS: Vitamin A transport and toxicity. N Eng! J Med 394:805, Muenter MD, Perry HO, Ludwig J: Chronic vitamin A intoxication with adults. Am J Med 50:129, Abraham GE: Bioavailability of selected nutrients from a dietary supplement. J Appl Nutr 37:61, Mira M, Stewart PM, Abraham SF: Vitamin and trace element status in premenstrual syndrome. Am J Clin Nutr 4 7: 636, 1988 Chuong et al. Vitamin A levels in premenstrual syndrome 647