Should I try an SSRI for premenstrual syndrome (PMS)?

Introduction

This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.

Key points in making your decision

If you have premenstrual symptoms that are moderate to severe and are regularly disrupting your life, you're probably looking for ways to take charge of your body. Consider the following when choosing your treatment options:

• Before trying a medicine for your symptoms, it's best to stabilize your body's endocrine system by reducing your caffeine, refined sugar, and sodium intake; getting regular aerobic exercise, such as walking or jogging; eating a balanced diet; and getting enough calcium, vitamin B6, and magnesium. After two to three menstrual cycles, you're likely to notice some improvement.
• For premenstrual and menstrual pain, you can use a nonsteroidal anti-inflammatory drug (NSAID), such as Motrin or Advil. NSAIDs block pain-producing prostaglandins, which increase during the premenstrual period.
• If you have disruptive emotional and physical PMS symptoms that persist even with lifestyle and dietary changes, a selective serotonin reuptake inhibitor (SSRI) is a treatment option. An SSRI is often effective for PMS and can be taken during the premenstrual weeks, or continuously.¹ But if you are trying to get pregnant, talk to your doctor-taking Paxil or Paxil CR in the early weeks of pregnancy may increase your chance of having a baby with birth defects.²
• If you have had a manic episode, have bipolar disorder or a seizure disorder, or take another medicine that cannot be used along with an SSRI, your doctor may recommend treatments other than SSRIs for your PMS.

Medical Information

What is premenstrual syndrome?

For as long as you have a menstrual cycle and ovulate, your hormone-producing endocrine system has powerful, cyclic effects on your body. While some women barely notice these effects, up to 80% of women normally have one or more premenstrual symptoms. These happen between the time you ovulate and the first days of your menstrual period.³ When premenstrual physical and emotional symptoms interfere with your relationships or responsibilities, they are called premenstrual syndrome (PMS). When these emotional symptoms or aggression become severe, it is called premenstrual dysphoric disorder (PMDD). In contrast to PMS, PMDD affects up to 8% of women.⁴

Because a woman's endocrine system is so complex, there are a number of possible hormones and other chemicals in the body that can trigger PMS symptoms. Serotonin is the best-known neurotransmitter chemical that impacts symptoms in many women with PMS. For many women, improving the brain's use of serotonin helps relieve a number of emotional and physical PMS symptoms.

What are selective serotonin reuptake inhibitors (SSRIs)?

SSRIs are a class of medicine that affects the brain's use of the neurotransmitter serotonin. This improvement in serotonin use is known to improve physical and emotional PMS symptoms. SSRIs are also used to treat depression, anxiety, menopausal hot flashes, and chronic pain.

SSRIs are usually the first-choice medicine for treating severe PMS and PMDD symptoms, including depression, anxiety, irritability, anger, mood swings, breast tenderness, bloating, headache, and joint and muscle pain. SSRI treatment only during the premenstrual phase appears to be as effective as continuous SSRI treatment.¹ And it costs less. If you have PMS symptoms that completely go away during your period, this approach is likely to work for you. But if you have emotional symptoms of depression or anxiety all of the time, taking an SSRI continuously may be a better option for you.

Commonly used SSRIs for PMS include sertraline (Zoloft), fluoxetine (Prozac, Sarafem), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa). They each have slightly different effects on mood. While one SSRI may not be right for you, another SSRI may work well. SSRI therapy for PMS usually brings relief within a few days of starting the medicine but can take longer.³

What are the side effects of SSRI treatment?

Side effects from SSRI treatment are usually not serious. But these side effects are fairly common, and they are why some people stop taking SSRI medicine.⁵ Some side effects will tend to subside over several weeks. Among women taking an SSRI for PMS, several side effects have been widely studied, including:

• Nausea, appetite changes, weight loss.
• Headache.
• Insomnia, fatigue.
• Nervousness.
• Difficulty with sexual desire, arousal, or orgasm.
• Dizziness.
• Tremors.
• Dry mouth.
• Rash (rare).
• Weight gain (rare), with long-term use.

FDA Advisories. The U.S. Food and Drug Administration (FDA) has issued:

• An advisory on antidepressant medicines and the risk of suicide. The FDA does not recommend that people stop using these medicines. Instead, a person taking an SSRI should be watched for any warning signs of suicide. This is especially important at the beginning of treatment or when doses are changed.
• A warning about the antidepressants Paxil and Paxil CR and birth defects. Taking these medicines in the first 12 weeks of pregnancy may increase your chance of having a baby with a birth defect.²
• A warning about taking triptans, used for headaches, with SSRIs (selective serotonin reuptake inhibitors) or SNRIs (selective serotonin/norepinephrine reuptake inhibitors). Taking these medicines together can cause a very rare but serious condition called serotonin syndrome.

Your Information

Your choices are:

• Continue using healthy lifestyle and dietary measures to reduce PMS or PMDD symptoms.
• Try an SSRI, either continuously or only during your premenstrual weeks.
• Talk to your health professional about other treatment options.

If you need more information, see the topic Premenstrual Syndrome (PMS) or selective serotonin reuptake inhibitors (SSRIs) for PMS and PMDD.

The decision about whether to try SSRI treatment for moderate to severe premenstrual symptoms takes into account your personal feelings and the medical facts.

These personal stories may help you make your decision.

Wise Health Decision

Use this worksheet to help you make your decision. After completing the worksheet, you should have a better idea of how you feel about using an SSRI. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to use or not use a selective serotonin reuptake inhibitor (SSRI).

Check the box below that represents your overall impression about your decision.

Return to the topic Premenstrual Syndrome (PMS).

References

Citations

1. Freeman EW, et al. (2004). Continuous or intermittent dosing with sertraline for patients with severe premenstrual syndrome or premenstrual dysphoric disorder. American Journal of Psychiatry, 161(2): 343-351.

2. U.S. Food and Drug Administration (2006). FDA Public Health Advisory: Paroxetine. Available online: http://www.fda.gov/cder/drug/advisory/paroxetine200512.htm.

3. Katz VL, et al. (2007). Primary and secondary dysmenorrhea, premenstrual syndrome, and premenstrual dysphoric disorder. In LO Eckert, GM Lentz, eds., Comprehensive Gynecology, 5th ed., pp. 901-913. Philadelphia: Mosby Elsevier.

4. Grady-Weliky TA (2003). Premenstrual dysphoric disorder. New England Journal of Medicine, 348(5): 433-437.

5. Kwan I, Onwude JL (2007). Premenstrual syndrome, search date November 2006. Online version of BMJ Clinical Evidence. Also available online: http://www.clinicalevidence.com.