Got PMS? Take Two Antidepressants, and Call Me in the Morning

Sci’s going to go ahead and admit, the last few weeks have been a little…brutal. Ok, maybe a LOT brutal. Grad school can be tough at times, and involve days that leave Scicurious wiped. But the posts must go on! And so, today your tough little grad student (YTLGS) is fortifying herself with the best cures imaginable, moose munch and liquor, to bring you today’s post.
(By the way, being poor, Sci accepts gifts to her blogging muse in the form of Moose Munch, dark chocolate of any kind, and liquor of all varieties except NightTrain. Contact her for details).
Todays post brought to you by sugar and…fermented sugars. Also the letter S. And the Journal Club that Sci has to give…soon. Very, very soon. Landen, et al. “Short onset of action of a serotonin reuptake inhbitior when used to reduce premenstrual irritability.” Neuropsychopharmacology, 2009.

So ladies, I’m sure you know what I mean when I talk about PMS. The bloating, the headaches, the irritability, the mood swings. In Sci’s case, the irritability and mood swings persist all month, and so I divide myself into PMS, DMS (during), and the in-between season, which is basically like the three seasons of the tropics, only more devastating to local fauna.
For most of us, PMS is not exactly debilitating. It’s annoying, sure, and you have to watch what you say for a while, but it doesn’t really impair function. But for some, PMS, and particularly the mood problems associated with it, can really impact daily function for a good portion of every month. Many women treat PMS symptoms with Selective Serotonin Reuptake Inhibitor, or SSRIs, which increase the amount of serotonin floating around in the synapses of your brain. Increased levels of serotonin can improve mood, or at least decrease things like irritability and depression.
However, I’m sure you’ve heard by now that most antidepressants take between two and three WEEKS to produce a noticeable effect on mood. This means that when women who are suffering PMS want to treat it, they need to take antidepressants all the time. Why does it take that long? We don’t really know. There are various theories out there, including the theory that your brain has to adapt to higher levels of serotonin with different receptor levels, as well as the idea that your neurons may change the number and concentration of dendrites, and it’s these changes that may produce antidepressant effects. Suffice it to say that this area is still under heavy investigation.
But it could be that certain effects of antidepressants may occur faster than others. For example, people will report decreases in things like anger and hostility within a few hours of taking an SSRI for the first time. So the authors of this study decided to look at the ACUTE (as in, within one or two doses) effects of SSRIs in women with PMS. After all, it would be useful if these women didn’t have to medicate all month long. They wouldn’t be subject to as many side effects, and it would certainly be a lot less expensive if they only had to take, say, 5 pills per month instead of 30.
So they took a group of 22 women who were known to suffer from PMS-related irritability had to be 50% above baseline irritability, and it had to be the dominant symptom). They monitored them for three months. For one month, the women recorded the duration and intensity of PMS-related irritability at baseline. For two months, the women were on paroxetine, otherwise known as Paxil. They did counterbalance the design to rule out effects of women being on Paxil for two months straight, or being off it in between. In each cycle, they made the women wait until they had been serious pissy for two days, and then allowed them to take the pill, whether Paxil or placebo, and rate the effects over the next few hours and days. They continued to take the pills until the onset of menses. The women were also blood sampled at various points to determine how much drug was in their system.
The results were pretty nice! When taking placebo, women expressed a marked increase in irritability, it got worse and worse as menses approached. When they were taking paroxetine, the irritable symptoms decreased, and they did so rapidly, with significance achieved by the second day of drug administration. Not only that, but even when the drug was at its most effects, blood levels of drug were relatively low, meaning that a low dose could help with irritability in as little as 24 hours!
It sounds awfully good, but there were side effects. Up to 40% of the women on Paxil complained of nausea after the first few doses. So it may not be for the faint of heart, but it’s still encouraging for those who may have horrible PMS, and who are unwilling to be treated all the time.
There were some downsides to the study, as could be expected with human studies. Humans are generally tougher to work with than animals, they’re always on all sorts of other drugs, and getting them to show up for tests is much more difficult. In this case, the study participants were recruited from another study, also involving paroxetine. This is actually a pretty big hangup, because only about 60% of those who take SSRIs respond to them favorably, so they already had a pool of responders right there. Not only that, the previous paroxetine study had been 3 months long, plenty of time for changes to take place in the brain , which may have influenced the outcome of this particular study. It’s good for the study that they knew they had people who would have a response to the drug, but the prior exposure may still present some problems.
Another issue is that, since 40% of the women felt nausea while on paroxetine, they probably knew when they were on drug, and so the results then may have been a little biased. I know that many of the people working on humans have to deal with that confound all the time. When a person knows they are on drug, they will behave differently.
But still, I like this study. It’s got some good, clear clinical relevance, not only in helping women with severe PMS, but in saving them money, as they wouldn’t have to take it all the time. It’ll be interesting to see if short-term treatment with SSRIs comes into clinical practice.
A word of warning, though. If you ARE taking antidepressants for PMS-related irritability, and you are prescribed by your doctor to take it all month long, DO NOT go off your meds without consulting your doctor. REALLY. This is because many SSRIs (Paxil being among them) can cause a “discontinuation syndrome” when they are stopped suddenly. This was probably avoided in the study because the patients were only on the drug for a short period of time, but if you’ve been on your SSRIs for a while, make SURE you consult with your doctor and slowly taper your dosage. Discontinuing SSRIs suddenly can cause major mood problems, not to mention things like seizures. I wouldn’t recommend it.
Mikael Landén, Helena Erlandsson, Finn Bengtsson, Björn Andersch, Elias Eriksson (2008). Short Onset of Action of a Serotonin Reuptake Inhibitor When Used to Reduce Premenstrual Irritability Neuropsychopharmacology, 34 (3), 585-592 DOI: 10.1038/npp.2008.86

13 Responses

  1. I’m glad you brought up the point about discontinuation syndrome, because I was itching to ask about that through the whole post until I got to the end.
    But here’s my other concern – wasn’t it found awhile back that taking Paxil and other SSRIs for a short time, then going off, then going back on, and so on to just really not be good for you?
    My other issue is this apparent “need” to control women’s irritability from PMS. It’s a symptom that primarily affects the people AROUND you. And we also can’t say with certainty that the irritability doesn’t stem from the physical symptoms of feeling like crap.
    It seems to me that it would be in the better interest of women to work on treating the physical symptoms of PMS and things like ability to concentrate before treating moodiness. I have no access to journal articles anymore because my MRU cancelled my library account and therefore can’t read the article you’re referring to. Did they address the relief (or not) of other psychological symptoms?
    It seems

  2. JLK- these were women who complained of irritability as their primary symptom. Maybe it makes sense to treat irritability first in that subset of women?
    Nonetheless, as a political point, I would be interested in the personality types of women who feel irritability is their main symptom… and in how strongly their irritability is percieved by those around them. Maybe the women who feel it’s a major problem are actually just trying to be too nice!
    What makes me happy about this study is that it finally shows some effect of antidepressants working on the kind of timescale the pharmacokinetics suggest 😉

  3. Yeah this is interesting. I was prescribed an antidepressant once before and it made me feel like I was on E later that evening for a while… and then i threw up. TWO WEEKS for an effect my ass, that stuff does something instantly. Needless to say, I’m not depressed and didn’t end up taking it regularly. I don’t really know why they gave it to me anyway…

  4. a crossover design would be useful in sorting out the differences in behavior of people who know they’re on the active drug.

  5. I was always jealous of women who only got irritable. I was usually curled up in constant pain of say… 6 on my pain scale. It was not that the pain was incredibly intense, it was ‘wear-you-down’ constant for usually 2 days.
    Since I’m long past all that, I now have the irritability that comes with Post Menopausal Syndrome which is really more dangerous to those around me, as there is no end in sight and I rather enjoy it.
    Seriously, ya reckon anyone will test whether SSRIs might have an effect on the painful PMS also?

  6. Yes, care package, she says. No care package, she says. Yes, bribes and treats, she says.
    I’m not falling for it this time, you know. 😉
    Good to have you blogging when you can. Take care of yourself.

  7. LOL. Don’t worry, Stephanie, I mostly just don’t want to seem like I’m begging for stuff, you know? I’m not STARVING, just on a diet that I like to call povertarianism. 🙂 But if you REALLY want to send Sci some moose munch to get her creative juices flowing, she will gladly cite you in her blog, and love you for the rest of her life (not that I don’t already have lots of reasons to love you).

  8. If a woman (and her associates) suffers from PMS, she should consider continuous contraception. No more period, no more hormonal fluctuation. The one big concern is cost. Birth control pills should be given away for free or should be subsidized by the state.

  9. Sci, I totally saw Moose Munch today at Starbucks for the FIRST time in my life, and I immediately thought of you!

  10. I once knew a lady who was a musician, a folk singer in fact. Before every performance she was become short tempered, have hot flashes, and would complain of aches and pains all through her body. Poor gal had pre-minstrel syndrome.

  11. How cool some of this research is getting press. Irritability was me on a *good* PMS day–On a bad one I was a crying, helpless, spiralling downward wreck.
    After trying lots of different things (different BC pills/regimens, calcium, vitamin B, exercise, yoga, etc etc, many of which helped, but only a bit), I decided it was worth trying an SSRI. I went to my GP (2 years ago) armed with a review article indicating that ‘intermittent’ dosing (taken in the 1-2 weeks prior to your period) of fluoxetine (Prozac) was as effective as ‘chronic’ dosing for many women, and asked to try this regimen. I was practically laughed out of his office. When I put my foot down based on the ‘science’, saying the worst that would happen is it didn’t work and I would go to the chronic regime, he rolled his eyes but caved.
    It has completely changed my life. The worst side effect I’ve had is the occasional headache (completely fixed by taking the pill in the morning, not the evening), which is more than offset by the fact that my physical PMS symptoms are actually improved, too (now *that’s* a topic for further research).
    Anyway, the research suggests there are different time scales for different effects of these drugs. Obviously they won’t be for everyone, but I’m certainly grateful (and taking it only a third of my life means a third the cost!).

  12. Help, there is so much contradictory advice with regards to SSRI’s. I am a happy, calm, self assured woman majority of the time but 7 days before my menstrual cycle I am irritable, moody, depressed and unsociable (and the rest!)So is it true I need to take the SSRI’s all the time?
    If not, do I need to take the SSRI for 3-4 weeks for it to get in my system then take it as and when I need…(for around 7 days)
    I have not taken any medication yet and my doctor said it is a drug that you have to remain on but in magazines and online it states that antidepressants can be taken for PART of a menstrual cycle.
    Thank you

  13. So I take a low dose of one SSRI continuously and then supplement with a 2nd the week before my period and it works better than anything.
    I am one of those weird people whose PMS symptoms become 100% continuous and devastating while on any sort of hormonal contraceptive.
    I was on Lupron therapy for 2 years and it gave me my life back but I couldn’t handle the severe menopausal symptoms. It started to become as debilitating as the illness.
    The SSRI combination works best but I’m still quite tired and depressed, I just no longer sleep 18 hours for a week or want to slit my wrists.

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