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

premenstrual cognitive disturbance, increased appetite,
increased sleep, and lethargy. 48 Paroxetine CR resulted
in significant improvement compared to placebo in
mood symptoms at 12.5 mg daily dosing, but physical
symptom reduction required 25 mg daily dosing. 53
Fluoxetine reduced symptoms that negatively impact
work capacity within the first cycle of treatment. 54
If initial exposure to one of the SSRIs proves problematic
due to side effects or lack of efficacy, another
SSRI should be utilized. Common side effects can be
found in Table 17.4. 55,56 Switching to another SSRI
involves discontinuing the first drug quickly while the
newer drug is titrated to an effective dose. If withdrawal
effects from the first medication result, its discontinuation
should be done more gradually. In the
case of luteal dosing, the new drug can be started with
the next menstrual cycle.
SSRIs should be taken in the morning, unless sedation
results, in which case the dose can be taken in the
late afternoon, generally before 4 pm to prevent insomnia.
Gastrointestinal side effects and headache are
usually transient; weight gain can also occur. 57 All
SSRIs can be associated with lowered libido and delayed
orgasm or anorgasmia. 58 Besides lowering dose or duration
of therapy, antidotes include dopaminergic agents,
such as bupropion; adrenergic agents such as Ritalin
(methylphenidate); buspirone; and phosphodiesterase
inhibitors like sildenafil. 58
When the possibility of becoming pregnant exists,
certain SSRIs might be preferred to others. As the
PMDD will disappear with pregnancy, therapy will not
be required. If the woman has underlying depression
and requires treatment, known risks of SSRI therapy 59
warrant individualized care.
Discontinuation symptoms should also be considered
in the choice of continuous, non-luteal dosing of
SSRI, as symptoms vary considerably depending upon
the drug and dosing schedule. Paroxetine has the most
Table 17.4 Common side effects of daily SSRIs
with an FDA indication for PMDD55 Side effect Fluoxetine Sertraline Paroxetine
Anxiety +++ + +
Sedation + ++ ++++
Insomnia ++++ ++++ ++++
Nausea ++++ ++++ ++++
Decreased
libido
+ + +
Weight gain 0/+ + ++
CLINICAL EVALUATION AND MANAGEMENT 155
significant withdrawal effects and is therefore weaned
slowly, tapering by half the dose every several days
until discontinued completely. The taper can be lengthened
if symptoms occur. Sertraline should also be
weaned slowly. Because of its long half-life, fluoxetine
at 20 mg daily can be stopped without a taper. Escitalopram
and citalopram should be tapered, but this can be
done fairly rapidly.
If a woman conceives while using an SSRI and continues
treatment, there are risks 60 of neonatal syndrome
at birth. Hence, treatment should be discontinued or a
psychiatric opinion should be sought if it is thought
that her condition is so severe that further psychotropic
therapy is required.
Anxiolytics
Other classes of psychotropic medications with some
efficacy for luteal phase dosing only include buspirone
(5HT 1A agonist), 10 mg 2–3 times per day, and alprazolam
(GABA A agonist), 0.25–0.5 mg taken 2–3 times
per day. Although these agents have shown only
minimal or modest usefulness for PMS/PMDD compared
to SSRIs, their intake results in fewer sexual side
effects. 52,61 These agents or other anxiolytics can also
be added (in the luteal phase only, in order to preclude
development of tolerance and addiction) to SSRIs if
anxiety persists while taking an SSRI.
Diuretics
Specific physical symptoms that are most troubling to
the patient may need to be addressed separately. For
example, in women with severe mastalgia and bloating,
use of spironolactone, an aldosterone receptor antagonist,
may be a helpful adjunct. A dose of 100 mg from
day 12 of the cycle to the onset of menses relieved PMS
symptoms in a placebo-controlled trial, and by cycle
three, with significant improvement in abdominal
bloating, swelling of extremities, breast discomfort,
and even mood symptoms of irritability, depression,
anxiety, and tension. 62–64
Gonadotropin-releasing hormone agonists
The use of a GnRH agonist to suppress ovarian sex
steroids provides symptomatic relief in the majority of
women with PMS; 65–68 however, long-term studies are
lacking. Bone density, and cardiovascular and vaginal
health can theoretically be maintained and vasomotor
symptoms prevented with a menopausal dose of continuous
estrogen/progestin or tibilone as hormone addback
therapy. 69 A GnRH analogue, even with hormone
add-back therapy, remains a third-line therapy if