Selective serotonin reuptake inhibitors for premenstrual dysphoric disorder: the emerging gold standard?

Profiling Proteins in the Hypothalamus and Hippocampus of a Rat Model of Premenstrual Syndrome Irritability

Premenstrual syndrome (PMS) refers to several physical and mental symptoms (such as irritability) commonly encountered in clinical gynaecology. The incidence of PMS has been increasing, attracting greater attention from medical fields. However, PMS pathogenesis remains unclear. This study employed two-dimensional gel electrophoresis (2DE) for proteomic map analysis of the hypothalamus and hippocampus of rat models of premenstrual syndrome (PMS) irritability. Matrix-assisted laser desorption/ionisation time of flight mass spectroscopy (MALDI-TOF-MS) was used to identify proteins possibly related with PMS irritability. Baixiangdan, a traditional Chinese medicine effective against PMS irritability, was used in the rat model to study putative target proteins of this medicine. The hypothalamus and hippocampus of each group modelling PMS displayed the following features: decreased expression of Ulip2, tubulin beta chain 15, α actin, and interleukin 1 receptor accessory protein; increased expression of kappa-B motif-binding phosphoprotein; decreased expression of hydrolase at the end of ubiquitin carboxy, albumin, and aldolase protein; and increased expression of M2 pyruvate kinase, panthenol-cytochrome C reductase core protein I, and calcium-binding protein. Contrasting with previous studies, the current study identified new proteins related to PMS irritability. Our findings contribute to understanding the pathogenesis of PMS irritability and could provide a reference point for further studies.

Selective serotonin reuptake inhibitors for premenstrual syndrome

BACKGROUND

Premenstrual syndrome (PMS) is a common cause of physical, psychological and social problems in women of reproductive age. The key characteristic of PMS is the timing of symptoms, which occur only during the two weeks leading up to menstruation (the luteal phase of the menstrual cycle). Selective serotonin reuptake inhibitors (SSRIs) are increasingly used as first line therapy for PMS. SSRIs can be taken either in the luteal phase or else continuously (every day). SSRIs are generally considered to be effective for reducing premenstrual symptoms but they can cause adverse effects.

OBJECTIVES

The objective of this review was to evaluate the effectiveness and safety of SSRIs for treating premenstrual syndrome.

SEARCH METHODS

Electronic searches for relevant randomised controlled trials (RCTs) were undertaken in the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, and CINAHL (February 2013). Where insufficient data were presented in a report, attempts were made to contact the original authors for further details.

SELECTION CRITERIA

Studies were considered in which women with a prospective diagnosis of PMS, PMDD or late luteal phase dysphoric disorder (LPDD) were randomised to receive SSRIs or placebo for the treatment of premenstrual syndrome.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies, assessed eligible studies for risk of bias, and extracted data on premenstrual symptoms and adverse effects. Studies were pooled using random-effects models. Standardised mean differences (SMDs) with 95% confidence intervals (CIs) were calculated for premenstrual symptom scores, using separate analyses for different types of continuous data (that is end scores and change scores). Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for dichotomous outcomes. Analyses were stratified by type of drug administration (luteal or continuous) and by drug dose (low, medium, or high). We calculated the number of women who would need to be taking a moderate dose of SSRI in order to cause one additional adverse event (number needed to harm: NNH). The overall quality of the evidence for the main findings was assessed using the GRADE working group methods.

MAIN RESULTS

Thirty-one RCTs were included in the review. They compared fluoxetine, paroxetine, sertraline, escitalopram and citalopram versus placebo. SSRIs reduced overall self-rated symptoms significantly more effectively than placebo. The effect size was moderate when studies reporting end scores were pooled (for moderate dose SSRIs: SMD -0.65, 95% CI -0.46 to -0.84, nine studies, 1276 women; moderate heterogeneity (I(2) = 58%), low quality evidence). The effect size was small when studies reporting change scores were pooled (for moderate dose SSRIs: SMD -0.36, 95% CI -0.20 to -0.51, four studies, 657 women; low heterogeneity (I(2)=29%), moderate quality evidence).SSRIs were effective for symptom relief whether taken only in the luteal phase or continuously, with no clear evidence of a difference in effectiveness between these modes of administration. However, few studies directly compared luteal and continuous regimens and more evidence is needed on this question.Withdrawals due to adverse effects were significantly more likely to occur in the SSRI group (moderate dose: OR 2.55, 95% CI 1.84 to 3.53, 15 studies, 2447 women; no heterogeneity (I(2) = 0%), moderate quality evidence). The most common side effects associated with a moderate dose of SSRIs were nausea (NNH = 7), asthenia or decreased energy (NNH = 9), somnolence (NNH = 13), fatigue (NNH = 14), decreased libido (NNH = 14) and sweating (NNH = 14). In secondary analyses, SSRIs were effective for treating specific types of symptoms (that is psychological, physical and functional symptoms, and irritability). Adverse effects were dose-related.The overall quality of the evidence was low to moderate, the main weakness in the included studies being poor reporting of methods. Heterogeneity was low or absent for most outcomes, though (as noted above) there was moderate heterogeneity for one of the primary analyses.

AUTHORS' CONCLUSIONS

SSRIs are effective in reducing the symptoms of PMS, whether taken in the luteal phase only or continuously. Adverse effects are relatively frequent, the most common being nausea and asthenia. Adverse effects are dose-dependent.

A narrative review of medical, chiropractic, and alternative health practices in the treatment of primary dysmenorrhea

OBJECTIVE

Primary dysmenorrhea and related issues are discussed as they influence the gynecological and social health of females during adolescence, adulthood, and senior maturity. Health practitioners are exposed to multiple approaches towards the management of menstrual pain. Clinical and social viewpoints target the causation, development, diagnosis, manifestation and management of primary dysmenorrhea. This narrative review includes the topic of the doctor-patient relationship in efforts of cultivating effectively communicative health practitioners. Controversial topics related to primary dysmenorrhea and the quality of life for women are addressed.

DATA SOURCES

A search for literature reviews, case studies, laboratory research, and clinical trials from 1985-2004 was performed using the MEDLINE database. Sources of additional information included textbooks, national organizational literature and contemporary articles.

DISCUSSION

Menstrual pain is a prevalent experience yet it is socially taboo for conversation; as such, it poses a hindrance to its management. The communication between the doctor and patient is a critical barrier point between establishing a diagnosis and determining an appropriate treatment plan. A multi-disciple treatment plan varies as much as patients themselves vary in personal experiences, needs, and preferences.

CONCLUSIONS

Medicinal prophylactics, physical therapeutics, non-acidic diets, herbal supplements, eastern therapies and the chiropractic manual adjustments of the spine are effective methods for the management of primary dysmenorrhea. The non-invasive management of primary dysmenorrhea includes the chiropractic adjustment with complimentary modalities, and other alternative health care practices. Medicinal prophylactics are invasive and pose a higher risk to long-term chemical exposure, side effects or irreversible conditions.

Sleep, Hormones, and Circadian Rhythms throughout the Menstrual Cycle in Healthy Women and Women with Premenstrual Dysphoric Disorder

A relationship exists between the sleep-wake cycle and hormone secretion, which, in women, is further modulated by the menstrual cycle. This interaction can influence sleep across the menstrual cycle in healthy women and in women with premenstrual dysphoric disorder (PMDD), who experience specific alterations of circadian rhythms during their symptomatic luteal phase along with sleep disturbances during this time. This review will address the variation of sleep at different menstrual phases in healthy and PMDD women, as well as changes in circadian rhythms, with an emphasis on their relationship with female sex hormones. It will conclude with a brief discussion on nonpharmacological treatments of PMDD which use chronotherapeutic methods to realign circadian rhythms as a means of improving sleep and mood in these women.

Duloxetine treatment for women with premenstrual dysphoric disorder: a single-blind trial

Premenstrual dysphoric disorder (PMDD) affects 3-8% of women of reproductive age and is characterized by severe mood symptoms that cause important functional impairment. Serotonergic antidepressants appear to be an effective treatment for this disorder. The purpose of this study was to collect evidence on the efficacy and tolerability of duloxetine, a dual reuptake inhibitor of serotonin and norepinephrine, in the treatment of PMDD. We conducted a pilot, single-blind, non-controlled, fixed-dose trial. After two cycles for diagnosis confirmation, including a single-blind placebo cycle, 20 women with PMDD were treated continuously for three menstrual cycles with 60 mg/d duloxetine. The primary measure of the efficacy of treatment with duloxetine was the significant reduction in premenstrual symptoms demonstrated by the comparison between the mean Daily Record of Severity of Problems (DRSP) scores at baseline to endpoint (p=0.0002). Statistically significant symptom reduction was observed in the first treatment cycle and throughout all the treatment phase. Clinical response, defined as a reduction 50% of baseline premenstrual symptoms, occurred in 65% of subjects (intention-to-treat population). Significant improvements were demonstrated by secondary measures, including reduction in self-rated functional impairment (p=0.01) and improvement in quality of life (p=0.04). The main side-effects associated with duloxetine were dry mouth, nausea, drowsiness, insomnia, decreased appetite, decreased libido, and sweating. Duloxetine was effective and generally well tolerated in the treatment of PMDD. Further large-scale, double-blind, placebo-controlled studies are needed to evaluate duloxetine as an additional treatment strategy for the management of PMDD.

Premenstrual syndrome and premenstrual dysphoric disorder: quality of life and burden of illness

Premenstrual symptoms are distressing for up to 20% of reproductive-aged women and are associated with impairment in interpersonal or workplace functioning for at least 3-8%. Typical symptoms of premenstrual syndrome and the severe form, premenstrual dysphoric disorder, include irritability, anger, mood swings, depression, tension/anxiety, abdominal bloating, breast pain and fatigue. The symptoms recur monthly and last for an average of 6 days per month for the majority of the reproductive years. For women with premenstrual dysphoric disorder, the symptoms can be as disabling as major depressive disorder. It has been estimated that affected women experience almost 3000 days of severe symptoms during the reproductive years. Until two decades ago, there were no effective treatments for severe premenstrual syndrome. Even in 2000, almost three-quarters of women in the USA with premenstrual disorders either did not seek help or sought treatment unsuccessfully from at least three clinicians for over 5 years. This review will focus on the epidemiology, diagnosis, treatment outcomes, quality of life and burden of illness for premenstrual disorders.

Treatment-emergent sexual dysfunction related to antidepressants: a meta-analysis

BACKGROUND

Sexual dysfunction (SD) is an important underestimated adverse effect of antidepressant drugs. Patients, in fact, if not directly questioned, tend to scarcely report them. The aim of the present meta-analysis was to quantify SD caused by antidepressants on the basis of studies where sexual functioning was purposely investigated through direct inquiry and specific questionnaires.

METHODS

A literature search was conducted using MEDLINE, ISI Web of Knowledge, and references of selected articles. Selected studies performed on patients without previous SD were entered in the Cochrane Collaboration Review Manager (RevMan version 4.2). Our primary outcome measure was the rate of total treatment-emergent SD. Our secondary outcome measures were the rates of treatment-emergent desire, arousal, and orgasm dysfunction.

RESULTS

Our analyses indicated a significantly higher rate of total and specific treatment-emergent SD and specific phases of dysfunction compared with placebo for the following drugs in decreasing order of impact: sertraline, venlafaxine, citalopram, paroxetine, fluoxetine, imipramine, phenelzine, duloxetine, escitalopram, and fluvoxamine, with SD ranging from 25.8% to 80.3% of patients. No significant difference with placebo was found for the following antidepressants: agomelatine, amineptine, bupropion, moclobemide, mirtazapine, and nefazodone.

DISCUSSION

Treatment-emergent SD caused by antidepressants is a considerable issue with a large variation across compounds. Some assumptions, such as the inclusion of open-label studies or differences in scales used to assess SD, could reduce the significance of our findings. However, treatment-emergent SD is a frequent adverse effect that should be considered in clinical activity for the choice of the prescribed drug.

Modest effects of repeated fluoxetine on estrous cyclicity and sexual behavior in Sprague Dawley female rats

In an earlier study, we reported that daily fluoxetine treatment (10 mg/kg/day) rapidly disrupted estrous cyclicity and sexual receptivity in adult, regularly cycling Fischer rats. The current study was designed to investigate if comparable fluoxetine treatment would similarly affect intact, regularly cycling Sprague Dawley rats. In the first experiment, fluoxetine was injected for 24 days. After 11-14 days of daily fluoxetine treatment, 40% of the rats showed a transient disturbance of the estrous cycle with elimination of sexual receptivity. In these affected rats, reduced sexual receptivity generally preceded disruption of vaginal cyclicity. In a second experiment, a shorter exposure was used to attempt to dissociate effects of fluoxetine on behavior and estrous cyclicity. Nine days of fluoxetine treatment eliminated sexual receptivity and proceptivity (hops/darts) in 40% and 46%, respectively, of rats without altering the estrous cycle. Female rats then received a 10th fluoxetine injection 30 min prior to assessment of sexual motivation (measured with the male preference paradigm). There was no effect of fluoxetine on male preference, but fluoxetine significantly reduced the number of crossings and seconds of grooming during preference testing. Therefore, effects of fluoxetine on estrous cyclicity and behavior of Sprague Dawley female rats were smaller and required longer to develop than previously reported in Fischer female rats. These findings reinforce a probable relationship between fluoxetine's effect on sexual activity and neuroendocrine disturbances and illustrate the importance of strain selection in attempting to model human disease.

Selective serotonin reuptake inhibitors and initial oral contraceptives for the treatment of PMDD: effective but not enough

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are almost unanimously considered to be very efficacious and the first line of pharmacologic treatment for premenstrual dysphoric disorder (PMDD) and premenstrual syndrome (PMS). There is a need to examine if this is actually the case. More recently, combined oral contraceptives (COCs) have been pursued due to their ovulation suppression effects. Their effects on PMS/PMDD should be further examined as well.

METHODS

For this review of the literature from 1990 to the present, MEDLINE, PsychLit, and Cochrane controlled trials register were searched. Randomized, double-blind, placebo-controlled clinical trials of SSRIs and COCs (N>20) that report the rate of responders and not just percent improvement in severity of symptoms were selected for study. The data extraction were the percentage or number of responders as reported by the original authors.

RESULTS

In many studies, only mean improvement in severity was reported. In all studies, the main inclusion criterion was meeting criteria for PMDD; this has not, however, been an outcome measure. However, only 16 reports that provided actual rate of responders could be included. The percentage of non-responders (100% minus active medication) to SSRIs and COCs was found to be higher than the reported percentage of women who responded to active medication (response rate to an SSRI or COC minus the response rate to placebo).

CONCLUSION

In the majority of larger-scale studies, once the placebo effect is accounted for, the percentage of women who respond to SSRIs or COCs is actually less than the percentage of women who do not respond at all. SSRIs provide an important step forward in the treatment of PMDD and PMS. COCs provide a different option, still, approximately 40% of women with PMDD do not respond to SSRIs. Treatment with a currently approved COC does not substantially improve the percentage of responders. Therefore, additional alternative targeted treatment modalities need to be developed.

Escitalopram administered in the luteal phase exerts a marked and dose-dependent effect in premenstrual dysphoric disorder

This is the first placebo-controlled trial evaluating the efficacy of the selective serotonin reuptake inhibitor (SSRI), escitalopram, in the treatment of premenstrual dysphoric disorder (PMDD). Women with PMDD (intention-to-treat population, n = 151) were treated intermittently for 3 months, during luteal phases only, with 10 mg/d escitalopram, 20 mg/d escitalopram, or placebo. Escitalopram was found to exert a marked and a dose-dependent symptom-reducing effect, 20 mg/d being clearly superior to 10 mg/d. Although the primary outcome parameter, that is, the sum of the symptoms irritability, depressed mood, tension, and affective lability, was decreased by 90% with 20 mg/d escitalopram, the effect of active treatment on breast tenderness, food craving, and lack of energy was more modest and not significantly different from that of placebo; this outcome supports our previous assumption that the former symptoms are more inclined to respond to intermittent administration of an SSRI than are the latter. Although the placebo response was high, the difference between the placebo group and the 20-mg/d escitalopram group with respect to the percentage of subjects displaying 80% or greater reduction in the rating of the cardinal symptom of PMDD, that is, irritability, was considerable: 30% versus 80%. Adverse events were those normally reported in SSRI trials, such as nausea and reduced libido, and were not more common in patients given 20 mg/d of escitalopram than in patients given the lower dose. This study supports the usefulness of escitalopram for the treatment of PMDD and sheds further light on how different components of this syndrome are differently influenced by intermittent administration of an SSRI.

Six-month paroxetine treatment of premenstrual dysphoric disorder: continuous versus intermittent treatment protocols

AIMS

Several trials have proved the efficacy of selective serotonin re-uptake inhibitors (SSRI) in the treatment of premenstrual dysphoric disorder (PMDD) in Western society. The SSRI can be administered continuously throughout the entire cycle or intermittently from ovulation to the onset of menstruation (luteal phase). The purpose of the present study was to compare continuous and intermittent paroxetine treatment in oriental PMDD women during 6 months follow up.

METHODS

Thirty-six subjects were evaluated and drug free for two menstrual cycles, and they received daily paroxetine (20 mg) for two further full cycles. They were then randomly divided into continuous or intermittent treatment groups (n = 16, 14) over the next four cycles. Responses were assessed every 2 weeks. Outcome measures included scores on the Prospective Record of the Impact and Severity of Menstrual Symptomatology (PRISM) calendar, Hamilton Rating Scale for Depression/Anxiety (HAMD/HAMA), and the Clinical Global Impression scale (CGI).

RESULTS

All these women had significant improvements in the HAMA, HAMD, CGI, and PRISM calendar. The rate of response to paroxetine treatment lay between 50% and 78.6% in the continuous-treatment group, and 37.5-93.8% in the intermittent-treatment group, as determined at the study end-point. Limitations of the present study included the open-label design and the incorporation of a limited sample size.

CONCLUSIONS

The present results indicate that paroxetine is effective in both continuous and intermittent treatment of oriental PMDD women, and that the effects of active treatment lasted for six consecutive treatment menstrual cycles.

The relevance of neuroactive steroids in schizophrenia, depression, and anxiety disorders

1. Neuroactive steroids are steroid hormones that exert rapid, nongenomic effects at ligand-gated ion channels. There is increasing awareness of the possible role of these steroids in the pathology and manifestation of symptoms of psychiatric disorders. The aim of this paper is to review the current knowledge of neuroactive steroid functioning in the central nervous system, and to assess the role of neuroactive steroids in the pathophysiology and treatment of symptoms of schizophrenia, depression, and anxiety disorders. Particular emphasis will be placed on GABAA receptor modulation, given the extensive knowledge of the interactions between this receptor complex, neuroactive steroids, and psychiatric illness. 2. A brief description of neuroactive steroid metabolism is followed by a discussion of the interactions of neuroactive steroids with acute and chronic stress and the HPA axis. Preclinical and clinical studies related to psychiatric disorders that have been conducted on neuroactive steroids are also described. 3. Plasma concentrations of some neuroactive steroids are altered in individuals suffering from schizophrenia, depression, or anxiety disorders compared to values in healthy controls. Some drugs used to treat these disorders have been reported to alter plasma and brain concentrations in clinical and preclinical studies, respectively. 4. Further research is warranted into the role of neuroactive steroids in the pathophysiology of psychiatric illnesses and the possible role of these steroids in the successful treatment of these disorders.

Premenstrual dysphoric disorder in an adolescent female

BACKGROUND

A severe cyclic constellation of affective symptoms during the luteal phase of the menstrual cycle is termed premenstrual dysphoric disorder (PMDD).

CASE

A 17-yr-old female was referred for evaluation of behavior changes with her menses. Parents noted behavior changes, two to three days before the onset and lasting till the end of her menses. Menarche was at 13 years. Periods were regular, with normal flow and duration and no dysmenorrhea. Psychosocial history was unremarkable. There was no history of sexual activity or abuse. Her physical exam was unremarkable. With the working diagnosis of premenstrual dysphoric syndrome she was asked to keep track of her menses on a menstrual calendar and her symptoms with a daily diary. She was treated with Fluoxetine 20 mg/day during the luteal phase of her menstrual cycle with complete resolution of her symptoms.

COMMENTS

In PMDD the mood disturbance occurs during the late luteal phase of the menstrual cycle (approximately 1 week before the onset of menstrual bleeding), remits after the onset of menses, and can be established by a prospective daily symptom log for two consecutive cycles. The symptoms are more severe than that of premenstrual syndrome, are associated with significant functional impairment and are cyclical. Symptoms were documented prospectively as starting a few days before her menstrual bleeding and remitting at the end of it. She responded to episodic use of a selective serotonin reuptake inhibitor. This disorder needs to be better recognized, because it can be easily treated.

Placebo-controlled trial comparing intermittent and continuous paroxetine in premenstrual dysphoric disorder

Serotonin reuptake inhibitors (SRIs) do not have to be administered continuously to be effective for premenstrual dysphoric disorder (PMDD), but can be given during luteal phases only. This is of practical importance, but also of theoretical interest since it suggests that the onset of action of SRIs is shorter in PMDD than in, for example depression. In this study, both continuous and intermittent SRI administration was compared with placebo, with the special purpose of analyzing if different PMDD symptoms respond differently depending on the treatment regimen. To this end, women meeting slightly modified DSM-IV criteria for PMDD (mean+/-SD age, 37+/-6.3 years) were treated for three menstrual cycles with paroxetine continuously, paroxetine during the luteal phase only, or placebo, the population completing at least one treatment cycle comprising 55-56 subjects per group. Continuous treatment with paroxetine reduced premenstrual symptoms effectively with a response rate of 85%. The effect size was highest for irritability (1.4) and lowest for lack of energy (0.5). Intermittent treatment was as effective as continuous treatment in reducing irritability, affect lability, and mood swings, but had a somewhat weaker effect on depressed mood and somatic symptoms. The study indicates that the response rate when treating PMDD with SRIs is high, and that irritability is a key target symptom. Symptoms such as irritability, affect lability, and mood swings appear to be more inclined to respond rapidly to SRIs, enabling intermittent treatment, than are, for example, the somatic symptoms.

Fluoxetine and norfluoxetine stereospecifically and selectively increase brain neurosteroid content at doses that are inactive on 5-HT reuptake

It has recently become more clearly understood that in human brain pathophysiology, neurosteroids play a role in anxiety disorders, premenstrual syndrome, postpartum depression, posttraumatic stress disorder, and depression. In the treatment of major depression, recent clinical studies indicate that the pharmacological profiles of fluoxetine and fluvoxamine are correlated with the ability of these drugs to increase the brain and cerebrospinal fluid content of allopregnanolone (Allo), a potent positive allosteric modulator of gamma-aminobutyric acid (GABA) action at GABAA receptors. Thus, the neurosteroid-induced positive allosteric modulation of GABA action at GABAA receptors is facilitated by fluoxetine or its congeners (i.e., paroxetine, fluvoxamine, sertraline), which may not block 5-HT reuptake at the doses currently prescribed in the clinic. However, these doses are effective in the treatment of premenstrual dysphoria, anxiety, and depression. In socially isolated mice, we tested the hypothesis that fluoxetine, norfluoxetine, and other specific serotonin reuptake inhibitor (SSRI) congeners stereoselectively upregulate neurosteroid content at doses insufficient to inhibit 5-HT reuptake; although they potentiate pentobarbital-induced sedation and exert antiaggressive action. Very importantly, the inhibition of 5-HT reuptake lacks stereospecificity and requires fluoxetine and norfluoxetine doses that are 50-fold greater than those required to increase brain Allo content, potentiate the action of pentobarbital, or antagonize isolation-induced aggression. Based on these findings, it could be inferred that the increase of brain Allo content elicited by fluoxetine and norfluoxetine, rather than the inhibition selective of 5-HT reuptake, may be operative in the fluoxetine-induced remission of the behavioral abnormalities associated with mood disorders. Therefore, the term "SSRI" may be misleading in defining the pharmacological profile of fluoxetine and its congeners. To this extent, the term "selective brain steroidogenic stimulants" (SBSSs) could be proposed.

Expert Guidelines for the Treatment of Severe PMS, PMDD, and Comorbidities: The Role of SSRIs

The hallmark feature of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) is the predictable, cyclic nature of symptoms or distinct on/offness that begins in the late luteal phase of the menstrual cycle and remits shortly after the onset of menstruation. PMDD is distinguished from PMS by the severity of symptoms, predominance of mood symptoms, and role dysfunction, particularly in personal relationships and marital/family domains. Several treatment modalities are beneficial in PMDD and severe PMS, but the selective serotonin reuptake inhibitors (SSRIs) have emerged as first-line therapy. The SSRIs can be administered continuously throughout the entire month, intermittently from ovulation to the onset of menstruation, or semi-intermittently with dosage increases during the late luteal phase. These guidelines present practical treatment algorithms for the use of SSRIs in women with pure PMDD or severe PMS, PMDD and underlying subsyndromal clinical features of mood or anxiety, or premenstrual exacerbation of a mood/anxiety disorder.

Paroxetine use in the treatment of premenstrual dysphoric disorder

Premenstrual dysphoric disorder, which affects 3-8% of women of reproductive age, is characterized by a combination of symptoms that may include depressed mood, irritability, anxiety and/or physical symptoms. These symptoms occur during the luteal phase of the menstrual cycle, with remission generally occurring within 3 days after the onset of menses. Presently, treatment guidelines for premenstrual dysphoric disorder focus on lifestyle management and psychopharmacologic interventions, with selective serotonin reuptake inhibitors being considered the first line of medication intervention. The US Food and Drug Administration and Health Canada recently approved paroxetine for the treatment of premenstrual dysphoric disorder. This article reviews the properties of this medication and its use in the treatment of premenstrual dysphoric disorder.

Premenstrual dysphoric disorder in adolescents: case reports of treatment with fluoxetine and review of the literature

Premenstrual dysphoric disorder (PMDD) is a periodic, recurrent, debilitating condition with severe psychological or affective symptoms during the late luteal phase. PMDD often begins during adolescence. Dysregulation of the serotonergic system has been proposed recently as its cause and fluoxetine has been recommended as an appropriate treatment. We report 3 adolescents with PMDD who were treated for 2 years with fluoxetine, resulting in complete symptom resolution, and review the clinical trials supporting its use. Case reports of successfully treated teenagers are an addition to the accumulated evidence of the efficacy of fluoxetine for treatment of PMDD in adult women. Together they may provide some justification for the compassionate use of fluoxetine for adolescent girls who are being disabled by PMDD. However, more research is called for: a randomized placebo-controlled trial in adolescents is warranted.

Luteal phase dosing with paroxetine controlled release (CR) in the treatment of premenstrual dysphoric disorder

OBJECTIVE

This clinical trial evaluated luteal phase dosing with paroxetine controlled release (CR) (12.5 mg and 25 mg) in the treatment of premenstrual dysphoric disorder (PMDD).

STUDY DESIGN

A multicenter, randomized, double-blind, placebo-controlled, 3-arm, fixed-dose study of luteal phase dosing with paroxetine CR in the treatment of PMDD. Three hundred seventy-three patients with PMDD were randomly assigned into the study. The primary measure of efficacy was the change from baseline in the mean luteal visual analogue scale (VAS)-Mood score. Secondary efficacy measures included disorder-specific evaluations, global assessments of disease severity, and assessments of functional impairment. Adverse events were recorded throughout the trial.

RESULTS

Patients treated with either dose of paroxetine CR demonstrated significantly greater improvements on the primary efficacy measure (change from baseline in mean luteal phase VAS-Mood scores) and on the majority of secondary efficacy measures compared with patients randomly assigned to placebo.

CONCLUSION

For the treatment of PMDD, luteal phase dosing with 12.5 mg and 25 mg of paroxetine CR is effective and generally well tolerated.

Memory function in women with premenstrual complaints and the effect of serotonergic stimulation by acute administration of an alpha-lactalbumin protein

Serotonergic hypofunction may underlie at least part of the symptoms that are experienced by women with premenstrual complaints, including memory deficits. In the current study we investigated changes in memory functions in the premenstrual phase compared to the early postmenstrual phase in 16 women with premenstrual complaints. In addition, the effect of an acute serotonergic stimulation by administration of an alpha-lactalbumin protein on premenstrual memory performance was assessed using a double-blind placebo-controlled crossover design. It was found that both short-term and long-term memory for words (30-word learning task) and abstract figures (abstract visual learning task) were mildly impaired in the premenstrual phase. Administration of alpha-lactalbumin during the premenstrual phase could only partially attenuate the memory performance decrements that are seen in the premenstrual phase. Specifically, alphalactalbumin improved long-term memory for abstract figures, but not for words. There were no effects of menstrual phase or alpha-lactalbumin on planning functions (computerized Tower of London). The data suggest that serotonergic hypofunction may play a role in premenstrual memory decline, but serotonergic mechanisms cannot fully account for observed cognitive changes in the premenstrual phase.

Cortical 3 alpha-hydroxy-5 alpha-pregnan-20-one levels after acute administration of Delta 9-tetrahydrocannabinol, cocaine and morphine

RATIONALE

The neuroactive steroid, 3alpha-hydroxy-5alpha-pregane-20-one (allopregnanolone) is a potent modulator of GABA(A) receptor function. Moreover, pharmacologically relevant concentrations of allopregnanolone are found in brain during physiological conditions (stress, pregnancy and menstrual cycle) and pharmacological challenge (ethanol, fluoxetine, olanzapine). Enhanced levels of neurosteroids are thought to contribute to the therapeutic effects of fluoxetine and various effects of ethanol via GABA(A) receptors. Moreover, neurosteroids influence rewarding effects of ethanol in some models and modulate activation of the hypothalamic pituitary adrenal (HPA) axis. Thus, it is possible that enhanced allopregnanolone levels are involved in the effects of abused drugs.

OBJECTIVES

To determine if other abused drugs elicit alterations in brain neurosteroid levels, Delta9-tetrahydrocannabinol (Delta9-THC), cocaine and morphine were administered to male rats.

METHODS

Cortical brain tissue and plasma were collected and analyzed for steroid concentrations using radioimmunoassays.

RESULTS

Delta9-THC (5 mg/kg, IP) elevated cortical allopregnanolone levels to pharmacologically active levels, while morphine (15 mg/kg, SC) produced a small but significant increase. Cocaine (30 mg/kg, IP) did not alter allopregnanolone levels, nor did lower doses of Delta9-THC or morphine. Plasma progesterone levels were elevated in both Delta9-THC and cocaine-treated animals.

CONCLUSIONS

Some, but not all, drugs of abuse produce increases in cortical allopregnanolone levels. In addition, increases in plasma steroid precursor levels do not always translate into increases in brain allopregnanolone levels.

Paroxetine Controlled Release for Premenstrual Dysphoric Disorder: Remission Analysis Following a Randomized, Double-Blind, Placebo-Controlled Trial

Objective: To compare the efficacy and safety of paroxetine controlled release (CR) (12.5 mg/day or 25 mg/day) versus placebo in premenstrual dysphoric disorder (PMDD).Method: A double-blind, randomized, placebo-controlled trial was conducted over 3 menstrual cycles in women aged 18-45 years with confirmed DSM-IV PMDD in 47 outpatient centers across the United States and Canada from November 1999 to January 2002. The primary efficacy measure was the visual analog scale (VAS)-Mood, which is the mean of 4 core symptoms: irritability, tension, depressed mood, and affective lability.Results: A statistically significant difference was observed in favor of paroxetine CR 25 mg versus placebo on the VAS-Mood (adjusted mean difference = -12.58 mm, 95% CI = -18.40 to -6.76; p < .001) and for paroxetine CR 12.5 mg versus placebo (adjusted mean difference = -7.51 mm, 95% CI = -13.40 to -1.62; p = .013). Paroxetine CR was generally well tolerated.Conclusion: Paroxetine CR doses of 12.5 mg/day and 25 mg/day are effective in treating PMDD and are well tolerated.

Assessment of sexual drive and desire in women with premenstrual dysphoric disorder who have been treated with fluoxetine

Objective To explore the impact of treatment with fluoxetine on sexual drive and desire (SDD) in women with premenstrual dysphoric disorder (PMDD). Methods Data were collected during a randomised, controlled, double-blind trial evaluating the efficacy of fluoxetine 20 or 60 mg/day versus placebo in the treatment of women with PMDD. Study subjects rated their SDD on the Premenstrual Tension Scale, Self Rating (PMTS-SR) during their follicular and luteal phases of the placebo run in cycles and the double-blind treatment cycles. Data were analyzed using chi-square test. Results Data were available for 184 subjects who rated their SDD during the follicular and luteal phases of two baseline (placebo) cycles and the following two treatment cycles. There was a trend for more women on fluoxetine to report improvement in luteal phase SDD compared to women on placebo (P=0.057). Conclusions Our data, contrary to expectations, suggest that fluoxetine treatment may restore SDD in women who experience decreased SDD as part of a cluster of symptoms associated with PMDD. Future trials with SSRIs should include specific measures of sexual functioning to further examine the potential beneficial versus side effects of these medications as they relate to phases of the menstrual cycle.

Effects of antidepressants on quality of life in women with premenstrual dysphoric disorder

This review examines the effects of antidepressant medications on premenstrual dysphoric disorder (PMDD) and the diminished quality of life (QOL) that accompanies the disorder. PMDD is a chronic condition in women that emerges in the second half of the menstrual cycle and remits during the menstrual period. The affective and behavioural symptoms of PMDD adversely affect functioning and QOL to a disabling degree, particularly in the domains of family and personal relationships, work productivity and social activities. The serotonergic antidepressants, specifically the selective serotonin reuptake inhibitors (SSRIs), are effective for PMDD. Continuous and luteal-phase dosing regimens with SSRIs are similarly effective and well tolerated. Treatment of PMDD with a serotonergic antidepressant significantly improves functioning and QOL in all studies that have systematically examined QOL issues in this disorder. Although the data show that PMDD is effectively treated with serotonergic antidepressants and that functional impairment that accompanies the disorder is also improved with treatment, the social and economic burden of PMDD continues to be widely unrecognised. Greater awareness of the effectiveness of treatments and reliable measures of the direct and indirect healthcare costs of the disorder when it remains untreated are needed.

Efficacy and tolerability of premenstrual use of venlafaxine (flexible dose) in the treatment of premenstrual dysphoric disorder

The objective of this study was to examine the efficacy and tolerability of intermittent dosing of venlafaxine for the treatment of premenstrual dysphoric disorder. One hundred and twenty-four women aged 18 to 45 years, with regular menstrual cycles and who reported significant premenstrual symptoms, were assessed prospectively to confirm their diagnosis of premenstrual dysphoric disorder. Twenty subjects with confirmed premenstrual dysphoric disorder entered a single-blind, placebo phase (1 cycle). Placebo nonresponders (n = 12) received 2 cycles of intermittent (premenstrual) treatment with venlafaxine (75 to 112.5 mg/d). Subjects initiated treatment 14 days before the anticipated onset of menses and discontinued it on the second day of bleeding. Doses could be adjusted after cycle 1 based on subjects' response and tolerability. Response to treatment was assessed based on changes in the Daily Rating Severity of Problems and Premenstrual Tension Syndrome Questionnaire scores from baseline (before the placebo cycle), as well as Clinical Global Impression-Severity scores. Discontinuation symptoms were assessed between treatment cycles, using the Discontinuation-Emergent Signs and Symptoms questionnaire. Eleven subjects concluded 2 cycles of intermittent dosing with venlafaxine. Nine subjects (81.8%) showed satisfactory response based on Clinical Global Impression of < or = 2. Changes in Daily Rating Severity of Problems scores and subscores (depression, physical symptoms, and anger) and in Premenstrual Tension Syndrome Questionnaire scores were significant (P < 0.05 for all comparisons, Wilcoxon tests). Intermittent treatment was well tolerated. This preliminary report suggests that premenstrual use of venlafaxine is an efficacious and well-tolerated treatment for premenstrual dysphoric disorder.

Paroxetine controlled release for premenstrual dysphoric disorder: a double-blind, placebo-controlled trial

BACKGROUND

Better characterization of safety and efficacy of multiple doses of selective serotonin reuptake inhibitors for the treatment of a wider range of symptoms of premenstrual dysphoric disorder (PMDD) will provide clinicians with flexibility to provide symptom relief along with acceptable tolerability. This study was designed to assess the efficacy and tolerability of multiple doses of paroxetine controlled release (CR) in PMDD.

METHODS

In a multicenter (43 outpatient U.S. sites), placebo-controlled trial, 327 females aged 18 to 45 years, with regular menstrual cycles, meeting DSM-IV criteria for PMDD, were randomly assigned to receive paroxetine CR 12.5 mg; paroxetine CR 25 mg; or placebo, once daily, for up to three treatment cycles. The primary efficacy outcome was change from baseline to end point in mean luteal phase Visual Analogue Scale-Mood (irritability, tension, affective lability, depressed mood) score.

RESULTS

At end point, subjects treated with paroxetine CR (12.5 mg and 25 mg) demonstrated significant improvement in VAS-Mood scores compared with those who received placebo (paroxetine CR 12.5 mg mean treatment difference vs. placebo, -8.7 mm; 95% CI, -15.7, -1.7; p =.015; paroxetine CR 25 mg mean treatment difference vs. placebo, -12.1 mm; 95% CI, -18.9, -5.3; p <.001). Results were also significant across measures of physical symptoms and social functioning. Paroxetine CR was well tolerated; 9.5% of subjects treated with 12.5 mg and 13.5% of subjects treated with 25 mg withdrew from the trial due to adverse events, compared with 6.5% of subjects in the placebo group.

CONCLUSIONS

Both doses of paroxetine CR 12.5 mg and 25 mg daily are effective and well tolerated in patients who suffer from PMDD. Efficacy with both doses affords greater flexibility to the prescribing physician.

Premenstrual exacerbation of depressive disorders in a community-based sample in the United States

OBJECTIVE

No published epidemiologic study has examined premenstrual exacerbation of depressive disorders (PME-DD) in a representative sample. Knowledge gained should indicate the burden of illness, suggest whom to monitor, and facilitate diagnosis. The objectives were to 1) ascertain the prevalence and predictors of PME-DD; and 2) test competing hypotheses that PME-DD is related to a) severity or history of depression, b) menstrual cyclicity in females in general, or c) a methodological artifact.

METHODS

Menstruating females (N = 900) from ages 13 to 53 living in urban or rural Illinois completed semi-structured psychiatric diagnostic interviews and rated symptoms of depression daily for two menstrual cycles; 58 had major depressive, dysthymic, or subclinical depressive disorders, and the remaining 842 were the non-depressed portion of the representative sample.

RESULTS

Depressed females had 1.34 (95% confidence interval, 1.02-1.66) symptoms exacerbated premenstrually. The best model for predicting exacerbation contained only age. Older women more often had symptoms worsen. Symptoms during the follicular phase were most severe for clinically depressed, intermediate for subclinically depressed, and least severe for non-depressed participants, ps < 0.001. Consistent with the hypothesis that exacerbation is related to cyclicity in all females, the number of symptoms that became worse did not differ between groups, ps < 0.46. Given no symptoms in one cycle, the odds of having symptoms in the next cycle were 0.91. Only 56% of non-depressed females taking antidepressants were asymptomatic all month long; the remaining 44% still had symptoms premenstrually.

CONCLUSIONS

Premenstrual exacerbation of depressive disorders is associated with deteriorated functioning over and above that already experienced by depressed females. Patients may be susceptible regardless of severity of depression, number of episodes, or remission status.

Treatment of premenstrual dysphoric disorder with luteal phase dosing of sertraline

Sertraline (Zoloft, Pfizer Inc.) is a selective serotonin re-uptake inhibitor (SSRI) which has been approved by the US FDA for the treatment of premenstrual dysphoric disorder (PMDD). PMDD is a severe form of premenstrual syndrome (PMS) which affects at least 5 - 8% of women of reproductive age. It is characterised by cyclic appearance at the late luteal phase of the menstrual cycle, and disappearance following the beginning of menses, with no symptoms during at least 1 week of the cycle - usually during the mid-follicular phase. Due to the cyclic luteal occurrence of PMDD, luteal phase dosing of SSRIs has been suggested and proven effective for sertraline as well as several other SSRIs. The clinical response of sertraline is reported to be within several days following initiation of treatment. Despite repeated cyclic discontinuation, no significant discontinuation adverse effects have been reported. In addition to its proven clinical efficacy, luteal-phase dosing may offer the advantages of minimising adverse effects of SSRIs while reducing the personal and economic burden of taking a prescription medication continuously for long periods and thus increasing compliance.

Recurrence of symptoms of premenstrual dysphoric disorder after the cessation of luteal-phase fluoxetine treatment

OBJECTIVE

The aim of this study was to use the data from two clinical trials to evaluate premenstrual dysphoric disorder symptom severity after the discontinuation of fluoxetine treatment.

STUDY DESIGN

A retrospective analysis of two clinical trials was performed. Patients were treated with fluoxetine or placebo for three cycles, with the use of several different dosing regimens, followed by single blind placebo treatment for one cycle. Assessments of relapse included the daily record of severity of problems, the Sheehan disability scale, the premenstrual tension scale-clinician rated, and the clinical global impressions-severity.

RESULTS

Premenstrual dysphoric disorder symptoms significantly increased after fluoxetine discontinuation. The scores did not return to baseline; however, the fluoxetine group was no longer significantly superior to placebo.

CONCLUSION

The two trials demonstrate that, after three cycles of treatment, premenstrual dysphoric disorder symptoms recur within the first cycle after treatment discontinuation. The rapid recurrence of symptoms further supports the view of premenstrual dysphoric disorder as a clinical entity distinct from depression.