Premenstrual Syndromes : PMS and PMDD - Rutuja :: The site ...

114 THE PREMENSTRUAL SYNDROMES
trials consistently demonstrating efficacy in the treatment
of emotional and physical symptoms with
minimal side effects. Figure 12.1 provides an algorithm
for hormonal treatments for PMS/PMDD. Oral contraceptives
are the agents of first choice because they most
closely approximately this goal. They do, however,
introduce a new progestogen cyclicity that may negate
its effect. Their efficacy in treating physical premenstrual
symptoms has been demonstrated in controlled trials
and they produce minimal to mild side effects. Moreover,
they provide additional benefits such as contraception,
control of abnormal uterine bleeding, and
management of other pelvic conditions. Contraceptives
containing drospirenone show potential. Recent data
suggest that low-dose estrogen and antiandrogenic/
antimineralocorticoid progestins, such as drospirenone,
Primarily physical symptoms
of PMS/PMDD in women
seeking contraception
OCPs
Physical symptoms
unrelieved
Short-term GnRH agonists +
add-back therapy
Physical symptoms
unrelieved
Danazol
Figure 12.1 Algorithm for hormonal treatment of
PMS/PMDD. OCPs = oral contraceptive pills; GnRH
agonists = gonadotropin-releasing hormone agonists.
Avoid estradiol patches and implants due to
insufficient evidence of efficacy and potentially
significant side effects from high-dose estrogen. Avoid
progesterone suppositories and micronized tablets
because of lack of efficacy. Avoid ovariectomy because
of insufficient efficacy data and major side effects.
Chasteberry and black cohosh may be suggested, but
presently there is insufficient data to suggest their
efficacy and/or potential side effects.
may also ameliorate emotional premenstrual symptoms,
but further study is needed.
A recent meta-analysis of GnRH agonists demonstrated
their efficacy in treating symptoms of PMS/
PMDD. Their side effect profile and cost precludes
long-term use, although there is some evidence to
suggest that side effects can be reduced by add-back
therapy with no detrimental effect on efficacy. Shortterm
therapy with GnRH agonists � add-back therapy
is recommended when other treatment has failed and
the woman demonstrates significant functional impairment
from physical symptoms.
Like GnRH agonists, danazol has consistently shown
efficacy in treating physical symptoms of PMS/PMDD
in controlled studies. However, its practical use is
limited by the need for concurrent administration of a
reliable contraceptive method, weight gain, mood
changes, acne, and possible virilization of the fetus.
Thus, danazol is a suggested treatment for PMS/PMDD
only when OCPs and GnRH agonists have failed, and
premenstrual symptoms are significantly impairing
daily functioning. It is a useful drug used in the luteal
phase only in treating breast symptoms, and this is
associated with minimal side effects.
High-dose estradiol has been investigated in a
number of trials. No incidents of venous thrombosis,
pulmonary embolus, or atypical endometrial hyperplasia
occurred, but risks remain high. Estradiol patches
and implants are not recommended for treating
PMS/PMDD by the authors of this chapter, but there
are differing views based on the same evidence (see
Chapter 14).
Historically, natural progesterone has been one of
the most commonly employed therapies in women with
PMS/PMDD, but controlled trials have consistently
shown no benefit of this hormone when compared with
placebo, whether administered as a vaginal suppository
or as oral micronized progesterone. Therefore, it is not
recommended as treatment.
Data regarding use of dietary supplements which
affect endocrine function is scant and conflicting.
Clinical experience has shown no significant side effects
of either chasteberry or cohosh, and there is anecdotal
evidence to suggest a benefit.
REFERENCES
1. American College of Obstetricians and Gynecologists: Premenstrual
syndrome. ACOG Practice Bulletin No. 15, April 2000.
2. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, 4th edn, text revision. Washington,
DC: American Psychiatric Association; 2000.
3. Roca CA, Schmidt PJ, Bloch M et al. Implications of endocrine
studies of premenstrual syndrome. Psychiatr Ann 1996; 26:577–80.