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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 2 to 26 of 226. Go back in thread:
Posted by Terry on March 11, 1999, at 15:51:23
In reply to PMDD - Premenstrual Dysphoric Disorder, posted by Jan on March 1, 1999, at 10:54:47
You might try birth control pills if you're not trying to get pregnant. They help control the progesterone surge at the end of your menstrual cycle associated with PMDD. Out of curiousity, which antidepressants did you try?
> PMDD - I'm looking for anyone being treated for it, and I'd like to know what the treatment consists of. I'm in my 30's and anti-depressant meds don't help at all. My Dr says that I'm to young for Estrogen therapy. I'm running out of options. Any information would be appriciated.
>
> Thank you.
Posted by Cal on May 12, 2000, at 16:17:12
In reply to PMDD - Premenstrual Dysphoric Disorder, posted by Jan on March 1, 1999, at 10:54:47
I am just curious. My wife was diagnosed with Bipolar several yrs ago. There would be times her emotions would take a hike an her family would put her into a psyh ward. Since we have met and now are married I have done much reaseach on the symtoms. What I have found that the symtoms match exactly the PMDD problem. Since this I have been in touch with a support group out of Canada on this issue. What they recomended is what we were in process of doing and that is a good suppliment and nutrition plan. But this group has detailed to me that a lot of ladies that are diagnosed as Bipolar are in fact dealing with PMDD. Obviosly this changes how this is dealt with. With this problem of PMDD there have been months that she would only have 1 sometimes 2 weeks that are good for her in a month. Everything from depression to always tired, muscle aches, sad feelings, marked anger, decreased interests in usual activities, dificulty in concentration, lethargic, feeling overwhelmed, marked anxiety, sense of hopelessness and self depreciating thoughts. Since we have a beter understaning on this issue it has helped me to deal with this in a much more constructive way. With the news letters sent out each much from the support group and much research done on that end it seems to help a lot in getting a handle on this.
I would love to hear if there are any others that deal with this?
I being the husband (male):). This has been a learning experience for me. Not a bad one I might add. But I have a much better understanding as to why they would have diagnosed her with Bipolar, it really seems to work much the same way.
It is estimated that 80% of women of reproductive age experience symptoms of PMS. In some cases the symptoms are relatively moderate. However, many women experience symptoms which are overtly severe and debilitating. Still others experience a specific and extremely severe set of symptoms known as PMDD (premenstrual dysphoric disorder). While the numbers are staggering, the medical profession remains at odds when it comes to the cause, diagnosis, and correct treatment. Many doctors still doubt the existence of PMS and PMDD. As a result PMS and PMDD are not always accurately identified or treated. Often, women's concerns regarding PMS are not taken seriously which leads to feelings of self-doubt, frustration and hopelessness.Here is a Link that will take you to the site I got this from and give you a better understanding on the issue.
http://tor-pw1.attcanada.ca/~vizprint/small.html
I had my wife to the doctors today to make sure there are no other problems. I ordered the literature offered at this site to get a better understanding on the issue myself. My wife has been reading her heart out on this and hopefully in the future we might have a better handle on things here.
We are in process of using the progesterone therapy to help with some of the surges in her system. I mentioned it to the Doc tonight and he aggreed that that would be a good place to start to help keep things on the leval. So I guess we will see. Good luck, I would love to hear if this is of any help to you. Cal
Since we started using the Progesterone Carla my wife has been feeling much better. I dont know what it all does I do know however that she is a much better lady to herself and I in a matter of 2 days there has been such a differance. This formula is in a PLO gel custom mixed by a compounding pharmacy. There are a lot of doc's that dont even know what that is. I did do a search on the PLO Gel. There are a few pharmacies online that offer the same product in diferant variations andd those can be easily custom mixed and changed at any time.
I am concerned reading all of the posts here that there are so many meds taken with so little results and many recurring problems in general. I know that any med can be applied topically with less than half needed if applied in this matter. My question is why is this not used more in the treatment for depression and various other problems with Bipolar.
I do hope this treatment with my wife will be successful in the long haul. I see such a change in her I am extastic about it. Yesterday she came home from work with a smile and just happy as a lark . :) Makes me wonder if some of the Bipolar problems could not be regualted with the same treatment. I do know that the Progesterone if used correctly will cause your body to self regulate the in body chemistry. The Doc I took her to suggested we go the the phsyc counseler. I come right off my chair. I was so upset about it and he did know it. I told him of my reasearch and when I presented it to him he stopped with that suggestion. Carla was afraid he would do that so I made sure we werent going there. After I showed him my reasearch he agreed to give this a try and see if this approach would work. She has been to so many Doc's in past and knows how they jerk you around with the meds and such with out really doing the research they should be doing. I am sooooo mad at the professional world thinking we dont know what our bodies are doing I cant stand it. I will not idoly stand by and let this happen again without my input and reasearch. I hope you all do the same.
Have a great day,
Cal
Posted by Noa on May 13, 2000, at 12:32:45
In reply to Re: PMDD - Premenstrual Dysphoric Disorder, posted by Cal on May 12, 2000, at 16:17:12
Cal, I think there is still a lot of knowledge about ther interrelationships among hormones, metabolism, etc. and psychiatric sypmtoms, that needs to be looked into and taught to doctors and patients. I am impressed with your stick-to-it-iveness in doing your research and supporting your wife. Keep us posted.
Oh, btw, since I am the so called "thyroid lady", I just have to ask: has she had good evals done of her thyroid functions? I know that post-partum thyroiditis is a common cause of severe post-partum depression, and I wonder if it has a role in premenstrual depression, too.
Posted by Cal on May 13, 2000, at 13:01:08
In reply to Re: PMDD - Premenstrual Dysphoric Disorder, posted by Noa on May 13, 2000, at 12:32:45
Yes there was a check on that last Dec. All seemed to be within the tolerances. Sometimes I wonder if the checks on hormones and others things are not checked to broadly. I wonder if there would be a way to brake them down again in half so the detection leval would determining minor fluctionations rather than say with in the tolerances they have allotted. I wonder if minor fluctuations is not what we need to look at instead of something witin the tolerances of say between 10 and 15 points.
Just a thought, Cal
Posted by Noa on May 13, 2000, at 13:47:35
In reply to Re: PMDD - Premenstrual Dysphoric Disorder, posted by Cal on May 13, 2000, at 13:01:08
Yes, Cal! For example, TSH is considered within normal limits if it is between .5 and about 5 international units. But there are many of us for whom the higher end of that feels awful!! While the typical internist might consider my 4.6 reading to be "normal", I am hypothyroid at that level of TSH. I now have an endocrinologist who has told me it is ok for my TSH to go as low as 0 if I need to in order to improve how I feel. That is considered radical. I read an article (see www.thyroid-info.com) by a physician who says that a TSH level of 2 or higher is highly predictive of later hypothyroid illness. And, it appears that the psychiatric manifestations of hypothyroidism can show up way before any of the physical symptoms do. So, when you get any tests done, ALWAYS get the actual numbers as well as the lab's "normal" ranges. Don't just accept a designation of "normal" or within normal limits, etc. Also, sometimes the basic tests don't go after more subtle endocrine problems. For example, you can have "normal" TSH, and normal T4 levels, but maybe low T3, which wouldn't affect the TSH level, but maybe are missing the protein that helps convert T4 (the stable version) to T3 (the usable version), so your cells are not getting any of the thyroid hormone, even tho there is plenty of it floating around in your blood.
For more info: The Thyroid Solution, by Ridha Arem
Living Well with Hypothyroidism, by Mary Shomon
www.thyroid-info.com (Mary Shomon's website)
Posted by Sher on June 27, 2000, at 17:19:36
In reply to Re: PMDD - Premenstrual Dysphoric Disorder, posted by Noa on May 13, 2000, at 13:47:35
Oh my GOSH!!!
Finally, I've come across something that's helpful--doctors certainly aren't!
I just turned 31 and have suffered (mostly in silence) with PMS and very uncomfortable mentrual cycles. I've been on the Pill to help regulate my flow, as well as my hormones--little difference in that respect. Then, last fall I was diagnosed with depression. Again, anti-depressants have done little to improve matters. I'm currently in counseling (for the depression). I went through the slew of bloodwork with nothing out of the ordinary ... but when I asked my doctor about the specifics of the tests (i.e., thyroid, hormone levels), she looked at me as if I were Elvis! ... And she was more concerned that my cholesterol was at an even 200--where it's been for the last 10 years. I guess there aren't a lot of doctors who are aware of this problem ...
My fiancé has been a great source of information, support, and patience. After doing some online research, he came across PMDD through WebMD ... damn, almost sounded as though I could've written the description/symptoms for it!
But now ... what do I do next? Do I go to my doctor with this information, or should I find out as much as possible before going to my doc? I know I haven't done ~tons~ of research, but can this be treated medically, or am I just stuck dealing with it? And, also, how can I find out for certain that PMDD is what really ails me?
I'm new to this whole "posting" thing--maybe I'm getting in too deep for my first post. Regardless, if there's anyone out there who happens to read this, give me your input. I need all the help/advice I can get!
Thanks,
Sher
Posted by Sara T on June 27, 2000, at 22:08:24
In reply to Re: PMDD - Premenstrual Dysphoric Disorder, posted by Sher on June 27, 2000, at 17:19:36
OK Sher,
Here's all you'd ever want to know about PMS and PMDD, from medscape.
Sara T.
NOTE: To view the article with Web enhancements, go to:
http://www.medscape.com/Medscape/WomensHealth/journal/2000/v05.n02/wh3025.moli/wh3025.moli-01.html
--------------------------------------------------------------------------------
Evaluating and Managing Premenstrual Syndrome
Margaret L. Moline, PhD, and Steven M. Zendell, RPSGT
[Medscape Women's Health 5(2), 2000. © 2000 Medscape, Inc.]
Abstract
Premenstrual syndrome (PMS), a common disorder in women, refers to physical and/or mood symptoms that appear predictably during the latter half of the menstrual cycle, last until menses begin, and are absent during the early part of the menstrual cycle. A diagnosis of PMS requires that the symptoms be severe enough to affect a woman's ability to function at home or in the workplace or in her relationships with others. Diagnostic assessment entails a thorough medical and psychiatric history and prospective daily ratings. Disorders such as major depression, anxiety, hypothyroidism, and diabetes must be excluded before a diagnosis of PMS can be considered. Treatment strategies include either eliminating the hormonal cycle associated with ovulation or treating the symptom(s) causing the most distress to the patient. Medical therapies are available for both treatment approaches but should be initiated only after behavioral measures have failed; the physician must also carefully weigh the severity of symptoms against the potential for adverse effects of treatment.Introduction
Premenstrual syndrome (PMS) has been a topic of research and controversy since the term was coined in 1931. More than 80 PMS treatments have been proposed since then, yet there is no clear consensus on a definition of the syndrome. Indeed, the etiology of PMS has not been fully elucidated. Affected women often do not know whether to seek help from a gynecologist or a psychiatrist, especially if the major symptoms are related to mood.
Despite these problems, women with PMS can be readily identified and successfully managed. This review is designed to discuss the possible causes of PMS and to examine the variety of treatment strategies that have been promulgated --some with good research support and others with little to none.PMS is the diagnosis given to women who exhibit a pattern of symptoms that occur regularly at some time after ovulation and that last until menses begins. Symptoms can begin any time after ovulation, but there must be a symptom-free interval during the follicular phase of the menstrual cycle. Several symptom patterns have been described (Figure 1). Some women experience a worsening of chronic conditions during the premenstrual phase of the menstrual cycle and may, as a result, believe that they have PMS. It is important to differentiate between an exacerbation of chronic symptoms, such as that seen in depression, and symptoms appearing solely during the premenstrual interval in one of the patterns described in Figure 1. It is possible for a woman with major depression to also have PMS, but the PMS symptoms would have to be distinct from the depression in order for a diagnosis of PMS to be made.
Figure 1. In pattern 1, symptoms begin during the week before menstruation and remit during menses. Pattern 2 differs in that symptoms begin around the time of ovulation and persist through the luteal phase. In pattern 3, a brief bout of symptoms occurs around ovulation, with the symptoms returning during the second week of the luteal phase. The fourth pattern depicts symptoms that begin at ovulation and continue through menses, leaving only a symptom-free week to 10 days. Whether these patterns represent distinct subgroups with implications for cause and treatment remains to be determined.
The research literature is inconsistent as to the number of symptoms that must be present to warrant a diagnosis of PMS. It is generally assumed that the symptoms, whether emotional or physical in nature (see Table 1), must have a negative impact on the woman's ability to function at home or in the workplace or on her relationships with others. Thus, many women will report symptoms that warrant therapeutic intervention, but only about 5% would receive a diagnosis of PMS.
There is a subgroup of women whose symptoms are primarily related to severe mood disorder. In these women, in addition to PMS, the diagnosis of premenstrual dysphoric disorder (PMDD) may be applied. This diagnosis is described in an appendix to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV). At least 5 symptoms, 4 of which are affective, are required for the diagnosis of PMDD, along with a requirement that the symptoms significantly affect occupational or social functioning.The PMDD diagnosis must be confirmed by prospective daily symptom ratings for at least 2 cycles. The use of rating instruments is also key to the diagnosis of PMS, because it is well known that the use of retrospective histories alone leads to overdiagnosis of PMS.
PMS, which affects about 5% of women, can begin at any time after puberty, although affected women tend to seek treatment when they reach their early to middle thirties. Anecdotal reports often temporally link the onset of symptoms to a gynecologic or obstetric event. Symptoms are not present during pregnancy or after menopause, although some women report PMS-like symptoms on a hormone replacement regimen of cyclic progestin following estrogen treatment. In fact, the observation that ovulation seems to be a key factor in the presence of PMS has prompted the use of hormone treatment strategies designed to prevent ovulation.
There may be a genetic component to the propensity toward PMS. Twin studies have shown a high concordance rate among monozygotic twins when compared with fraternal twins and siblings.[1] There also seems to be a familial link to PMS and to such other illnesses as major depression.[2]
Diagnosis
PMS and PMDD are diagnoses of exclusion; other physical and psychiatric disorders must be ruled out before either diagnosis can be made. The steps are outlined in Table 2.
Disorders such as anemia, diabetes, thyroid disease, endometriosis, other endocrine abnormalities, and fibrocystic breast disease need to be excluded as possible etiologic factors. Major depression, dysthymia, and anxiety disorders are among the key psychiatric disorders that also need to be ruled out.The ratings are used to compare symptom severity during the premenstrual phase with the asymptomatic follicular phase. The average of ratings during those 2 intervals can be easily compared. If 5 or more symptoms change markedly in severity, and if there is no other diagnosis that can account for the symptoms, a diagnosis of PMS is appropriate. It is important to note that a constraint of 5 symptoms for the diagnosis is the opinion of the authors and, in general, research groups have adopted less conservative criteria. We have adopted this constraint to avoid overdiagnosis of the syndrome.
Treatment Strategies
Over the years, many potential etiologies for PMS have been discussed in the literature, with most being associated with treatment recommendations. Hormonal deficiencies or excesses, various vitamin deficiencies, neurotransmitter irregularities, prostaglandin dysregulation, and several psychosocial theories have been cited. None has been shown to completely explain PMS. Thus, management of patients is not specifically targeted to correct a well-described pathophysiology.
Nevertheless, there are several steps in the management of symptoms in women with PMS. Typically, a set of behavioral changes are recommended before pharmacotherapy is instituted (see Table 3). Patient education about the nature of the syndrome is paramount, as is encouraging the patient to engage in regular exercise, limit salt and caffeine intake, and regulate sleeping and waking routines. In addition, the consumption of frequent small meals can be helpful.A daily symptom diary is a useful educational tool. In addition to its diagnostic value, the diary provides a visual record of the symptomatic intervals, with their onset and resolution each month, which can be helpful to the patient and her family. The pictorial validation of her cycle may stimulate the patient to schedule activities so as to minimize stress and negative influences that might exacerbate her symptoms as well as help her gain a sense of mastery over the disorder.
Exercise has been shown in several studies of premenopausal women (not necessarily suffering from PMS) to be helpful in minimizing negative mood.[3,4] Fluid retention has also been reported to be reduced with aerobic exercise.[5] Aerobic exercise may therefore be helpful in relieving both the affective and bloating symptoms of PMS. Although there are not many data specifically addressing exercise as a treatment for women with PMS, it seems reasonable as a recommendation because advocating regular exercise is a generally healthful suggestion.
Premenstrual limiting of salt intake has been proposed to alleviate symptoms of fluid retention, weight gain, bloating, and breast swelling and tenderness. Although no strong supportive data exist, it also seems reasonable to recommend this strategy to women with these physical symptoms, because Americans in general tend to consume more salt than is recommended by several national medical groups.
Caffeine restriction is often recommended for women with symptoms of premenstrual irritability. This has not been addressed specifically for women with PMS but is a third reasonable suggestion. Caffeine limitation may also reduce insomnia.
Many women with PMS have sleep difficulties, either insomnia or excessive sleepiness. Physicians should encourage these women to adopt consistent bedtimes and waketimes at least during the luteal phase of the cycle, but preferably all month long. Consistent bedtimes tend to decrease sleep latency and are an important part of good sleep hygiene. Women with insomnia should also be counseled against the use of alcohol as a sedative, because sleep architecture is altered by alcohol, and sleep disturbance can ensue.
The concept of consuming frequent small meals arose from a subsequently disproven theory that PMS is the result of impaired glucose tolerance. However, the strategy may prove helpful to those women who typically engage in premenstrual food binges.[6]
It is important to be aware that the patient may experience a loss of self-esteem if behavioral measures fail to relieve her symptoms. Reassurance is crucial. For such patients, 1 of 2 pharmacologic treatment approaches then becomes appropriate. The first is to alter the menstrual cycle by blocking ovulation; the second is to treat a specific symptom that is most problematic to the patient.
A Note About PMS Treatment Trials
Most treatment trials typically assess both physical and emotional symptoms of PMS, even if the drug is hypothesized to act on a specific complaint. One problem that is frequently encountered in PMS and PMDD treatment research is the use of composite symptom scores. To qualify for inclusion in the study, patients need to have a certain score, which may reflect physical and emotional symptoms. When the results of the study are reported, however, it may not be clear which particular symptoms were alleviated. It is thus important to review the study methodology in treatment trials, because many research groups use composite scores for inclusion criteria, and the symptoms that actually resolve as a result of treatment may be obscured by such techniques.Altering the Menstrual Cycle
Treatments that interfere with the menstrual cycle include several types of hormonal therapies and surgery. (see Table 4)
It is important to note that not all hormonal approaches, including exogenous progesterone treatments, interfere with the menstrual cycle. Researchers generally agree that ovulation must be blocked for this type of treatment strategy to be successful.Oral contraceptives. Data are mixed regarding the use of oral contraceptives to treat PMS. Large retrospective studies have provided some support for their use because oral contraceptive users reported milder symptoms.[7,8] However, more recent prospective studies have not shown impressive differences from placebo.[9,10] In addition, oral contraceptives may lead to symptoms of depression in some susceptible women.[11]
Gonadotropin-Releasing Hormone (GnRH) Agonists. Various modes of GnRH drug administration have been used to treat women with PMS. Depending on the dosages, menstrual cycling can be eliminated completely, or only ovulation can be suppressed. However, GnRH agonists lead to "chemical menopause" and thus clinical concerns about hypoestrogenemia, osteoporosis, and other symptoms associated with menopause. As a result, several types of steroid "add-back" regimens have been developed to create an artificial hormonal environment to minimize unwanted side effects. The polypharmacy required by this hormonal approach is economically costly.
Treatment of women with PMS with such regimens has produced mixed results. Some studies have found no clinical improvement compared with placebo in the active treatment group. Two studies suggest that women with severe mood symptoms may not benefit from this therapeutic regimen.[12,13] There are, however, studies showing clear benefit of GnRH agonists plus add-back therapy for women with PMS.[14] Therefore, more research is necessary before this treatment option can be fully endorsed.
Danazol. Danazol has been used to eliminate menstrual cycles reversibly by inhibiting gonadotropin release. It is used to treat endometriosis and fibrocystic breast disease. In a double-blind study of women with PMS who received danazol on a daily basis, danazol was found to be superior to placebo in relief from breast pain, lethargy, anxiety, and increased appetite; for other common symptoms, however, danazol was no better than placebo. Of note is that many women withdrew from the study because of side effects.[15] Other studies with daily dosing have shown efficacy, and 1 study linked treatment success to ovulation suppression.[16,17]
The use of danazol during the luteal phase only has also been investigated.[18] Although the trial was successful, it is hard to reconcile the mechanism of action, because an intermittent dosing schedule would not suppress ovulation. A recent report on luteal phase-only danazol found that the treatment was effective only for premenstrual mastalgia and not for other symptoms of PMS.[19] Thus, further research is required to determine the specific utility of danazol.
Estradiol patches and implants. Estradiol implants and transdermal hormone delivery systems have been tested in women with PMS as another method of blocking ovulation and creating a hormonal milieu more like the asymptomatic follicular phase. The addition of a progestin is also required as part of the therapeutic regimen to prevent uterine hyperplasia. Both methods of delivery have been reported as successful in double-blind studies, but the implant trial was associated with a high rate of subsequent hysterectomy.[20] Low-dose skin patches delivering 100 mcg of estradiol per day (plus 10 days of progestin) have been shown to be superior to placebo for symptom relief and for blocking ovulation.[21] Longer-term studies are required to validate this promising option.
Progesterone. Luteal phase progesterone treatment of women with PMS is perhaps the most controversial treatment regimen. The rationale for proposing the use of progesterone in the 1940s was that a small sample of symptomatic women appeared to have evidence of progesterone deficiency on the basis of uterine biopsies.[22] Many subsequent studies have been unable to confirm such a deficiency.[23-26] Further information weighing against progesterone as an option includes the observation that symptoms appear in menopausal and postmenopausal women on estrogen treatment after progestin is added. Numerous double-blind studies have not consistently shown superiority of the hormone to placebo when progesterone was administered during the last week to 10 days before menses.
On the other hand, progesterone treatment that is used as a contraceptive such as norethisterone enantate may be effective because ovulation is blocked.[27] A double-blind study is required before support of this treatment can be considered.
Surgery. Surgical treatment for PMS usually refers to bilateral ovariectomy. Although PMS symptoms are effectively eliminated, premature menopause results, which is associated with loss of bone density, cardiovascular changes, and symptoms of hypoestrogenemia. Thus, this radical treatment option should be considered very cautiously if it is to be used only to relieve PMS.
There are also survey reports that hysterectomy alone can lead to a reduction in physical and affective PMS symptoms.[28] It is interesting to consider whether the absence of a physical marker of the phase of the menstrual cycle (menstruation) is the key factor associated with the less severe symptoms in general. There has been speculation in the literature that PMS symptoms may either be the result of cultural expectation or a "kindling" phenomenon. Prospective studies of women with PMS before and after hysterectomy should prove insightful in examining the role of expectation in the expression of the syndrome.
Other Hormonal Treatments
Thyroid hormone. In the 1980s, there was a report by a research group that more than 90% of their patients with PMS had 1 or more symptoms of hypothyroidism.[29] After reporting a successful open trial of levothyroxine, they conducted a second trial that was criticized for its methodology.[30-33] PMS has been shown not to be masked hypothyroidism. Further, a double-blind study did not demonstrate the effectiveness of thyroid hormone compared with placebo.[34] If a clinician suspects that a patient with PMS has thyroid dysfunction, that disorder should be addressed first. If PMS symptoms persist, additional management may be required.
Spironolactone. This drug is a synthetic steroid receptor agonist of aldosterone with some antiandrogenic properties. It has been used in PMS treatment trials in large part because of its diuretic properties. The results of studies of spironolactone during the luteal phase have been mixed; a double-blind trial does suggest efficacy of the drug at a dosage of 100 mg from day 14 through the onset of menstruation.[35]
Drugs That Alter Fluid Balance
Among the first proposed treatments for PMS were diuretics. The original rationale was to use diuretics to rid the body of excess estrogen (an early, now disproven, etiology), but currently diuretics are used primarily to manage bloating and weight gain. Many diuretics have been studied: ammonium chloride, thiazide, metolazone, chlorthalidone, triamterene, and spironolactone. Results from these studies suggest that weight gain and bloating can be relieved but that diuresis is not effective for treating all types of premenstrual symptoms.[36,37] Further, some data suggest that only women who gain weight premenstrually may benefit from a diuretic.[37,38]
A methodologic problem with research on diuretics is that it is possible to differentiate the treatment from the placebo arm. Thus, in future research on this treatment in particular, but also on any therapeutic regimen with a characteristic side effect (eg, sedation), investigators should pay careful attention to the choice of placebo.
Prostaglandin-related Treatments
Mefenamic acid.The prostaglandin inhibitor, mefenamic acid, is used in the treatment of primary dysmenorrhea, menorrhagia, and other short-term conditions characterized by moderate pain. The rationale for using prostaglandin inhibitors is based on a hypothesis that PMS results from an excess of prostaglandins. Prostaglandins are involved in fluid balance and act as neurotransmitters centrally; therefore, they could conceivably play a role in the pathogenesis of PMS symptoms. In several double-blind studies, mefenamic acid treatment 3 times daily during the luteal phase was shown to be more effective than placebo in treating common symptoms of PMS.[39-42] However, the symptoms that were alleviated with mefenamic acid differed between studies. These studies were not replications of one another, and the results varied. Because such major symptoms as depression, tension, and irritability were inconsistently reduced with mefenamic acid, this drug does not have an important role as a treatment modality at this time. Future research should address the issue of whether it may be appropriate for women with predominantly physical symptoms.
Naproxen Sodium. This drug has been used to treat women with PMS in a double-blind trial. Symptoms related to pain resolved as predicted, whereas those related to negative affect did not. This study provides a role for analgesics in the treatment of premenstrual pain and also underscores the need to define the patient population for clinical trials.Prostaglandin precursors. These are free fatty acids, such as those found in evening primrose oil. Use of this oil was based on the theory that women with PMS might have inadequate concentrations of prostaglandin E1, thereby exposing them to the deleterious effects of excess prolactin--an unlikely etiology. Since then, evening primrose oil has been tested in controlled trials in a variety of dosages and preparations.[43-45] Overall, the results of these studies suggest that evening primrose oil is not significantly superior to placebo, except perhaps for relieving breast discomfort. A meta-analysis of placebo-controlled trials of evening primrose oil supports the view that evening primrose oil should not be recommended as a treatment for PMS.[46]
Modifying and/or Supplementing the Diet
Dietary changes have been recommended for women with PMS since the 1950s. The suggestion to consume frequent small meals has been discussed earlier in this review, as has evening primrose oil. Several vitamins, calcium and magnesium supplements, tryptophan, and vitamin/mineral preparations have been suggested as treatment options.
Vitamin B6. This vitamin has been suggested as a treatment for PMS on the basis of its role in carbohydrate and gonadal steroid metabolism and on an association between vitamin B6 deficiency and symptoms of depression that was reported in 1 study. However, women with prospectively confirmed PMS have not been shown to be deficient in vitamin B6. Treatment trials have not shown uniform statistical superiority of the vitamin to placebo.In addition, there are serious concerns about vitamin B6 safety. The literature suggests that there is a dose-versus-time relation (large doses take a shorter time) to the development of peripheral neuropathy and other neurologic symptoms.[47] Doses of more than 50 mcg/day may be problematic; megadoses should be avoided altogether.
Vitamins A and E. Both of these vitamins have been proposed as treatments for PMS. The studies of vitamin A are not compelling. Vitamin E (alpha tocopherol) has been used to treat fibrocystic breast disease and cystic mastitis. In double-blind studies of vitamin E, some alleviation of PMS symptoms was noted, but it had no clear-cut efficacy.[48]
Calcium. Calcium supplements have been shown to relieve symptoms of water retention, negative affect, food cravings, and pain in women with PMS.[49] One interesting study controlled both calcium and manganese intake in healthy women without PMS and found that higher calcium intake was associated with better mood and behavior symptoms and less water retention premenstrually.[50] Calcium and vitamin D may also be helpful in the treatment of menstrual migraine.[51] Calcium supplements may be added to the list of behavioral changes, as ensuring adequate daily consumption of this mineral is important for good health.
Magnesium. Magnesium supplements have also begun to be studied. One study reported that mild premenstrual symptoms related to fluid retention resolved after 2 months of treatment.[52]
Tryptophan. Years ago, this amino acid precursor of serotonin was touted in the lay press as the cure for PMS. However, until recently, there had been no treatment trial of tryptophan alone for the treatment of PMS (there was an unsuccessful trial of tryptophan plus vitamin B6). One recent study found that tryptophan improved mood when given to women with premenstrual dysphoria.[53] Treatment was administered during the luteal phase. Another small open study suggests that tryptophan should be explored further as a treatment option.[54] This would be predicated on the removal of constraints on its manufacture and sale in the US market. However, given concerns about tryptophan safety in the past, this treatment option should be viewed with caution.
One method of increasing the levels of available tryptophan is to consume a specially formulated carbohydrate-rich beverage. Such a drink has been tested in a small double-blind trial of women with PMS.[55] Psychological and appetitive symptoms of PMS were relieved, suggesting that further studies of this treatment option should be pursued.
Miscellaneous vitamin and mineral supplements. Several nonprescription multivitamin-and-mineral supplements are available. Only "Optivite for Women" (Optimox) has been the subject of some research. If a woman consumed12 tablets per day as was the case in several of the studies of this product, she would receive 600 mg of vitamin B6, a dose that has been associated with increased risk of neurologic disorders. Thus, on safety grounds alone, these tablets cannot be recommended.
Other over-the-counter products for PMS. There are several brands of products sold over-the-counter for the treatment of PMS. One major type is a combination preparation that includes a mild diuretic, an analgesic, and an antihistamine. The latter is presumably to help with symptoms of irritability and tension. The concept of treating women with PMS with antihistamines may actually be derived from the 1950s, when a researcher proposed that the cause of PMS was an "allergy" to endogenous hormones. There are very few data in the research literature about these products, which have been available for many years. It would be desirable to know the results of double-blind treatment trials using more recent research standards with well-defined subject populations.
Psychotropic Medications
Until about the past 10 years, there had been relatively few treatment trials of psychotropic medications for the treatment of PMS, despite the frequency of troubling affective symptoms in this disorder. Some possible explanations for this include: (1) the lag time from the onset of treatment to symptom remission with some types of psychotropic drugs; (2) lack of experience of gynecologists or general practitioners with these types of drugs; and (3) the perceived stigma of mental illness impeding a woman's choice to seek out a mental health professional to treat her affective symptoms. Since PMDD and its predecessor, late luteal phase dysphoric disorder, have been defined, research on psychotropic drugs has continued in earnest.
Tricyclic antidepressants. Nortriptyline has been shown to be effective in an open trial of women with PMDD.[56] Clomipramine has been examined in 2 double-blind treatment trials,[57,58] the first with daily dosing and the second with intermittent dosing beginning at ovulation. Although both studies of clomipramine reported clinical improvement, the trials were small and need to be replicated before this option can be endorsed.One double-blind trial has examined the use of desipramine (compared with methylscopolamine bromide without placebo) for women with PMS or PMDD.[59] Both drugs resolved the symptoms above baseline. However, because of the high placebo response rate that is well known in research on PMS, additional research is needed to validate either treatment as an option.
Selective Serotonin Reuptake Inhibitors (SSRIs). Fluoxetine has now been studied in several large treatment trials that have demonstrated its efficacy for women with PMDD when taken throughout the menstrual cycle. A recent study of its long-term efficacy suggests that the drug is well tolerated and also effective over time.[60,61] In December 1999, the United States Food and Drug Administration's psychopharmacologic drugs advisory committee unanimously agreed there is enough evidence to suggest that fluoxetine is a safe and effective treatment for women with PMDD.
Sertraline has also been reported to be effective treatment for PMDD in both an open trial (against desipramine) and in a double-blind study (against placebo).[62,63] Recent interest in sertraline has focused on the issue of full-cycle or half-cycle dosing as a therapeutic regimen.[64-66] These studies suggest that luteal phase dosing may be as effective as full-cycle treatment.
Fluvoxamine had been reported to be ineffective in the treatment of women with PMS. However, a more recent open-label treatment trial of this SSRI showed clinical efficacy for PMDD.[67] Therefore, further investigation of this drug should be performed.
An interesting recent double-blind trial compared paroxetine, an SSRI, with naprotiline, a noradrenergic reuptake inhibitor, and placebo. Paroxetine was superior to both naprotiline and placebo, suggesting that PMS does not respond to all types of antidepressants. A long-term (10-cycle) open-label study of paroxetine for severe PMS showed that it was effective in relieving irritability and anxiety symptoms.[68]
The serotonin reuptake inhibitor most recently studied in women with PMS is nefazodone. In an open trial, patients receiving this drug improved, and the drug was well tolerated.[69] A controlled trial of this drug would be very useful.
Citalopram has also been reported for the treatment of premenstrual irritability or depressed mood.[70] Intermittent luteal-phase dosing was more effective than placebo. Future research on this option seems warranted.
Because these drugs have shown to be effective, what also remains to be determined is the optimal timing of the drug. Some data from studies of clomipramine, citalopram, and sertraline suggest that half-cycle dosing may be effective and, if so, would certainly be more convenient and less costly for the patient.[58,64-66,70] Future research should be designed to address this point. It should be noted, however, that SSRIs have considerable side effects, including gastrointestinal disturbances, headache, sedation, insomnia, activation, weight gain, impaired memory, excessive perspiration, paresthesia, and sexual dysfunction.[71,72]
Anxiolytics - Alprazolam. Alprazolam has been shown to be effective in some but not all treatment trials.[26,73-75] The advantage of this drug is that it has a relatively short delay from initial administration to effectiveness and therefore can be used during half of the cycle. However, there are concerns about tolerance and dependence as well as the required careful tapering that needs to occur during menses. It may be used cautiously for the treatment of women with irritability, anxiety, and depression.
Psychotherapy and Other Therapeutic Techniques
Formal studies of psychotherapy have been lacking until quite recently. One study has addressed the use of cognitive behavioral therapy (CBT) in the treatment of PMS.[76] The positive results of this controlled trial suggest that further studies of psychotherapies with proven efficacy in the treatment of other psychiatric disorders, such as major depression, with CBT or interpersonal therapy (IPT) should be explored for the patient population with PMS.
Other studies have examined guided imagery and reflexology therapy for the treatment of women with PMS. [77] In an open-label trial, patients with PMS improved with progressive muscle relaxation exercises followed by guided imagery.[78] The reflexology study applied pressure to actual reflex points on the ears, hands, and feet and compared the response with application to incorrect reflex points as the control. The group receiving the "true" reflexology treatment improved more than the control group. These studies suggest that additional research should be conducted to determine the role of alternative medicine therapies in the treatment of PMS.
Management Guidelines
Management of patients who may have PMS or PMDD begins with a review of the results of the medical and psychological diagnostic workup and daily ratings (if they were indicated) with the patient. Treatment of a physical problem (eg, hypothyroidism) or psychiatric disorder (eg, depression) may eliminate the premenstrual complaints and thus should be done before a diagnosis of PMS is made. Clinicians may also consider dietary supplementation with calcium at this point. Having ruled out other medical illnesses, the clinician can then assign the patient to 1 of 5 categories: (1) women with PMS, (2) women with PMDD, (3) women with both a psychiatric disorder and PMS (or PMDD), (4) women with only a psychiatric disorder (not PMDD), and (5) women without either PMS or a psychiatric disorder. A woman who comes to a PMS clinic and believes that she has PMS tends to have either PMS or a psychiatric disorder such as dysthymia.
Completing the daily ratings is fundamentally important. First, the ratings define the pattern of the patient's symptoms, thereby supporting or negating the retrospective history of PMS that prompted the woman to seek an initial evaluation. Second, the clinician can use the visual aid in conference with the patient, especially in cases where the pattern is not consistent with the diagnosis of PMS. Third, through the rating process, an important first step in management has been taken. As they chart their symptoms, many women gain a sense of control over their problems. Visualizing the type, severity, and timing of symptoms can make them seem more manageable. This sense of control may be enough to relieve some women's distress and make other interventions unnecessary.If the menstrual cycle is to be manipulated, the clinician can try (1) transdermal estrogen with cyclic oral progesterone, (2) danazol (though with caution about side effects), or (3) GnRH agonists with steroid hormone replacement. None of these options has overwhelming research-based support, but the rationale for manipulating the cycle is fairly clear, ie, blocking ovulation and hormone cycling. Each is apparently reversible but has risks and benefits unique to the particular patient that will determine which option is best for her. The long-term effect of these techniques has not been studied.
If the decision is made to treat the most troubling symptom or symptoms, the following treatment strategies may be used depending on the diagnosis.
Women With PMS or PMDD
This group of women is heterogeneous and experiences symptoms of varying duration, severity, and type.
Women with predominantly psychological symptoms that require medication. Women with PMDD have more severe emotional symptoms than women with PMS. Women with PMDD need intensive management because the symptoms are so debilitating. Psychotropic drugs have usually been tested only in women with PMDD; therefore, whether women with less severe emotional symptoms (ie, women with PMS) should take such medications daily is an assessment that must be made cautiously.The results of several studies suggest that an SSRI is a good choice for women with PMDD. [60,61,64,65]
In general, short-term use of a benzodiazepine, such as alprazolam, may be considered for treatment of depression (with and without anxiety). A problem with this class of drugs, however, is that dependence and tolerance occur quickly. Thus, before a benzodiazepine is prescribed, the clinician should be familiar enough with the patient to know whether she manifests signs of an addictive personality. Women who clearly show no such tendencies, or who are in general reluctant to take any unnecessary medication, may benefit from a clinical trial of alprazolam. However, depressed women can become disinhibited on benzodiazepines, and depressive symptoms may actually worsen. In addition, the drug must be tapered gradually during menses to avoid withdrawal symptoms, which can include exacerbation of anxiety, shakiness, palpitations, tremor, and seizures. If the initial intermittent use (ie, during the premenstruum only) of the benzodiazepine is successful, the patient should be monitored regularly to ascertain whether continued use remains effective and to prevent habituation to the medication.
Women with predominantly physical symptoms that require medication. Diuretics have been shown to be useful in the treatment of women with symptoms of bloating and weight gain.[37,38] The literature suggests that the latter symptom is key, as women with weight gain seem to benefit from diuretics, but not all women who experience bloating actually gain weight. For a woman who complains of bloating, it is important to objectively quantify weight, documenting both daily weight and feeling of bloating in a daily diary. In choosing a diuretic, care must be taken to avoid hypokalemia and aldosteronism.
Bromocriptine may relieve severe symptoms of breast swelling or pain. Another option may be tamoxifen or danazol.[79] A patient with mastodynia should check with her physician for other treatment options before using these medications.
Women whose primary symptoms are fatigue or insomnia should be instructed about sleep hygiene. Sleep hygiene includes keeping a regular schedule, limiting caffeine and alcohol consumption after noon, limiting the use of sedative-hypnotics, and avoiding exercise or emotional/alerting activities before retiring to bed. Prescribing a sedative-hypnotic for premenstrual insomnia is not recommended, because tolerance and dependence can occur, and residual daytime sedation is common. Tryptophan may be an option in the future, if it is reapproved by the FDA.
Women with premenstrual headaches should try any of the common nonprescription analgesics (aspirin, acetaminophen, ibuprofen) at the onset of the headache.
Food cravings are probably best treated with behavior modification techniques addressing eating habits and diet. Although d-fenfluramine has been proposed as a treatment for the symptoms of carbohydrate craving associated with PMS with associated improvements in mood,[80] it is not yet clear whether women with PMS or PMDD without carbohydrate craving as a major symptom would benefit from the medication.
Women with mixed symptoms. Most women with PMS have mixed symptoms, and no panacea for mixed PMS symptoms exists. For such women, a judgment must be made as to which symptom has the most negative impact on the woman's daily activities. If the affective symptoms are more bothersome to the patient than the physical ones, psychotropic agents may be prescribed on a trial basis. Despite the fact that these are psychotropic medications, research results suggest that, when effective, both psychological and physical symptoms are alleviated.
Women with a psychiatric disorder and PMS (or PMDD). In these women, premenstrual exacerbations of their psychiatric illness can occur in addition to new symptoms that occur premenstrually. It is important to treat the underlying psychiatric disorder before tackling the premenstrual symptoms. Some studies suggest that dosing levels of the psychotropic drugs may need to vary across the menstrual cycle to obtain the desired therapeutic effect. However, more than 1 treatment modality may be required to treat women with a dual diagnosis.
Women with a psychiatric disorder but without PMS or PMDD. These women should be shown how their pattern of symptom ratings differs from that of women with PMS; that is, their symptoms are not limited to the premenstrual phase of the menstrual cycle but occur persistently throughout the month. When the severity of their symptoms warrant treatment, they should be referred to an appropriate mental health professional.
Women without PMS. As with the patients in the previous group, women without PMS should be shown (1) that their daily symptom ratings do not meet criteria for PMS; (2) that their physical examination does not indicate another medical disorder; and (3) that their psychological evaluation has ruled out a mental illness. Short-term supportive psychotherapy may be helpful for those women who have difficulty dealing with the negative finding.
Conclusion
Additional research on treatment approaches for both PMS and PMDD is needed. Until the etiology of PMS is known, the best current choice is either a symptom-oriented management approach or a modification of the menstrual cycle. Pharmacotherapy should be initiated only after (1) a diagnosis has been made on the basis of both physical and psychological evaluations, (2) confirmation has been obtained by prospective daily symptom ratings, and (3) simpler behavioral measures such as education and support have failed. The medication used for a particular woman must be chosen carefully. The severity of her impairment must be weighed against short-term and possible long-term adverse effects of the treatment. Future research should focus on differential pharmacotherapy for women with different types of symptoms and on the minimum critical interval of treatment during the menstrual cycle.Table 1. Common Symptoms of Premenstrual Syndrome
Anger
Anxiety
Bloating or weight gain
Breast swelling or tenderness
Cramps
Depression; feeling sad, hopeless, or blue
Decreased alertness or concentration
Decreased self-esteem
Decreased interest in usual activities
Fatigue or lethargy
Food craving or overeating
Gastrointestinal complaints
Headache or migraine
Irritability, agitation, or listlessness
Mood swings
Muscle and joint pain
Sleep disturbances (insomnia, hypersomnia)
Tension
Table 2. Diagnosis of Premenstrual Syndrome (PMS)
History
Retrospective history of PMS
Review of physical symptomsGynecologic
Fluid balance
Appetite
Sleep
Headaches
Others
Review of psychological symptomsMedical and Psychological Examinations
Rule out other disorders (eg, anemia, thyroid disease, and endometriosis),
Rule out psychiatric illness in a complete psychiatric history and examinationProspective Daily Ratings of Symptoms
At least 2 menstrual cycles
Table 3. Education and Behavioral Changes
Educate patient about the nature of the syndrome and maintaining a daily symptom diary
Encourage patient to make behavioral changesEngage in regular exercise
Limit salt
Limit caffeine
Practice good sleep hygiene
Avoid eating or drinking binges
Table 4. Treatments That Alter the Menstrual Cycle
Oral contraceptives
Gonadotropin-releasing hormone analogues (with "add-back" steroids)Danazol
Estradiol patches and implants
Depot progestin
Surgery
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Posted by Cal on June 28, 2000, at 14:19:51
In reply to Re: PMDD - Premenstrual Dysphoric Disorder, posted by Sher on June 27, 2000, at 17:19:36
Hello All Again,
Just a note on this subject. My wife Carla is doing well. she still has her ups an downs from time to time. But much better than she used to . We have been sticking to the diet as the Transtions publication directs and with the progesteron therapy it seems to be working better than it used to.http://tor-pw1.attcanada.ca/~vizprint/small.html
If you follow this link it will take you to the website that explains much of this in more detail. There is no real cure more than better nutrition on this issue of PMDD. There are a lot of helps in the medical that help you to understand what happens but there is no doc I have spoken with that will tell me there is a cure because there is none. So we are still continuing in the nutrition to help with the symptoms. There are no easy answers to this thing that is for sure. My wife takes multipac of Mature Female vitamins which consists of 3 caps and 7 tabs we get from the Vitamin Shop online, 400 mg -SAMe, 200mcg Chromium Piclinate, 800mcg Folic Acid. Outside of that during the time of her mensus we stick to real basic whole foods with lots of nuts and beans, rice ect. In the mornings there is the power shake to get you going. :) Which consists of 1 c Orange juce 1 banana, 6 large frozen strawberries and several slices of frozen peaches orother fuits to taste. With 2 scoops of soy protien, The soy is important. All in a blender makes a nice drink.
It seems to make things better for her and thats whats important to me.
I hope this helps , Cal
Posted by noa on June 28, 2000, at 18:53:43
In reply to Re: PMDD - Premenstrual Dysphoric Disorder, posted by Sher on June 27, 2000, at 17:19:36
BTW, apparently hypothyroidism is thought to contribute to high cholesterol.
Posted by Linda already exists on October 8, 2000, at 11:46:10
In reply to Re: PMDD - Premenstrual Dysphoric Disorder-long » Sher, posted by Sara T on June 27, 2000, at 22:08:24
Thank you Sara. Very interesting information.
After reading the different patterns of PMS I see that I have experienced pattern 1 (symptoms begin during the week before menstruation and remit during menses ) when I was younger. As time passed I went to pattern 2, (symptoms begin around the time of ovulation and persist through the luteal phase). I never experienced pattern 3 but am now experiencing pattern 4 (symptoms that begin at ovulation and continue through menses, leaving only a symptom-free week to 10 days. The symptoms used to let up once my period came down, but now at age 46 and perimenopausal I don’t get a normal week till after menstruation stops.) I could tell when I ovulate because I get pelvic cramping. This month I ovulated around day 12 of my cycle, so that gave me about 7 good days this month. After ovulation it is a steady downfall, each day getting worse and worse with symptoms. Not only are the symptoms emotional, but physical as well. The physical symptoms used to be bloating and breast tenderness – but now I get pain in my leg bones, lower back, cramping in my pelvic area, freezing chills, that I have to get in bed covered with 3 blankets and the heat all the way up, only to find my self after an hour or so feeling hot as hell and lowering the heat and taking my sweatshirt off. Insomnia sets in, some months worse than others and this month has been a doozy for that. I am so fatigued that it is hard for me to get myself out of the house or for that matter do anything. On my one good week, I am myself again, and making plans for my life, only to have everything go down the tubes, cause I once again get sick when I ovulate.
I have tried quite a few of the treatment strategies listed in this article. None so far have worked.
The first thing my doc recommended was exercise. Oh that was fun. After not sleeping all night, and then getting out and exercising got me even more fatigued. It did not help me sleep the next night, and I was so spaced out from lack of sleep. He wanted me to set a regimen of waking up at a certain time in the morning, and not napping, and then going to bed at a certain time at night to create a good sleeping pattern. Well this just did not work.
Then he wanted to give me birth control pills but I was scared of them being I smoke. Well onward to other doctors. I found one doctor that worked with me and we tried all sorts of hormone regimens. It was finally apparent that I had to stop ovulation, and one of the options for doing that was birth control pills. Well I tried them and at first it was a God send – but then it seem’s the effect of the protestin in them got me really fatigued. My triglyceride levels went up, so did my platelets, and I felt like crap. So I stopped them.
Previous to that I was taking estrogen and tried different types of progesterones/progestins and could not tolerate any of progestins/progesterones and I tried all of them. So now I am on estradiol gel alone.
They are now marketing Prozac under the name Sarafem for PMDD. It is 20 mg. of Prozac. I am afraid to take 20 mg. of Prozac to start, so I asked my doctor to prescribe 10 mg and we will see what will happen with that. I am on day 3 of the Prozac. If 10 mg. does not do the trick, I will go on to 20 mg. If that does not do the trick, then I will see my gyn. to get a bilateral ovariectomy. I had previously spoken to my gyn. and primary care physician about having this procedure done. My primary care physician said “don’t do it you are almost at menopause and this will stop” – My gyn said I will still get symptoms of low estrogen. Taking ERT certainly could rectify that, but then I don’t want to be on estrogen for the rest of my life, but I am afraid I do not have any choice in the matter, because I don’t feel like I have a life now. Plus I realize that taking estrogen without progesterone is risky and could cause endometrial cancer. But I cannot tolerate progesterone any any way shape or form.
I have to get everything done within that one good week of the month and I am just tired of this. Tired of the inconsistency of my life. I need to go to work, but just can’t commit myself to a job, knowing how sick I get. I am in school now as my mind needs mental stimulation, and I am just taking one class, but I can’t even concentrate on the reading when I get close to my period. Can’t even drive when I get close to my period because my head is not clear enough to focus on driving safely, so someone has to drive me to school. This frustrates me beyond belief. I thought that maybe going to school and getting my mind off of how I feel would help the situation, but it did not.
I don’t know if anybody read this all they way down to this point, but if ya did – bravo and thanks!!! I just needed to vent!
Thank you Sara for posting that info. It was quite interesting.p.s. I tried the vitamin supplements and herbs too. NOTHING helped. NOTHING! I am really hoping the Prozac will ease this up. Even just a little bit would be helpful. I am so tired of this. Too many years of this – and as the years go by, it gets worse and worse. It is not only frustrating by quite embarrassing that I can’t function like a normal human being.
> OK Sher,
> Here's all you'd ever want to know about PMS and PMDD, from medscape.
> Sara T.
>
>
> NOTE: To view the article with Web enhancements, go to:
> http://www.medscape.com/Medscape/WomensHealth/journal/2000/v05.n02/wh3025.moli/wh3025.moli-01.html
>
>
> --------------------------------------------------------------------------------
>
>
> Evaluating and Managing Premenstrual Syndrome
> Margaret L. Moline, PhD, and Steven M. Zendell, RPSGT
> [Medscape Women's Health 5(2), 2000. © 2000 Medscape, Inc.]
>
>
> Abstract
> Premenstrual syndrome (PMS), a common disorder in women, refers to physical and/or mood symptoms that appear predictably during the latter half of the menstrual cycle, last until menses begin, and are absent during the early part of the menstrual cycle. A diagnosis of PMS requires that the symptoms be severe enough to affect a woman's ability to function at home or in the workplace or in her relationships with others. Diagnostic assessment entails a thorough medical and psychiatric history and prospective daily ratings. Disorders such as major depression, anxiety, hypothyroidism, and diabetes must be excluded before a diagnosis of PMS can be considered. Treatment strategies include either eliminating the hormonal cycle associated with ovulation or treating the symptom(s) causing the most distress to the patient. Medical therapies are available for both treatment approaches but should be initiated only after behavioral measures have failed; the physician must also carefully weigh the severity of symptoms against the potential for adverse effects of treatment.
>
> Introduction
> Premenstrual syndrome (PMS) has been a topic of research and controversy since the term was coined in 1931. More than 80 PMS treatments have been proposed since then, yet there is no clear consensus on a definition of the syndrome. Indeed, the etiology of PMS has not been fully elucidated. Affected women often do not know whether to seek help from a gynecologist or a psychiatrist, especially if the major symptoms are related to mood.
> Despite these problems, women with PMS can be readily identified and successfully managed. This review is designed to discuss the possible causes of PMS and to examine the variety of treatment strategies that have been promulgated --some with good research support and others with little to none.
>
> PMS is the diagnosis given to women who exhibit a pattern of symptoms that occur regularly at some time after ovulation and that last until menses begins. Symptoms can begin any time after ovulation, but there must be a symptom-free interval during the follicular phase of the menstrual cycle. Several symptom patterns have been described (Figure 1). Some women experience a worsening of chronic conditions during the premenstrual phase of the menstrual cycle and may, as a result, believe that they have PMS. It is important to differentiate between an exacerbation of chronic symptoms, such as that seen in depression, and symptoms appearing solely during the premenstrual interval in one of the patterns described in Figure 1. It is possible for a woman with major depression to also have PMS, but the PMS symptoms would have to be distinct from the depression in order for a diagnosis of PMS to be made.
>
>
>
>
> Figure 1. In pattern 1, symptoms begin during the week before menstruation and remit during menses. Pattern 2 differs in that symptoms begin around the time of ovulation and persist through the luteal phase. In pattern 3, a brief bout of symptoms occurs around ovulation, with the symptoms returning during the second week of the luteal phase. The fourth pattern depicts symptoms that begin at ovulation and continue through menses, leaving only a symptom-free week to 10 days. Whether these patterns represent distinct subgroups with implications for cause and treatment remains to be determined.
>
> The research literature is inconsistent as to the number of symptoms that must be present to warrant a diagnosis of PMS. It is generally assumed that the symptoms, whether emotional or physical in nature (see Table 1), must have a negative impact on the woman's ability to function at home or in the workplace or on her relationships with others. Thus, many women will report symptoms that warrant therapeutic intervention, but only about 5% would receive a diagnosis of PMS.
> There is a subgroup of women whose symptoms are primarily related to severe mood disorder. In these women, in addition to PMS, the diagnosis of premenstrual dysphoric disorder (PMDD) may be applied. This diagnosis is described in an appendix to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV). At least 5 symptoms, 4 of which are affective, are required for the diagnosis of PMDD, along with a requirement that the symptoms significantly affect occupational or social functioning.
>
> The PMDD diagnosis must be confirmed by prospective daily symptom ratings for at least 2 cycles. The use of rating instruments is also key to the diagnosis of PMS, because it is well known that the use of retrospective histories alone leads to overdiagnosis of PMS.
>
> PMS, which affects about 5% of women, can begin at any time after puberty, although affected women tend to seek treatment when they reach their early to middle thirties. Anecdotal reports often temporally link the onset of symptoms to a gynecologic or obstetric event. Symptoms are not present during pregnancy or after menopause, although some women report PMS-like symptoms on a hormone replacement regimen of cyclic progestin following estrogen treatment. In fact, the observation that ovulation seems to be a key factor in the presence of PMS has prompted the use of hormone treatment strategies designed to prevent ovulation.
>
> There may be a genetic component to the propensity toward PMS. Twin studies have shown a high concordance rate among monozygotic twins when compared with fraternal twins and siblings.[1] There also seems to be a familial link to PMS and to such other illnesses as major depression.[2]
>
>
> Diagnosis
> PMS and PMDD are diagnoses of exclusion; other physical and psychiatric disorders must be ruled out before either diagnosis can be made. The steps are outlined in Table 2.
> Disorders such as anemia, diabetes, thyroid disease, endometriosis, other endocrine abnormalities, and fibrocystic breast disease need to be excluded as possible etiologic factors. Major depression, dysthymia, and anxiety disorders are among the key psychiatric disorders that also need to be ruled out.
>
> The ratings are used to compare symptom severity during the premenstrual phase with the asymptomatic follicular phase. The average of ratings during those 2 intervals can be easily compared. If 5 or more symptoms change markedly in severity, and if there is no other diagnosis that can account for the symptoms, a diagnosis of PMS is appropriate. It is important to note that a constraint of 5 symptoms for the diagnosis is the opinion of the authors and, in general, research groups have adopted less conservative criteria. We have adopted this constraint to avoid overdiagnosis of the syndrome.
>
>
> Treatment Strategies
> Over the years, many potential etiologies for PMS have been discussed in the literature, with most being associated with treatment recommendations. Hormonal deficiencies or excesses, various vitamin deficiencies, neurotransmitter irregularities, prostaglandin dysregulation, and several psychosocial theories have been cited. None has been shown to completely explain PMS. Thus, management of patients is not specifically targeted to correct a well-described pathophysiology.
> Nevertheless, there are several steps in the management of symptoms in women with PMS. Typically, a set of behavioral changes are recommended before pharmacotherapy is instituted (see Table 3). Patient education about the nature of the syndrome is paramount, as is encouraging the patient to engage in regular exercise, limit salt and caffeine intake, and regulate sleeping and waking routines. In addition, the consumption of frequent small meals can be helpful.
>
> A daily symptom diary is a useful educational tool. In addition to its diagnostic value, the diary provides a visual record of the symptomatic intervals, with their onset and resolution each month, which can be helpful to the patient and her family. The pictorial validation of her cycle may stimulate the patient to schedule activities so as to minimize stress and negative influences that might exacerbate her symptoms as well as help her gain a sense of mastery over the disorder.
>
> Exercise has been shown in several studies of premenopausal women (not necessarily suffering from PMS) to be helpful in minimizing negative mood.[3,4] Fluid retention has also been reported to be reduced with aerobic exercise.[5] Aerobic exercise may therefore be helpful in relieving both the affective and bloating symptoms of PMS. Although there are not many data specifically addressing exercise as a treatment for women with PMS, it seems reasonable as a recommendation because advocating regular exercise is a generally healthful suggestion.
>
> Premenstrual limiting of salt intake has been proposed to alleviate symptoms of fluid retention, weight gain, bloating, and breast swelling and tenderness. Although no strong supportive data exist, it also seems reasonable to recommend this strategy to women with these physical symptoms, because Americans in general tend to consume more salt than is recommended by several national medical groups.
>
> Caffeine restriction is often recommended for women with symptoms of premenstrual irritability. This has not been addressed specifically for women with PMS but is a third reasonable suggestion. Caffeine limitation may also reduce insomnia.
>
> Many women with PMS have sleep difficulties, either insomnia or excessive sleepiness. Physicians should encourage these women to adopt consistent bedtimes and waketimes at least during the luteal phase of the cycle, but preferably all month long. Consistent bedtimes tend to decrease sleep latency and are an important part of good sleep hygiene. Women with insomnia should also be counseled against the use of alcohol as a sedative, because sleep architecture is altered by alcohol, and sleep disturbance can ensue.
>
> The concept of consuming frequent small meals arose from a subsequently disproven theory that PMS is the result of impaired glucose tolerance. However, the strategy may prove helpful to those women who typically engage in premenstrual food binges.[6]
>
> It is important to be aware that the patient may experience a loss of self-esteem if behavioral measures fail to relieve her symptoms. Reassurance is crucial. For such patients, 1 of 2 pharmacologic treatment approaches then becomes appropriate. The first is to alter the menstrual cycle by blocking ovulation; the second is to treat a specific symptom that is most problematic to the patient.
>
>
> A Note About PMS Treatment Trials
> Most treatment trials typically assess both physical and emotional symptoms of PMS, even if the drug is hypothesized to act on a specific complaint. One problem that is frequently encountered in PMS and PMDD treatment research is the use of composite symptom scores. To qualify for inclusion in the study, patients need to have a certain score, which may reflect physical and emotional symptoms. When the results of the study are reported, however, it may not be clear which particular symptoms were alleviated. It is thus important to review the study methodology in treatment trials, because many research groups use composite scores for inclusion criteria, and the symptoms that actually resolve as a result of treatment may be obscured by such techniques.
>
> Altering the Menstrual Cycle
> Treatments that interfere with the menstrual cycle include several types of hormonal therapies and surgery. (see Table 4)
> It is important to note that not all hormonal approaches, including exogenous progesterone treatments, interfere with the menstrual cycle. Researchers generally agree that ovulation must be blocked for this type of treatment strategy to be successful.
>
> Oral contraceptives. Data are mixed regarding the use of oral contraceptives to treat PMS. Large retrospective studies have provided some support for their use because oral contraceptive users reported milder symptoms.[7,8] However, more recent prospective studies have not shown impressive differences from placebo.[9,10] In addition, oral contraceptives may lead to symptoms of depression in some susceptible women.[11]
>
> Gonadotropin-Releasing Hormone (GnRH) Agonists. Various modes of GnRH drug administration have been used to treat women with PMS. Depending on the dosages, menstrual cycling can be eliminated completely, or only ovulation can be suppressed. However, GnRH agonists lead to "chemical menopause" and thus clinical concerns about hypoestrogenemia, osteoporosis, and other symptoms associated with menopause. As a result, several types of steroid "add-back" regimens have been developed to create an artificial hormonal environment to minimize unwanted side effects. The polypharmacy required by this hormonal approach is economically costly.
>
> Treatment of women with PMS with such regimens has produced mixed results. Some studies have found no clinical improvement compared with placebo in the active treatment group. Two studies suggest that women with severe mood symptoms may not benefit from this therapeutic regimen.[12,13] There are, however, studies showing clear benefit of GnRH agonists plus add-back therapy for women with PMS.[14] Therefore, more research is necessary before this treatment option can be fully endorsed.
>
> Danazol. Danazol has been used to eliminate menstrual cycles reversibly by inhibiting gonadotropin release. It is used to treat endometriosis and fibrocystic breast disease. In a double-blind study of women with PMS who received danazol on a daily basis, danazol was found to be superior to placebo in relief from breast pain, lethargy, anxiety, and increased appetite; for other common symptoms, however, danazol was no better than placebo. Of note is that many women withdrew from the study because of side effects.[15] Other studies with daily dosing have shown efficacy, and 1 study linked treatment success to ovulation suppression.[16,17]
>
> The use of danazol during the luteal phase only has also been investigated.[18] Although the trial was successful, it is hard to reconcile the mechanism of action, because an intermittent dosing schedule would not suppress ovulation. A recent report on luteal phase-only danazol found that the treatment was effective only for premenstrual mastalgia and not for other symptoms of PMS.[19] Thus, further research is required to determine the specific utility of danazol.
>
> Estradiol patches and implants. Estradiol implants and transdermal hormone delivery systems have been tested in women with PMS as another method of blocking ovulation and creating a hormonal milieu more like the asymptomatic follicular phase. The addition of a progestin is also required as part of the therapeutic regimen to prevent uterine hyperplasia. Both methods of delivery have been reported as successful in double-blind studies, but the implant trial was associated with a high rate of subsequent hysterectomy.[20] Low-dose skin patches delivering 100 mcg of estradiol per day (plus 10 days of progestin) have been shown to be superior to placebo for symptom relief and for blocking ovulation.[21] Longer-term studies are required to validate this promising option.
>
> Progesterone. Luteal phase progesterone treatment of women with PMS is perhaps the most controversial treatment regimen. The rationale for proposing the use of progesterone in the 1940s was that a small sample of symptomatic women appeared to have evidence of progesterone deficiency on the basis of uterine biopsies.[22] Many subsequent studies have been unable to confirm such a deficiency.[23-26] Further information weighing against progesterone as an option includes the observation that symptoms appear in menopausal and postmenopausal women on estrogen treatment after progestin is added. Numerous double-blind studies have not consistently shown superiority of the hormone to placebo when progesterone was administered during the last week to 10 days before menses.
>
> On the other hand, progesterone treatment that is used as a contraceptive such as norethisterone enantate may be effective because ovulation is blocked.[27] A double-blind study is required before support of this treatment can be considered.
>
> Surgery. Surgical treatment for PMS usually refers to bilateral ovariectomy. Although PMS symptoms are effectively eliminated, premature menopause results, which is associated with loss of bone density, cardiovascular changes, and symptoms of hypoestrogenemia. Thus, this radical treatment option should be considered very cautiously if it is to be used only to relieve PMS.
>
> There are also survey reports that hysterectomy alone can lead to a reduction in physical and affective PMS symptoms.[28] It is interesting to consider whether the absence of a physical marker of the phase of the menstrual cycle (menstruation) is the key factor associated with the less severe symptoms in general. There has been speculation in the literature that PMS symptoms may either be the result of cultural expectation or a "kindling" phenomenon. Prospective studies of women with PMS before and after hysterectomy should prove insightful in examining the role of expectation in the expression of the syndrome.
>
>
> Other Hormonal Treatments
> Thyroid hormone. In the 1980s, there was a report by a research group that more than 90% of their patients with PMS had 1 or more symptoms of hypothyroidism.[29] After reporting a successful open trial of levothyroxine, they conducted a second trial that was criticized for its methodology.[30-33] PMS has been shown not to be masked hypothyroidism. Further, a double-blind study did not demonstrate the effectiveness of thyroid hormone compared with placebo.[34] If a clinician suspects that a patient with PMS has thyroid dysfunction, that disorder should be addressed first. If PMS symptoms persist, additional management may be required.
> Spironolactone. This drug is a synthetic steroid receptor agonist of aldosterone with some antiandrogenic properties. It has been used in PMS treatment trials in large part because of its diuretic properties. The results of studies of spironolactone during the luteal phase have been mixed; a double-blind trial does suggest efficacy of the drug at a dosage of 100 mg from day 14 through the onset of menstruation.[35]
>
>
> Drugs That Alter Fluid Balance
> Among the first proposed treatments for PMS were diuretics. The original rationale was to use diuretics to rid the body of excess estrogen (an early, now disproven, etiology), but currently diuretics are used primarily to manage bloating and weight gain. Many diuretics have been studied: ammonium chloride, thiazide, metolazone, chlorthalidone, triamterene, and spironolactone. Results from these studies suggest that weight gain and bloating can be relieved but that diuresis is not effective for treating all types of premenstrual symptoms.[36,37] Further, some data suggest that only women who gain weight premenstrually may benefit from a diuretic.[37,38]
> A methodologic problem with research on diuretics is that it is possible to differentiate the treatment from the placebo arm. Thus, in future research on this treatment in particular, but also on any therapeutic regimen with a characteristic side effect (eg, sedation), investigators should pay careful attention to the choice of placebo.
>
>
> Prostaglandin-related Treatments
> Mefenamic acid.The prostaglandin inhibitor, mefenamic acid, is used in the treatment of primary dysmenorrhea, menorrhagia, and other short-term conditions characterized by moderate pain. The rationale for using prostaglandin inhibitors is based on a hypothesis that PMS results from an excess of prostaglandins. Prostaglandins are involved in fluid balance and act as neurotransmitters centrally; therefore, they could conceivably play a role in the pathogenesis of PMS symptoms. In several double-blind studies, mefenamic acid treatment 3 times daily during the luteal phase was shown to be more effective than placebo in treating common symptoms of PMS.[39-42] However, the symptoms that were alleviated with mefenamic acid differed between studies. These studies were not replications of one another, and the results varied. Because such major symptoms as depression, tension, and irritability were inconsistently reduced with mefenamic acid, this drug does not have an important role as a treatment modality at this time. Future research should address the issue of whether it may be appropriate for women with predominantly physical symptoms.
> Naproxen Sodium. This drug has been used to treat women with PMS in a double-blind trial. Symptoms related to pain resolved as predicted, whereas those related to negative affect did not. This study provides a role for analgesics in the treatment of premenstrual pain and also underscores the need to define the patient population for clinical trials.
>
> Prostaglandin precursors. These are free fatty acids, such as those found in evening primrose oil. Use of this oil was based on the theory that women with PMS might have inadequate concentrations of prostaglandin E1, thereby exposing them to the deleterious effects of excess prolactin--an unlikely etiology. Since then, evening primrose oil has been tested in controlled trials in a variety of dosages and preparations.[43-45] Overall, the results of these studies suggest that evening primrose oil is not significantly superior to placebo, except perhaps for relieving breast discomfort. A meta-analysis of placebo-controlled trials of evening primrose oil supports the view that evening primrose oil should not be recommended as a treatment for PMS.[46]
>
>
> Modifying and/or Supplementing the Diet
> Dietary changes have been recommended for women with PMS since the 1950s. The suggestion to consume frequent small meals has been discussed earlier in this review, as has evening primrose oil. Several vitamins, calcium and magnesium supplements, tryptophan, and vitamin/mineral preparations have been suggested as treatment options.
> Vitamin B6. This vitamin has been suggested as a treatment for PMS on the basis of its role in carbohydrate and gonadal steroid metabolism and on an association between vitamin B6 deficiency and symptoms of depression that was reported in 1 study. However, women with prospectively confirmed PMS have not been shown to be deficient in vitamin B6. Treatment trials have not shown uniform statistical superiority of the vitamin to placebo.
>
> In addition, there are serious concerns about vitamin B6 safety. The literature suggests that there is a dose-versus-time relation (large doses take a shorter time) to the development of peripheral neuropathy and other neurologic symptoms.[47] Doses of more than 50 mcg/day may be problematic; megadoses should be avoided altogether.
>
> Vitamins A and E. Both of these vitamins have been proposed as treatments for PMS. The studies of vitamin A are not compelling. Vitamin E (alpha tocopherol) has been used to treat fibrocystic breast disease and cystic mastitis. In double-blind studies of vitamin E, some alleviation of PMS symptoms was noted, but it had no clear-cut efficacy.[48]
>
> Calcium. Calcium supplements have been shown to relieve symptoms of water retention, negative affect, food cravings, and pain in women with PMS.[49] One interesting study controlled both calcium and manganese intake in healthy women without PMS and found that higher calcium intake was associated with better mood and behavior symptoms and less water retention premenstrually.[50] Calcium and vitamin D may also be helpful in the treatment of menstrual migraine.[51] Calcium supplements may be added to the list of behavioral changes, as ensuring adequate daily consumption of this mineral is important for good health.
>
> Magnesium. Magnesium supplements have also begun to be studied. One study reported that mild premenstrual symptoms related to fluid retention resolved after 2 months of treatment.[52]
>
> Tryptophan. Years ago, this amino acid precursor of serotonin was touted in the lay press as the cure for PMS. However, until recently, there had been no treatment trial of tryptophan alone for the treatment of PMS (there was an unsuccessful trial of tryptophan plus vitamin B6). One recent study found that tryptophan improved mood when given to women with premenstrual dysphoria.[53] Treatment was administered during the luteal phase. Another small open study suggests that tryptophan should be explored further as a treatment option.[54] This would be predicated on the removal of constraints on its manufacture and sale in the US market. However, given concerns about tryptophan safety in the past, this treatment option should be viewed with caution.
>
> One method of increasing the levels of available tryptophan is to consume a specially formulated carbohydrate-rich beverage. Such a drink has been tested in a small double-blind trial of women with PMS.[55] Psychological and appetitive symptoms of PMS were relieved, suggesting that further studies of this treatment option should be pursued.
>
> Miscellaneous vitamin and mineral supplements. Several nonprescription multivitamin-and-mineral supplements are available. Only "Optivite for Women" (Optimox) has been the subject of some research. If a woman consumed12 tablets per day as was the case in several of the studies of this product, she would receive 600 mg of vitamin B6, a dose that has been associated with increased risk of neurologic disorders. Thus, on safety grounds alone, these tablets cannot be recommended.
>
> Other over-the-counter products for PMS. There are several brands of products sold over-the-counter for the treatment of PMS. One major type is a combination preparation that includes a mild diuretic, an analgesic, and an antihistamine. The latter is presumably to help with symptoms of irritability and tension. The concept of treating women with PMS with antihistamines may actually be derived from the 1950s, when a researcher proposed that the cause of PMS was an "allergy" to endogenous hormones. There are very few data in the research literature about these products, which have been available for many years. It would be desirable to know the results of double-blind treatment trials using more recent research standards with well-defined subject populations.
>
>
> Psychotropic Medications
> Until about the past 10 years, there had been relatively few treatment trials of psychotropic medications for the treatment of PMS, despite the frequency of troubling affective symptoms in this disorder. Some possible explanations for this include: (1) the lag time from the onset of treatment to symptom remission with some types of psychotropic drugs; (2) lack of experience of gynecologists or general practitioners with these types of drugs; and (3) the perceived stigma of mental illness impeding a woman's choice to seek out a mental health professional to treat her affective symptoms. Since PMDD and its predecessor, late luteal phase dysphoric disorder, have been defined, research on psychotropic drugs has continued in earnest.
> Tricyclic antidepressants. Nortriptyline has been shown to be effective in an open trial of women with PMDD.[56] Clomipramine has been examined in 2 double-blind treatment trials,[57,58] the first with daily dosing and the second with intermittent dosing beginning at ovulation. Although both studies of clomipramine reported clinical improvement, the trials were small and need to be replicated before this option can be endorsed.
>
> One double-blind trial has examined the use of desipramine (compared with methylscopolamine bromide without placebo) for women with PMS or PMDD.[59] Both drugs resolved the symptoms above baseline. However, because of the high placebo response rate that is well known in research on PMS, additional research is needed to validate either treatment as an option.
>
> Selective Serotonin Reuptake Inhibitors (SSRIs). Fluoxetine has now been studied in several large treatment trials that have demonstrated its efficacy for women with PMDD when taken throughout the menstrual cycle. A recent study of its long-term efficacy suggests that the drug is well tolerated and also effective over time.[60,61] In December 1999, the United States Food and Drug Administration's psychopharmacologic drugs advisory committee unanimously agreed there is enough evidence to suggest that fluoxetine is a safe and effective treatment for women with PMDD.
>
> Sertraline has also been reported to be effective treatment for PMDD in both an open trial (against desipramine) and in a double-blind study (against placebo).[62,63] Recent interest in sertraline has focused on the issue of full-cycle or half-cycle dosing as a therapeutic regimen.[64-66] These studies suggest that luteal phase dosing may be as effective as full-cycle treatment.
>
> Fluvoxamine had been reported to be ineffective in the treatment of women with PMS. However, a more recent open-label treatment trial of this SSRI showed clinical efficacy for PMDD.[67] Therefore, further investigation of this drug should be performed.
>
> An interesting recent double-blind trial compared paroxetine, an SSRI, with naprotiline, a noradrenergic reuptake inhibitor, and placebo. Paroxetine was superior to both naprotiline and placebo, suggesting that PMS does not respond to all types of antidepressants. A long-term (10-cycle) open-label study of paroxetine for severe PMS showed that it was effective in relieving irritability and anxiety symptoms.[68]
>
> The serotonin reuptake inhibitor most recently studied in women with PMS is nefazodone. In an open trial, patients receiving this drug improved, and the drug was well tolerated.[69] A controlled trial of this drug would be very useful.
>
> Citalopram has also been reported for the treatment of premenstrual irritability or depressed mood.[70] Intermittent luteal-phase dosing was more effective than placebo. Future research on this option seems warranted.
>
> Because these drugs have shown to be effective, what also remains to be determined is the optimal timing of the drug. Some data from studies of clomipramine, citalopram, and sertraline suggest that half-cycle dosing may be effective and, if so, would certainly be more convenient and less costly for the patient.[58,64-66,70] Future research should be designed to address this point. It should be noted, however, that SSRIs have considerable side effects, including gastrointestinal disturbances, headache, sedation, insomnia, activation, weight gain, impaired memory, excessive perspiration, paresthesia, and sexual dysfunction.[71,72]
>
> Anxiolytics - Alprazolam. Alprazolam has been shown to be effective in some but not all treatment trials.[26,73-75] The advantage of this drug is that it has a relatively short delay from initial administration to effectiveness and therefore can be used during half of the cycle. However, there are concerns about tolerance and dependence as well as the required careful tapering that needs to occur during menses. It may be used cautiously for the treatment of women with irritability, anxiety, and depression.
>
>
> Psychotherapy and Other Therapeutic Techniques
> Formal studies of psychotherapy have been lacking until quite recently. One study has addressed the use of cognitive behavioral therapy (CBT) in the treatment of PMS.[76] The positive results of this controlled trial suggest that further studies of psychotherapies with proven efficacy in the treatment of other psychiatric disorders, such as major depression, with CBT or interpersonal therapy (IPT) should be explored for the patient population with PMS.
> Other studies have examined guided imagery and reflexology therapy for the treatment of women with PMS. [77] In an open-label trial, patients with PMS improved with progressive muscle relaxation exercises followed by guided imagery.[78] The reflexology study applied pressure to actual reflex points on the ears, hands, and feet and compared the response with application to incorrect reflex points as the control. The group receiving the "true" reflexology treatment improved more than the control group. These studies suggest that additional research should be conducted to determine the role of alternative medicine therapies in the treatment of PMS.
>
>
> Management Guidelines
> Management of patients who may have PMS or PMDD begins with a review of the results of the medical and psychological diagnostic workup and daily ratings (if they were indicated) with the patient. Treatment of a physical problem (eg, hypothyroidism) or psychiatric disorder (eg, depression) may eliminate the premenstrual complaints and thus should be done before a diagnosis of PMS is made. Clinicians may also consider dietary supplementation with calcium at this point. Having ruled out other medical illnesses, the clinician can then assign the patient to 1 of 5 categories: (1) women with PMS, (2) women with PMDD, (3) women with both a psychiatric disorder and PMS (or PMDD), (4) women with only a psychiatric disorder (not PMDD), and (5) women without either PMS or a psychiatric disorder. A woman who comes to a PMS clinic and believes that she has PMS tends to have either PMS or a psychiatric disorder such as dysthymia.
> Completing the daily ratings is fundamentally important. First, the ratings define the pattern of the patient's symptoms, thereby supporting or negating the retrospective history of PMS that prompted the woman to seek an initial evaluation. Second, the clinician can use the visual aid in conference with the patient, especially in cases where the pattern is not consistent with the diagnosis of PMS. Third, through the rating process, an important first step in management has been taken. As they chart their symptoms, many women gain a sense of control over their problems. Visualizing the type, severity, and timing of symptoms can make them seem more manageable. This sense of control may be enough to relieve some women's distress and make other interventions unnecessary.
>
> If the menstrual cycle is to be manipulated, the clinician can try (1) transdermal estrogen with cyclic oral progesterone, (2) danazol (though with caution about side effects), or (3) GnRH agonists with steroid hormone replacement. None of these options has overwhelming research-based support, but the rationale for manipulating the cycle is fairly clear, ie, blocking ovulation and hormone cycling. Each is apparently reversible but has risks and benefits unique to the particular patient that will determine which option is best for her. The long-term effect of these techniques has not been studied.
>
> If the decision is made to treat the most troubling symptom or symptoms, the following treatment strategies may be used depending on the diagnosis.
>
>
> Women With PMS or PMDD
> This group of women is heterogeneous and experiences symptoms of varying duration, severity, and type.
> Women with predominantly psychological symptoms that require medication. Women with PMDD have more severe emotional symptoms than women with PMS. Women with PMDD need intensive management because the symptoms are so debilitating. Psychotropic drugs have usually been tested only in women with PMDD; therefore, whether women with less severe emotional symptoms (ie, women with PMS) should take such medications daily is an assessment that must be made cautiously.
>
> The results of several studies suggest that an SSRI is a good choice for women with PMDD. [60,61,64,65]
>
> In general, short-term use of a benzodiazepine, such as alprazolam, may be considered for treatment of depression (with and without anxiety). A problem with this class of drugs, however, is that dependence and tolerance occur quickly. Thus, before a benzodiazepine is prescribed, the clinician should be familiar enough with the patient to know whether she manifests signs of an addictive personality. Women who clearly show no such tendencies, or who are in general reluctant to take any unnecessary medication, may benefit from a clinical trial of alprazolam. However, depressed women can become disinhibited on benzodiazepines, and depressive symptoms may actually worsen. In addition, the drug must be tapered gradually during menses to avoid withdrawal symptoms, which can include exacerbation of anxiety, shakiness, palpitations, tremor, and seizures. If the initial intermittent use (ie, during the premenstruum only) of the benzodiazepine is successful, the patient should be monitored regularly to ascertain whether continued use remains effective and to prevent habituation to the medication.
>
> Women with predominantly physical symptoms that require medication. Diuretics have been shown to be useful in the treatment of women with symptoms of bloating and weight gain.[37,38] The literature suggests that the latter symptom is key, as women with weight gain seem to benefit from diuretics, but not all women who experience bloating actually gain weight. For a woman who complains of bloating, it is important to objectively quantify weight, documenting both daily weight and feeling of bloating in a daily diary. In choosing a diuretic, care must be taken to avoid hypokalemia and aldosteronism.
>
> Bromocriptine may relieve severe symptoms of breast swelling or pain. Another option may be tamoxifen or danazol.[79] A patient with mastodynia should check with her physician for other treatment options before using these medications.
>
> Women whose primary symptoms are fatigue or insomnia should be instructed about sleep hygiene. Sleep hygiene includes keeping a regular schedule, limiting caffeine and alcohol consumption after noon, limiting the use of sedative-hypnotics, and avoiding exercise or emotional/alerting activities before retiring to bed. Prescribing a sedative-hypnotic for premenstrual insomnia is not recommended, because tolerance and dependence can occur, and residual daytime sedation is common. Tryptophan may be an option in the future, if it is reapproved by the FDA.
>
> Women with premenstrual headaches should try any of the common nonprescription analgesics (aspirin, acetaminophen, ibuprofen) at the onset of the headache.
>
> Food cravings are probably best treated with behavior modification techniques addressing eating habits and diet. Although d-fenfluramine has been proposed as a treatment for the symptoms of carbohydrate craving associated with PMS with associated improvements in mood,[80] it is not yet clear whether women with PMS or PMDD without carbohydrate craving as a major symptom would benefit from the medication.
>
> Women with mixed symptoms. Most women with PMS have mixed symptoms, and no panacea for mixed PMS symptoms exists. For such women, a judgment must be made as to which symptom has the most negative impact on the woman's daily activities. If the affective symptoms are more bothersome to the patient than the physical ones, psychotropic agents may be prescribed on a trial basis. Despite the fact that these are psychotropic medications, research results suggest that, when effective, both psychological and physical symptoms are alleviated.
>
> Women with a psychiatric disorder and PMS (or PMDD). In these women, premenstrual exacerbations of their psychiatric illness can occur in addition to new symptoms that occur premenstrually. It is important to treat the underlying psychiatric disorder before tackling the premenstrual symptoms. Some studies suggest that dosing levels of the psychotropic drugs may need to vary across the menstrual cycle to obtain the desired therapeutic effect. However, more than 1 treatment modality may be required to treat women with a dual diagnosis.
>
> Women with a psychiatric disorder but without PMS or PMDD. These women should be shown how their pattern of symptom ratings differs from that of women with PMS; that is, their symptoms are not limited to the premenstrual phase of the menstrual cycle but occur persistently throughout the month. When the severity of their symptoms warrant treatment, they should be referred to an appropriate mental health professional.
>
> Women without PMS. As with the patients in the previous group, women without PMS should be shown (1) that their daily symptom ratings do not meet criteria for PMS; (2) that their physical examination does not indicate another medical disorder; and (3) that their psychological evaluation has ruled out a mental illness. Short-term supportive psychotherapy may be helpful for those women who have difficulty dealing with the negative finding.
>
>
> Conclusion
> Additional research on treatment approaches for both PMS and PMDD is needed. Until the etiology of PMS is known, the best current choice is either a symptom-oriented management approach or a modification of the menstrual cycle. Pharmacotherapy should be initiated only after (1) a diagnosis has been made on the basis of both physical and psychological evaluations, (2) confirmation has been obtained by prospective daily symptom ratings, and (3) simpler behavioral measures such as education and support have failed. The medication used for a particular woman must be chosen carefully. The severity of her impairment must be weighed against short-term and possible long-term adverse effects of the treatment. Future research should focus on differential pharmacotherapy for women with different types of symptoms and on the minimum critical interval of treatment during the menstrual cycle.
>
> Table 1. Common Symptoms of Premenstrual Syndrome
> Anger
> Anxiety
> Bloating or weight gain
> Breast swelling or tenderness
> Cramps
> Depression; feeling sad, hopeless, or blue
> Decreased alertness or concentration
> Decreased self-esteem
> Decreased interest in usual activities
> Fatigue or lethargy
> Food craving or overeating
> Gastrointestinal complaints
> Headache or migraine
> Irritability, agitation, or listlessness
> Mood swings
> Muscle and joint pain
> Sleep disturbances (insomnia, hypersomnia)
> Tension
>
>
> Table 2. Diagnosis of Premenstrual Syndrome (PMS)
> History
> Retrospective history of PMS
> Review of physical symptoms
>
> Gynecologic
> Fluid balance
> Appetite
> Sleep
> Headaches
> Others
> Review of psychological symptoms
>
> Medical and Psychological Examinations
> Rule out other disorders (eg, anemia, thyroid disease, and endometriosis),
> Rule out psychiatric illness in a complete psychiatric history and examination
>
> Prospective Daily Ratings of Symptoms
> At least 2 menstrual cycles
>
>
>
> Table 3. Education and Behavioral Changes
> Educate patient about the nature of the syndrome and maintaining a daily symptom diary
> Encourage patient to make behavioral changes
>
> Engage in regular exercise
>
> Limit salt
>
> Limit caffeine
>
> Practice good sleep hygiene
>
> Avoid eating or drinking binges
>
>
>
> Table 4. Treatments That Alter the Menstrual Cycle
> Oral contraceptives
> Gonadotropin-releasing hormone analogues (with "add-back" steroids)
>
> Danazol
>
> Estradiol patches and implants
>
> Depot progestin
>
> Surgery
>
>
>
> References
> Dalton K, Dalton M, Guthrie K. Incidence of the premenstrual syndrome in twins. Br Med J. 1987;295:1027-1028.
> Kantero RL, Widholm O. A statistical analysis of the menstrual patterns of 8,000 Finnish girls and their mothers. IV. Correlations of menstrual traits between adolescent girls and their mothers. Acta Obstet Gynecol Scand. 1971;14(suppl):30-36.
> Steege JF, Blumenthal JA. The effects of aerobic exercise on premenstrual symptoms in middle-aged women: a preliminary study. J Psychosom Res. 1993;37:127-133.
> Aganoff JA, Boyle GJ. Aerobic exercise, mood states and menstrual cycle symptoms. J Psychosom Res. 1994;38:183-192.
> Prior JC, Vigna Y. Conditioning exercise and premenstrual symptoms. Reprod Med. 1987;32:423-428.
> Tufts Nutrition Letter. 1988;6(8).
> Kutner SJ, Brown WL. Types of oral contraceptives, depression and premenstrual symptoms. J Nerv Ment Dis. 1972;155:153-162.
> Andersch B, Hahn L. Premenstrual complaints. II. Influence of oral contraceptives. Acta Obstet Gynecol Scand. 1981;60:579-583.
> Bancroft J., Rennie D. The impact of oral contraceptives on the experience of perimenstrual mood clumsiness, food craving and other symptoms. J Psychosom Res. 1993;37:195-202.
> Graham CA, Sherwin BB. The relationship between mood and sexuality in women taking oral contraceptives as a treatment for premenstrual symptoms. Psychoneuroendocrinology. 1993;18:273-281.
> Herzberg B, Coppen A. Changes in psychological symptoms in women taking oral contraceptives. Br J Psychiatry. 1970;116:161-164.
> West CP, Hillier H. Ovarian suppression with the gonadotropin-releasing hormone agonist goserelin (Zoladex) in management of the premenstrual tension syndrome. Hum Reprod. 1994;9:1058-1063.
> Brown CS, Ling FW, Andersen RN, Farmer RG, Arheart KL. Efficacy of depot leuprolide in premenstrual syndrome: effect of symptom severity and type in a controlled trial. Obstet Gynecol. 1994;84:779-786.
> Mortola JF. Applications of gonadotropin-releasing hormone analogues in the treatment of premenstrual syndrome. Clin Obstet Gynecol. 1993;36:753-763.
> Watts JF, Butt WR, Edwards RL. A clinical trial using danazol for the treatment of premenstrual tension. Br J Obstet Gynaecol. 1987;94:30-34.
> Halbreich U, Rojansky N, Palter S. Elimination of ovulation and menstrual cyclicity (with danazol) improves dysphoric premenstrual syndromes. Fertil Steril. 1991;56:1066-1099.
> Hahn PM, Van Vugt DA, Reid RL. A randomized, placebo-controllled, crossover trial of danazol for the treatment of premenstrual syndrome. Psychoneuroendocrinology. 1995;20:193-209.
> Sarno AP Jr, Miller EJ Jr, Lundblad EG. Premenstrual syndrome: beneficial effects of periodic low-dose danazol. Obstet Gynecol. 1987;70:33-36.
> O'Brien PM, Abukhalil IE. Randomized controlled trial of the management of premenstrual syndrome and premenstrual mastalgia using luteal phase-only danazol. Am J Obstet Gynecol. 1999;180:18-23.
> Watson NR, Studd JWW, Savvas M, et al. The long-term effects of estradiol implant therapy for the treatment of premenstrual syndrome. Gynecol Endocrinol. 1990;4:99-107.
> Smith RN, Studd JW, Zamblera D, Holland EF. A randomised comparison over 8 months of 100 micrograms and 200 micrograms twice weekly doses of transdermal oestradiol in the treatment of severe premenstrual syndrome. Br J Obstet Gynaecol. 1995;102:475-484.
> Israel RS. Premenstrual tension. JAMA. 1938;110:1721-1723.
> Hammarbäck S, Damber JE, Bäckström T. Relationship between symptom severity and hormone changes in women with premenstrual syndrome. J Clin Endocrinol Metab. 1989;68:125-130.
> Ying Y, Soto-albors CE, Randolph JF, et al. Luteal phase defect and premenstrual syndrome in an intfertile population. Obstet Gynecol. 1987;69:96-98.
> Halbreich U, Alt IH, Paul L. Premenstrual changes: impaired hormonal homeostasis. Endocrinol Metab Clin N Am. 1988;17:173-194.
> Freeman EW, Rickels K, Sondheimer SJ, et al: A double-blind trial of oral progesterone, alprazolam, and placebo in treatment of severe premenstrual syndrome. JAMA. 1995;274(1):51-57.
> Gunston KD. Norethisterone enantate in the treatment of premenstrual syndrome. S Afr Med J. 1995;85:851-852.
> Braiden V, Metcalf G. Premenstrual tension among hysterectomized women. J Psychosom Obstet Gynaecol. 1995;16:145-151.
> Brayshaw ND, Brayshaw DD. Thyroid hypofunction in premenstrual syndrome. N Engl J Med. 1986;315:1486-1487.
> Dalton K. Premenstrual syndrome and thyroid dysfunction - commentary [letter]. Integr Psychiatry. 1987;5:186-187.
> Hamilton JA. Premenstrual syndrome and thyroid dysfunction - commentary [letter]. Integr Psychiatry. 1987;5:192-193.
> Rubinow DR, Schmidt PJ. Premenstrual syndrome and thyroid dysfunction - commentary [letter]. Integr Psychiatry. 1987;5:187-189.
> Steege JR, Nemeroff CB. Premenstrual syndrome and thyroid dysfunction - commentary [letter]. Integr Psychiatry. 1987;5:185-186.
> Nicolai TF, Mulligan GM, Gribble RK, et al. Thyroid function and treatment in premenstrual syndrome. J Clin Endocrinol Metab. 1990;70:1108-1113.
> Wang, M. Hammarbäck, Lindhe BA, Bäckström T. Treatment of premenstrual syndrome by spironolactone: a double-blind, placebo-controlled study. Acta Obstet Gynecol Scand. 1995;74:803-808.
> Appleby BP. A study of premenstrual tension in general practice. Br Med J. 1960;1:391-393.
> Werch R, Kana R. Treatment of premenstrual tension with metolazone: double-blind evaluation of a new diuretic. Curr Ther Res. 1976;19:565-572.
> Hoffman, J. A double-blind crossover clinical trial of an OTC diuretic in the treatment of premenstrual tension and weight gain. Curr Ther Res. 1979;26:575-580.
> Budoff PW. The use of prostaglandin inhibitors for the premenstrual syndrome. J Reprod Med. 1983;28:469-478.
> Jakubowicz DL, Godard E, Dewhurst J. The treatment of premenstrual tension with mefenamic acid: analysis of prostaglandin concentration. Br J Obstet Gynaecol. 1984;91:79-84.
> Gunston KD. Premenstrual syndrome in Capetown. Part II. A double-blind placebo-controlled study of the efficacy of mefenamic acid. S Afr Med J. 1986;70:159-160.
> Mira M, McNeil D, Fraser IS, et al. Mefenamic acid in the treatment of premenstrual syndrome. Obstet Gynecol. 1986;68:395-398.
> Puolakka J, Makarainen L, Viinikka L, et al. Biochemical and clinical effects of treating the premenstrual syndrome with prostaglandin synthesis precursors. J Reprod Med. 1985;30:149-153.
> Callender K, McGregor M, Kirk P, et al. A double-blind trial of evening primrose oil in the premenstrual syndrome: nervous symptom subgroup. Human Psychopharm. 1988;3:57-61.
> Khoo SK, Munro C, Battistutta D. Evening primrose oil and treatment of premenstrual syndrome. Med J Aust. 1990;153:189-192.
> Budeiri D, Li Wan Po A, Dornan JC. Is evening primrose oil of value in the treatment of premenstrual syndrome? Control Clin Trials. 1996;17:60-68.
> Schaumberg H, Kaplan J, Windebank A, et al. Sensory neuropathy from pyroxidine abuse. A new megavitamin syndrome. N Engl J Med. 1983;309:445-448.
> London RS, Murphy L, Kitlowski KE, et al. Efficacy of alpha-tocopherol in the treatment of PMS. J Reprod Med. 1987;32:400-404.
> Thys-Jacobs S, Starkey P, Bernstein D, Tian J. Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Premenstrual Syndrome Study Group. Am J Obstet Gynecol. 1998;179:444-452.
> Penland JG, Johnson PE. Dietary calcium and manganese effects on menstrual cycle symptoms. Am J Gynecol. 1993;168:1417-1423.
> Thys-Jacobs S. Vitamin D and calcium in menstrual migraine. Headache. 1994;34:544-546.
> Walker AF, De Souza MC, Vickers MF, Abeyasekera S, Collins ML, Trinca LA. Magnesium supplementation alleviates premenstrual symptoms of fluid retention. J Womens Health. 1998;7:1157-1165.
> Steinberg S, Annable L, Young SN, Liyanage N. A placebo-controlled clinical trial of L-tryptophan in premenstrual dysphoria. Biol Psychiatry. 1999;45:313-320.
> Steinberg S, Annable L, Young SN, Belanger MC. Tryptophan in the treatment of late luteal phase dysphoric disorder: a pilot study. J Psychiatry Neurosci. 1994;19:114-119.
> Sayegh R, Schiff I, Wurtman J, Spiers P, McDermott J, Wurtman R. The effect of a carbohydrate-rich beverage on mood, appetite, and cognitive function in women with premenstrual syndrome. Obstet Gynecol. 1995;86(4 pt 1):520-528.
> Harrison WM, Endicott J, Nee J. Treatment of premenstrual depression with nortriptyline: a pilot study. J Clin Psychiatry. 1989;50:136-139.
> Sundblad C, Modigh K, Andersch B, et al. Clomipramine effectively reduces premenstrual irritability and dysphoria: a placebo-controlled trial. Acta Psychiatr Scand.1992;85:39-47.
> Sundblad C, Hedberg MA, Eriksson E. Clomipramine administered during the luteal phase reduces the symptoms of premenstrual syndrome: a placebo-controlled trial. Neuropsychopharmacology. 1993;9:133-145.
> Taghavi E, Menkes DB, Howard RC, Mason PA, Shaw JP, Spears GF. Premenstrual syndrome: a double-blind controlled trial of desipramine and methylscopolamine. Int Clin Psychopharmacol. 1995;10:119-122.
> Steiner M, Steinberg S, Stewart D, et al. Fluoxetine in the treatment of premenstrual dysphoria. Canadian Fluoxetine/Premenstrual Dysphoria Collaborative Study Group. N Engl J Med. 1995;332:1529-1534.
> Pearlstein TB, Stone AB. Long-term fluoxetine treatment of late luteal phase dysphoric disorder. J Clin Psychiatry. 1994;55(8):332-335.
> Freeman EW, Rickels K, Sondheimer SJ, Wittmaack FM. Sertraline versus desipramine in the treatment of premenstrual syndrome: an open-label trial. J Clin Psychiatry. 1996;57:7-11.
> Yonkers KA, Halbreich U, Freeman E, Brown C, et al. Symptomatic improvement of premenstrual dysphoric disorder with sertraline treatment. Sertraline Premenstrual Dysphoric Collaborative Study Group. JAMA. 1997;278:983-988.
> Halbreich U, Smoller JW. Intermittent luteal phase sertraline treatment of dysphoric premenstrual syndrome. J Clin Psychiatry. 1997;58:399-402.
> Young SA, Hurt PH, Benedek DM, Howard RS. Treatment of premenstrual dysphoric disorder with sertraline during the luteal phase: a randomized, double-blind, placebo-controlled crossover trial. J Clin Psychiatry. 1998;59:76-80.
> Freeman EW, Rickels K, Arredondo F, Kao LC, Pollack SE, Sondheimer SJ. Full- or half-cycle treatment of severe premenstrual syndrome with a serotonergic antidepressant. J Clin Psychopharmacol. 1999;19:3-8.
> Freeman EW, Rickels K, Sondheimer SJ. Fluvoxamine for premenstrual dysphoric disorder: a pilot study. J Clin Psychiatry 1996;57(suppl 8):56-59; discussion 60.
> Sunblad C, Wikander I, Andersch B, Eriksson E. A naturalistic study of paroxetine in premenstrual syndrome: efficacy and side effects during ten cycles of treatment. Eur Neuropsychopharmacol. 1997;7:201-206.
> Freeman EW, Rickels K, Sondheimer SJ, et al. Nefazodone in the treatment of premenstrual syndrome: a preliminary study. J Clin Psychopharmacol 1994;14(3):180-186.
> Wikander I, Sundblad C, Andersch B, et al. Citalopram in premenstrual dysphoria: is intermittent treatment during luteal phases more effective than continuous medication throughout the menstrual cycle? J Clin Psychopharmacol. 1998;18:390-398.
> Masand PS, Gupta S. Selective serotonin-reuptake inhibitors: an update. Harv Rev Psychiatry. 1999;7:69-84.
> Mortola JF. A risk-benefit appraisal of drugs used in the management of premenstrual syndrome. Drug Saf. 1994;10(2):160-169.
> Diegoli MS, da Fonseca AM, Diegoli CA, Pinotti JA. A double-blind trial of four medications to treat severe premenstrual syndrome. Int J Gynaecol Obstet. 1998;62(1):63-67.
> Evans SM, Haney M, Levin FR, Foltin RW, Fischman MW. Mood and performance changes in women with premenstrual dysphoric disorder: acute effects of alprazolam. Neuropsychopharmacology. 1998;19(6):499-516.
> Berger CP, Presser B. Alprazolam in the treatment of two subsamples of patients with late luteal phase dysphoric disorder: a double-blind, placebo-controlled crossover study. Obstet Gynecol. 1994;84(3):379-385.
> Blake F, Salkovskis P, Gath D, Day A, Garrod A. Cognitive therapy for premenstrual syndrome: a controlled trial. J Psychosom Res. 1998;45:307-318.
> Oleson T, Flocco W. Randomized controlled study of premenstrual symptoms treated with ear, hand, and foot reflexology. Obstet Gynecol. 1993;82:906-911.
> Groer M, Ohnesorge C. Menstrual cycle lengthening and reduction in premenstrual distress through guided imagery. J Holist Nurs. 1993;11:286-294.
> BeLieu RM. Mastodynia. Obstet Gynecol Clin North Am. 1994;21:461-477.
> Brzezinski AA, Wurtman JJ, Wurtman RJ, et al. d-Fenfluramine suppresses the increased calorie and carbohydrate intakes and improves the mood of women with premenstrual depression. Obstet Gynecol. 1990;76:296-301.
>
>
>
> --------------------------------------------------------------------------------
Posted by Doug Anderson on November 15, 2000, at 23:55:25
In reply to PMDD - Premenstrual Dysphoric Disorder, posted by Jan on March 1, 1999, at 10:54:47
It seems to me that each case is so different that there is not one difinitive solution. Some may find benefit in diet and exercise. Some with this plus hormone replacement therapy. The one common thread is that love, patience and support from a partner can play a crucial role in helping to control this disorder. Guys; don't give up on the one you love. Be as strong as you can be. Thanks to Cal and his wife for giving me the strength to fight the good fight for the one I love. Doug
Posted by R.Anne on November 17, 2000, at 20:57:48
In reply to Re: PMDD - Premenstrual Dysphoric Disorder, posted by Doug Anderson on November 15, 2000, at 23:55:25
I think that's great that you are patient, loving and supportive toward your partner. She surely will thrive with someone like you!
******
> It seems to me that each case is so different that there is not one difinitive solution. Some may find benefit in diet and exercise. Some with this plus hormone replacement therapy. The one common thread is that love, patience and support from a partner can play a crucial role in helping to control this disorder. Guys; don't give up on the one you love. Be as strong as you can be. Thanks to Cal and his wife for giving me the strength to fight the good fight for the one I love. Doug
Posted by SLS on November 17, 2000, at 21:26:41
In reply to Re: PMDD - Premenstrual Dysphoric Disorder, posted by R.Anne on November 17, 2000, at 20:57:48
Hi.
I'm sorry if I am repeating something already covered, but I really have a hard time reading through entire threads.
I'm sure you all know that Lilly has released a re-packaged and renamed version of Prozac (fluoxetine) named Serafem that is marketed specifically for PMDD.
Has anyone used one of the SSRIs successfully for PMDD?
- Prozac, Serafem = fluoxetine
- Zoloft = sertraline
- Luvox = fluvoxamine
- Celexa = CitalopramHow about Effexor or Nardil?
What is the current first-line treatment for PMDD?
Are these drugs to be taken continually or cyclically?
Again, I apologize if these questions are redundant.
- Scott
Posted by Doug Anderson on November 18, 2000, at 11:36:58
In reply to Re: PMDD - Premenstrual Dysphoric Disorder, posted by R.Anne on November 17, 2000, at 20:57:48
> I think that's great that you are patient, loving and supportive toward your partner. She surely will thrive with someone like you!
Thanks R.Anne, when you love someone you do all you can. I don't know if I could deal with this if it was happening to me. She is the strong one. Doug
> ******
> > It seems to me that each case is so different that there is not one difinitive solution. Some may find benefit in diet and exercise. Some with this plus hormone replacement therapy. The one common thread is that love, patience and support from a partner can play a crucial role in helping to control this disorder. Guys; don't give up on the one you love. Be as strong as you can be. Thanks to Cal and his wife for giving me the strength to fight the good fight for the one I love. Doug
Posted by Doug Anderson on November 18, 2000, at 11:47:22
In reply to Re: PMDD - Premenstrual Dysphoric Disorder, posted by SLS on November 17, 2000, at 21:26:41
> Hi.
>
> I'm sorry if I am repeating something already covered, but I really have a hard time reading through entire threads.
>
> I'm sure you all know that Lilly has released a re-packaged and renamed version of Prozac (fluoxetine) named Serafem that is marketed specifically for PMDD.
>
> Has anyone used one of the SSRIs successfully for PMDD?
>
> - Prozac, Serafem = fluoxetine
> - Zoloft = sertraline
> - Luvox = fluvoxamine
> - Celexa = Citalopram
>
> How about Effexor or Nardil?
>
> What is the current first-line treatment for PMDD?
>
> Are these drugs to be taken continually or cyclically?
>
> Again, I apologize if these questions are redundant.
>
>
> - Scott
Dear Scott,
Diet and exercise are the first line of treatment. Some use hormone replacement such as progesterone gel. The ssri's are a drastic step. They can cause more depression and decrease sexual response. These drugs are used for bipolar disorder and carry a stigma too. That can be psychologically detrimental. Look to natures way first. Love and patience are primary .Plan diet and exercise together along with other activities around her cycle. Saying I love you every day, even if she is at her worst will show support. She will feel better about herself when she gets back to normal. Again, drugs are the last resort. Good luck. Doug
Posted by SLS on November 18, 2000, at 17:54:47
In reply to Re: PMDD - Premenstrual Dysphoric Disorder, posted by Doug Anderson on November 18, 2000, at 11:47:22
Dear Doug,
Thanks for responding.
It is refreshing to see an algorithm that does not include drugs.
- Scott
> > Hi.
> >
> > I'm sorry if I am repeating something already covered, but I really have a hard time reading through entire threads.
> >
> > I'm sure you all know that Lilly has released a re-packaged and renamed version of Prozac (fluoxetine) named Serafem that is marketed specifically for PMDD.
> >
> > Has anyone used one of the SSRIs successfully for PMDD?
> >
> > - Prozac, Serafem = fluoxetine
> > - Zoloft = sertraline
> > - Luvox = fluvoxamine
> > - Celexa = Citalopram
> >
> > How about Effexor or Nardil?
> >
> > What is the current first-line treatment for PMDD?
> >
> > Are these drugs to be taken continually or cyclically?
> >
> > Again, I apologize if these questions are redundant.
> >
> >
> > - Scott
> Dear Scott,
> Diet and exercise are the first line of treatment. Some use hormone replacement such as progesterone gel. The ssri's are a drastic step. They can cause more depression and decrease sexual response. These drugs are used for bipolar disorder and carry a stigma too. That can be psychologically detrimental. Look to natures way first. Love and patience are primary .Plan diet and exercise together along with other activities around her cycle. Saying I love you every day, even if she is at her worst will show support. She will feel better about herself when she gets back to normal. Again, drugs are the last resort. Good luck. Doug
Posted by S Howard on November 18, 2000, at 22:37:50
In reply to Re: PMDD - Premenstrual Dysphoric Disorder, posted by SLS on November 18, 2000, at 17:54:47
I have posted this before but I think it's worth considering: get rid of the period and you get rid of the PMS. This can be accomplished by Norplant or Depro-Provera injections. I have had success with both for many years now... I couldn't imagine going back to having periods and PMS, it's such needless pain. I've heard people say, "It's not right, it's not natural..."
well, tooth decay is natural too, but wouldn't you go to the dentist if you were in pain? Damn Skippy you would, at least I hope you would.
-Gracie
Posted by SLS on November 19, 2000, at 0:48:31
In reply to Re: PMDD - Premenstrual Dysphoric Disorder, posted by S Howard on November 18, 2000, at 22:37:50
Hi Gracie.
I was hoping that no one would misconstrue my post as being a discouragement of the usage of medication. Because there is such intense focus here on using drugs (natural or synthetic) as treatment, I sometimes worry that some of us develop tunnel-vision. I thought it was nice to be reminded to look around once in a while.Not being a woman, I cannot appreciate the many intricacies of womanhood. I think if I were a woman suffering from a severe premenstrual psychobiological disruption, I would probably opt for treatment using hormones rather than antidepressants.
Without having looked into PMS or PMDD, I don't know if severe cases are always treatable with hormones. Are they?
There is a bunch of other stuff going on in the body and brain of a woman other than the secretion of pituitary and gonadal hormones. I know that the brain has its own timekeepers. In biology, there are so many examples of 28-day metabolic and behavioral cycles, that it is obvious that life on earth evolved under the influences of the lunar cycle. Life developed in the ocean, where the moon has its most obvious effects - the tide. If I am not mistaken, it is within the tidal waters that life evolved. Perhaps there are other cycles located deeper in the nervous system that are independent of the tides of hormones that contribute to PMDD. I don't know.
My questions are:
1. Does abolition of the menstrual cycle always work?
2. If not, why?
3. How often and how well do SSRIs help, and which ones in particular are the most effective?> I have posted this before but I think it's worth considering: get rid of the period and you get rid of the PMS. This can be accomplished by Norplant or Depro-Provera injections. I have had success with both for many years now... I couldn't imagine going back to having periods and PMS, it's such needless pain.
> I've heard people say, "It's not right, it's not natural..."
This is sometimes such a silly argument. Who has come to decide that it is not precisely man's place in nature to use nature to better his own life, and of all else that surrounds him? After all, everything man makes, he makes from what already exists in nature - even those unstable elements that are not produced elsewhere in the universe. Leaf-cutter ants actually culture and harvest their own food. They are fungus farmers. The ants don't eat the leaves. The fungus eats the leaves. The ants eat the fungus. Even worse than that, these same ants make their own herbicide to keep other species of fungi out of their gardens. They encourage the growth a special bacteria on their "chins". These bacteria secrete an antibiotic. Yes, that's right. Leaf-cutter ants have been refining their own antibiotics long before we began to walk upright and accidentally ran into penicillin.
It's not right. Its not natural.
- Scott
Posted by Doug Anderson on November 19, 2000, at 10:24:20
In reply to Re: PMDD - Premenstrual Dysphoric Disorder, posted by S Howard on November 18, 2000, at 22:37:50
>
> I have posted this before but I think it's worth considering: get rid of the period and you get rid of the PMS. This can be accomplished by Norplant or Depro-Provera injections. I have had success with both for many years now... I couldn't imagine going back to having periods and PMS, it's such needless pain. I've heard people say, "It's not right, it's not natural..."
> well, tooth decay is natural too, but wouldn't you go to the dentist if you were in pain? Damn Skippy you would, at least I hope you would.
> -GracieGracie, Have you had any side effects by ending your cycle such as those seen in menopause. If not, have you seen any side effects worth noting. I would really like to know. Every experience brings me new insight and help to the one I love.
Doug
Posted by pullmarine on November 20, 2000, at 2:26:17
In reply to Re: PMDD - Premenstrual Dysphoric Disorder, posted by Doug Anderson on November 15, 2000, at 23:55:25
They say you're crazy by Caplan
Posted by Janice1 on November 20, 2000, at 19:42:48
In reply to Re: PMDD - Premenstrual Dysphoric Disorder, posted by SLS on November 18, 2000, at 17:54:47
hi Scott,
I would qualify for PMDD, but I'm not really looking for another diagnosis since i'm both bipolar and ADHD. Somehow, for me, the severe anxiety at ovulation and severe PMS I'll call it, is linked to both these disorders. My bipolar, like most bipolars, became active at puberty. ONe of my rapid cycling cycles has developed and revolves around my menstral cycle - with a severe depression right after menses.
Anyway, no ADs have helped. No mood stabilizers have had any noticeable affect. Exercise may help a bit. I haven't experimented with diet.
I do get complete relief from all of this from the birth control pill. It works like a dream for me.
>
I hope you're okay Scott. I check up to see how you are doing once in a while. I wish you luck with your new doctor. I still say little prayers for you. Janice
Posted by SLS on November 20, 2000, at 20:39:13
In reply to Scott, posted by Janice1 on November 20, 2000, at 19:42:48
Hi Janice.
Thanks for the warm sentiments. This place can make me feel so good. Very nice.
I didn't know that anxiety was associated with ovulation. How do you experience this anxiety? How long does it last? Is it common? What do you do about it, if anything?
> One of my rapid cycling cycles has developed and revolves around my menstral cycle - with a severe depression right after menses
Isn't this unusual? I am not clear on precisely what the word "menses" means. Does it refer to the onset of menstrual flow (first day) or the entire period?
A lady friend of mine who suffers with a soft bipolar type depression has done well on a combination of Effexor and Wellbutrin. Unfortunately, she still suffers a significant premenstrual depression. In addition, her cycle is irregular. I wonder if there is such a thing as a desychronization between estrogen and progesterone secretions. Her luteal phase is probably truncated.
I have urged her for over a year to speak to one of her doctors about the use of sex hormone therapy for her PMS. It is significant enough for her to miss days at work. She is currently taking birth-control pills, but I don't know what the formulation is. Is the "mini-pill" still popular? There may not be enough estrogen in the preparation she is using.
*** Question: What formulation of birth control pill is best suited for minimizing premenstrual mood fluctuations?
Gosh, what you pretty little girls have to go through to make life worth living for us clueless little boys.
Janice, I hope you are feeling as well as you sound.
I am doing significantly better than I was over the summer. I have recently added Zyprexa to my treatment regime. I am encouraged. But then again, I am so easily encouraged despite my history. I haven't figured out why.
Any input you could provide regarding PMS and hormone therapy would be helpful.
- Scott
Posted by Janice1 on November 22, 2000, at 21:24:15
In reply to Re: Scott, posted by SLS on November 20, 2000, at 20:39:13
> Hi Scott,
>
> I didn't know that anxiety was associated with ovulation. How do you experience this anxiety? How long does it last? Is it common? What do you do about it, if anything?I was also told once by a doctor that anxiety wasn't associated with ovulation. I'm not sure if they know differently now, but I experienced this monthly for 1-3 days (varying in intensity). The anxiety was over nothing usually - just building mountains out of moldhills, and staying up all night doing it. The only way i got rid of it was to go on the birth control pill which prevents a woman from ovulating.
>
> > One of my rapid cycling cycles has developed and revolves around my menstral cycle - with a severe depression right after menses
>
> Isn't this unusual? I am not clear on precisely what the word "menses" means. Does it refer to the onset of menstrual flow (first day) or the entire period?I'm not certain if I used the word correctly either. The depression would usually start on the fifth day after the beginning of my period. And the hypomania would begin right after ovulation, right after experiencing 2 to 3 sleepless nights worrying about silly things.
>
> A lady friend of mine who suffers with a soft bipolar type depression has done well on a combination of Effexor and Wellbutrin. Unfortunately, she still suffers a significant premenstrual depression. In addition, her cycle is irregular. I wonder if there is such a thing as a desychronization between estrogen and progesterone secretions. Her luteal phase is probably truncated.You could put it this way, if her cycle wasn't irregular, I highly doubt she'd have PMS problems.
>
> I have urged her for over a year to speak to one of her doctors about the use of sex hormone therapy for her PMS. It is significant enough for her to miss days at work. She is currently taking birth-control pills, but I don't know what the formulation is. Is the "mini-pill" still popular? There may not be enough estrogen in the preparation she is using.
>
> *** Question: What formulation of birth control pill is best suited for minimizing premenstrual mood fluctuations?I really don't know Scott. I use Cyclen birth control (if that means anything). It's is a common pill and could be the mini-pill you are talking about. I think she should experiment with some other birth control pills under a doctor's supervision - Or get a customized birth control pill.
>
> Gosh, what you pretty little girls have to go through to make life worth living for us clueless little boys.my boyfriend was not clueless about this because I was certainly not pretty around that time of month :+)
>
> Janice, I hope you are feeling as well as you sound.
>
I am Scott. Really great, there is hope. I'm finally just got relief a few months ago at 34 and have been suffering from this garbage since I was 12.> I am doing significantly better than I was over the summer. I have recently added Zyprexa to my treatment regime. I am encouraged. But then again, I am so easily encouraged despite my history. I haven't figured out why.
>
I am very happy for your Scott. Maybe you are an optimistic depressed person Scott. As funny as the term sounds, I'm sure it happens.> Any input you could provide regarding PMS and hormone therapy would be helpful.
>
I really don't see how anything but hormones could really help. Exercise helps me a bit, but by no means is anywhere near the answer for me. I have heard quitting sugar can help significantly, and there is a part of me that believes this - maybe because it's the only thing i haven't tried.Take care of yourself Scott,
your friend, JaniceThere seems to be so much they don't know about how hormones interact with mental illnesses.
Posted by KarenB on November 22, 2000, at 22:36:57
In reply to Re: Scott, posted by Janice1 on November 22, 2000, at 21:24:15
> I was also told once by a doctor that anxiety wasn't associated with ovulation.Ahhhh ha ha ha ha ha. That's a good one!
Janice,
So good to hear from you. I have missed being around all you good people. I've been away - away finding out, from a reliable source this time, that I am not only ADD but Bipolar - well, predominately Bipolar - well, maybe not ADD at all. Maybe just Bipolar. I doubt that but we'll see... I truly think I am both.
It's been a rough road for the past couple of months but I am now regaining my cognitive function and especially my memory that so many chemicals had taken away. I am on one medication - Tegretol for mood stabilization and I am doing better than I have in years, in a shockingly "normal" sort of way.
Back on the subject - PMS almost always throws me into a mixed state, sometimes of frightening proportions. You are right that they just don't know enough about the link between hormones and mental health.
I only wish I could find a doctor who was thinking only half as much as those on this board.
BTW Janice: To WHICH birth control pill do you refer?
Cheers to you all. Howdy, Scott.
Karen
Posted by Anna P. on November 22, 2000, at 23:48:53
In reply to Re: Janice!, posted by KarenB on November 22, 2000, at 22:36:57
>
> > I was also told once by a doctor that anxiety wasn't associated with ovulation.
>
> Ahhhh ha ha ha ha ha. That's a good one!
>
> Janice,
>
> So good to hear from you. I have missed being around all you good people. I've been away - away finding out, from a reliable source this time, that I am not only ADD but Bipolar - well, predominately Bipolar - well, maybe not ADD at all. Maybe just Bipolar. I doubt that but we'll see... I truly think I am both.
>
> It's been a rough road for the past couple of months but I am now regaining my cognitive function and especially my memory that so many chemicals had taken away. I am on one medication - Tegretol for mood stabilization and I am doing better than I have in years, in a shockingly "normal" sort of way.
>
> Back on the subject - PMS almost always throws me into a mixed state, sometimes of frightening proportions. You are right that they just don't know enough about the link between hormones and mental health.
>Hi Karen,
It's so nice to have you back. I was wandering what happened with you.Anna P.
>
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