Questions relating to premenstrual asthma

Table 1 Etiological factors in premenstrual asthma

Group	Factor	Ref.	Design	Level of factor in PMA	Level of factor in non PMA	P vaule	Evidence level1
Hormones	Estrogen	Pasaoglu et al[41]	Pre-post study	PM: 89.3 pg/mL	PM: 72 pg/mL	N/A	4
	Estrogen	Pereira et al[40]	Cross-sectional study	PO: 111.49 pg/mL PM: 95.9 pg/mL	PO: 131.31 pg/mL PM: 123.83	(for change) 0.845	4
	Progesterone	Pasaoglu et al[41]	Pre-post study	PM: 7.3 pg/mL	PM: 9.2 pg/mL	N/A	4
	Progesterone	Pereira et al[40]	Cross-sectional study	PO: 0.83 pg/mL	PO: 1.39 pg/mL	(for change) 0.225	4
				PM: 6.82 pg/mL	PM: 6.31
	Estrogen/	Pereira et al[40]	Cross-sectional study	PO: 219.26 pg/mL	PO: 356.6	0.865	4
	Progesterone			PM: 35.53 pg/mL	PM: 355.22	0.371
	LH	Pasaoglu et al[41]	Pre-post study	PM: 3.5 mU/mL	PM: 4.9 mU/mL	N/A	4
	FSH	Pasaoglu et al[41]	Pre-post study	PM: 13.3 mIU/mL	PM: 3.3 mIU/mL	N/A	4
Inflammation	LTC4	Nakasato et al[19]	Pre-post study	PO: 24.0 pg/mL	PO: NA1	NA	4
				PM: 69.0 pg/mL	PM: NA1
	LTC4	Pereira et al[52]	Cross-sectional study	PO: 1.5 ng/mL	PO: 1.4 ng/mL	NS	4
				PM: 1.31 pg/mL	PM: 1.29
	Prostaglandin F2α	Eliasson et al[53]	Cross-sectional study	Early cycle: 143 pg/0.1 mL	169.3 pg/0.1 mL	NS1	4
				Late cycle: 15.9 pg/0.1 mL	9.5 pg/0.1 mL	NS1
Atopy	Total IgE (geometric mean)	Pereira et al[47]	Cross-sectional study	206.31	87.99	0.01	4
	Total IgE (% > 100 kU/L)	Pereira et al[47]	Cross-sectional study	84	43	0.001	4
	Total IgE (mean)	Rao et al[48]	Cross-sectional study	208.4	292.2	0.06	4
	Phadiatop (% +)	Pereira et al[47]	Cross-sectional study	68	50	0.17	4
	Skin prick test +	Rao et al[48]	Cross-sectional study	60 (76%)	297 (88%)	0.01	4
Others	Aspirin sensitivity	Rao[48]	Cross-sectional study	23 (39%)	36 (10%)	< 0.0001	4
	Use of aspirin or non-steroidal anti-inflammatory drugs	Forbes[58]	Cross-sectional study	14/38 (36.8%)	172/421 (40.9%)	NS	4

¹Oxford Centre for Evidence-based Medicine-Levels of Evidence (March 2009, http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/). N/A: Not available; PMA: Premenstrual asthma; NS: Not significant; LTC: Leukotrienes.

Table 2 Specific treatments used in premenstrual asthma

Group	Treatment	Ref.	Design	patients	Outcome	Results	P vaule	Evidence level
Hormonal	Oral or intramuscular progesterone	Beynon et al[68]	Case-series	3	Premenstrual dips in peak flow	3 eliminated premenstrual dips in peak flow	NS	4
	Estrogen	Ensom et al[25]	Cross-over trial	12 (mild severity)	Asthma Quality of Life Questionnaire, FEV1	No differences	NS	1b
		Ensom et al[69]	Case report	1 (severe asthma)	Symptoms, pulmonary function, peak flow	Improved	N/A	4
	OC	Murphy et al[18]	Case-series	28 (16 with PMA)	OC use (%)	5.42% in Non PMA 6.38% in PMA	NS	4
		Tan et al[44]	Cross-sectional study	18 (9 taking OC)	Changes between follicular and luteal phases in airway reactivity and peak flow	Changes in patients not taking OC; No changes in patients taking OC	0.03 NS	4
		Derimanov et al[70]	Case report	1	Deterioration of asthma, decline of pulmonary function tests	After discontinuing the contraceptives, her condition returned to baseline	N/A	4
	Gonadotropin analogues	Murray et al[71]	Case report	1	Respiratory symptoms, PEFR dips premenstrual and prednisolone dosage and hospital admissions	Improvement	N/A	4
Anti-inflamma-tory	Anti-leukotrienes: pranlukast	Nakasato et al[19]	Pre-post study	5	Respiratory symptoms, PEFR	Improved asthma symptom scores, inhibited maximal decreases in PEFR	< 0.05 < 0.01	4
	Anti-leukotrienes: montelukast	Pasaoglu et al[41]	Pre-post study	24 mild asthma-tics (11 with PMA)	PEFR and symptom scores	Improvement in PEFR variability and symptom scores in women with PMA. No differences in women without PMA	0.005 0.002	4
	Prostaglandin synthesis inhibitors: sodium meclofenomate	Shimoda et al[72]	Cross-over trial	17 PMA	Peak flow, symptoms score	Improvement in peak flow during the early premenstrual period. No effect on the exacerbation of asthma during the late premenstrual period and early menstruation	0.025 NS	2
Others	Phytoestrogens soy genistein	Bime et al[77]	Case series	300 poorly controlled asthma	FEV1 and asthma control	Participants with little or no genistein intake had a lower baseline FEV1 and poorer asthma control than those with a moderate or high intake	0.01 0.001	4
	Phytoestrogens soy isoflavone	Smith et al[78]	Clinical trial	386 poorly controlled asthma	FEV1 at 24 wk symptoms, episodes of poor asthma control, asthma control test score	Not result in improved lung function or clinical outcomes	NS	1b

N/A: Not available; NS: Not significant; PEFR: Peak expiratory flow rate; PMA: Premenstrual asthma; OC: Oral contraceptives.