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

clinical evidence that concomitant use of oral contraceptives
and antidepressants affects the safety or efficacy
of either agent. 55 There is also no evidence of ovulation
disturbance in women using SSRIs or SNRIs, although
a dose-dependent change in cycle length in women with
PMDD treated with continuous dosing of fluoxetine
has been noted. 56
Despite the chronicity, symptom severity, and burden
of illness associated with severe PMS/PMDD, RCTs have
focused only on acute phase therapy. Most studies report
on improvement (not remission) of symptoms after 2–3
treatment cycles only and it is therefore not known
whether women are able to stop medications after a
period of time and remain well. It is also not known
whether the efficacy of these interventions wanes over
time, or whether the rapid remission of symptoms could
result in better long-term treatment outcome. Studies
are needed to identify whether or not some women
develop tolerance to the SSRI over time that necessitates
increases in dosage or switch to another medication,
and whether or not some women stay in remission
for a period of time following SSRI discontinuation.
Nevertheless, preliminary data suggest that there is a
recurrence of symptoms after the cessations of shortterm
(three cycles) treatment 57 and that long-term fluoxetine
treatment is effective and well-tolerated. 58
All the studies reported here have excluded the younger
age group of adolescents (12–18 years of age), who are
nevertheless known to suffer from PMS/PMDD. 59
Thus, there is no evidence-based information regarding
the efficacy of these interventions for this age group,
and regulatory agencies around the world have
excluded them when granting the use of SSRIs for this
indication.
ANXIOLYTICS
The anxiolytics alprazolam 60–65 and buspirone 29,66
have demonstrated efficacy in some but not all trials
(Table 15.4); however, the magnitude of the therapeutic
effect is not as high as for the SSRIs/SNRIs. The sideeffect
profile and the potential for dependence, especially
with alprazolam, make them a less desirable
option, to be used preferably as a third line of choice.
CONCLUSIONS
It is now more than 15 years since the first reports
appeared in the literature on the effectiveness of
serotonin-enhancing agents in treating women with
severe premenstrual symptoms. Based on data to date
on more than 3000 women who participated in more
PSYCHOTROPIC THERAPIES 137
than 40 studies, both open-label and RCTs, using clomipramine,
SSRIs, or SNRIs, there is now ample evidence
that supports the beneficial role that these medications
have in this condition. Both continuous and intermittent
dosing are believed to be effective, but the decision
as to which regimen to use has to be made on an individual
basis. Continuous dosing should be reserved for
women with a history of comorbid anxiety or depressive
disorders or for women who experience concurrent
subsyndromal (underlying) anxiety or mood symptoms
throughout the entire cycle. These women may also
benefit from semi-intermittent dosing, i.e. dose increase
during the late luteal phase (e.g. Wikander et al 39 ).
Continuous dosing may also be the choice for women
who may find it easier to adhere to the daily dosing
regimen. Intermittent, or even symptom-onset dosing,
may be more appropriate for women with ‘pure’ PMS/
PMDD, i.e. those whose symptoms are limited to the
late luteal phase only, with a definite ‘on-off’ presentation.
This should also be the option for women who
prefer not to take medication throughout the entire cycle
or who experience bothersome side effects (especially
sexual dysfunction), which can be minimized with
intermittent dosing.
The choice of anxiolytics is limited, but both alprazolam
and buspirone have been shown, primarily, to
reduce premenstrual irritability. These medications, to
be used intermittently or even for a couple of days, on
a ‘as-needed basis’ (prn), should be reserved mostly for
women who are intolerant to the serotonergic or noradrenergic
agents and they should be used cautiously
due to their addictive nature.
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