Dr. Bob's Psychopharmacology Tips Biological Therapies in Psychiatry Alan J. Gelenberg, M.D.

Treating PMS

While most women experience some physical and emotional changes premenstrually, a minority are clinically impaired by the premenstrual syndrome (PMS). For ages, unproven and largely ineffectual remedies were promulgated. In recent years, however, greater methodologic rigor has enhanced clinical research on this condition. Better still, the advent of the serotonin-selective reuptake inhibitor (SSRI) antidepressants has shown that medication can alleviate PMS symptoms and reverse dysfunction. Several recent reviews present evidence and knowledgeable opinions on treating PMS.

Dr Walter Brown notes that SSRIs have a much more rapid onset of action when used to treat PMS than when the same drugs are used to treat depression. (1) PMS symptoms improve almost immediately, while depressive symptoms typically take several weeks to lift. This author also observes that while serotonergic, noradrenergic, and other agents appear equal in efficacy when treating depression, only highly serotonergic antidepressants are effective for PMS. Further evidence for the role of serotonin in PMS is that tryptophan, the essential amino acid that serves as a dietary precursor for serotonin, and fenfluramine (Pondimin and Redux), which stimulates serotonin neurotransmission, also appear effective against PMS. Moreover, women with PMS show abnormalities in blood serotonin.

What about other antidepressants? Yonkers and Brown write about an ongoing, multicenter trial of venlafaxine (Effexor) for premenstrual dysphoric disorder (PMDD). (2) Venlafaxine can be started at 25 mg bid to manage side effects and then increased by 25 to 37.5 mg/day each cycle until remission is achieved. Investigators hope venlafaxine's rapid onset of action will be beneficial in this type of intermittent disorder. An open trial suggested that nefazodone (Serzone) may be effective against PMDD or premenstrual exacerbation (PME) of a preexisting mood disorder when administered in daily doses of 200 to 500 mg throughout the menstrual cycle.

Anxiolytic agents too might have a role to play. Limited data suggest possible efficacy for buspirone (Buspar). Yonkers and Brown also use alprazolam (Xanax) for women with mild PMS symptoms of limited duration. They recommend a starting dose of 0.25 mg bid or tid, increased as needed.

In many studies of drugs to treat PMS, agents are administered daily throughout the month. But some women appear to benefit from taking a drug only during the premenstrual week or starting with the first symptom and ending with the beginning of menses. For example, clomipramine (Anafranil) is efficacious when administered only in the luteal phase of the menstrual cycle. Although there are no systematic data on the long-term use of drugs for premenstrual disorders, Yonkers and Brown state that symptom relief appears to be maintained.

What else can be done to combat PMS symptoms? Pearlstein cites recommendations to increase complex carbohydrate consumption. (3) When combined with more frequent meals, this strategy might enhance cerebral uptake of tryptophan, thereby making more serotonin available. Some women find exercise alleviates symptoms. Other nonpharmacologic strategies include cognitive behavioral therapy and relaxation training.

When symptoms of PMS, PMDD, or PME rise to the level of clinical significance, serotonergic antidepressants often can bring relief, with dosage and timing individualized for each patient. Recommendations for diet, exercise, and other nonpharmacologic strategies -- as alternatives or additions to drug treatment -- also can be considered based on preferences and circumstances.

1. Brown WA: PMS: A quiet breakthrough. Psychiatr Ann 1996; 26: 569-570.
2. Yonkers KA, Brown WA: Pharmacologic treatments for premenstrual dysphoric disorder. Psychiatr Ann 1996; 26: 586-589.
3. Pearlstein T: Nonpharmacologic treatment of premenstrual syndrome. Psychiatr Ann 1996; 26: 590-594.

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Original article copyright 1997 Biological Therapies in Psychiatry.
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